Question
What should I do if I suspect that a coworker is impaired in the workplace? Are there various means to address it without being the bad guy?
 | Response from Michael G. O'Neil, PharmD Professor, Department of Pharmacy Practice, Consultant, Drug Diversion and Substance Abuse, South College School of Pharmacy, Knoxville, Tennessee |
Impairment may be defined as an inability to complete job-related activities and consistently communicate or think rationally without error while performing professional duties. Traditionally, impairment in the healthcare work environment has been characterized by individuals with drug or alcohol addiction, abuse of illicit substances, or misuse of prescription drugs.
It has been estimated that 10%-15% of all healthcare professionals may abuse drugs or alcohol in their lifetime.[1]Kessler and colleagues[2] reported that about 30% of individuals between 15 and 54 years of age reported having at least 1 psychiatric disorder, including major depression and anxiety disorders, within a 12-month period.
Psychiatric illnesses other than addiction often contribute to impairment of health professionals. Table 1 lists common conditions that may contribute to psychiatric impairment.
Table 1. Common Causes of Psychiatric Impairment in the Workplace
| Drug and alcohol addiction |
| Depression |
| Bipolar hypomania |
| Anxiety disorders (eg, obsessive-compulsive disorder, generalized anxiety disorder |
| Posttraumatic stress disorder |
| Medication side effects |
| Chronic sleep deprivation |
Characteristics of substance abuse, mood disorders, and other medical conditions are often the same or overlap, making assessments difficult. Common signs of impairment are listed in Table 2.
Table 2. Common Signs of Impairment
| The smell of alcohol or marijuana on breath |
| Falling asleep while working |
| Slurred speech |
| Persistent tardiness |
| Frequently leaving the work environment |
| Increasing absenteeism |
| Changes in personal hygiene (eg, not showering, unlaundered clothing) |
| Significant and persistent changes in moods |
| Persistent errors |
| Increasing conflict with other employees or patients |
| Belligerence to supportive inquiries |
| Involvement in discrepancies of controlled substances in the workplace |
Frequently, impaired individuals have more than 1 cause of impairment. Rarely do impaired healthcare professionals demonstrate only 1 sign of impairment, and usually a combination of behaviors is necessary to determine whether an intervention at some level is necessary. Levels of intervention are listed in Table 3.
Table 3. Levels of Intervention
| Level 1: One-on-one collegial approach |
| Level 2: Report to clinician in charge, security, and management |
| Level 3: Report to applicable Board (eg, Pharmacy, Nursing, Medicine) and law enforcement |
The healthcare professional's role in addressing an impaired coworker is critical to the safety of patients and the impaired individual, and it is part of his or her professional responsibility.
Case 1
JA is a nurse working in an inpatient cardiology unit. A medical assistant thought she smelled alcohol on his breath a few times but was unsure. JA has been making 2-3 errors per week over the past few months. He frequently leaves the clinic to retrieve "things he needs" from the car. What action should these behaviors warrant?
Any single event in this case does not indicate impairment (ie, the questionable smell of alcohol, increased errors, and frequent trips to the car). Collectively, these signs are probably indicative of a significant issue.
In most cases of drug or alcohol addiction, initial denial of a problem is predictable. Errors are frequently blamed on others, or excuses are made to cover up the problem. Usually, management tracks errors, and this frequently leads to further inquiries or increased observance by management. If management has addressed the issue, then continued vigilance by coworkers is warranted.
If the situation has not been addressed by management, a level 1 intervention is necessary. Simple, sincere inquiries, such as, "I've noticed you seem a little distracted in the past few months. Are you doing okay?" may lead to further positive discussions that reveal a situation that can now be directed to a counselor or physician. Belligerence and anger resulting from the supportive inquiry may become another flag that requires a level 2 intervention. Continued errors with persistent denial of any problems despite supportive suggestions would put patients at risk, and JA should be reported to management or the professional board (level 3 intervention).
In many states, health professional assistance programs are available. These programs often provide information or support that may direct the next necessary steps. These organizations should be utilized whenever possible.
Case 2
A nurse reports that he has noticed slurred speech from physician CB while she was on the phone and when she counseled a patient. This speech pattern is atypical for this physician. Her error rate is minimal, but over the past month she has appeared extremely fatigued and has been increasingly late for work. What level of intervention is necessary for CB?
A level 1 intervention is necessary. When CB was approached this way, she quickly revealed that she was "not okay." She shared that she was recently diagnosed with a seizure disorder and depression and had not adjusted well to the side effects of lamotrigine, which caused her to slur her speech and made waking up in the morning difficult. Encouraged follow-up with her neurologist and psychologist led to medication adjustments and return to normal behaviors.
Case 3
A pharmacist reports to you that KL was seen putting a stock bottle of a schedule II controlled substance in her purse. KL is a recent hire. Her moods are somewhat labile but not distractive to the work environment. The medical history is unknown. What action is warranted for KL?
Before false accusations are made on the basis of hearsay information, it is the pharmacist's responsibility to notify the pharmacist-in-charge and security (level 2 intervention). Federal law requires an inventory of controlled substances and report of any suspected loss of controlled substances (level 3 intervention). Unsubstantiated claims can be quickly resolved with an inventory. Review of security films and dispensing records direct further investigation if necessary. Unfortunately, in this type of scenario, should the coworker actually have an impairment, intervention is likely to occur only after the theft has been substantiated and the coworker has been discharged.
Conclusion
Clinicians have a professional responsibility to protect patients. When a coworker is suspected to be impaired, at a minimum a level 1 intervention should occur. Understanding that other health-related factors may cause or contribute to impairment is key when addressing potential impairment of a coworker. Professional health programs or organizations should be utilized whenever possible.
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