Wednesday, August 31, 2016
The mission of the Nurse Assistance Network (NAN), a program of the Oregon Nurses Foundation, is to protect patients and nurses by reaching nurse colleagues before a substance use or a mental health problem impairs performance, or, failing that, before impairment becomes a danger to patients, colleagues, and the community. NAN also seeks to stimulate a network of local support resources that encourages affected nurses to adopt a personal program of recovery from a substance use disorder, and/or a mental disorder, or other cause of potentially impaired practice. Finally, NAN conducts outreach to raise awareness through education and training. The role of NAN is strictly one of referral, rehabilitative support, and education and is separate from any disciplinary aspect of a licensee’s practice. NAN is here to help Oregon nurses, not to regulate them.
The NAN Response Line is a valuable resource when a nurse, co-worker, or family member has a question and needs a quick reliable answer. It’s a message phone number that anyone can call, and has a threefold purpose: (1) to respond to inquiries, (2) to offer information relevant to impaired practice, rehabilitation, and nurse monitoring programs, and (3) to make referrals to assistance.
Often the nurse with a problem is in desperate need of immediate information or at least feels desperate. While the NAN Response line is not a “24-hour hotline,” it operates on a regular business schedule, and trained professional staff return calls no later than the next business day and often within minutes. The NAN Response Line phone number is 888-516-2796.
The phone assistance service started in April, 2013 and has provided information, support and referral for 33 nurses in 40 calls. The range of problems for which nurses seek solutions is broad, including issues related to:
· The Health Professionals Services Program (HPSP) and the Oregon State Board of Nursing (OSBN) Probation Program
o Self-referral to HPSP
o Completing the license renewal questionnaire when the nurse is enrolled as a self-referral in HSPS
o OSBN requirements for worksite monitoring
o Questions about OSBN probation vs HPSP
· OSBN investigation and licensing processes
o Confidentiality of substance use information in a clinical evaluation
o Licensing in Oregon when enrolled in a another state’s nurse monitoring program
o Legal problems that could impact a nurse’s license to practice
o Potential effect on employment opportunities when a nurse has a misdemeanor marijuana conviction in another state
o Effect of a California DUII conviction on an Oregon RN license
o Prescription fraud with police involvement
· Professional support for nurses
o Location of health professional recovery support groups
o Treatment resources
o Peer support
· Situations with a nurse colleague
o Perspective of the ANA Code of Ethics for Nurses on impaired practice
o Colleague tested positive for a prohibited substance at work
o How to address workplace bullying
o Assistance with a formal grievance
o Colleague caught diverting narcotic medication at work
o Supervisor education
NAN has collected a wealth of knowledge about resources in Oregon to assist with problems like those listed above. NAN members have also volunteered to assist nurses 1 to 1 on the phone with personal peer support. Indeed, a big part of the NAN response has been to provide a calm, supportive, professional message: “You have options.”
Finally, Oregon nurses are fortunate that the NAN Response Line is staffed by Perla Estrada, a licensed social worker with over 8 years of direct service related to substance use and mental health disorders. In addition, Ms. Estrada worked in the management team at the Health Professionals Services Program and knows how monitoring works.
Again, the NAN Response Line phone number is 888-516-2796.
Chris O’Neill, RN, DMin
Consultant for the Oregon Nurses Foundation
Thursday, May 26, 2016
Collaboration. I was thinking about how to describe the many projects the WorkHealthy Oregon (WHO) program at Oregon Nurses Foundation (ONF) leads or co-leads and realized it’d be helpful to start with a definition. I googled “nursing collaboration” and, sure enough, the answer and a relevant example popped up. The American Nurses Association collaborated with the American Organization of Nurse Executives on a document titled “ANA/AONE Principles for Collaborative Relationships between Clinical Nurses and Nurse Managers.” They agreed that collaboration requires “people working together in a prescribed role with a shared goal in mind.”
