Returning to work and Potential Relapse

Returning to work

The board considers fitness for re-entry to work when the nurse demonstrates stability in recovery and minimal risk for harm when returning to practice. The following are modified guidelines offered by the Idaho Board of Nursing (IBN, 2012)

• Return to practice may be allowed when the nurse demonstrates stability in recovery as evidenced by:
  • Abstinence; and/or
  • Statement from the treatment provider that the nurse is following the recommended treatment plan; and
  • Statement from the treatment provider that the nurse demonstrates stability sufficient for return to practice.
• Return to practice is conditioned on:
  • Support of the place of employment;
  • Support of immediate supervisor;
    
  • Collaborative agreement among the employer, consultant and program monitor regarding:
    
    • Appropriate unit assignment, shift assignment;
    • Limitations on practice (e.g., shift schedules, overtime, access to controlled substances, employment setting, supervision);
    • Written job performance evaluation procedures and reports (Click to leave RnCeus.com to view the Florida IPN Work Performance form);
    • Worksite monitoring and reports;
    • Written protocol in place in the event of relapse:
      • Cease active practice;
        
      • Notify program monitor;
        
      • Immediately resume diligent adherence to the treatment/recovery program; and
        
      • Resumption of practice only on the recommendation of a qualified evaluator and the program monitor.

Potential for relapse

Relapse is the return to the use of a substance after a period of abstinence. Adjusting to life after treatment can be difficult. Non-compliance and relapse after treatment are widespread occurrences.

Community aftercare programs help recovering alcoholics and drug users once they return to work. Support programs like Alcohol Anonymous and Narcotics Anonymous can help keep nurses on the path to avoiding alcohol and drug abuse.

Kelly (2010; 2009) reported on a long-term study of participants in AA and formal treatment programs. At the eight-year follow-up, 46% who chose formal treatment were abstinent, while 49% who attended AA only were abstinent. Individuals who participated in both formal programs and AA had the highest abstinence rates.

The National Institute on Drug Abuse reports that drug addiction after treatment has a relapse rate between 40% and 60%. Fortunately, the alternative to discipline programs for nurses are more effective. For example, the Florida alternative to discipline program (IPN) reports a relapse rate of about 9% for SUD.

Relapses occur most frequently during the first few years after detoxification but can occur at any time, particularly after stressful events. Some state board of nurse examiners requires random urine and blood testing even after the nurse returns to work. Some may require written self-reports.

It is advised individuals with drug and alcohol addiction avoid contact with those with whom they have participated in drug use and alcohol consumption during the recovery phase of their illness (Whitney, 2015). On occasion, persons with one addiction can then become involved in another addiction, like gambling.

Nurses treated for mental illness can also experience relapse. Nurses who have mental health issues are subject to similar barriers to treatment adherence as the general psychiatric population. The side effects of antipsychotic medications are highly prevalent and significantly associated with lower adherence (DiBonaventura, 2012). According to Velligan et al. (2009), only 51% of prescribed medications are taken by patients with serious mental health disorders. Nonadherence can be due to side effects, particularly weight gain, sedation, and the belief that the medications are no longer needed.

Concerning nurses impaired by physical disabilities, nurses report failing to use an assistive device, e.g., hearing aids. However, there is a significant lack of published research in this area of nursing and occupational sciences.

Avoiding relapse will be a lifelong endeavor for our affected colleagues.
Smiley & Reneau (2020) found bimonthly random drug tests, daily check-ins, and a minimum 3-year length of stay in a program were associated with successful program completion. In addition, structured support group meetings and mutual support meetings were also helpful. The following are helpful tips for colleagues, friends, and family members helping nurses in recovery.

1. Accepting SUD as a chronic illness rather than a personality flaw.
2. Remembering that stress, cues (people, places, things, and moods) linked to the SUD experience, and access to drugs are the most common triggers for relapse.
   
3. Investigating the pharmacology of medications used to interfere with these triggers to help impaired nurses sustain their recovery.
   
4. Know about stress-related disorders, compassion fatigue, and burnout.
   
5. Experiencing or witnessing life-threatening or traumatic events impacts everyone differently.
   
6. In some circumstances, distress can be managed successfully to reduce associated adverse health and behavioral outcomes.
   
7. In other cases, some people may experience clinically significant distress or impairment, such as acute stress disorder, post-traumatic stress disorder (PTSD)external icon, or secondary traumatic stress (also known as vicarious traumatization).
   
8. Compassion fatigue and burnout may also result from chronic workplace stress and exposure to traumatic events during the COVID-19 pandemic (Mumba et al., 2019).

Nurse colleagues must avoid enabling an impaired nurse by covering for them. The professional nurse must always protect the patient and report any relapse or behavior of a colleague that could harm patients.

References:

DiBonaventura, M., Gabriel, S., Dupclay, L., Gupta, S. & Kim, E. (2012) A patient perspective of the impact of medication side effects on adherence: results of a cross-sectional nationwide survey of patients with schizophrenia. BMC Psychiatry. 12,20.

Idaho Board of Nursing. (2012). The program for recovering nurses.. Accessed on 9/3/2012 https://ibn.idaho.gov/IBNPortal/IBN/publications/Important_Information_for_Participants.pdf.

Kelly, J. K. (2010). The role of the mutual-help group in extending the framework of treatment. U.S. Department of Health and Human Services.

Kelly, J.F., Magill, M. & Stout, R.L. (2009). How do people recover from alcohol dependence? A systematic review of the research on mechanisms of behavior change in Alcoholics Anonymous. Addiction Research and Theory 17(3), 236–259, 2009.

Mumba, M. N., Baxley, S. M., Cipher, D. J., & Snow, D. E. (2019). Personal factors as correlates and predictors of relapse in nurses with impaired practice. Journal of Addictions Nursing, 30(1), 24–31.

Smiley, R. & Reneau, K. (2020). Introduction Outcomes of Substance Use Disorder Monitoring Programs for Nurses. Journal of Nursing Regulation. 11(2), 28-35.

Velligan, D. I., Weiden, P.J., Sajatovic, M., Scott, J., Carpenter, D., Ross, R. et al. (2009). The expert consensus guideline series: adherence problems in patients with severe and persistent mental illness. J Clin Psychiatry. 70 (4), 1-46.

Whitney, B. (2015). The Break-Up: Leaving Your Drinking Buddies Behind. Retrieved on Sept 7, 2017, from https://www.addiction.com/12011/the-break-up-leaving-your-drinking-buddies-behind/