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Preamble
This information was designed as an aid to educate certified registered nurse anesthetists, family members, colleagues, and health care administrators about chemical dependency. It is our hope that the information contained within will serve as a useful resource to both the chemically dependent practitioner and those who are in a position to offer guidance and support.
History
A little over a decade ago, a challenge was issued to nursing by the American Nurses Association (ANA) to offer treatment to addicted nurses before disciplinary action was taken. Although chemical dependency was already considered a treatable disease by the American healthcare system, this disease concept was not widely accepted for the addicted healthcare provider.
The American Medical Association, in the early 1980s, advocated that each state medical association establish an impaired physicians committee (now referred to as physician recovery programs) and aggressively petition state legislatures to approve diversion legislation. This enabled treatment to be offered to addicted physicians without having a negative impact on their licenses, as long as they continued to meet certain requirements. By the early 1990s, all 50 states had these options available to physicians. Thirty states to date have a similar option for nurses called alternative programs. These programs provide an alternative to licensure discipline as long as the nurse voluntarily complies with a monitoring contract.
In 1983, the American Association of Nurse Anesthetists (AANA) established an Ad Hoc Committee on Chemical Dependency. The visionary activities of this initial committee included development of a position statement, organization of educational seminars, aids and resources. The committee established the concept of peer advisors or resource Certified Registered Nurse Anesthetists (CRNAs) from each state that would serve as a network for information and support. The state peer advisor is appointed by their respective state nurse anesthesia association.
Position Statement on Chemical Dependency
Chemical dependency is defined as the use or abuse of a substance by persons unable or unwilling to terminate its utilization. The AANA recognizes addiction as a disease characterized by a chronic, progressive process that may destroy the professional, the family, and the community.
The AANA recognizes that anesthesia providers, because of their exposures and the nature of their work, appear to be at a high risk for substance abuse. In order to address these concerns within the profession, the AANA has established the Peer Assistance Advisors Committee (PAAC) to serve as a resource and support for nurse anesthesia practitioners and students.
The functions of the AANA Peer Assistance Advisors include: a) assessing the nature and impact of the disease of addiction on nurse anesthesia practice; b) educating nurse anesthetists, students, employers and the public about addiction; c) investigating the availability and effectiveness of treatment modalities; d) advocating research into the education, prevention, intervention, treatment and recovery of addiction; and, e) assisting individuals or organizations when requested in the formulation of guidelines regarding intervention, treatment, aftercare and reentry into the workplace of addicted nurse anesthetists.
Adopted by AANA Board of Directors November 1984. Revised February 1998.
Recovering CRNAs reentering the profession can serve as role models for other recovering CRNAs. Much is to be learned and shared by this group of anesthesia providers. A network of recovering CRNAs has been formed and is called Anesthetists in Recovery (AIR). AIR is a national support organization involved with both education and networking for reasons of peer assistance.
CRNAs in recovery from chemical dependency who would be willing to network with other CRNAs can call Art Zwerling, CRNA, MS, MSN, FAAPM, at 215-635-0183 or write to him at 8233 Brookside Road, Elkins Park, PA 19027. Information about individuals participating in the AIR network is maintained in a confidential manner.
Identification of Chemical Dependency
It is often difficult to identify an impaired colleague. Two reasons for this are denial on the part of the chemically dependent professional, as well as colleagues, and the enabling behavior of coworkers.
Watch for trends and patterns that indicate a change in the person and his or her job performance. These can initially be very subtle and may occur over many months or years. Generally, documentation of performance and behavior of a suspected colleague is essential to an objective evaluation as well as crucial to an effective resolution or intervention (See sample policy). Facts must be written, clear, concise and include specific dates, times and other witnesses. Hearsay must never be recorded – only observable behavior or the results of poor or questionable performance.
Anesthetists often enable colleagues to continue bad behavior or poor performance by making excuses, accepting inadequate work or covering up mistakes. To be part of the solution, coworkers need to stop enabling and talk clearly about the observed behaviors.
Coworkers have certain legal responsibilities in identifying and reporting the chemically dependent CRNA. Many states have mandatory reporting laws which may hold colleagues responsible for harm to patients if they fail to report a coworker in whom abuse is suspected. In those states with alternative programs, confidential reporting to the programs, absolves the colleague from reporting to the nursing regulatory board.
