Supervisor Training Makes a Difference with a Tough Issue

What’s it like to be able to confidently deal with one of the trickiest problems a leader can face in the workplace? If you have been in management for a while, it’s likely that you or one of your colleagues has encountered worker substance abuse and there is a story to tell. Typically it is a disaster story with a nurse losing her job, her reputation, and sometimes her license to practice nursing—her career. It’s time for that story to change and the supervisor is in the leading role.

In the U.S., estimates vary quite a bit when it comes to the extent of problem substance use in the nursing profession. But many experts accept that addiction in nursing occurs at about the same percentage as the general adult population as a whole—between 9% and 10%. If you add binge drinking into the mix—and the impairing sequelae of hangover—the estimate is 16%.¹

To be sure, nurse licensing boards are actively addressing substance abuse. There are over 12,000 nurses enrolled in alternative-to-discipline programs (alternative programs). ² Alternative programs are offered by boards of nursing in most but not all states, and their mission is to protect patient safety.

At the same time, alternative programs offer nurses the opportunity to become healthy by taking personal responsibility for their recovery from a substance use disorder. Successful completion means that formal discipline is avoided and the monitoring does not become public through a board notice.

Most nurses enrolled in alternative programs return to the practice setting. Typically the nurse has license restrictions in the workplace, like no overtime, no night shift, and no administration of narcotic medication. And usually random testing for drugs and alcohol is required as well as successful compliance with a treatment plan.

One of the most important elements of workplace monitoring is direct observation of the nurse’s performance and periodic written reports to the alternative program. This is when the supervisor has the primary role in protecting patient safety and supporting a nurse to be successful in early recovery.

Recognizing and intervening in nurse performance problems possibly related to substance abuse is tricky. But it can end well if supervisors are prepared well. And nurse leaders should carefully consider how prepared they are to address the problem.

Ginny Pecora is the nurse administrator for an outpatient eye surgery center in a small city in Oregon. She has directly encountered the problem and developed professional and organizational resources to effectively manage it. Recently she talked about her personal experience.

“We are facing some challenges regarding turnover and recruitment,” said Pecora. “I’ve been at the surgery center twenty years, and a lot of us are about the same age. Not only has the surgery center matured; so have a lot of the employees.”

Many administrators are facing a similar problem. Recruiting qualified nurses who also fit well with the team culture is a key organizational objective.

Pecora explained that the nurse who trained her twenty years ago is now retiring. And, one of the nurse anesthetists retired last year at age 75. Like the healthcare industry in general, she must recruit new team members, hire them, and retain them in a competitive environment.

She understands the employment advantages of her outpatient surgery center and uses them in her recruitment. “We provide a nice environment for nurses. Some who apply for a job here have pretty much burned out on the pace at the hospital or have satisfied their adrenalin rush for acute issues. They’re tired of the rotating shifts, or the 12-hour shifts, the unpredictable work schedule, high patient-to-nurse ratio—all of which is stressful. Our environment is attractive to them.”

Like other administrators, Pecora is not looking to simply fill the schedule with warm bodies. She cares about quality and recruits skilled professionals to her nursing team. Her surgery center may offer much lower stress and more schedule stability but it is still a specialty area. Even though the pace and stress levels are different, patients are at risk if the nurses aren’t competent and reliable.

Thus, once hired and successfully oriented to the team, Pecora wants to retain nursing talent. And, that’s where developing the skill to recognize performance problems possibly related to substance use and supporting nurses in early recovery comes in.

“I was in the process of hiring a qualified fulltime nurse anesthetist. This involves running a national advertisement, because it’s very rare to find them in a small city like ours. People call from all over the U.S. CRNA’s command a high salary, and you get people calling up asking about salary and benefits.” She was contacted by someone she considered a serious candidate for an open nurse anesthetist position. When she talked with him on the phone, he said he wasn’t in practice and she asked why he wasn’t currently working. He told her that he had completed substance use treatment and was in recovery, there were not many jobs in his state, and he couldn’t be hired back at his previous job.

Pecora had previous experience with nurses in early recovery. While she needed to be thoughtful about making a “good hire,” a personal history of substance abuse alone was not a barrier to her considering the candidate.

“I decided that I could figure out how to support a person in recovery. I knew the issues, I had the right attitude, I understood what I was up against, and I wanted to make it work for this young man. I thought I could make this a win-win, but I wanted to bolster my knowledge and supervisor skills.”

Through the grapevine, Pecora found out about the Fit to Perform program, a training opportunity that might help if she hired the nurse in early recovery. She heard that this online supervisor training was available and also that the board of nursing required training for nurse managers who supervise a nurse enrolled in the alternative program, like the nurse who had applied for a job.

