DIDACTIC UNIT G: Impaired Practitioners and Recovery

DIDACTIC UNIT G: Impaired Practitioners and Recovery

Total Time: 3-4 hours

Overview: This unit will discuss the health care practitioner population who are impaired. The unit will aid in placing into perspective the historical components, implications, and the recovery process of impaired professionals. The unit will also address the symptoms, planned intervention, intervention, and recovery process.
Terminal Objective: The student will be able to describe the symptoms and patterns of use for an impaired professional. They will be able to describe the legal, moral and ethical implications of an impaired professional as related to the individual, the community, and society. The student will be able to formulate and implement a plan for intervention and recovery of impaired practitioners.
Recommended Teaching Methods:

Group Process

Lecture

Discussion

Readings

Role Playing

Course Outline:

LXIX. Historical components of substance abuse by health practitioners

A. Substance abuse and the Ancients

B. European medical professionals and drug experimentation

C. Early American use and abuse of drugs

D. Literature reviewing SA among CRNAs

LXX. Prevalence of SA among professionals

A. Predisposition to SA by professional practitioners

B. Talbott's "Conspiracy of Silence"

C. Critical patterns of SA

1. Disciplinary actions

2. Voluntary treatment

3. Intervention and Recovery

D. Impaired professionals and punitive outcomes

LXXI. Substance abuse the "Disease"

A. Symptoms of addicted professionals

1. Behaviors

2. Physical signs

3. Economic problems

B. Occupational hazards concerning SA

1. Availability of drugs

2. Stress

3. Limited socialization

LXXII. Administration and SA

A. Responsibilities of Management

B. Policies and procedures for SA

C. Behavior

1. Recording patterns

2. Administrators response

3. Colleagues response

4. Family response

D. Intervention for the impaired professional

E. Recovery and aftercare of the impaired professional

F. Employee Assistance Programs (EAP)

G. Referral for colleagues

H. Contracts for colleagues returning to work

LXXIII. Ethical, moral and value conflicts of the impaired professional

A. AANA and ANA Professional codes for SA

B. Ethical dilemmas for reporting colleagues

C. Ethical concerns for patient safety

LXXIV. Peer Assistance and Recovering professionals

A. Role and responsibility

B. Continuing education in SA

C. Support groups for

1. Impaired professional

2. Colleagues

3. Family

D. Networking

References:

American Association of Nurse Anesthetist. (1992). Peer Assistance Manual. Chicago, IL: American Association of Nurse Anesthetists.

