Journal of Nursing Management, 2015, 23, 794–802

Common risky behaviours checklist: a tool to assist nurse supervisors to assess unsafe practice DAVID M. CADIZ

PhD

1

, DONALD M. TRUXILLO

PhD

2

and CHRIS O’NEILL

RN, DMin

3

Assistant Director, Oregon Nurses Foundation, Tualatin, OR, 2Professor, Industrial/Organizational Psychology, Departmemt of Psychology, Portland State University, and 3Program Director, Oregon Nurses Foundation, Tualatin, OR, USA 1

Correspondence David M. Cadiz Oregon Nurses Foundation 18765 SW Boones Ferry Road Ste. 200, Tualatin OR 97062 USA E-mail: [email protected]

CADIZ D.M., TRUXILLO D.M. & O’NEILL C.

(2015) Journal of Nursing Management 23, 794–802. Common risky behaviours checklist: a tool to assist nurse supervisors to assess unsafe practice Aim To describe the development of the Common Risky Behaviour Checklist, a tool to aid nurse supervisors in determining when a nurse may be questionably fit to perform, particularly in cases of substance abuse. Background A significant number of nurses may have substance use disorders that could manifest as unsafe performance at work, and nurse supervisors lack the tools to assess a nurse’s fitness to perform at work. Method Job analysis techniques were used to identify the critical impairment behaviours for the tool. Job analysis is a legally defensible, multi-stage process used in the organisational psychology field to develop work performance assessments. Results A screening tool was developed for nurse supervisors to assess when a nurse may be questionably fit to perform. Conclusion The development of this checklist is one of several needed advancements in order to address the issue of fitness to perform and patient safety. Implications for nursing management The Common Risky Behaviour Checklist offers nurse managers assistance in protecting patient safety by providing a quick (one-page), systematic, behaviour-based method to collect information that can inform urgent decisions, trigger performance corrections and can complement formal organisational documentation processes in cases of unsafe practice due to substance abuse.

Keywords: common risky behaviour checklist, nurse fitness to perform, substance abuse, unsafe practice Accepted for publication: 16 December 2013

Background Most U.S. states provide nurses with an alternative-todiscipline programme (alternative programme) option when substance use and/or a mental disorder is a practice concern, and there is also growing international interest in the alternative programme model (Monroe & Kenaga 2010). These programmes are offered by boards of nursing to nurses in recovery from substance use disorders to allow them to practise 794

while being monitored to reduce the risks of unsafe practice. In its guidelines, the National Council of State Boards of Nursing (NCSBN 2011) recommends that nurses enrolled in alternative programmes be required to commit to several protective measures including a return to work agreement, random drug testing, restricted access to medications in the work setting, recovery support group attendance and an identified worksite monitor to observe work performance. DOI: 10.1111/jonm.12214 ª 2014 John Wiley & Sons Ltd

Common risky behaviors checklist

Effective worksite monitoring is the key to identifying when a nurse may not be performing in a safe or professional manner. However, there is a critical gap in the availability of evidence-based supervisor practice and valid supervisory aids to help determine when the nurse may not be fit to perform assigned duties. Typically, a direct supervisor or a worksite monitor oversees the practice of a nurse enrolled in an alternative programme when they return to duty (Young 2008). The NCSBN (2011) recommends in-service education for supervisors to recognise when there is a concern about fitness for duty. In their review of the literature, Serra et al. (2007) note that the fitness-for-work literature generally lacks an evidence-based, valid and effective decision-making process for assessing fitness for work. Thus, not only should supervisor education be a priority in order to protect the public from unsafe practice, but tools to aid supervisors to assess nurse fitness should be available as well. Unfortunately, such tools are currently lacking, despite the importance of successfully recognising and intervening in unsafe practice. The nurse supervisor is at the centre of protecting patient safety because it is their ethical and legal responsibility to assure safety for patients, co-workers and others at the worksite. However, supervisors may lack the training and knowledge to recognise signs of potentially unsafe practice, which may hinder their ability to implement the policies of the employer and standards of practice that ensure patient safety. NCSBN (2011) states in its guidelines: ‘Although work place supervisors continue to be on the front line in terms of identifying employees with problems, they are still often reluctant to intervene and even refer to EAP1 programmes [sic]. More education and direction is needed for workplace supervisors to assist them in learning to intervene with workplace substance use issues or to utilise support personnel to assist them in addressing these issues (pp. 51)’. We previously addressed the development of an evidence-based supervisor skill training curriculum (Cadiz et al. 2012). In the current paper, we present a valid tool that can assist supervisors to recognise when an employee may be potentially unfit to perform, particularly in cases where substance use is suspected. We also describe the process used to develop and validate the tool, and ensure its job-relatedness. 1

