Digital Repository Doctoral Projects Fall 2021 Development of an Evaluator Toolkit for the Utah Professionals Health Program Paige Erickson Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Erickson, P. (2021) Development of an Evaluator Tookit for the Professionals Health Program. Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. Development of an Evaluator Toolkit for the Utah Professionals Health Program by Paige Erickson A project submitted in partial fulfillment of the requirements for the degree of DOCTOR OF NURSING PRACTICE Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, Utah December 12, 2021 Jessica Bartlett, DNP, CNM, RN, IBCLC__(signature) Faculty Advisor/Committee Chair (Jessica Bartlett, DNP, CNM, RN, IBCLC) Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE (signature) Graduate Programs Director Running head: UPHP EVALUATOR TOOLKIT 1 Development of an Evaluator Toolkit for the Utah Professionals Health Program Paige Erickson Weber State University UPHP EVALUATION TOOLKIT 2 Abstract 10-15% of healthcare providers (HCPs) will struggle with substance use disorders (SUDs) or misuse substances throughout their careers. Since HCPs with SUDs are a safety risk, they must receive prompt treatment. The Utah Professionals Health Program (UPHP) is ideal for HCPs to get the treatment they need. The purpose of this Doctor of Nursing Practice (DNP) project was to provide a toolkit so that UPHP evaluators can assess HCPs with SUD accurately and quickly to determine an appropriate recovery plan. This DNP project involved creating a toolkit for the UPHP evaluator responsible for assessing HCPs seeking entrance into the program. The toolkit was developed for the UPHP website and provided information and resources about becoming a UPHP evaluator. It also includes a comprehensive evaluation example, intake forms, and guidelines to determine appropriate recovery interventions. The UPHP Executive Advisory Committee reviewed and unanimously approved the evaluator toolkit. The toolkit was adopted by UPHP and made available on the UPHP website. Feedback from the committee included: the website was easy to navigate; it will increase consistency among UPHP evaluators; and finally, it will help with accurate evaluations for the HCP with SUD. The UPHP is an important recovery program for HCPs with SUDs. It offers a confidential, non-punitive approach while assisting the HCP on their road to recovery. Developing and implementing an evaluation toolkit for such programs improves consistency and accurate evaluation and ultimately helps the HCP return safely to practice. Keywords: substance use disorder, addiction, healthcare professional, treatment, recovery, safety-sensitive, specialized treatment, education, stigma, non-punitive UPHP EVALUATION TOOLKIT 3 Development of an Evaluator Toolkit for the Utah Professionals Health Program Healthcare professionals (HCPs) are considered champions of health; however, their substance misuse and addiction rates are no different from the general population (Butler Center for Research, 2015). It is suggested that 10-15% of health care professionals will misuse substances throughout their lifetime (Alunni-Kinkle, 2015; Braquehais et al., 2014). Healthcare professionals and the general population who misuse substances face similar barriers with similar consequences, such as suicide and overdose (Braquehais et al., 2014). However, healthcare professionals with substance use disorder (SUD), who delay seeking treatment, may place their patients at immediate risk for harm (Brooks, Gendel, Early, & Gundersen, 2018;2017). Professional Health Programs (PHPs), such as the Utah Professionals Health Program (UPHP), are available to HCPs with substance use disorder (SUD) and offer a confidential, non-punitive approach while assisting the HCP on their road to recovery. A comprehensive clinical evaluation must be performed before participating in a PHP to determine the participant's eligibility and determine the best course of treatment. The successful assessment of HCPs has unique challenges as these professions and positions may enable the individual's SUD and increase the risk for both patient harm and self-harm. Therefore, evaluators of HCPs with SUD must be specifically trained on how to work with this population. The purpose of this Doctor of Nursing Practice (DNP) project was to provide a toolkit so that UPHP evaluators can assess HCPs with SUD accurately and quickly to determine an appropriate recovery plan. The Search The search for peer-reviewed articles was conducted via Weber State University's online library. The databases included Academic Search Ultimate, Medline, PubMed, Gale Academic OneFile, JAMA, Sage Journals, Science Direct, and CINAHL Complete. Google Scholar was UPHP EVALUATION TOOLKIT 4 also utilized in this search to access relevant literature. Substance