American Nurses' Association. (1988). Standards of addiction nursing practice with selected diagnoses and criteria. Kansas City, MO: American Nurses' Association.
American Nurses' Association. (1984). Addictions and psychological dysfunctions in nursing. Kansas City, MO: American Nurses' Association.
American Psychiatric Association. (1997). Diagnostic and statistical manual (DSM-IV). Washington, DC: APA, American Psychiatric Association.
Anthony, W. A. (1972). Societal rehabilitation: Changing society's attitudes toward the physical and mentally disabled. Rehabilitation Psychology. 19, 117-126.
Assareh, S. (1987). Substance abuse testing in the workplace: A review. American Association of Occupational Health Nursing Journal. 35(5), 204-209, 246-248.
Barten, J. & Talbott, S. (Eds.). (1989). Primary prevention in psychiatry: The state of the art. Washington,D.C.: American Psychiatric Press.
Bennett, G., Vourakis, C., & Woolf, D. (1983). Substance abuse: Pharmacological, developmental and clinical perspectives. New York: John Wiley.
Bissell, L. & Jones, R.W. (1976). The alcoholic physician: A survey. American Journal of Psychiatry. 133, 1142-1146.
Bissell, L. & Jones, R.W. (1981). The alcoholic nurse. Nursing Outlook. 29(2), 96-101.
Bissell, L. & Haberman, P. (1984). Alcoholism in the professionals. New York: Oxford University Press.
Bissell, L. & Royce, J. (1987). Ethics for addiction professionals. Center City, MN: Hazelden Foundation.
Black, C. (1982). It will never happen to me. Denver: MAL Books.
Blume, S.B. (1987). Confidentiality of patient records in alcoholism and drug treatment programs. New York: American Medical Society on Alcoholism and Other Drug Dependencies, Inc. and National Council on Alcoholism, Inc.
Bok, S. (1987). Whistleblowing and professional responsibilities. New York University Education Quarterly. 11(4), 2-10.
Burkhalter, P. (1975). Alcoholism, drug abuse and addiction: A study of nursing education. Journal of Nursing Education. 14, 30-35.
Cannon, B.L. & Brown, J. S. (1988). Nurses' attitudes toward impaired colleagues. Image. Summary 20, 9-101
Carter, A.J. (1983). Nurses: Alcohol and drug abuse training in nursing schools. Alcohol Health and Research World. 8, 24-29.
Clark, M. (1988). Preventing drug dependency: Part I, recognizing risk factors. Journal of Nursing Administration. 191(1), 21-26.
Clark, M.D. (1988). The recovering nurse: The employment interview. Nursing Management. 19, 33-37.
Clement, S. (1986). The identification of alcohol-related problems by general practitioners. British Journal of Addiction. 81, 257-264.
Cross, L. (1985). Chemical dependency in our ranks. Nursing Management. 16, 15-16.
Dogoloff, L. & Angarola, R. (1985). Urine testing in the workplace. New York: American Council for Drug Education.
Drew, L. (1987, June). The problem with testing. Newsweek.
Estes, N.J. & Heinemann, M.E. (Eds.). (1986). Alcoholism: Development, consequences, and interventions. St. Louis, MO: C.V. Mosby.
Greenspan, S.I. (1985). Research strategies to identify developmental vulnerabilities for drug abuse. Research Monograph No. 56. Washington, D.C.: National Institute for Drug Abuse. pp 136-154.
Gurel, M. (1976). An alcoholism training program: Its effect on trainees and faculty. Nursing Research. 25, 127-132.
Haack, M. & Hughes, T. (1987). Addiction in the nursing profession: Approaches to intervention and recovery. New York: Springer Publishing.
Helwick, S. A. (1985). Substance abuse education in medical school: Past, present, and future. Journal of Medical Education. 60(9), 707-711.
Hoffman, A.L. & Estes, N.J. (1986). A tool for measuring body and behavioral experiences. Alcohol Health and Research World. 11(1), 26-29.
Holder, J.P. (1986). The effects of clinical education setting on student anxiety levels. Journal of the American Association of Nurse Anesthetists. 54, 537.
Holmes, P.R. (1975). The many faces of alcoholism. Supervisor Nurse. 6(9), 16-19.
Kilty, K. (1975). Attitudes toward alcohol and alcoholism among professionals and non professionals. Journal of Studies on Alcohol. 36(3), 327-347.
Lewis, C.E. & Lewis, M. (1984). Peer pressure and risk-taking behaviors in children. American Journal of Public Health. 74, 580-584.
Long, P. Gelfand, G., & McGill, D. (1991). Inclusion of alcoholism and drug abuse content in curricula of varied health care professions. Journal of the New York State Nurses Association. 22(1), 9-12.
McAuliffe, W.E. (1984). Nontherapeutic opiate addiction in health professionals: A new form of impairment. American Journal of Drug and Alcohol Abuse. 10, 1-22.
McDonough, J.P. (1990). Personality, addiction and anesthesia. Journal of the American Association of Nurse Anesthetists. 58(3), 193-200.
Murphy, S.A. (1991). An empirically based substance abuse course for graduate students in nursing. Journal of Nursing Education. 30(6), 274-277.
Naegle, M. (1985). Creative management of impaired nursing practice. Nursing Administration Quarterly. 9(3), 16-26.
National Institute on Drug Abuse. (1991). National household survey on drug abuse: Main findings 1990. (DHHS Publication No. ADM 91-1788). Rockville, MD: U.S. Department of Health and Human Services.
Norris, J., Pierson, F. & Waugaman, W. (1988). Critical factors associated with substance abuse and chemical dependency in nurse anesthetists. Journal of Alcohol and Drug Education. Winter, 6-11.
Smith, D.E. & Seymour, R. (1985). A clinical approach to the impaired health professional. International Journal of Addictions. 39, 1327-1332.
Siegal, H. & Rudisill, J.R. (1983). Teaching medical students about substance abuse in a weekend intervention program. Journal of Medical Education. 58(4), 322-327.