EAP is an acronym for employee assistance programme. EAPs are a benefit offered by many employers and are intended to help employees deal with personal issues that could negatively affect an employee’s health, well being, and/or work performance. ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 794–802

Method A set of rigorous steps was used to develop a tool that can be helpful to a supervisor in making a decision to reduce safety risk, particularly when time is limited. The approach followed for the tool development is called job analysis. Job analysis is a legally defensible, multi-stage and well-validated process in the organisational psychology field. It is used to identify critical incidents, job-related tasks and examples of behaviours that differentiate good and poor performance, including the development of tools to assess work performance (Cascio & Aguinis 2011, Gatewood et al. 2011). Job analysis was adopted because it is a systematic process for collecting information on the important work-related aspects of a job that can be used to develop criteria for performance or, in our case, impaired performance.

Design of the study There were six phases in our tool development process including a literature review, critical incident collection and item generation, item reduction and categorisation, subject matter expert review, item refinement and form design, and nurse supervisor feedback review. The six phases took place over 10 months from June 2010 to March 2011. The goal of each phase, the method used to collect the information related to the phase, and how the outcome of the phase informed the subsequent phase are displayed in Table 1. In the results we have provided a description of the process used in each phase.

Ethical considerations Because three of the phases involved human subjects, and due to the sensitive nature of substance use in the workplace, ethical considerations around confidentiality and anonymity were addressed in our survey data collection protocol, which was approved by the Institutional Review Board (IRB) at the second author’s institution (HSRRC 101387 and HSRRC 101372). Informed consent cover letters were attached to the front of the paper surveys collected from the subject matter experts. The letter outlined what we were asking the participants to do, identified any risks to participate, identified what benefits were associated with participation, discussed the privacy protections in place for the participants, and emphasised that participation was voluntary. At the end of the consent letter, participants were notified that returning the survey 795

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focus group. The facilitator described next the categories of impairment identified by the Canadian Nurse Association (2009) report and asked participants to write down any additional impairment behaviours that occurred to them as a result of reviewing the different impairment categories. As mentioned before, the Canadian Nurse Association (2009) categories lacked definitions, therefore, the research team created definitions to aid the focus group participants to develop indicators for these categories which are displayed in Table 2. In the final part, participants were asked to generate a list of impairment behaviours from the perspective of alcohol vs. drug induced impairment behaviours and whether the participants could generate behaviours that were specific to the two types of impairment. After the completion of all the focus groups, the authors combined their notes into a single list of behaviours associated with substance use in the workplace. We initially planned to conduct a fourth focus group of alternative programme graduates, but decided that from an ethical perspective the anonymity of the participants of these programmes was a higher priority. Therefore, we developed an anonymous online survey asking the same questions and using the same prompts as the face-to-face focus groups. Two intermediaries whom the potential participants knew through their treatment programmes distributed an e-mail that contained a link to the survey. The research team had no direct contact with the participants, thus maintaining participants’ anonymity. We had seven survey participants and added their responses to the list collected from the face-to-face focus groups. The open-ended questions on the survey were analysed by all three authors to identify key themes and behaviours indicating substance use and fitness to perform. The focus groups and survey process generated 136 total behaviours. The 136 behaviours were separate from the 87 behaviours that were identified from the

literature review. Therefore, 223 total impairment behaviours were collated through the first two phases of the tool development.