WHO’s role is as a workplace health and safety promotion program that collaborates with other organizations and agencies to: 1) reduce workplace safety concerns, 2) retain valuable workers, and 3) raise worker satisfaction as they meet personal health goals. Some of the biggest personal health challenges for nurses are substance use and mental and emotional problems. WHO has addressed these major problems across the career span by developing online and local resources, including skill training for student nurses, staff nurses, and nurse managers.
In this article, I’d like to take a retrospective view of a major collaboration project in Oregon that demonstrates how a valuable project addressed a serious education gap and spread organically to provide rich new opportunities.
In 2010, I responded to a request for a speaker on the topic of substance abuse in the nursing profession, checked the nursing literature for evidence-based education programs, and found a gap. Several articles identified the importance of education, but the cited references didn’t lead to specific education courses.
Research about substance abuse in the nursing profession has been growing. But I was interested not so much in diagnosis, treatment, and recovery of substance use or mental disorders. In my opinion, substance use or mental disorders are difficult to distinguish from ordinary life issues and a staff nurse should not be required to identify the source or reason for a worksite problem. Rather, a staff nurse should be aware of when to speak up about any performance problem that causes a concern and how to do it effectively. Indeed, the WHO perspective is that if a nurse waits to be sure about the “reason” for a significant performance problem, she probably waited too long.
Our profession has a long way to go when it comes to speaking up about a colleague’s performance that causes concern. One recent study of 6,500 nurses and nurse managers found that, despite the increasing use of safety checklists and other protocols, many nurses are reluctant to speak up about their concerns even when a colleague uses dangerous shortcuts, appears incompetent for their responsibilities, and/or displays disrespect for other team members or patients and families. The American Association of Critical-Care Nurse, the Association of perioperative Registered Nurses, and VitalSmarts conducted the study collaboratively and identified a set of factors that facilitated a nurse to speak up about her or his concerns. The factors include the following:
1. When the issue wasn't urgent, they collected facts, ran pilot tests, and worked behind the scenes.
2. They assumed the best and spoke up. Sometimes it just takes one person to pave the way.
3. They explained their positive intent—how they wanted to help the caregiver as well as the patient.
4. They took special efforts to make it safe for the caregiver to avoid creating defensiveness.
5. They used facts and data as much as possible, often taking the other person into the actual situation.
6. They avoided making accusations and telling negative stories.
7. They diffused or deflected the person’s anger and emotion.
The underlined phrases above indicate knowledge, skills, and attitudes that can be strengthened through specialized education—which is exactly what WHO developed together with Linfield-Good Samaritan School of Nursing faculty and student nurses in 2010. ONF staff conducted formal focus groups with both faculty and nurses to assess the need for specialized education regarding substance use and mental disorders among nurses. The ANA Code of Ethics for Nurses was used as the motivating force for nurses to take action when they have a concern about a colleague’s performance that may put patient or coworker safety at risk—performance that may or may not be related to substance use or mental problem. We worked together with faculty to identify where the new course content would fit in the senior year and piloted the course. Dr. David Cadiz measured learning outcomes, and the development team refined the didactic and skill practice components based on faculty and student feedback. Ultimately, the results were published in the Journal of Nursing Education. Collaboration was having powerful results!
But the collaboration didn’t end there. Dissemination of the standardized course beyond the original host school required a more flexible format, one that could be accommodated at other nursing education programs where no more than a single 50-minute academic hour was available. One solution to the “time crunch” issue was to reinvent the course as a “flipped classroom.”
What’s a flipped classroom? A flipped classroom is an education strategy in which learners (students or staff nurses) come to class already prepared with the relevant didactic information and then engage with others in classroom activities like problem-based learning. WHO’s Speak Up for Safety course for student and staff nurses involves individual students accessing basic information online at their own pace, then organizing into small groups in the classroom for communication skill practice. The learning impact has been impressive: increased knowledge, increased willingness to speak up about a colleague’s questionable performance, and decreased stigma related to substance use and mental disorders.