Spencer, F.L. (1988). Attitudes of registered nurses toward their peers who are perceived as substance abusers: Abstract. Association of Black Nursing Faculty in Higher Education Newsletter. 1(4).

Sullivan, E.J., Bissell, L. & Williams, E. (1987). Chemical dependency in nursing: The deadly diversion. Redwood City, CA: Addison-Wesley Publishing.
Swenson, I. Havens, B. & Champagne, M. (1987). Interpretations of state board criteria and disciplinary procedures regarding impaired nurses. Nursing Outlook. 35, 108-110.
U.S. Department of Education. (1988). Drug prevention curricula: A guide to selection and implementation. Washington, D.C.: Office of Educational Research and Improvement.
Ward, C.E. (1983). Drug use in anesthesia training programs. Journal of the American Medical Association. 250, 922-926.
Wegscheider, S. (1981). Another chance. Palo Alto, CA: Science and Behavior Books.

Substance Abuse Curriculum: MODULE 3

CLINICAL UNITS A-I: Advanced clinical medical sequelae, diagnosis, and treatment of SA

Total Time: 15 hours

Overview: The clinical units will provide the student with advanced experience to apply scientific knowledge in caring for the SA patient. There will be an extensive opportunity for employing knowledge and skills concerning the SA patient. Additionally, there will be an opportunity to engage in multidisciplinary collaboration and networking of community organizations for the treatment of SA. One important component of this module is to delve extensively into the diagnosis, intervention, treatment and recovery process of the substance abuse patient.
Terminal Objective: a) The student should be able to conduct an interview, history, and physical, screening questions and follow-up history, evaluation of laboratory data to establish a diagnosis of SA. b) Conduct a family interview to establish and discuss the diagnosis and work with denial of SA. c) Initiate a referral for further assessment and treatment to a local community resource. d) Participate in a formal intervention session under the supervision of a trained SA professional. e) Present and disseminate the SA research project.
Recommended Teaching Methods:

Group Process

Lecture

Discussion

Readings

Videos

Role Playing and videotaped sessions

Case presentations

Instructional Activity Sequence:

First hour is dedicated to conference time conducted by a clinical faculty member examining the process of relating the diagnosis, intervention and working with denial.

Second and third hours include a participation in the methods for an extensive interview, history and physical using a variety of criteria, mnemonics, laboratory tests, and other instruments.

Fourth through the seventh hours are for participating in advanced or upper level group sessions under the direction of a clinical faculty counselor.

Eighth through tenth hours provides the opportunity to present a diagnosis of SA, intervene, and work with denial.

Eleventh through twelfth hours allow demonstration of a plan for intervention, basic intervention, referral skills and the aftercare process.

Thirteenth and Fourteenth hours allow students to disseminate results from research projects.

Fifteenth hour students should be debriefed for the previous activities allowing for expression of feelings and supporting reflection into areas needing improvement.

Course Outline:

LXXV. Clinical assessment and diagnostics of SA

A. Performing clinical assessment and diagnostic procedures

B. Advanced exploration of the interpretation of data concerning SA

C. Participating in family intervention

1. Planning the process

2. Intervention

3. Working with denial

4. Recovery and aftercare contracts

D. Utilizing diagnostic, and treatment skills in SA

1. Detailed history and physical for SA

2. Diagnosing SA

3. Detailed history from family

4. Planning Treatment for SA

5. Referral of SA patient

6. Follow-up history

E. Presentations of appropriate cases for review

F. Presentation of SA research project

G. Debriefing concerning experiences in SA education
References:

Arif, A., & Westermeyer, J. (Eds.) (1988). Manual of drug and alcohol abuse. New York: Plenum Medical Books Co.

