SECRET LIFE Even your most trusted employees could fall victim to substance abuse.

Have you ever smelled alcohol on the breath of an employee or been unable to explain away erratic behavior as a string of bad days? Those are the red flags of alcohol or substance abuse that jeopardize staff and patient safety. Here's how to address the situation.

1. Observe. The smell of alcohol is somewhat obvious, but illegal drug abusers are sometimes more challenging to detect. Look for patterns of inappropriate or bizarre behavior, or mildly inappropriate behavior that threatens patients or staff. If suspected employees are on duty, you have a responsibility to act. If they're off-duty, your responsibility to them is rooted in concern for their well-being, not as a work supervisor.

2. Document. If you suspect substance abuse, the appropriate action is based on the frequency and severity of the warning signs. Document every questionable behavior by noting the date it occurred and what you noticed or what was said between you and the suspect employee. Before acting, always double-check your observations with another supervisor or manager. Trusting your instincts is key, but validating your worries is incredibly important, especially when dealing with something as serious as substance abuse. Deciding to act on your suspicions is harder than you think, and shouldn't be done alone.

3. Confront. Once you've decided to confront a suspected substance abuser, ask for support from your risk manager or another facility supervisor. Contact an outsourcing lab or local hospital's emergency room to schedule an immediate "reasonable cause" drug test. Inform the suspect employee that you've scheduled a drug test and that failure to undergo the test could result in termination, then have them sign a consent form. You or another supervisor should drive the employee to the test site. (You're liable if you observe them under the influence and they get in an accident while driving to the appointment; don't put their safety and your legal liability at risk.) Cover the employee's shift, keeping all information about the drug test confidential.

4. Test. A practitioner certified in drug-screening procedures should obtain blood or urine samples because any mistakes made during the testing will negate the result, making it inadmissible in court. Never attempt to obtain specimens at your facility.

Drugs tested for during routine screenings include amphetamines, barbituates, cocaine, canabanoids (marijuana), opiates, phencyclidine (PCP), benzodiazipines, methadone and propoxyphene. If the drug you suspect is different than these, alert the drug screener in writing. Note that alcohol, meperidine and fentanyl (substance abusers in surgical settings might have easy access to the latter 2 drugs) are not on the list, and won't be tested for routinely. Also know that blood and urine tests screen for specific drugs, so be sure the test you schedule is appropriate for the substance you suspect — yet another reason why trained professionals should administer screenings.

Signs and symptoms
Employees don't need to demonstrate all of these indicators. An isolated incident does not necessarily indicate a problem, but patterns or changes in behavior should raise your suspicions.

Physical:

• smell of alcohol on breath
• impaired motor coordination, slurred speech, flushed face
• numerous injuries, burns and bruises with vague explanations
• weight loss, poor nutrition
• pupillary changes
• fluid retention

Job performance:

• neglected duties
• does minimum work necessary
• dangerous practices
• difficulty meeting schedules and deadlines
• illogical, sloppy or delayed charting
• constant errors in judgment
• slow responses to emergency situations
• frequent medication errors
• discrepancies between narcotic sign-outs and time documentation

Behavioral:

• DWI
• personality changes
• irritability, extreme and rapid mood swings
• volatile temper
• social withdrawal
• elaborate excuses for behavior
• unkempt appearance
• excessive use of mouthwash and mints
• defensive when questioned about medication errors

Time and attendance:

• calls in sick before or after weekends
• frequent use of restroom
• mysterious disappearances, long lunch hours
• arrives early to work or stays late
• frequent "no-show" status

Last chance
If drug tests come back positive, follow your policies and procedures in enforcing the consequences. Keep in mind, however, that addicts are often unable to adequately perform their duties. By documenting their problem behaviors or failed job performances, you'll likely have more than enough evidence to take appropriate action long before resorting to messy confrontations or drug tests that can be contested in court.

INTERVENTION
Confronting Substance Abusers

HELPING HAND Offer addicts help in battling their demons and starting down the road to recovery.

1. Face your own denial. Don't fall into the trap of thinking trusted employees you've known for years wouldn't or couldn't abuse drugs or alcohol. Sometimes it's the people you least expect.

2. Have a caring attitude. ? Be sure the suspected employee knows you're not labeling or judging them. Listen with the ear of your heart.

3. Name the choice. Give substance abusers clear-cut behavioral choices, which are likely dictated by your policies and procedures. Tell them they need to clean up their act or enter rehab to remain employed. Make it that simple.

4. Motivate. Implore addicts to face their problems and change their ways. Don't use confrontations as "gotcha" moments. Substance abusers might no longer be employable, but don't ignore their personal issues. Offer them support moving forward in their recoveries, perhaps by referring them to your facility's rehab program. External motivations effect change, but substance abusers need to internalize motivations for them to be truly impactful, and it's easier to internalize those motivations if they trust you. Even if you don't initially see changes in addicts' behaviors, know that you've impacted their lives. It may take years for them to grab control of their addictions, but your actions might have been the final straw that started them down the road of recovery.

— Lisa Moschkau, RN, BSN, MASL