ONF needed both new funding and new partners to fill the gap. Fortunately, ONF successfully competed for grant funding from the Addictions and Mental Health Division at the Oregon Health Authority. We also found two competent and eager partners: Chemeketa Community College in Salem and Michael Mac Innovations, a curriculum design company based in Eugene with expertise in substance use disorders. The project was guided by Dr. Cadiz and had solid evaluation components, including (quantitative) survey results and (qualitative) focus group information. When delivered, the flipped classroom design had substantially similar results to the original classroom-only version, and we were in business to disseminate!
Dissemination of evidence-based education courses is an important strategy for assisting in career development. Dr. Cadiz and Perla Estrada, WHO Program Manager, pitched the positive learning impact of the course at an annual meeting of nurse program deans hosted by the Oregon State Board of Nursing in 2015. Several other nurse education programs indicated interest, and, since then, three have successfully integrated the flipped classroom course into their programs: Walla Walla School of Nursing in Portland, Treasure Valley Community College in Ontario, and Linfield School of Nursing.
Furthermore, the course has been revised to assist currently licensed staff nurses. Ms. Estrada has been consulting with a large Oregon healthcare employer to pilot the staff nurse version and expects to pilot the course in summer, 2016. And recently another twist to the collaboration story emerged. ONF has been delighted to welcome the Intervention Project for Nurses (IPN) in St. Augustine, Florida as partners to pilot a customized version of the course with Florida staff nurses.
ONF and IPN have collaborated on a nurse supervisor education project since 2014, and they have been aware of our progress with the flipped classroom. The Oregon and Florida partners entered into a cost-sharing agreement to customize the student and staff nurse versions of the course for Florida and to co-develop a worksite monitor course for nurses who volunteer to monitor the practice of nurses enrolled in nurse monitoring for a substance use or mental disorder. Both states will benefit from the mutually shared outcome data and experience from the joint project.
The Speak Up For Safety course has been and continues to be a great opportunity for nurses to fill the education gap with evidence-based courses. And it’s been rewarding for all the engaged individuals and organizations to work together and achieve success. The joint effort to fill the education gap is a good example of what collaboration is supposed to be about: people working together in their prescribed roles to reach a shared goal.
Chris O’Neill, RN, DMin
Oregon Nurses Foundation Consultant
Reference: Maxfield, D., Grenny, J., Lavandero, R., and Groah, L., (2015). The silent treatmeny: why safety tools and checklists aren’t enough to save lives. Accessed, May 24, 2016: https://psnet.ahrq.gov/resources/resource/21435
Saturday, April 30, 2016
On July 1st 2017, seven years after its initial inception under House Bill 2345, the Oregon Health Professionals’ Services Program (HPSP) will no longer fall under administrative jurisdiction of the Oregon Health Authority (OHA), as currently operated under ORS 676.190 and OAR 415-065. Instead administrative authority will revert back to the individual participating health profession licensing boards, establishing the Impaired Health Professional Program Work Group (Work Group).
Changes to the original law come after the current participating health profession licensing boards (Board of Dentistry, Board of Nursing, Board of Pharmacy, and Medical Board), represented by Medical Board, Executive Director, Kathleen Haley, JD, proposed legislative changes that would allow the boards to contract directly with a vendor to provide monitoring services, thus eliminating OHA as the administrative authority. House Bill 4016 passed both the House and Senate Committees on Health Care with no opposition, and was signed into law by Gov. Kate Brown on March 1st 2016.
During the February 1st 2016 House Committee on Health Care public hearing, chaired by Rep. Mitch Greenlick (D) who was the original proponent of HB 2345, Haley testified on behalf of all four participating boards stating that, “over the years, the administrative cost to the health boards for the HPSP program has increased…with this change [in legislation] the participating health boards will save an estimated $300,000 per biennium.” A Fiscal Impact of Proposed Legislation submitted to the House Committee on February 8th 2016 shows a breakdown of projected cost savings per health profession licensing board as follows: Medical Board $96,906, Board of Nursing $169,070, Board of Pharmacy $20,895, and Board of Dentistry $25,115.