Reduction of the list of behaviours An iterative review process, including three rounds, was used to reduce the list to a non-redundant set of observable behaviours in the third phase of the tool development. The authors first examined the 223 behaviours collated from the literature and focus groups to eliminate redundancy. Each author independently reviewed the list of behaviours and identified behaviours for removal. Behaviours that were identified for elimination on all of the authors’ lists or on two of the three author’s lists were excluded. Behaviours that were identified for deletion by only one of the authors were discussed at a meeting and removal decisions for exclusion were made when the research team reached consensus. During the second round of the review process, each author also sorted the behaviours into the four categories identified in the Canadian Nurse Association (2009) report – physical, social, performance and drug diversion to validate whether the typology was comprehensive enough to accommodate all the behaviours that we had collected. During this process, the authors decided that the behavioural categories needed to be reorganised because we had difficulty sorting specific behaviours into only one category. For instance, the behaviours in the drug diversion and performance categories were found to be closely associated and were combined into a general category termed ‘performance’. Additionally, the team decided to create sub-categories within the major categories because the sub-categories provided a clearer definition of behaviours that should be included in each respective major category which made the sorting process easier and more consistent. For example, attendance/work pattern changes, documentation, drug diversion, decision-making and policy

Table 2 Impairment categories, category definition and number of items CNA (2009) category

Common risky behaviour checklist category

Physical

Physical

Performance

Cognitive performance

Social Drug diversion

Interpersonal concerns Drug diversion/policy deviation Attendance/work pattern changes

798

Number of items (CRBC)

Definition Indicators that are visibly apparent on the person who has potential or actual substance use issues Indicators that are reflected in the person’s ability to deductively reason and make sound professional decisions Indicators that are reflected in a person’s social interactions on the job Indicators that are associated with stealing drugs on the job Indicators that are reflected in changes in the person’s presence at work

8 5 5 24 7

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According to professional and legal standards, before setting out to develop any assessment tool, existing job analyses should be reviewed (Equal Employment Opportunity Commission, & Equal Employment Opportunity Commission 1978, Gatewood et al. 2011). Thus, before developing the Fit to Perform Checklist, we reviewed existing, published job analyses. The search query using PubMed and terms ‘nurse’ and ‘job analysis’ identified two existing nurse job analyses (National Council of State Boards of Nursing 2009, U.S. Department of Labor’s Occupational Information Network (O*NET)). These were reviewed by the first author, who is also a subject matter expert in the fields of nursing and substance use, and the second author, who is an expert in the field of job analysis. Specifically, each job analysis was examined for the way that it organised nurse core activities into activity groups. We considered these as potential frameworks to categorise workplace impairment behaviours because our assumption was that a descriptive job analysis would tie the impairment behaviours to specific groups of activities that are expected to be performed by nurses. Finally, we conducted a third literature search for behavioural indicators of impairment to compile a list of existing behaviours from extant research. The search terms used in this PubMed search were ‘workplace impairment cues’, ‘chemical dependency workplace indicators’ and ‘alcohol and drug abuse workplace indicators’, which returned 283 articles. The first author reviewed systematically each article to see if any behavioural indicators or cues were identified in the papers and whether they were specific to the workplace and nurses, what process was used for identifying the behaviours, the framework used to categorise the behaviour, and whether the article cited secondary sources when identifying the behaviours. This process reduced the number of relevant articles to 12, which are displayed in Appendix S1. Articles that listed general diagnostic criteria of intoxication rather than workplace-specific indicators were excluded. The research team combined the workplace behavioural indicators reported in the literature into a single list and removed the duplicate behaviours, resulting in an initial list of 87 observable workplace, nurse related impairment behaviours and potential categories within which to organise the behaviours. The literature review was the starting point for a list of observable behaviours and for the tool. The challenge in the literature search was that we were unable to identify any articles that would have described a method for how the list of workplace impairment behaviours was developed. Also the categorisation ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 794–802

typologies lacked definitions which made it difficult to sort impairment behaviours. Because of these challenges we adopted the Canadian Nurse Association (2009) typology (physical, social, performance and drug diversion) to categorise the impairment behaviours. It contains categories and category labels generally aligned with workplace activities better than the other typologies.