use disorder, addiction, healthcare provider, safety-sensitive, education, impaired, diversion, rehabilitation, and stigma were search terms used to locate articles specific to this review. Variations were used of these terms to ensure a thorough search. The most current research was utilized for this review; however, dates range from 1998 to 2020 and include one article from 1972 to ensure the inclusion of all sentinel studies related to this topic. Literature Review Substance Use Disorder SUD or addiction is a neurobiological condition (Burda, 2020) in which an individual loses control of their use of alcohol, illegal or legal prescription drugs, and medications (Mayo Clinic Staff, 2017). Individuals with SUD often have a disproportionately strong response to dopamine-releasing substances like opiates, alcohol, nicotine, amphetamines, and cocaine. This exaggerated response can be preexisting or drug-induced (Samuelson & Bryson, 2017). Characteristics of SUDs are impaired behavior and brain function in an individual, which can cause considerable harm to self and society as a whole (Yang, Wong, Grivel, & Hasin, 2017). In SUD, an individual continues using substances even while experiencing significant substance-related problems (Carter, McMullan, & Patrician, 2019). Factors increasing the risk of SUD include genetic make-up, ethnicity, gender, the presence of other comorbidities, substance abuse in adolescence, socioeconomic status, friends and family with SUDs, quality of life, and availability of the substance (The Department of Veterans Affairs & the Department of Defense, 2015). Individuals struggling with SUD are frequently reluctant to seek treatment as they tend to deny their substance use is problematic or lack the resources needed to access such treatment UPHP EVALUATION TOOLKIT 5 (Mayo Clinic Staff, 2017). It is estimated that in 2018, 21.2 million people in the US needed substance use treatment, which translates to about 8% of the US population. Of those 21.2 million people, 6.1 million received substance use treatment, with 2.4 million receiving treatment at a specialty facility. In those who needed SUD treatment but did not receive it, one in three had no insurance and could not afford it (SAMSHA, 2019). Consequences. Consequences related to SUD can range from being mildly life-altering to fatal. Some of the most common negative social consequences of substance use include accidents, involvement in fights, police encounters, impaired driving, difficulty maintaining relationships, and employment (Tómasson & Vaglum, 1998). Societal costs of substance misuse are estimated to be over $532 billion each year; this includes tobacco, illicit drug, and alcohol use. These costs associated with substance use are due to the treatment of disease, criminal activity, violence, lost productivity, unwanted and unplanned sex, premature death, law enforcement, prosecution, incarceration, and probation (Friedland, n.d.). In particular, prescription opioid misuse is responsible for $78.5 billion each year in the US, related to health care costs, lost productivity, and crime (US Official News, 2018). Krebs et al. (2017) estimate that substance misuse, not including tobacco, costs the US $220 billion annually and $69.9 billion in criminal justice costs alone. People with SUD are more likely to achieve lower levels of education. For example, Ellis, Kasper, and Cicero (2020) surveyed patients (N = 14,349) entering opioid treatment programs across the united states. They found that just 7.8% of treatment-seeking opioid users had earned a bachelor's or advanced degree compared to the US population as a whole, of whom 32.2% are estimated to have earned a bachelor's/advanced degree. In addition, 56.7% of respondents reported using opioids while attending an educational institution, the majority in UPHP EVALUATION TOOLKIT 6 high school. Lower levels of education result in unobtained jobs or jobs with inadequate financial compensation, reduced benefits, and jobs that require physical labor; these types of jobs put people at risk for continued opioid use or relapse due to their physical nature (Cerdá et al., 2017). SUD puts individuals at risk for suicide, drug overdose, and death. The National Vital Statistics System reports that in 2019 there were 70,630 drug overdose deaths in the US, which is a 4% increase from 2018. 