Also providing testimony was Christopher Hamilton, PhD, MPA, Monitoring Programs Director for Reliant Behavioral Health (RBH), the vendor currently contracted under OHA to deliver monitoring services. RBH has been the sole vendor for HPSP since July 1st 2010 and has collaborated with the participating health profession licensing boards and OHA to develop and implement a unified statewide program as directed under HB 2345. Hamilton testified that while RBH was not speaking in support or opposition of HB 4016 it did want to remind the Committee of the original intent of the law under HB 2345 which “was not just to implement a program, but also provide a programmatic check and balance.”
The original bill, House Bill 2345, was passed during the 2009 Legislative Session. The intent was to establish a consolidated statewide monitoring program for healthcare professionals who were struggling with a substance use disorder and/or mental health diagnosis in order to ensure public safety and the licensee’s ability to practice safely. Prior to July 1st 2010 each health profession licensing board administered their own monitoring program separately with its own set of monitoring guidelines. House Bill 2345 not only consolidated the different monitoring programs, it also required the programs to operate under the same guidelines in order to ensure consistency in monitoring practices throughout the boards. An Advisory Committee, consisting of all participating boards, OHA, RBH, and the Oregon Nurses Foundation (consultants to OHA), was immediately formed following the passage of the bill. Over the course of the past six years, the Advisory Committee has worked collaboratively to ensure HPSP upholds public safety while providing healthcare professionals the opportunity to safely practice within their chosen profession.
What do these changes mean for Oregon Nurses?
Discussions with Ruby Jason, Executive Director, Oregon State Board of Nursing, in February 2016 indicated that the OSBN did not at the time anticipate any changes in their utilization of the alternative to discipline program (HPSP). Jason reported that the board did not have any issues with the monitoring services being provided by RBH and would continue to collaborate with the participating boards under the new changes. Nurses currently participating in HPSP, board-referred or self-referred, will continue to participate in the monitoring program as directed by their individual monitoring agreements. Additionally, in a recent discussion with Hamilton in April 2016, he reported that the OSBN has continued to refer nurses to the HPSP since the passage of the new law and has not shown any signs of reducing the number of referrals to the program.
Individual Cost to Nurses
Despite the reduction in program cost to the participating boards it is not anticipated that the cost of monitoring will be reduced or increased for nurses currently participating in HPSP. The cost currently incurred by individual program participants is based solely on the cost of individual toxicology testing and “as needed” third party evaluations due to specific program non-compliance such as positive toxicology tests. The actual cost of program administration is paid for by the OSBN. Below is a cost estimate for individual licensee participation as provided by RBH.
1. Toxicology testing: $60 to $125 per test depending on the testing panel. Test cost includes collection, transportation, analysis, and Medical Review Officer. With compliance, the testing frequency will reduce annually. The grid below represents the estimated toxicology cost per year assuming licensee maintains programs compliance
Estimated Cost (poly substance)
Estimated Cost (alcohol)
2. Any third party evaluations that may be required, including a fitness for duty evaluation. Cost varies from $300-$1500. Payment is made directly to the third party evaluator.
3. Safe Practice evaluation required for self-referrals: $1500
4. Mental health/substance assessment required for self-referrals: $300-$1500. Payment is made directly to the third party evaluator.
5. Medical Board licensees must pay for weekly group meetings for initial two years: $42 per week.
6. Medical Board licensees with a substance use disorder must pay for meetings with a periodic monitoring consultant upon the completion of group meetings. Fee varies according to licensure of consultant.