Critical incident generation The second phase of tool development was to collect ‘critical incident’ behaviours using a focus group method. A critical incident describes the job behaviour in question, the context in which the behaviour occurred, and the consequences of the behaviour (Gatewood et al. 2011). The critical incident technique is a standard procedure used in the development of employee performance criteria (Gatewood et al. 2011). For the purpose of focus groups, we defined critical incident behaviours within the context of substance abuse, that is, as specific, observable behaviours that occur at the workplace when the individual performing the behaviour is under the influence of drugs or alcohol. To collect these critical incidents, four 60-minutes focus groups were conducted with a wide variety of participants including nurse supervisors and administrators, hospital association and nurse labour union representatives, pharmacists and nurses previously enrolled in an alternative programme. We created the following protocol for the focus group interviews. Before the day of the focus group, we e-mailed the participants and asked them to think about what they would consider to be signs of impairment at work. The first author served as the focus group facilitator for each focus group and started with a brief introduction including the confidentiality ground rules because of the sensitivity of the topic area. The focus group agenda and data collection included three approaches and parts. The participants were handed 5 9 7 inch note cards to write down their responses. They were told that the note cards would be handed in at the end of the focus group to the research team and that the cards accounted for additional responses that may not have been voiced during the focus group. The second and third authors took notes and asked for clarifications if they were unable to understand the participants’ responses. After the brief introduction, the participants were asked to write down and share any behavioural signs of impairment that came to mind as a result of the preliminary instruction that was e-mailed prior to the 797

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focus group. The facilitator described next the categories of impairment identified by the Canadian Nurse Association (2009) report and asked participants to write down any additional impairment behaviours that occurred to them as a result of reviewing the different impairment categories. As mentioned before, the Canadian Nurse Association (2009) categories lacked definitions, therefore, the research team created definitions to aid the focus group participants to develop indicators for these categories which are displayed in Table 2. In the final part, participants were asked to generate a list of impairment behaviours from the perspective of alcohol vs. drug induced impairment behaviours and whether the participants could generate behaviours that were specific to the two types of impairment. After the completion of all the focus groups, the authors combined their notes into a single list of behaviours associated with substance use in the workplace. We initially planned to conduct a fourth focus group of alternative programme graduates, but decided that from an ethical perspective the anonymity of the participants of these programmes was a higher priority. Therefore, we developed an anonymous online survey asking the same questions and using the same prompts as the face-to-face focus groups. Two intermediaries whom the potential participants knew through their treatment programmes distributed an e-mail that contained a link to the survey. The research team had no direct contact with the participants, thus maintaining participants’ anonymity. We had seven survey participants and added their responses to the list collected from the face-to-face focus groups. The open-ended questions on the survey were analysed by all three authors to identify key themes and behaviours indicating substance use and fitness to perform. The focus groups and survey process generated 136 total behaviours. The 136 behaviours were separate from the 87 behaviours that were identified from the

literature review. Therefore, 223 total impairment behaviours were collated through the first two phases of the tool development.

Reduction of the list of behaviours An iterative review process, including three rounds, was used to reduce the list to a non-redundant set of observable behaviours in the third phase of the tool development. The authors first examined the 223 behaviours collated from the literature and focus groups to eliminate redundancy. Each author independently reviewed the list of behaviours and identified behaviours for removal. Behaviours that were identified for elimination on all of the authors’ lists or on two of the three author’s lists were excluded. Behaviours that were identified for deletion by only one of the authors were discussed at a meeting and removal decisions for exclusion were made when the research team reached consensus. During the second round of the review process, each author also sorted the behaviours into the four categories identified in the Canadian Nurse Association (2009) report – physical, social, performance and drug diversion to validate whether the typology was comprehensive enough to accommodate all the behaviours that we had collected. During this process, the authors decided that the behavioural categories needed to be reorganised because we had difficulty sorting specific behaviours into only one category. For instance, the behaviours in the drug diversion and performance categories were found to be closely associated and were combined into a general category termed ‘performance’. Additionally, the team decided to create sub-categories within the major categories because the sub-categories provided a clearer definition of behaviours that should be included in each respective major category which made the sorting process easier and more consistent. For example, attendance/work pattern changes, documentation, drug diversion, decision-making and policy

Table 2 Impairment categories, category definition and number of items CNA (2009) category

Common risky behaviour checklist category

Physical

Physical

Performance

Cognitive performance

Social Drug diversion

Interpersonal concerns Drug diversion/policy deviation Attendance/work pattern changes

798

Number of items (CRBC)