70.6% of the nearly 71,000 drug overdose deaths in 2019 involved an opioid (CDC, 2021). Additionally, individuals with drug and alcohol disorders are 17 and 10 times more likely to die from suicide than their peers, and the lifetime prevalence of suicide attempts ranges from 20% to 50% (Artenie et al., 2015). By administering questionnaires to 797 individuals who reported injecting drugs in the previous six months, Artenie et al. (2015) found a positive association between alcohol and sedative-hypnotics (particularly benzodiazepines) and cannabis, and the increased likelihood of later suicide attempts. Overall, an individual with SUD has increased chances of negative social consequences, including, but not limited to, lower education levels, jobs with more inadequate financial compensation, the risk for suicide/suicide attempts, drug overdose and death by overdose, and increasing the nation's taxpayer costs. Barriers. Proven successful treatment options are available for individuals struggling with SUD and can improve their quality and length of life; however, many treatment barriers exist. Barriers in SUD include, but are not limited to, the stigma of SUD and lack of access to care/treatment options. Some suggest that stigma is the leading cause of the lack of access to SUD/addiction treatment. Some factors that mediate the stigma associated with SUD/addiction include the misconception that addiction is not a disease but a deliberate choice; the partition between addiction treatment and the rest of the medicine; the language that is associated with UPHP EVALUATION TOOLKIT 7 addiction; and how the criminal justice system rarely incorporates medical judgment into their approach to people with addiction (Wakeman & Rich, 2018). Healthcare Providers with Substance Use Disorder SUD and addiction have existed in literature since 1869. Since the early 1840s, consecutive with the initiation of using ether as an anesthetic in surgery by a surgeon familiar with its recreational effects, the abuse of anesthetics and analgesics, particularly by HCPs, has increased significantly (Butler Center for Research, 2015). HCPs belong to a psychologically vulnerable profession and are at risk for mental health issues, including SUD. Today, health care professionals are expected to be professionals, and each has shared values and standards that govern their work. In medical professionalism, self-regulation is central to the ideology of the autonomous roles of HCPs (Wynia, 2010). Unfortunately, the autonomous and self-regulating qualities which HCPs possess often result in the repression of help-seeking behaviors; this becomes problematic for a HCP with SUD being a safety-sensitive population. The rate of HCPs with SUD mirrors that of the general population, which, depending on the region, is 10 to 15%. However, physicians have a rate five times higher than the general population of prescription drug abuse and addiction, especially in their use of opioids and benzodiazepines (Samuelson & Bryson, 2017). This startling rate of abuse is suspected to be related to the ease of access to prescription drugs. Some studies suggest that 87% of physicians have prescribed medications to themselves and HCPs who have prescriptions for pain medications, 55.3% wrote the prescription themselves (Butler Center for Research, 2015). One study found that the Texas Board of Nursing's drug and alcohol-related disciplinary actions accounted for one-third of the corrective actions taken (Ramshaw, 2010). Additionally, alcohol and drug abuse are the leading cause of medical license withdrawal and disciplinary action UPHP EVALUATION TOOLKIT 8 against physicians by state licensing authorities in the US (Vayr, Herin, Jullian, Soulat, & Franchitto, 2019). Risk Factors. Working in healthcare requires human contact and rapid decision-making skills that can drastically impact a patient's social, financial, and medical well-being. High work-related stress, exposure to death, trauma, illness, extreme work responsibilities, and sleep deprivation give HCPs a spot among the top six most stressful professions (Butler Center for Research, 2015; Koinis et al., 2015). Risk factors for the development of SUD in HCPs include gender (males more common), epigenetics, novelty-seeking behavior traits, comorbid psychiatric disorders, stress, ease of access, prior history of SUD, or experimentation with the use of a significant opioid drug (morphine, fentanyl, hydromorphone), and a family history of SUD (Samuelson & Bryson, 2017). Merlo et al. (2013) interviewed 55 physicians monitored by their state physician health program (PHP) due to SUD-related impairment. They reported the five primary reasons for prescription drug misuse were: to manage physical pain, emotional/psychiatric distress, stressful situations, for recreational purposes, and to avoid withdrawal symptoms. Risk factors for nurses susceptible to SUD in the workplace are lack of SUD education, ease of access, attitudes towards drugs and drug use, role strain, and enabling behavior from peers and managers (Bettinardi-Angres, Pickett, & Patrick, 2012). Stress is linked to the facilitation of substance use in humans, and stressful experiences can increase an individual's chances to develop drug self-administration, inducing a drug-prone phenotype (Piazza & Le Moal, 1998). This