7. Costs tend to decrease in years two-five, due to decrease in testing frequency.
The Health Professionals’ Services Program will continue to run “business as usual” and will remain under the administrative authority of OHA until July 1st 2017, and, while there does not appear to be any major programmatic changes to the day to day operations of HPSP, it is still uncertain what, if any, other changes may occur under the new administrative authority of the Impaired Health Professional Program Work Group. Additionally, it is uncertain if the Oregon Nurses Foundation will continue to be part of the group. Nevertheless, in collaboration with the Nurse Assistance Network, the ONF will continue to advocate and provide assistance and resources for impaired nurses in the State of Oregon.
If you or a fellow RN would like assistance with recovery resources, please contact the NAN Response Line at (888)516-2796 to reach a trained recovery support volunteer ready to help you.
Perla Estrada, LMSW, MBAProgram Manager
Friday, February 26, 2016
The Substance Abuse and Mental Health Services Administration (SAMHSA) has a useful working definition based on a stakeholder consensus approach. It states that recovery is:
A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.
This definition gets a little closer to ground level—perhaps 1,000 feet above—with descriptions of what they call the “key dimensions” of a recovery lifestyle.
• Health: Overcoming or managing one's disease(s) as well as living in a physically and emotionally healthy way.
• Home: A stable and safe place to live.
• Purpose: Meaningful daily activities, such as a job, school, volunteerism, family caretaking, or creative endeavors, and the independence, income, and resources to participate in society.
• Community: Relationships and social networks that provide support, friendship, love, and hope.
These added details are helpful to a person trying to understand the lived meaning of recovery and more useful than the disease model of alcoholism and drug addiction that focuses on pathology. Still, what’s missing, according to Lee Ann Kaskutas, is the “voice of experience of individuals undergoing the [recovery] process themselves.” And with her research colleagues, Dr. Kaskutas has systematically collected and sorted many voices of those in the recovery process so that all of us—nurses in recovery, managers, colleagues, friends, family, and clinicians—can gain a firmer grasp on what recovery looks like.
I’m not qualified to critique the research methodology and limitations of their research report (Kasutas et al., 2014), and the authors sort the data demographically for those who want an in-depth picture. But my experience in the prevention and treatment of substance use disorders makes comment irresistible, and what follows is my “take” on the contribution Kaskutas et al. are making by making the voices of recovery audible.
It’s most useful to think of the research product as more of a profile of the recovery process, rather than an all-encompassing definition. Dr. Kaskutas calls the discrete details elements, and the recovery voices are especially convincing to me because the research protocol permits the participants to self-determine their recovery status (“in recovery,” “recovered,” “used to have an alcohol or drug problem but don’t anymore,” or “in medication-assisted recovery”). Clinicians might balk at that approach because the determination of “recovery status” is not verifiable from an “objective” perspective. However, the methodology is unavoidably subjective because the point of the research strategy is to get inside the recovery experience. I think of the research product having the same kind of value as “participant observation” in social anthropology, combined with the strengths of a standardized survey instrument.
This is how the data were collected. The researchers recruited thousands of participants who self-identified as in recovery and used survey results from 9,341 survey completers. Participants selected from a list of 167 vetted items that described some aspect of recovery by assigning a recovery value to each item: (a) “definitely belongs in your definition of recovery,” (b) “somewhat belongs in your definition of recovery,” (c) “does not belong in your definition of recovery, but may belong in other people’s definition of recovery,” and (d) “does not really belong in a definition of recovery.”
The research team grouped the selected items into five categories they called “factors” including:
1. Abstinence in Recovery
2. Essentials in Recovery
3. Enriched Recovery
4. Spirituality in Recovery
5. Uncommon Elements of Recovery
Using the research results, the Alcohol and Recovery Group has posted an easy to use list of the 39 most salient features or behaviors that clearly demonstrate “the many positive ‘ways of being’ that define recovery” based on the voices of those in recovery (http://arg.org/project/what-is-recovery/). Here’s their list.