The Oregon State Board of Nursing offers qualified nurses an opportunity to enter a four-year alternative program. The program requires monthly safe practice reports from the nurse supervisor and also requires them to complete specialized supervisor training.

“So I contacted the company that offered the training and found out the Fit to Perform supervisor training was being evaluated as part of a federal grant and offered to nurse supervisors for free. The timing could not have been better!”

Time is precious for nurse managers and nurses generally. Evidence-based training has become the standard, so many won’t willingly invest time and effort in poorly developed training that has not been evaluated and that have results that are worthwhile. The rigorous control group design used to evaluate the online Fit to Perform training provides what a potential user wants to see: improved declarative and applied knowledge, improved confidence, and improved behavioral intentions to use the knowledge and skills,

On average, it takes about 2.5 hours to complete the 8 modules of the online training. It includes details about the supervisor role related to risky performance, recognizing specific risky behaviors, choosing the best course of action based on the level of observed risk, documenting factual observations, preparing for and conducting an effective performance improvement meeting with the employee, neutralizing tension in high-risk situations, and more. The training course incorporates the “constructive confrontation” model,^3,4 one of the most commonly used intervention approaches that relies on supervisors identifying troubled employees on the basis of job performance or behavior problems rather than the substance problem, which can simply be denied by the employee. Using constructive confrontation techniques, job performance is clearly documented and real consequences of future behavior are articulated.

Under a grant from the National Institute on Drug Abuse, the positive results of the rigorous evaluation are being prepared for publication. The program awards 2.5 hours of continuing education credit and is now available to all nurse supervisors.

But, it is in the application of what is learned that the value appears. Pecora makes an important observation about her own experience. “The training has been extremely helpful to me as an administrator. It’s given me a much larger context to appreciate why the behavior monitoring skills are valuable. And it’s given me and the other nurse supervisors at the surgery center a single frame of reference and common language to work from.”

For example, when one of her supervisors mentions a “meeting” with an employee who is being monitored, they both know right away what that meeting is all about, and how to conduct that meeting. Even though they took the training 18 months ago, Pecora says they still remember it and use the skills regularly.

“The training is concise, accessible, and has all the tools you need. It’s a perfect resource for a nurse manager with or without background about the disease or the recovery process, and perhaps especially for those without the background. It includes a checklist for recognizing specific observable behaviors that are cause for concern and a structured format for meeting with the employee about performance problems. And, there are sample forms that can be downloaded.”

When asked about why someone who doesn’t currently have a nurse in recovery or believes that substance use is not a problem in their staff would take the training, Pecora had this caution. “I would remind administrators that a certain number of your employees will have substance use problems that may affect their nursing practice. You don’t know when or who, but it will very likely happen. In fact, you will have to be prepared to deal with your best nurse. Believe me, it happens. Every nurse supervisor needs to be ready with the skills and tools to respond.”

Pecora believes an old thinking habit still affects many nurses and nurse managers like a long hangover. “Attitude can play a big role in how effective we are as supervisors. For example, you rarely notice the person in recovery. They don’t match the stereotypes of the addict we see on television or the very debilitated patients we often serve in our nursing practice. Most people don’t realize that the colleague with those excellent skills and great teamwork is also in recovery. So, nurse managers can have a very one-sided and negative view of chemical dependency. And new supervisors are scared out of their wits!”

She goes on to explain a very practical dimension to the issue. “There are highly skilled and reliable nurses who are also in recovery and need to be supported. When you hire someone in early recovery, you’re actually hiring someone with known issues. Taking the training, you will learn how to manage this person in the best way possible for both of you. In fact, the principles and skills are useful for managing all employees, not only those in an alternative program.”

Still, even with her success hiring and retaining nurses in early recovery, Pecora empathizes with her management colleagues when they balk at taking the time it takes to become effective dealing with staff substance abuse. “A lot of people think that dealing with employees with substance use issues is what HR does. Well, HR doesn’t live on your floor; they don’t work with your employees day-to-day; they don’t observe the behaviors. HR is a resource, but you are the one who can monitor and influence employee behavior and work performance.”

“Dealing with chemical dependency is very complex,” she says. “I don’t care how long someone’s been a supervisor. Once you get into the heat of the moment and an employee answers emotionally to your reasonable request, you have to be grounded. The constructive confrontation tools you learn really do help. It is so much better to respond objectively using these tools instead of going to the other extreme and firing the person.”

If there is any message that can read between the lines of Pecora’s story it’s that sometimes a nurse leader has to invest time to save time. Effective management of difficult problems like workplace substance abuse can save lots of time. It can be a very good return on your investment.