Definition Indicators that are visibly apparent on the person who has potential or actual substance use issues Indicators that are reflected in the person’s ability to deductively reason and make sound professional decisions Indicators that are reflected in a person’s social interactions on the job Indicators that are associated with stealing drugs on the job Indicators that are reflected in changes in the person’s presence at work

8 5 5 24 7

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Common risky behaviors checklist

deviations were used as sub-categories in the performance category. Moreover, cohesion-related behaviours and professionalism were sub-categories used in the social behaviour category. Finally, abuse-masking behaviour (i.e. behaviours that hide abuse like constantly using breath mints) was included in the physical category. In the third round of review, the first and second authors identified items that are objective, observable and relate to performance of core nursing tasks. For example, ‘appears distracted’ was a behaviour that was removed from the list because it was based on a subjective opinion and not directly related to a core nursing task. In contrast, ‘fails to ensure observation or co-signing for narcotic wastage’ was a behaviour that was retained because it was objective and related to a core nursing task. Examining the behaviours using the criterion of observable behaviours related to core job tasks, the number of behaviours was further reduced from 151 to 61. In the final round, the third author reviewed and reworded the list of 61 behaviours to make them action/behaviour focused and further reduced the list from 61 to 49 behaviours, eliminating behaviours that were redundant, deemed too vague, or were not closely tied with substance use per se. The process not only significantly reduced the amount of behaviours, but also resulted in a new categorisation of the impairment behaviours. In Table 2 we list the Canadian Nurse Association (2009) categories along with the categories, the definition of each category and the number of items in each category that were left from our review and reduction process.

Subject matter expert (SME) review The fourth phase of development was the subject matter expert (SME) review of the reduced list of behaviours that had emerged from the first three phases. In this case, SMEs were substance use and recovery experts and drug impairment assessment experts. Four SMEs responded to a survey that asked them to review and rate each behaviour on its level of importance (on a 5-point Likert-type response scale: 1, unimportant to 5, very important) as a behaviour related to ‘fitness for duty’. They also rated to what degree each behaviour differentiates (on a 3-point Likert-type response scale: 1, does not differentiate to 3, clearly differentiates) a person who is fit for duty from one who is not. The participants were also asked to add, delete, reword items and/or move items to different categories as needed (Appendix S2: The Survey). ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 794–802

The result of this process was a revised list of 58 behaviours. A second set of SMEs, nine nurse supervisors, were asked to review and respond to an updated survey with the revised list of behaviours (Appendix S3: The Updated Survey). Data from the surveys were entered into Statistical Package for the Social Sciences (version 17.0; SPSS Inc., Chicago, IL, USA) for descriptive analysis, which included calculating the mean (average) rating for each behaviour on the ‘importance’ and ‘differentiation’ response scales. The supervisors’ mean responses for each behaviour are displayed in Appendix S4. The information gathered was used to develop a set of decision rules and scores for cut-off points to identify behaviours to remove. Any behaviours that were below 4.0 on mean importance ratings (range: 1–5) and below 2.0 on mean differentiation ratings (range: 1–3) were removed. This is a standard procedure used in job analysis surveys to identify critical, job-related tasks and behaviours (Cascio & Aguinis 2011, Gatewood et al. 2011).

Final refinement of the behavioural list The fifth phase of tool development was the further refinement of the form design to improve a nurse supervisor’s feasibility of use. For example, several behaviours referred to changes in charting could have been stated with one behaviour. Another behaviour referred to a hospitalised patient who reports medications brought from home as missing, even though some hospitals may limit patient ability to bring medications from home to the bedside for nurse administration. Finally, there was also a behaviour related to pharmacy practice which was not as applicable to nurses. The final list of behaviours was composed of 29 behavioural indicators of workplace impairment derived from the five phases of the tool development process and organised into a checklist format that fits on a single (8.5 9 11 inch) paper sheet. Limiting the tool to one page was based on feedback and discussion with nurse supervisors that indicated they would be more likely to use a tool that is short and requires less of their time. Additionally, to facilitate use, behaviours were phrased objectively to assist supervisors in the formal documentation process of behaviours.