Abstinence in Recovery
· No use of alcohol
· No abuse of prescribed medication
· No use of non-prescribed drugs
Essentials of Recovery
· Being honest with myself
· Being able to enjoy life without drinking or using drugs like I used to
· Handling negative feelings without using drugs or drinking like I used to
· Changing the way I think through things
· Not replacing one destructive dependency with another
· Taking care of my mental health more than I did before
· A realistic appraisal of my abilities and my limitations
· Being able to deal with situations that used to stump me
· Freedom from feeling physically sick because of my drinking or using
· Dealing with mistakes
· Striving to be consistent with my beliefs and values in activities that take up the major part of my time and energy
· Being able to have relationships where I am not using people or being used
· Having people around me who know how to get through life without using alcohol or other drugs like they used to
· Getting along with family and friends better than I did before
· Trying to live in a place that is not overrun with alcohol and drugs
· A process of growth and development
· Taking responsibility for the things I can change
· Reacting to life’s ups and downs in a more balanced way than I used to
· Living a life that contributes to society, to your family, or to your betterment
· Having tools to try to feel inner peace when I need to
· Developing inner strength
· Improved self-esteem
· Taking care of my physical health more than I did before
· Learning how to get the kind of support from others that I need
· Being the kind of person that people can count on
Spirituality in Recovery
· Being grateful· About giving back
· About helping other people to not drink or use drugs like they used to
· Appreciating that I am part of the universe, something bigger than myself
· Becoming more open-minded about spirituality than before
· Feeling connected to a spiritual being or force that helps me deal with difficulties in life
· Spiritual in nature and has nothing to with religion
Uncommon Elements of Recovery (Note: The four elements listed below were retained by the researchers because they “represented diverse approaches to recovery” even though they had low scores compared with the items above.)
· Physical and mental in nature and has nothing to do with spirituality or religion
· No use of tobacco
· Religious in nature
· Non-problematic alcohol or drug use [permitted]
How can this information be used? The authors identified three ways: (1) to guide the development of recovery support services; (2) to provide a tool for internal quality monitoring and program accountability; and (3) to reduce stigma by increasing public understanding through relevant, positive descriptions of the recovery experience.
Surely, publishing the results of their research has contributed to increased understanding because the details of the recovery experience are much more clear. Not every item in the list above is as personal and relevant as saying “I feel grateful.” But, on the whole, the list does give voice to the lived experience of recovery. And that’s helpful to those starting their recovery journey, as well as the rest of us … who can benefit from a ground level view.
Chris O'Neill, RN, DMin
Source: Kaskutas, L. A., et al. (2014). Elements that define recovery: the experiential perspective. J. Stud. Alcohol Drugs, 75, 999–1010, 2014
Thursday, December 31, 2015
Earlier this year, with the assistance of a State Innovation Grant from the Addictions and Mental Health Department, the Oregon Nurses Foundation (ONF) developed, piloted, and evaluated a student nurse education program aimed at improving a nurse’s response to workplace concerns related to a peer’s behavior or performance in the workplace. The program, called Speak Up For Safety, showed positive results amongst nursing students at both Chemeketa Community College in Salem (for more details on the Chemeketa pilot click here) and Linfield School of Nursing in Portland (for Linfield details click here). Based on research conducted by Dr. David Cadiz, the pilot showed significant improvement in a nurse’s knowledge, confidence to speak up about performance concerns, and a reduction in stigma toward nurses with substance use disorders. Furthermore, feedback from participating faculty felt the training provided useful and effective tools for nurses, and ONF has continued to work with Chemeketa and Linfield to incorporate Speak Up For Safety as a standard component of the nursing curriculum.
