Returning to work and Potential Relapse

The National Council of State Boards of Nursing, Inc (NCSBN) has developed a Nurse Manager’s Guide to Substance Use disorder (SUD) in Nursing (2018) which includes guidelines on how to establish a workplace that can assist in maintaining recovery once the nurse returns to work.

The nurse executive can meet NCSBN guidelines by:

• Developing and implementing policy that meet standards and regulations
• Organizing in-service education on SUD,
• Disseminating resources,
• Inform manager’s and staff of the legal responsibility to identify nurses with signs of SUD and the importance of intervening,
  • Dispel myths and misconceptions surrounding SUD
  • Ensure that the staff knows how to recognize the signs of SUD in a colleague
  • Maintain a confidential, open-door policy
  • Inform staff of the nurse practice act and regulations regarding SUD
  • Understand that a nurse with SUD needs support and treatment, not negativity and hostility from colleagues.

In general the staff managers should have a policy in place on the unit that outlines SUD, as well as a procedure to follow should the manager or staff become aware of a nurse that may be impaired by SUD or experiencing a relapse.
https://www.ncsbn.org/public-files/Mgr_SUDiN_Brochure_2014.pdf

The board also recommends each facility have policies, laws and regulations need to identify specific criteria for a nurse’s return to practice.

The return-to-work agreement establishes the terms and conditions of employment which include:

• any practice restrictions
• monitoring requirements
• procedures in the event of a relapse
• length of time the agreement is in effect.

The board recommends a worksite monitor who supervises the return-to-work monitoring. This monitoring includes reinforcing the practice restrictions, performance evaluations, and behavioral evaluations.

The monitor and nurse manager must continue to be aware of the same signs, symptoms and behavioral changes associated with SUD. If relapse is suspected, it is crucial to follow the reporting requirements in the return-to-work agreement, facility policies or jurisdiction’s nurse practice act and regulations.

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. Louisiana has a comprehensive program in the recovering nurse program. https://www.lsbn.state.la.us/recovering-nurse-program/

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.

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/