Feedback from nurse supervisors The final phase of the tool’s development involved nurse supervisors reviewing and commenting on the 799

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revised checklist at a supervisor skills training for worksite monitors who supervise nurses in an alternative programme. Specifically, participants were asked whether any behaviours were miscategorised, needed to be added, needed clarification, should be deleted, or were redundant. When reviewing the feedback from nurse supervisors, it was found that most suggestions had already been considered in previous refinement phases, which meant that the number of changes implemented based on this final review was minimal. The review of the feedback increased the research team’s confidence that the content of the checklist material was valid and relevant to the end-user. Participants were asked to indicate on a 5-point scale (1, strongly disagree to 5, strongly agree) whether the checklist is useful to aid in determining fitness to perform and whether they had any suggestions for formatting the form. Nineteen of 27 training participants (nurse supervisors) provided written feedback, for a response rate of 70%. The checklist was well received as indicated by average response to the item, ‘this checklist is useful to aid in determining fitness to perform’, which was 4.33 out of 5.

Discussion As a result of the multi-phased process, we developed the Common Risky Behaviour Checklist (CRBC), a tool to aid nurse supervisors in determining when a nurse may be questionably fit to practise, particularly in cases of substance abuse. Job analysis was adopted to inform the development of the CRBC because it is a legally defensible and well-validated process used to identify critical, job-related tasks and behaviours to be used for a variety of workplace applications including the development of performance assessment tools (Cascio & Aguinis 2011, Gatewood et al. 2011). Ultimately, the meticulous set of steps associated with job analysis established the assessment tool’s job-relevance in that it captures behaviours that would be displayed in a nurse practice setting (e.g. Gatewood et al. 2011). The final version of the checklist is displayed in Figure 1. Although we followed a valid and systematic tool development process, there are limitations associated with the tool that can be addressed in future research. First, we did not investigate the empirical sensitivity and specificity of the tool. In other words, future research is needed to establish support for the criterion-related or predictive validity of the tool. Second, and related to the first limitation, we do not know whether certain behavioural indicators or specific 800

categories are stronger predictors than others and could be given different weights and therefore maybe the tool could also be parsimoniously reduced to just a few categories. Third, we recognise that organisations already have established human resources policies and processes associated with workplace drug use and performance assessment which may be in conflict with the CRBC. Therefore, examination and reconciliation with internal policies and processes will need to occur prior to the adoption of the tool into practice. Fourth, the tool was developed mainly with the input from nurses in acute care settings, and all of these behaviours may not generalise to all nurse practice settings. For example, the ‘drug diversion’ category may not apply to a practice setting where drugs are not dispensed, such as in a community clinic. Future research should test the tool’s reliability by utilising it across practice settings, and if significant differences are identified, setting-specific behavioural indicators could be added to customise the tool for the particular setting. A final limitation is whether exposure to the tool alone improves the knowledge, awareness and ability of supervisors to identify impaired performance or whether more formal substance use training is needed to observe positive effects. From our previous research (Cadiz et al. 2012), we have observed positive effects of a supervisor training where the tool was embedded in the content of the broader training. Future research could examine the impact of a CRBCspecific training focused on improving a nurse supervisor’s ability to identify impaired performance due to substance use.

Conclusions Because of the rigorous process used to develop the CRBC, we are confident that the checklist is helpful for the direct supervisor in protecting patient safety and managing a nurse with a potential substance use issue. It has four relevant strengths and features, namely that it, (1) is an objective tool to collect information about five behavioural categories, (2) guides the systematic collection of information for urgent decisions as well as information that can reveal performance patterns over time, (3) provides descriptive, specific language that can be used in formal documentation, and (4) organises information in a single one-page format that can later be transferred to appropriate organisational forms. In the absence of a commonly accepted standard that fits all practice settings, we strongly recommend that nurse supervisors receive evidence-based training ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 794–802

Common risky behaviors checklist

Common Risky Behaviours Checklist Below is a checklist of observable behaviors that may aide a supervisor when assessing if a health care professional is questionably fit for duty particularly in cases of substance abuse. It is not intended for performance evaluation or as a substitute for documentation required by an organisation’s substance abuse and personnel policies. Please note that each employee may display or present unique behaviors not described below. Attendance/Work Pattern Changes Shows up when not scheduled for shift. Takes extended breaks during the shift, sometimes without telling colleagues and without explanation. Calls in sick frequently or uses other excuses to miss assigned shifts. Pattern of calling in sick before or after a weekend/multiple days off.