Vicky Gelatt of MichaelMac Innovations, LLC in Eugene was the lead curriculum designer, and Chris O’Neill, ONF Consultant, acted as a content expert and classroom facilitator. The course employed a “flipped classroom” design wherein student nurses completed an online segment with textbook information prior to participating in a live skill-practice session in the classroom. It takes about 20 minutes to complete online. Adding the skill practice made an important difference in the outcome measure, showing a significant reduction in stigma toward substance use disorders. A finding that is in line with statements in the ANA Code of Ethics for Nurses which calls for the support and advocacy of impaired nurses.
Additionally, ONF presented the pilot findings at the Schools of Nursing Deans and Directors meeting sponsored by the Oregon State Board of Nursing and hosted at Clackamas Community College in mid-October where it received positive responses and interest from many schools throughout the state. Among them Walla Walla University and Treasure Valley Community College which will both be hosting a training for their nursing students in January 2016.
Following the positive results of the student training ONF, in partnership with the Florida Intervention Project for Nurses (IPN), embarked on expanding the educational program with the development of two additional modules of the flipped-classroom course: staff nurse and workplace monitor.
The Staff Nurse Module
The staff nurse module of the Speak Up For Safety program is specifically designed for nurses currently in the workforce. The training is aimed at improving a nurse’s level of skill and confidence in recognizing and assessing the level of risk when they have concerns that a colleague’s performance doesn’t meet professional and/or practice standards and may be harmful to patient safety. In addition, it provides nurses with the necessary tools to address common barriers to taking action, determine the appropriate course of action required, and clearly communicate their concerns.
The recently completed staff nurse module of Speak Up For Safety is now ready for pilot. ONF is currently in discussions with one major hospital organization in the Portland Metro area for a potential partnership and is seeking other willing organizations interested in piloting the staff version. Evaluation of the learning impact will be used to revise the staff nurse module.
The Worksite Monitor Module
The worksite monitors module is currently under development in collaboration with Florida IPN. In the previous months we shared a two-part blog on the findings from recent Florida focus groups aimed at understanding the relationship between monitored nurses and the worksite monitor in relation to successful program completion (click here for Part 1 and here for Part 2). These focus groups have provided useful information for the content development of the worksite monitor module which will be designed for nurses who accept the role of formally monitoring a nurse enrolled in either the Oregon State Board of Nursing’s Probation program or Oregon’s alternative to discipline program called the Health Professionals’ Services Program. ONF anticipates having this module completed by the Spring of 2016 and ready for pilot shortly thereafter.
The long and short of it is that Speak Up for Safety is a specialized education course focused on a major public health problem in our profession, among our valued co-workers. It is a collaborative effort guided by rigorous evaluation results, incorporating new information as it becomes available. Its three stage module approach provides nurses at different phases of their career with invaluable information to assist them in navigate through the difficult challenges they will encounter when they come face to face with this issue in the workplace. Most importantly, nurses can build confidence in their ability to protect patients while assisting their fellow nurse in obtaining the resources necessary to improve their safe practice. Oregon nurses can be proud that with our colleagues in Florida we are doing the hard work of blazing a trail to a more-healthy profession.
If you have questions about any of the different modules of the Speak Up For Safety program, are interested in accessing the training, or wish to partner with ONF to pilot our most recent modules, please feel free to contact Perla Estrada at firstname.lastname@example.org.
Perla Estrada, LMSW, MBA
WorkHealthy Oregon Program Manager
Chris O'Neill, RN, DMin
Dave Cadiz, MBA, PhD
Perla Estrada, LMSW, MBA
WorkHealthy Oregon Program Manager
Chris O'Neill, RN, DMin
Dave Cadiz, MBA, PhD
Monday, November 30, 2015
In a previous blog, we described what nurses enrolled in monitoring for a substance use or mental disorder expect when they return to the practice setting. Using recent data provided from two focus groups with nurses enrolled in Florida’s Intervention Project for Nurses (IPN) monitoring program, several challenges were identified. Enrolled nurses reported that their worksite monitor may:
- Lack understanding of the monitoring contract requirements and/or doesn’t conduct initial meeting with the licensee to learn about the requirements
- Not conduct a check-in meeting with the licensee prior to completing quarterly report to the monitoring program
- Lack understanding of the disease model
- Not complete the quarterly written report in a timely way
- Not assist when the licensee needs to be excused from the unit to comply with the random drug screen requirement
In addition, sometimes the person who is responsible to conduct worksite monitoring tasks changes frequently, which we interpret as a potentially preventable disruption to consistent monitoring.
