There are numerous signs related to job performance and attendance that could indicate an employee has a chemical dependency problem. Some of these include (Catanzarite, 1992):

• late to work
• disregards standards of care and practice
• poor judgment
• disorganization
• unreasonable excuses for poor performance
• blames others
• confusion about the work schedule
• difficulty prioritizing
• frequent breaks or time away from work area
• inappropriate behavior
• unsteady work pace
• commits errors
• increased sick days usage
• appears on the unit on days off

There are also numerous physical symptoms that may be exhibited by an individual employee that could indicate chemical dependency. Some of these include (Catanzarite, 1992):

• GI upset
• difficulty with speech
• increased anxiety
• chronic hangover
• diarrhea
• shakiness
• inattentiveness
• alcohol on breath
• diaphoresis
• sniffling, sneezing
• clumsiness
• flushed face
• watery eyes
• frequent complaints of not feeling well

There are also behavior changes that an individual employee may exhibit that might be related to chemical dependency. These include (Catanzarite, 1992):

• mood swings
• drowsiness at work
• suspiciousness
• unusual attendance patterns
• frequent use of breath mints or gum
• disappearance from the unit or into the restroom after accessing drugs
• depression
• defensiveness
• over reaction to criticism
• telling lies or fabrication of the truth
• poor personal appearance

There are also nursing unit specific signs that may indicate drug diversion is taking place on the nursing unit. These include (Catanzarite, 1992):

• discrepancies on the controlled drug count record
• unwitnessed or excessive waste of controlled drugs
• increased quantity of drugs required on the nursing unit
• tampering with drugs, vials or containers
• discrepancies between what the physician orders and controlled drug records
• discrepancies between nursing notes, medication records, and controlled drug records
• inconsistencies with individual patient prn doses required from shift to shift
• controlled drugs given to patients on the day of discharge, or recorded after discharge or transfer
• a change back to the administration of IM or IV pain medication when an individual patient had progressed to oral pain medication
• patients complaining of not receiving medication or not attaining pain relief from medications they received
• a nurse giving medication to patients outside his/her assignment
• defensiveness by an individual when questioned about medications administered or medications picked up, delivered or stocked

The first step is to review unit records. The controlled drug sign-out sheets provide the manager with valuable information. These records are helpful to detect: variances in the administration of medications to individual patients; variances in adhering to policies and procedures; trends on wastage and breakage; failure to properly sign-out controlled drugs; failure to attain cosignatures when required; increased drug supply needs for the unit; or an unusual number of sign-outs from an individual nurse (Catanzarite, 1992). Home health agencies may have additional sources for information due to the nature of nursing practice in this setting. It is often very helpful to work with a pharmacist in reviewing these records. Even if there is no reason to suspect drug abuse occurring on the nursing unit, it is a good idea to review the controlled drug sign-out sheets regularly

If some concerns or inconsistencies are identified during the review of the controlled drug sign-out sheets, patient records should then be reviewed. Often if there are inconsistencies in the drug sign-out sheet, there are inconsistencies in the matching patient records. Individual patient records that relate to the identified inconsistencies should be reviewed for medication administration patterns, pain relief notations, and accuracy and appropriateness of the nursing documentation. Records to be reviewed include: nursing notes, medication administration records, prn medication records, and other patient records pertaining to the administration of medications. Sometimes erratic handwriting will be seen within the documentation which may be indicative of a problem.

If an individual employee is suspected of possible impairment, that employee's personnel records should be reviewed. The record should be reviewed for employment trends such as frequent job changes. Also incident reports and accident reports may indicate problems such as inattention, impaired judgment or lack of control caused by alcohol or other drug use. Performance evaluations may demonstrate a decline in job performance or a trend in disciplinary actions.

Attendance records can also provide specific data that indicate a problem. Does the employee frequently use sick days? Are there trends in when the absences occur, for example, during or after holiday weekends? Do absences occur after recorded high medication use for patients? Are there trends in exchanging days off, in days worked, or in overtime use?

In addition, the manager needs specific documentation of signs and symptoms related to an individual. This documentation is essential in order to assist in deciding what action needs to be taken, to avoid enabling, to meet legal requirements, and to be able to present information to the employee during an intervention.

Sometimes a nurse manager and/or staff become involved in enabling without intending to do so. They may tend to attribute the signs and symptoms they have observed to something other than chemical dependency. Therefore, the staff believe they have a rationale for not taking action. Enabling can be a very subtle process. Gathering objective data helps the manager and the staff to take action when needed.

Gathering specific information on an individual helps to keep the process legally sound. It is important to substantiate that actions taken were based on facts and objective information. Sometimes the employee will threaten or initiate a lawsuit. Objective facts and evidence can help defuse such threats, as well as serve as a defense in the event a lawsuit is actually filed (Catanzarite, 1992).

Another important legal concern is to maintain the integrity and confidentiality of the documentation. All records should be kept separate from the individual nurse's personnel record in a secure location. The discovery of any physical evidence such as used syringes, medication vials, containers of alcohol, etc., should be documented. The safe keeping or disposal of this evidence should be discussed with the nurse executive, legal counsel, and other appropriate personnel.