The burnout and additional stress brought on by the COVID-19 pandemic may be leading more clinicians to abuse alcohol and drugs. It is critical that quality and peer review leaders be on the lookout for such impairment.

Conditions have combined to create an elevated risk of impaired clinicians, says Jay Kaplan, MD, FACEP, medical director of care transformation at LCMC Health in New Orleans.

The stress related to COVID-19 is just the latest factor that has many clinicians looking for relief in unhealthy ways. One of the biggest stressors has been the adoption of electronic health records (EHR) that require constant attention, even during off-hours, Kaplan says.

One study revealed physicians spend 90 minutes tending to the EHR after clinic hours, usually at home in what they called “clinical pajama time.”1

The authors of other papers examined how EHR requirements may negatively affect nurses and their abilities to structure workflows and communicate with colleagues effectively.2,3

COVID-19, piled on top of EHR requirements and other everyday stresses, means quality professionals should be on high alert for any signs of impairment, Kaplan says. When the pandemic started, Kaplan visited with physicians, other clinicians, and staff to help assess their ability to cope with the challenges of the pandemic.

“I heard a lot about feelings of fear, frustration, and anger,” Kaplan says. “I told them that if they needed to just go to a closet for a few minutes and cry, there was nothing wrong with that. They could just tell their colleagues they would be gone a few minutes, but they would return. The other thing I did was to make them aware of all the resources we offer in terms of help for people under this kind of stress, reminding them we are on their side, and encouraging them to reach out if they need help.”

It is important to be proactive in reaching out to clinicians, either as a group or individuals, Kaplan adds.

One challenge with COVID-19 is the stress continues, with no end in sight, as opposed to a crisis like a hurricane or a violent incident at the hospital, Kaplan notes. The pandemic also affects the clinicians’ families, whereas the home should be a respite from the stresses of work.

“I talked to one physician whose 14-year-old son had always been the golden child, but the isolation from the lockdown was causing him to act out in bad ways. In addition to everything at work, [the clinician] had to go home to that because the virus was affecting every part of his life,” Kaplan says. “Another had lost five close friends to COVID, and nobody knew that. A nurse manager told me that her brother had been laid off, and their two-income home had become a one-income home.”

LCMC Health has developed a peer support or “second victim” response program with experts trained in psychological first aid who can spot people in trouble, directing them to the available resources for help.

Kaplan predicts that when the COVID-19 crisis passes, there will be more cases of not only substance abuse issues but also post-traumatic stress disorder among clinicians. Thus, the importance of instituting peer support response programs now.

“Whether it’s from the isolation, the way people’s lives changed, and all the ongoing stress from how the pandemic is changing the business side of medicine, there are so many stressors, and [clinicians] are human. They sometimes react to stress in less-than-ideal ways, just like everyone else.”

LCMC Health recently hosted a town hall-type event in which it demonstrated how clinicians can access the employee assistance program. Clinicians may be conditioned to not appear “weak” in front of others. This can lead to clinicians closing off their emotions from others, retreating to isolation and substance abuse. “We need to emphasize that, especially in these times, seeking emotional support should be considered a healthy response to everything going on around us,” Kaplan says.

Look for Burnout Signs

Recognizing when healthcare providers need help is the first step, says Tasha Holland-Kornegay, PhD, LPCS, a licensed counselor and founder of the platform Wellness In Real Life, which assists healthcare providers who are looking to destress.

One of the main stressors that cause healthcare professionals to turn to alcohol or drugs is burnout, she says. It is one thing to know what the major symptoms of burnout are, but spotting how they manifest in a work environment is different, she says. This is especially difficult in environments that view exhaustion as a weakness.

“Many healthcare environments are infused with this type of perfectionism and workaholism. This creates a toxic workplace culture in which employees don’t feel comfortable discussing their symptoms,” Holland-Kornegay observes.

Symptoms such as emotional exhaustion, physical exhaustion, and negative thinking are hard to spot in others, especially if they are actively hiding it, Holland-Kornegay says. The key things to look for are cynical attitudes about oneself or others, keeping oneself isolated from co-workers, and shortness with patients, along with any other suggestion of mounting inner struggles.

“At the end of the day, without creating a more accepting workplace culture, healthcare facilities won’t have the luxury of preventing burnout,” she cautions. “They’ll have to deal with curing it after the fact.”

Preventing burnout in health facilities will entail a broad redefining of workplace culture, Holland-Kornegay says. Stress, fatigue, and exhaustion need to be more widely accepted as real issues rather than signs of weakness that should be “powered through,” she says. When workers are burned out, they need to relax and recharge.

“Working harder to power through it will just dig a deeper hole,” Holland-Kornegay says. “The best intervention is to solve it at the root. When that isn’t possible, establish wellness policies and places for co-workers to meet up, talk, and relax.”

Superheroes Still Are Human

The public’s belief that a lot of healthcare professionals are “superheroes” who operate on a higher level and do not fall victim to vulnerabilities and fragility actually can increase the risk of substance abuse and other impairments, says Bill Hopkins, JD, healthcare partner in the Austin, TX, office of Shackelford, Bowen, McKinley, and Norton.