In this article, we will add to the knowledge base by reporting what worksite monitors in two separate focus groups said about their experience. To begin with, worksite monitors described their perspective of the worksite monitor role in clear terms. The role of the worksite monitor is to: 1) provide accountability and support to the nurse returning to practice, 2) ensure safe practice that conforms to the nurse practice act, and 3) liaise between the nurse and the monitoring program.
Focus group participants provided many other useful comments that can be parsed into three categories. The focus group participants provided information about what is required in terms of knowledge, skills, and attitudes (or capabilities) of nurses performing the worksite monitor role. Let’s look at what they said about each.
Worksite Monitors said that the role requires one to know, understand, and/or recognize:
- The expectations and boundaries in the relationship with the monitored nurse
- Hospital policy regarding monitored nurses
- The IPN program expectations and responsibilities of the worksite manager
- How and when to communicate with the IPN case manager
- Misconceptions about the worksite monitor role and duties
- Pertinent contacts at IPN and the organizational chain of command
- Level of risk at the worksite and how to respond
- One’s own limitations
- The addictive disease process and recovery process
- The stigma associated with the disease of addiction
Skills & Practices
Worksite Monitors should:
- Ensure a psychologically safe work environment
- Complete routine written reports
- Manage the work schedule to accommodate the nurse for drug screens
- Build rapport with the monitored nurse through open communication
- Ensure the monitored nurse is safe to practice to reduce organizational risk
- Watch for “red flags” of impairment and/or diversion of medication
- Possess conflict resolution skills
- Possess communication skills
- Possess critical thinking skills
- Refer to the Employee Assistance Program as needed
- Possess counseling skills*
- Evaluate the monitored nurse’s ability to manage workplace stress effectively*
Attitudes or Capabilities
Worksite Monitor should:
- Maintain open communication with the monitored nurse
- Provide support and encouragement to the monitored nurse
- Be available to discuss any concerns or issues
- Maintain confidentiality about nurse participation in monitoring
- Be responsible to schedule time to meet with the monitored nurse
- Be patient, a good listener, and make no assumptions
- Be open and honest
- Eliminate or decrease personal bias about addiction
In addition to knowledge, skill, and attitude expectations, the focus group participants described difficult situations in the relationship. Among the most difficult situations are the following.
- Initial discussion with the monitored nurse after she/he tests positive
- A monitored nurse that displays a “bad attitude” on the job
- Being “blamed” by the monitored nurse when the worksite monitor appropriately reports “red flags” to the IPN case manager
- Being challenged by the monitored nurse for performance ratings reported on the periodic written report
- Monitoring a nurse who in the past has been a nurse peer
At Oregon Nurses Foundation we have a different stance on workplace monitor skills and responsibilities when it comes to “counseling” and “managing stress” as reported in the focus groups (see asterisked items above). To be clear, we believe the worksite monitor should always focus on performance—does the licensee’s nursing practice meet professional standards and organizational policies—rather than pursue or assume the cause of performance problems, for example, workplace stress. Furthermore, we highlight the boundary between worksite responsibilities of observing nursing performance and intervening when appropriate vs. clinical responsibilities like counseling.
Nevertheless, the lists of knowledge, skills, attitudes, and most difficult problems above are instructive and useful in the development of specialized education for nurses who agree to be worksite monitors. Taken together with the information from the nurses enrolled in monitoring, the information from worksite monitors provides core content for specialized education courses for worksite monitors, nurse peers, and student nurses.
Chris O’Neill, RN, DMin