Evidence of alcohol or drug use, odor of alcohol on breath, heavy perfume or mouthwash, wearing long sleeves Consistently signs out more narcotics than peers Makes preoperative rounds or visits at unusual hours Comes to work during scheduled time off and loiters around departmental drug supply Chooses inappropriate type or amount of drug Increasing mood liability with frequent, unexplained anger, overreacts to criticism Isolates and withdrawals from peers Gradual decline in work performance, job shrinkage Increasing or unexplained tardiness or absenteeism Frequent illness or physical complaints Dishonesty, often over trivial or unimportant matters Increasing difficulty with peers, supervisors, and authority Frequent home crises — family illness and situational problems Elaborate excuses Inappropriate choice and dose of drugs Tremors, "Monday morning shakes." Loss of time on duty — increased breaks, missing from post Confusion, lack of concentration, distant Spasmodic work pattern Proximity to source off and on duty
Note
This policy and set of procedures are provided as a sample and must be individualized to meet the specific needs of your work setting, taking into account the nurse practice act of your state, and any pre-existing policy concerning chemical dependency (i.e., drug testing, pre-employment screening, employee assistance programs, etc.)
Purpose
This facility (name) has a vital interest in maintaining a safe, healthy and efficient environment for its employees and patients, an environment free from the misuse of drugs and alcohol. Recognizing that chemical dependency is both a disease and a professional hazard, the purpose of this policy is to provide guidelines for the reduction, confrontation and management of substance abuse within the department of anesthesia.
Policy
It is the policy of the department to provide a safe, fair working environment for all anesthesia practitioners and their patients.
Procedures
I. Education - All members of the department will be informed about their risk of becoming chemically dependent, how to recognize impairment in the workplace, the importance of proper intervention, and how to assist those with a prior substance abuse history to reenter the department. Supervisory personnel will receive training on the conduct, behavior and indicators of drug and alcohol abuse. They will also be trained in the guidelines and administration of the department and institutional policies on chemical dependency.
The department is responsible for conducting an education and training program, as well as providing information on related resources.
A. A minimum of six educational hours specific to chemical dependency shall be provided each member of the department.
B. Offerings will be provided by experts in the community, multimedia resources, and/or practitioners in recovery.
C. The department will maintain a resource file of:
1. The names, addresses and telephone numbers of community drug and alcohol counseling and rehabilitation programs.
2. Relevant educational materials from the state licensing bodies and professional associations to include:
a. Medical and Nurse Practice Acts relevant to impairment.
b. State Peer Assistance Committees.
c. Pertinent AANA and American Society of Anesthesiologists (ASA) resource publications/ material on peer assistance.
d. Information on the AANA Peer Assistance Hotline and the ASA Committee of Occupational Health and Safety will be prominently posted within the department.
3. Mental health providers and entities designed to assist employees with personal or behavioral problems.
II. Drug Testing - Anesthesia providers shall be required to submit to drug testing as a condition of employment. Failure or refusal to cooperate with any aspect of this policy including, but not limited to, refusal to sign forms consenting to drug testing or the refusal to submit to urine or blood sampling for testing to determine use of, or impairment by, a controlled substance or intoxicant will result in disciplinary action up to and including discharge and the reporting of failure to follow protocol.
Applicants and employees will be required to sign an acknowledgment form and consent to this policy. Random testing of employees has been deemed unlawful in some states without cause. An employee may be required to undergo a blood test or urinalysis under any of the following circumstances:
A. When there is reason to believe in the opinion of this facility that an employee is under the influence of intoxicants, non-prescribed narcotics, hallucinogens, marijuana or other non-prescribed controlled substances.
B. After the occurrence of a reported work-related injury/illness, or accident while on the facility property or during work hours.
C. During any physical examination provided by the facility.
D. When employees have been on leave of absence, or have not worked within the twelve weeks preceding their return date.
Testing Procedure
Drug testing will be conducted utilizing the following measures:
A. Employees will be required to sign the facility’s consent forms.
B. Employees will be required to sign the chain of custody forms provided by the testing laboratory.
C. Employees should disclose any medication, whether prescribed or over-the-counter, as well as any dietary intake which could alter a drug screen.
D. The facility will use a laboratory for testing which meets the current scientific and technical guidelines for drug testing programs.