Baird, M.A. (1985). Chemical dependency: A protocol for involving the family. Family Systems Medicine. 3, 216-220.
Block, M.R. & Coulehan, J.L. (1987, Jan.). Teaching the difficult interview in a required course on medical interviewing. Journal of Medical Education. 62(1), 35-40.
Bluhm, J. (1987). When you face the chemically dependent patient: A practical guide for nurses. St. Louis, MO: Ishiyaku EuroAmerica, Inc.
Cavanaugh, R.M. (1986, Mar.). Obtaining a personal and confidential history from adolescents. An opportunity for prevention. Journal of Adolescent Health Care. 7(2), 118-122.
Chappel, J.H., Veach, T.L. & Krug, R. (1985). The substance abuse attitude survey: An instrument for measuring attitudes. Journal Studies of Alcohol. 46(1), 48-52.
Chappel, J.N. (1973, May 14). Attitudinal barriers to physician involvement with drug abusers. Journal of the American Medical Association.
Clark, W.D. (1985, Nov.). The medical interview: Focus on alcohol problems. Hospital Practice. pp. 59-68.
Clark, W.D. (1981). Alcoholism: Blocks to diagnosis and treatment. American Journal of Medicine. 71, 275- 286.
Cox, A. (1981). Training guidelines and workbook for the behavioral management of intoxicated and disruptive clients. Toronto, Canada: Addiction Research Foundation.
Craig, R.J. (1988). Diagnostic interviewing with drug-abusers. Professional Psychological Research Practice. 19(1), 14-20.
Cyr, M.G. & Wartman, S.A. (1988). The effectiveness of routine screening questions in the detection of alcoholism. Journal of the American Medical Association. 259, 51-54.
Deveny, P. & Saunders, S. (1986). Physicians' handbook for medical management of alcohol and drug related problems. Toronto, Canada: Addiction Research Foundation.
Ewing, J.A. (1984). Detecting alcoholism: The CAGE Questionnaire. Journal of the American Medical Association. 252, 1905-1907.
Gitlow, S.E. & Peyser, H.S. (1980). Alcoholism: A practical treatment guide. New York: Grune and Stratton.
Holt, S. Skinner, H.A. & Israel, Y. Early identification of alcohol abuse: Clinical and laboratory indications. Canadian Medical Association Journal. 124, 1279-1299.
Johnson Institute. (1987). How to use intervention in your professional practice. Minneapolis: Johnson Institute.
Johnson Institute. (1979). Chemical dependency and recovery are a family affair. Minneapolis: Johnson Institute.
Johnston, L.D., O'Malley, P.M. & Bachman, J.G.(1987). National trends in drug use and related factors among American high school students and young adults, 1975-1986. (DHHS Publication No. ADM 87-1535). Washington, DC: U.S. Government Printing Office.
Keltner, N., Schwecke, L., & Bostrom, C. (1991). Psychiatric Nursing: A psychotherapeutic management approach. St. Louis, MO: Mosby-Year Book.
Lipkin, M., Quill, T.E. & Napodano, R. (1984). The medical interview: A core curriculum for residencies in internal medicine. Annals of Internal Medicine. 100, 277.
Manno, J.E. (1986). Interpretation of urinalysis results. Urine Testing for Drugs of Abuse. Research Monograph Series, No. 73. Rockville, MD: National Institute on Drug Abuse.
Milhorn, H.T. (1988). The diagnosis of alcoholism. American Family Physician. 37, 175-183.
Miller, M.R. & Hester, R.K. (1986). Inpatient alcoholism treatment: Who benefits? American Psychologist. pp. 794-805.
Mumford, E., Anderson, R. Cuerden, T. & Scully, J. (1984). Performance-based evaluation of medical student' interviewing skills. Journal of Medical Education. 59, 133.
National Council on Alcoholism. (1972). Criteria for the diagnosis of alcoholism. Annals of Internal Medicine. 77, 249-258.
Skinner, H.A., Holt, S., Schuller, R., Roy, J., & Israel, Y. (1984). Identification of alcohol abuse using laboratory tests and a history of trauma. Annals of Internal Medicine. 101, 847-851.
Stillman, P.L., Burpeace-DiGregorio, M.Y., Nicholson, G.I., Sabers, D.L., & Stillman, A.E. (1983). Six years of experience using patient instructors to teach interviewing. Journal of Medical Education. 58, 941.
Tarter, R. & Hegedus, A. (1991). The drug use screening inventory. Alcohol Health and Research World. 15(1), 65-75.
Taylor, R.B. (1982). Health promotion: A guide to clinical practice. Norwalk: Appleton-Century-Crofts.
Tiebout, H.M. (1953). Problems of addiction and habituation. New York: Grune and Stratton.
Washton, A.M. & Gold, M.S. (Eds.) (1987). Cocaine. New York: Guilford Press.
Weinberg, J.R. (1974). Interview techniques for diagnosing alcoholism. American Family Physician. 9, 107-115.
Werner, A. & Schneider, J.M. (1974). Teaching medical students interactional skills: A research based course in the doctor-patient relationship. New England Journal of Medicine. 290, 329.