Cognitive Performance Forgets how to complete simple tasks. Makes inaccurate judgments regarding patient care. Exhibits confusion about directions or instructions. Unable to accurately communicate specific patient information with team members and/or patients. Inability to complete assigned tasks that others do adequately. Consistent inability to improve performance or conduct even with training or counseling. Interpersonal/Social Performance Exhibits aggression or hostility towards patients and/or coworkers. Responds aggressively when provided performance feedback. Crosses professional boundaries through inappropriate sharing of personal information with patients.

Figure 1 Common risky behaviours checklist.

1

Policy Adherence/Drug Diversion Loiters around medicine supply. Insists on performing narcotic counts alone. Reports medication being wasted when the medication was not wasted. Reports wasting more of a drug than seems likely. Inconsistencies between narcotic records and patients’ medical charts for medications administered. Has no explanation for medicine withdrawals. Waits until alone to open narcotics cupboard and/or to draw up medication. Patients consistently complain that pain is not improving after receiving pain medication. Reports lost or wasted medications frequently. Fails to ensure observation or cosigning for narcotic wastage. Asks others to withdraw narcotics for his/her patients. Offers to cover other nurses’ breaks to administer medications to their patients. PRN1 medications for a patient administered at higher frequency than other shifts.

PRN is an acronym for the Latin phrase 'Pro re nata' and is commonly used to mean 'as needed' or 'as the situation

in relevant skills, be administratively supported to implement organisational policies, and be equipped with accurate observation tools that assist them to determine risk when intervening in unsafe or unprofessional practice. The development of this checklist is one of several needed advancements in order to address the issue of fitness to perform, and ultimately, patient safety.

Implications for nursing management Nurse supervisors are often work site monitors of nurses enrolled in alternative programmes. Thus, they are in a unique position to assist the nurse to remain in the profession through supportive interactions, while reducing risks to patient safety through close performance monitoring (Young 2008). However, nurse managers generally lack the awareness and skills required to recognise or intervene with a nurse who is misusing substances, which ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 794–802

Physical Performance Alcohol-like odor on breath. Stumbles/staggers while walking. Changes in speech pattern (for example, slurred, fast, slow). Fumbles/drops equipment.

makes education a priority to deal with nurses with a substance use disorder (Dunn 2005). Furthermore, because of their responsibilities, nurse supervisors and managers should be aware that they may be legally responsible for damage or injury caused by a subordinate – a topic beyond the scope of our project. Nevertheless, it behoves the supervisor to obtain appropriate legal guidance about their duties under the law to determine that subordinate performance meets the clinical standard for patient care. The CRBC tool will assist the nurse supervisor to collect relevant objective information as the basis of corrective action and for providing information in any subsequent investigation. Thus, the CRBC tool can serve multiple purposes, for example, use in training to increase supervisor knowledge and awareness to identify substandard performance that may be due to substance use (Cadiz 801

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et al. 2012). In addition, it can be used objectively to track and document trends in behaviour which is useful in an intervention to correct subordinate performance problems. No matter how the tool is used, it can potentially reduce the liability and risks associated with compromised patient care and workplace safety related to impaired performance.

Source of funding Funding for the development of the Common Risky Behaviour Checklist was provided to Drs Cadiz and O’Neill by the Oregon Health Authority (OHA). The views expressed in this manuscript do not reflect the official policies of the funders.

Ethical approval Ethical approval was obtained from the Institutional Review Board (IRB) at Portland State University (HSRRC #101387 and HSRRC #101372).

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Supporting information Additional Supporting Information may be found in the online version of this article: Appendix S1. Substance use impairment workplace indicators, categorization frameworks, and method used to identify indicators. Appendix S2. Subject matter expert (SME) survey. Appendix S3. Nurse manager/supervisor updated survey. Appendix S4. Nurse supervisor rated mean importance and differentiation.

ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 794–802

Common risky behaviours checklist: a tool to assist nurse supervisors to assess unsafe practice.

To describe the development of the Common Risky Behaviour Checklist, a tool to aid nurse supervisors in determining when a nurse may be questionably f...
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