E. A second test will be used on any positive screen.
F. All positive drug tests will be verified by a medical review officer. If it is determined that there is a legitimate medical explanation for the positive results, the medical review officer shall report the test results as negative.
Confidentiality
Testing and test results will be handled confidentially with disclosure of results provided only to those individuals with a need to know. Upon request, employees will be provided a copy of test results.
Prescription Drugs
Employees and applicants who have been taking legally prescribed drugs or over-the-counter medications should disclose this use prior to testing. A confidential consent form requesting information concerning this drug usage will be provided each employee or applicant prior to testing.
III. Insurance Provisions - Because anesthesia providers are at increased risk of becoming addicted, this department will strive to make available as part of its benefits package both healthcare and disability insurance policies which have provisions for chemical dependency and mental health treatment.
IV. Narcotic Accountability - A written, consistent process of narcotic accountability will be followed by all members of the department.
The use of all scheduled drugs, and others deemed necessary by the department administrators, will be managed as follows:
A. All scheduled drugs will be kept under double lock and signed for only by authorized individuals according to regulatory guidelines, i.e., the Drug Enforcement Agency (DEA).
B. Narcotics will not be exchanged between department members, not even narcotics signed out for the same patient between primary and relieving anesthetists.
C. All unused portions of drugs will either be returned to a centralized, locked depository with one way access that can only be opened by the narcotics control officer, or returned to a staffed pharmacy.
D. Assays on unused portions of anesthesia drugs, as well as audits of anesthesia and PACU records, will be conducted periodically and if suspicion warrants.
E. When no centralized locked depository exists, all drug wastage will follow facility guidelines with documented double witness wastage. Periodic random assays of syringes will be conducted in those departments where wastage is not routinely returned to a centralized depository or pharmacy.
V. Quality Assurance - Written periodic evaluations of department members and random audits of written records will be a part of the Q&A process. This information will remain confidential and undiscoverable until such time that intervention or discipline may be required.
This review shall include anesthesia records, PACU notes and narcotic inventory/usage.
A. Unusual trends, violations or errors will be documented and investigated within the department.
B. When sufficient evidence exists that inappropriate narcotic usage has occurred, a specific investigation will begin with a more in-depth review of specific records. This should also trigger the request for a drug screen.
VI. Documentation - Appropriate documentation will commence upon suspicion of misuse of anesthesia drugs, or signs of drug or alcohol abuse.
Upon suspicion of substance misuse, documentation shall be as follows:
A. Note changes in behavior (appearance, demeanor), and time in the department especially when off duty.
B. Documentation will be kept by the department head or supervisor in non-discoverable files, but may be made a part of the employee’s record should disciplinary action be warranted.
C. Documentation shall include names of those that can substantiate the observations, and should include specific dates and circumstances of all notations.
VII. Confrontation - When there is sufficient documented evidence that an employee is abusing substances, or when evidence exists that the employee is diverting controlled substances from the department, a confrontation will be planned. Employees shall be offered the option to self-report to a professional recovery program. Consult the AANA Peer Assistance Resource Directory for the contact information in your state.
A meeting or intervention shall be planned to confront the employee with documented questionable behavior. The planning and conduct of this confrontation shall be as follows:
A. A confrontation will be planned that includes:
1. sufficient documented evidence
2. the presence of the principle observers of the questionable behavior
3. a trained individual capable of conducting an intervention, and recognition of the potential for immediate placement of the employee in a facility for assessment and possible treatment.
B. An extended leave of absence shall be granted to the employee for chemical dependency treatment which leaves intact all applicable insurance plans and benefits. The individual will be advised how payment will continue to be provided for such benefits and/or how they may continue their own benefits (COBRA).
C. If the employee refuses to comply with a request that they be assessed for chemical dependency, the information collected to date will be submitted to the appropriate regulatory agency for further investigation and probable discipline.
VIII. Reentry: Anesthesia providers with a prior history of chemical dependency may reenter the department if they can show sufficient evidence of successful completion of treatment and documentation of active recovery.
Applicants or employees with a prior history of chemical dependency will:
A. Provide evidence of successful completion of drug/alcohol rehabilitation and sustained active recovery/sobriety.
B. Possess current licensure, or any required registration.
C. Comply with the conditions for active recertification as a CRNA, as determined by the Council on Recertification.
D. Have their history kept in confidence and their anonymity protected until such time that they choose to divulge their anonymity.