Formative Evaluation of Module 3

Substance Abuse Curriculum

Reference Sheet 1.5

Using the following scale please rate your accomplishments of the objectives in Module 3 including the didactic and clinical components of the substance abuse curriculum.
1-------2-------3-------4-------5

Low Moderate High

Accomplishment
Level of Accomplishment
____Understanding the physiologic basis of maternal and child, fetal, neonatal and newborn addiction.
____Discuss the pharmacologic basis and principles of abused substances, their clinical manifestations as they relate to anesthesia.
____Anticipating interactions of abused drugs and polysubstance abuse with anesthetics.
____Recognizing the primary elements in the process of immunosuppression and deactivation of the immune response.
____Identifying factors which predispose substance abusers to AIDS.
____Formulating preventative treatment modalities for AIDS.
____Developing and presenting educational and prevention programs for communities concerning substance abuse.
____Networking with professionals outside the immediate clinical setting, discussing resources available and formulating a collaborative network of professionals in the area of substance abuse.
____Implement preventative methodologies and evaluate the outcomes.
Reference Sheet 1.5 (cont.)
____Diagnosing the symptoms and patterns of use in the impaired professional.
____Describing the legal, moral, and ethical implications of the impaired professional and how they relate to the individual, the community, and society.
____Implementing a plan for intervention, treatment and recovery of the impaired professional.
____Conducting an interview, history, physical, interpretation of laboratory data, screening questions, and follow-up history
____Conducting a family interview discussing diagnosis and working with denial.
____Initiate referral for future assessment and treatment to local community resources.
____Participation in formal intervention sessions with trained substance abuse professionals.
____Presenting and disseminating the substance abuse research project.
Additional Comments:

Summative Evaluation

Substance Abuse Curriculum

Reference Sheet 1.6

Using the scale please rate your level of accomplishment for the learning objectives for the entire substance abuse curriculum.
1--------2--------3--------4--------5

Low Moderate High

Accomplishment
Level of Accomplishment
____Identifying familiar behavior patterns in the chemically dependent.
____Recognizing the common medical outcomes of the substance abuser.
____Discussing the treatment modalities utilized for the chemically dependent.
____Developing personal insight into values, attitudes, behaviors, and morals concerning substance abuse.
____Describing the effects of substance abuse on the family unit and special populations that are affected by substance abuse.
____Describing the moral, cultural, ethical, legal, and social considerations in chemical dependency.
____Demonstrating the basic skills for diagnosis, intervention, and employment of treatment for the substance abuser.
____Identifying the appropriate collaborative course in the prevention, intervention, and treatment of substance abusers.
____Describing the role of the nurse anesthetist in the prevention of substance abuse.
____Engaging effectively in research of substance abuse.
Reference Sheet 1.6 (cont.)
____Demonstrating an active effort to change personal negative attitudes and stereotypes regarding chemical dependency and the substance abuser.
____Evaluating the effectiveness of efforts in prevention, intervention, and treatment of substance abuse.
____Formulating steps to respond to chemical abuse patterns.
____Demonstrating a change in the values, beliefs, perceptions and stereotypical attitudes of the learner.
____Demonstrating an active role in the education and dissemination of substance abuse information in the community.
Additional Comments:

Substance Abuse Post-test

Module 3

Reference Sheet 1.7

Please rate your skill in performing each of the following clinical duties concerning the substance abuse (SA) patient and using the following scale.
1-----2-----3-----4-----5

Low Moderate High

Skill Skill Skill
Skill Level
_______ 1. Composing a problem list of the physiological concerns of the SA patient.
_______ 2. Discussing the epidemiology of SA.
_______ 3. Identifying the characteristics of commonly abused substances.
_______ 4. The pharmacological principles to consider for SA.
_______ 5. Defining the DSM IV diagnostic criteria and performing intervention.
_______ 6. Discussing the etiology of SA.
_______ 7. Recognizing the legal, ethical, and moral issues in SA.
_______ 8. Demonstrate basic assessment and diagnostic skills for SA.
_______ 9. Recognizing the attitudinal obstacles to good communication with the SA patient and family.
_______ 10. Dealing with an impaired colleague.