“The reality is that while they do incredible lifesaving acts and operate under tremendous amounts of stress, they are actually very human, make mistakes, and sometimes succumb to the same temptations that happen to the rest of us,” Hopkins says. “What often makes this temptation so much worse for healthcare professionals is that while we might have a stressful day and reach out for a bottle of alcohol or a smoke, for healthcare professionals, that temptation might lead them to look at the incredible access they have to really powerful medications.”

Based on their need to be able to work and function at a high level, the impaired healthcare professional can be difficult to discover, Hopkins says. They know and understand the potency and effectiveness of medications. Clinicians can quickly figure out their tolerance and limitations that will not only give them the relief they need, but also allow them to continue to function and work.

“Much like the regular drinker, who convinces himself or herself that they are OK to drive, the healthcare professional becomes equally talented at convincing himself or herself that they are not impaired or adversely affected by their self-medication,” he says. “This ‘functional’ impaired professional can be very hard to spot.”

Added to this, the professional may become convinced he or she “needs” the medication to either cope with the stress, the pain, or the hours of the job. There may be no consideration to work without it, Hopkins says.

Since he or she figures out the “right balance” of medication, the impaired professional does not appear to be in an altered state without some significant scrutiny. The best way for a facility to discover the impaired professional is to create a culture of trust where all the employees recognize they are empowered and expected to protect the dignity and integrity of the facility, Hopkins says.

“This culture is one that illustrates that no one individual is more important than the goals of the facility and taking care of the patients. With this kind of culture, everyone is far more likely to pay attention to any actions of fellow employees. If concerns are raised, either confront the professional or utilize the systems in place to address the concerns,” Hopkins says.

“Too often, when facilities do not have this type of culture, the impaired healthcare professional is protected and covered for because he or she is deemed too important to confront,” Hopkins continues. “The proper consideration for patient safety is ignored, because nothing adverse has ever happened before.”

Impairment Often Overlooked

Typically, in this type of scenario, the impaired professional is not discovered until he or she becomes sloppy and either makes a mistake or appears so impaired that it cannot be ignored, Hopkins says. Often, the first signs of impairment are behavioral, not clinical.

“If people are educated to pay attention to that kind of stuff, the flags tend to get raised a lot faster. Even though misappropriation of medications is not required for the truly sophisticated impaired healthcare professional, another strategy for discovery of impairment is to make sure that the auditing systems are in place to discover when a healthcare professional might be so desperate for medications that they steal them from the patients and the facility,” Hopkins says. “Having effective auditing systems will raise a flag when these medications are missing and hopefully address it before a pattern is developed that defrauds the facility and, more importantly, may deny a patient much needed medication.”

Once a healthcare professional is discovered to be impaired or appears to be struggling with chemical dependency issues, a facility must confront the professional to confirm the depth of the problem.

From there, leaders can determine if other actions may need to be taken. This might include medication audits and a review of patient records to make sure the proper protocols have been followed during this impairment period.

Next is the question of how to deal with the professional. Fortunately, most states, in affiliation with the license process, have set up programs to address impairment issues of healthcare professionals, Hopkins notes.

Instead of referring the healthcare professional to a standard rehab program or the licensure board, these programs are specifically designed to address the professional’s chemical dependency issues.

Also, by enrolling in such programs, this maximizes the likelihood the professional can continue working, albeit under specific limitations and/or restrictions. These programs also incorporate requirements for drug testing, counseling, and therapy, so the healthcare professional’s mind can heal along with his or her body.

“If a healthcare professional is dedicated to getting better, then these programs are very effective and offer a path to get the healthcare professional back to work safely, while also guaranteeing patient safety,” Hopkins says. “If these programs are not an option, then there really is no alternative but to refer the healthcare professional to his or her licensure board. Depending on the board, they may have the ability to provide some of the rehabilitative care similar to that found in those impairment programs.”

REFERENCES

  1. Arndt BG, Beasley JW, Watkinson MD, et al. Tethered to the EHR: Primary care physician workload assessment using EHR event log data and time-motion observations. Ann Fam Med 2017;15:419-426.
  2. Wisner K, Lyndon A, Chesla CA. The electronic health record’s impact on nurses’ cognitive work: An integrative review. Int J Nurs Stud 2019;94:74-84.
  3. Schenk E, Schleyer R, Jones CR, et al. Impact of adoption of a comprehensive electronic health record on nursing work and caring efficacy. Comput Inform Nurs 2018;36:331-339.

SOURCES

  • Tasha Holland-Kornegay, PhD, LPCS, Raleigh, NC. Email: tasha@wellnessirl.com.
  • Bill Hopkins, JD, Healthcare Partner, Shackelford, Bowen, McKinley, and Norton, Austin, TX. Phone: (512) 542-5101. Email: bhopkins@shackelford.law.
  • Jay Kaplan, MD, FACEP, Medical Director, Care Transformation, LCMC Health, New Orleans. Phone: (504) 894-6701.