E. Be treated with respect and afforded all opportunities granted to others with disabilities.
F. Abide fully with all departmental policies, and shall comply with the conditions set forth in a rigid written reentry contract. (See below).
Revised by the AANA Peer Assistance Advisors Committee, August 1999
It is important that individuals be treated by trained personnel in the field of addiction. Treatment may require a multidisciplinary approach including internal medicine, neurology, psychiatry, and addictionology. After the initial assessment is completed and it is determined the chemically dependent professional should be in treatment, treatment options are presented and finalized. Factors to be considered include insurance benefits, financial resources, and medical leave. Treatment may be either inpatient/residential or outpatient, free-standing or hospital-based, depending on the severity of the problem, and the availability of treatment facilities. A component of treatment may include family therapy and other adjuncts that are appropriate for other underlying conditions. Treatment should be a transition to recovery that orients the addict to 12-step programs, peer support groups and appropriate monitoring programs. Treatment facilities may also act as a liaison in the recovery process between addict and employer.
It is extremely important to make sure the impaired practitioner remains in an aftercare program and has support from family and friends and participates in formal support groups, such as Alcoholics Anonymous, peer assistance programs or others. Most treatment programs design an aftercare program which includes signing a statement of commitment to adhere to the aftercare program, documenting attendance at support meetings, agreeing to totally abstain from whatever caused the problem whether alcohol, drugs, or other behaviors. The recovering person must be committed to the fact that rehabilitation is a lifelong effort.
Reentry into anesthesia after a period of absence creates a stressful time of readjustment. A person who has been in treatment for an addictive disease will experience the same period of adjustment as a person who has been away from clinical anesthesia for any other reason. Recovering persons should be encouraged not to rush back to work, but to allow time to develop a new lifestyle and new coping mechanisms. Individuals who are in recovery from substance abuse may reenter the practice of their profession more aware of their feelings, who they are, what their goals are and better equipped to seek support from peers than prior to seeking treatment.
CRNAs reentering the workplace fear rejection by their peers. They are ready and willing to work to regain the trust and respect from their peers, but they need to be met half-way in this effort.
Recovering CRNAs are aware of their disease of chemical dependency, a disease requiring their attention for a lifetime to prevent relapse. The development of accountability and responsibility is stressed in the course of treatment for chemical dependency and so the recovering professional often becomes a stronger, more dependable employee with a willingness to work hard, and expend great effort in keeping their personal and professional life at a high standard.
The employing institution has a legal obligation to the public. Historically, most institutions do not want to accept the potential legal liability by employing a recovering professional. However, trends are changing slowly. More institutions are establishing peer assistance programs to help and support the recovering individual. Aftercare contracts and new lab screening techniques have given the institution the tools necessary to assure the public and protect itself. New medications are also available to the individual in the recovery process.
Before reentry into the work place, a return to work contract should be established between the employer and recovering employee. Each contract should be geared toward the particular individual involved according to his or her particular situation. Also, state regulatory board rules and guidelines should be taken into consideration when designing a reentry contract. A reentry contract may be more restrictive than the state requirements, but must not be more lenient.
Before a recovering professional reenters an anesthesia department, the department manager should assess the feelings and concerns of the staff. The manager will need to monitor the individual through reentry and keep in close contact with the recovering employee. Evaluations should be performed periodically as stipulated in the return to work contract. Sensitivity and support from the staff is essential to help the recovering employee adjust.
For the first six months to a year, naltrexone (ReVia®) or disulfiram (Antabuse®) may be used as an adjunct to the return to work program.
The use of naltrexone (ReVia®) and disulfiram (Antabuse®), as well as other medications prescribed for the anesthetist should be determined by the certified addictionologist or primary physician in charge of the medical/psychological care of the recovering CRNA.
Privileges for the CRNA to resume administration of scheduled drugs (ex. narcotics) to patients should be made by the individual responsible for supervising their progress in the workplace in conjunction with the addictionologist and/or primary physician. Rigid drug accountability policies must be in place as part of this expanded scope of practice.
Legal counsel should draft the actual reentry contract. A sample contract is provided via a link below.
Model Reentry Contract
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