Nurse's poor performance exposes health issue

This story describes a nurse with long term alcohol misuse. Her name and identifying characteristics may have been changed to maintain privacy.

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The Council received a complaint about RN Sarah’s performance from her aged care employer in 2017. Sarah was 55 and had been registered as a nurse since the 1980’s. She had worked in various settings including acute care and aged care. She had worked for her current employer for the past three years.

How Sarah’s complaints began

Twenty years ago, Sarah had been the subject of health complaints to the regulator. The NSW Health Department advised the Board (at the time) of Sarah’s positive criminal record check relating to larceny and drink-driving. The Board provided Sarah with professional counselling and closed the matter.

Fifteen years ago, Sarah appropriately self-disclosed another drink-driving offence with an eight-month home detention sentence. She breached her detention and was sentenced to five months at a correctional centre. Though the Board was aware of her situation from her self-notification, it took no action because she was undergoing mandated treatment and wasn’t practising as a nurse at the time.

A year later, an employer notified the Board that Sarah was suffering an impairment. The Board required Sarah to attend an Impaired Registrants Panel which imposed conditions on her registration requiring her to seek treatment and be supervised.

Another year later, health assessments indicated that her alcohol use was in remission and supervisor reports indicated satisfactory performance. The Panel recommended removing her conditions and she was discharged from the Board’s health program.

Twelve years later…

The Board didn’t receive any more complaints about Sarah for 12 years, when a new complaint came in from her employer about her performance.

Her employer said Sarah had demonstrated a significant departure from professional standards, placing the public at risk of harm. Sarah had difficulty with problem solving, leadership, time management and medication management. Sarah couldn’t recall and apply policy, safe practice or new information.

The employer moved Sarah to a non-clinical role as a result of the issues.

What the Council did: Urgent short-term action

The Board (now the Council) and the Health Care Complaints Commission (HCCC) considered the complaint and Sarah’s history.

Even though Sarah was in a non-clinical role, she was using her nursing skills and was still employed as a registered nurse. Due to potential risk to the public, the Council took immediate action, requiring Sarah to work under supervision when practising as a registered nurse.

Although the issues were related to poor performance, the HCCC and Council agreed the complaint should be managed in the health program after considering her history.

Sarah’s health deterioration

Sarah was assessed by a neuropsychologist who found cognitive deficits in her non-verbal reasoning and information processing. She also displayed deficits in thinking quickly and flexibly.

The deficits may have resulted from her previous alcohol use and binge drinking. Sarah reported that she had ceased drinking alcohol 6 months ago and was attending Alcoholics Anonymous.

The neuropsychologist’s opinion was that the deficits would likely impact on her capacity to work as a registered nurse in acute care settings. He recommended Sarah work in a structured nursing environment with routine duties.

What the Council did: Longer-term conditions

The Council’s Impaired Registrants Panel considered Sarah’s health assessment and her responses. With her agreement, the Panel imposed conditions requiring her to work under supervision, with regular supervision reports. She was not to engage in agency nursing, not to work as a sole practitioner on any shift, and was only permitted to administer medication under direct supervision.

She was monitored by the Council and required to have regular health assessments and continue with health treatment, supervision and monitoring. 

Sarah challenged her conditions

Two years later, Sarah requested a review of her conditions. Although her employer had supported her through this process, Sarah didn’t find her non-clinical role stimulating and missed her role as a clinical nurse. She was looking for work in aged care and was frustrated that she could not find a job in clinical practise. She acknowledged her memory was not good and she hadn’t worked in the capacity of a registered nurse for more than three years.

In the latest health assessments, the psychologist and neuropsychologist reported she had cognitive dysfunction secondary to chronic alcohol dependency (which was in remission) and major depression. The nature of her cognitive impairment would likely cause ongoing concern in a busy and challenging environment.

The panel had concerns about her level of insight about how her cognitive deficits may impact on her practice. She also hadn’t kept up her continuing professional development. During the hearing she spoke slowly and lost track of the discussion several times.

The panel’s decision

The panel felt Sarah didn’t have the capacity to work safely as a registered nurse and recommended she undergo a performance assessment to evaluate this. Sarah asked to undertake a refresher course prior to the assessment. She explained she wasn’t ready to surrender her registration. 

The panel discussed the associated costs of a refresher course or sufficient CPD, and the challenges she may experience due to her cognitive impairment. Sarah believed she could overcome these challenges.

The panel decided to continue to monitor her in the health pathway (with Sarah not working as a nurse) and to assess her health and performance when she next requested a review, following the refresher education she informed the panel she planned to do. 

The Council did not receive another request for review from Sarah. The next year Sarah advised that she was no longer employed by the aged care facility in any capacity and she surrendered her registration.

Key lessons

Sarah abstained from alcohol while in the health pathway 15 years ago. Unfortunately she relapsed a few years later but did not self-report or pursue appropriate treatment. The Council only became aware of Sarah’s relapse after significant cognitive damage had occurred.

Had Sarah, one of her employers, or the Council been able to identify her relapse, she might have re-entered the health program sooner with the potential to improve her health outcomes over time. While this may have resulted in conditions, these would have been likely to be protective of both Sarah and patients. They may also have been less restrictive than those ultimately required by the progression of her alcohol use disorder. 

How health issues can be missed

  • By employers:
    • During the relapse, Sarah worked with several employers while drinking at levels sufficient to result in cognitive dysfunction. Her frequent changing of employers may have prevented them from identifying either performance or health issues.
    • Alternatively, sometimes when employers raise initial concerns with a practitioner, the practitioner resigns before an assessment can occur.
  • By practitioners:
    • Some practitioners are reluctant to seek help for their health issues because they fear being reported and losing their registrations. There have been recent changes to the mandatory reporting requirements in order to encourage practitioners to seek appropriate treatment. These changes will take effect in early 2020. Treating practitioners will only be required to report patient practitioners if they believe there is a substantial risk of harm to the public or patients.

What we can do better

  • For employers:
    • Sarah’s last employer did several things well. They identified Sarah’s significant performance issues that posed a risk of harm to patients and they appropriately made a mandatory notification to the Council. They also continued to support her by offering her a non-clinical role where risks were minimised.
    • This type of support from employers is very important. It demonstrates to employees that it is safe for them to be open and honest with their employer, which encourages them to seek help earlier. It also provides employment, stability and support for the practitioner while they recover. Employers will have limits to the support they can offer, but reasonable accommodations can make a big difference to an employee’s recovery.
    • Making a notification to the Council is one way that employers can support their employees when they notice a practitioner with performance issues or a lack of self-awareness about a health impairment. The Council’s aim is not to punish practitioners who are reported, but to ensure that they are able to return to work safely. The Council can call for health assessments and health monitoring to enable the practitioner’s recovery.
  • For practitioners:
    • Practitioners should be aware of their level of wellbeing and health. It is important to take appropriate breaks and seek support when becoming either mentally or physically unwell.
    • It is important for a practitioner to notify employers when a health issue has potential to negatively impact on practice. This enables the employer to make reasonable adjustments to maintain patient safety and support the practitioner’s health. Self-notification to the regulator may also be required for more serious and longer-lasting illness that impacts on practise.
    • Self-reporting demonstrates awareness and understanding of professional behaviour. Self-reporting doesn’t mean you will lose your registration or have to stop working. Regulators intervene for health issues only when the issues are likely to result in poor clinical judgement, unsafe practice and risk of harm to patients (and when the practitioner lacks awareness of this). Many practitioners with reported health disorders (both physical and mental) obtain appropriate treatment and are able to practise safely.