information is supported by Vaillant, Sobowale, and McArthur (1972) and suggests that being a physician alone increases stress and SUD. This study UPHP EVALUATION TOOLKIT 9 followed Harvard sophomores for 30 years and found that the 47 who became physicians had higher rates of miserable marriages, alcohol and drug abuse, and psychotherapy use. Symptoms of an HCP with SUD. For quite some time, HCPs with SUD may appear functional and healthy. Often, the source of drugs the HCP is addicted to is at their workplace, so for some time in the early stages of SUD, the HCP will remain extraordinarily attentive and physically present at their job. Thus, it may not be until very late in the SUD that evidence of an individuals' impaired state is apparent (Samuelson & Bryson, 2017). Tell-tale signs of a HCP with a SUD are (Samuelson & Bryson, 2017; Toney-Butler, Siela, 2019): • mood changes with periods of depression, anger, and euphoria • spending more time at the hospital or workplace even while off duty or rounding at odd hours • volunteering for extra shifts • refusing relief for lunch or coffee breaks • frequent bathroom breaks • frequent mistakes and tardiness • increased discrepancies in controlled substance records • regular reports of patients not receiving pain relief • paranoia • poor charting • weight gain or loss • disheveled appearance • withdrawal from family, friends, and leisure activities UPHP EVALUATION TOOLKIT 10 • and frequent unexplained absences. Consequences. Being a HCP with SUD can lead to a loss of career and license, health issues, destruction of family and personal life, and even death by suicide, overdose, or other SUD complications like heart and liver disease or communicable infections. A HCP with unhealthy substance use often struggles with depression; this combination of mental illness and SUD increases their risk of suicide (Artenie et al., 2015). When a diagnosis of SUD is suspected or revealed, HCPs, especially physicians, may choose to sacrifice their careers by ending their lives or quitting rather than disclosing their problem. They do this, not knowing the resources available to aid in a successful recovery and a return to a healthy life and practice (Vayr, Herin, Jullian, Soulat, & Franchitto, 2019). Impaired HCPs can also cause others to suffer, including their families, peers, the institutions they work for, and the patients they treat. Adverse effects of unhealthy substance use can be seen in 15.1% to 20.8% of providers' families (Sørensen, Pedersen, Vedsted, Bruun, & Christensen, 2016). In addition, unhealthy substance use may impair the HCP from providing safe and adequate patient care. For example, Suzuiki et al. (2004) found that nurses with poor mental health, including substance misuse and addiction, reported higher medical errors than nurses classified as having good mental health. As a result, impaired HCPs are at risk for negligence, medical malpractice actions, and criminal charges, including felony prosecution. In 2010, the medical liability costs were estimated to be $55.6 billion, with $17-29 billion in preventable medical injuries (Mello, Chandra, Gawande, & Studdert, 2010). Many of these preventable injuries could be attributed to impaired HCPs, as estimates of HCPs with SUD working-impaired are between 10% and 15%. These patients of impaired HCPs can develop decreased trust in HCPs, infections from contaminated needles from HCPs diverting UPHP EVALUATION TOOLKIT 11 medications, become medical error victims, and experience undue pain or death (Toney-Butler, Siela, 2019). Failing to report or recognize impairment in HCPs can negatively affect an institution and fellow HCPs who share a patients' care. Peers of HCPs with SUD can also receive disciplinary action for failing to report their colleagues and face liability issues themselves. Institutions also face civil liability issues by failing to recognize or address impairment in a HCP. Malpractice incidents can decrease an institutions' reputation and increase Workers' Compensation costs (Toney-Butler & Siela, 2019). Treatment.Physician's Health Programs (PHPs) were developed in the US in the late 1970s. A PHP's mission is to help sick doctors establish mental and overall wellness and support safe medical practice; PHPs monitor for long-terms (about five years) once doctors enter the program. A HCP's offense or lack of violations determines if they qualify for disciplinary action, such as revoking or suspending their license, and admittance into a diversion or alternative-to-discipline program, like a PHP. Contingent on the physicians' compliance with the PHP recommendations, the PHP acts as a support and sanctuary from professional and legal consequences (Braquehais, Tresidder, & DuPont, 2015). PHPs are responsible for promoting early detection, evaluation, assessment, and physicians' referral to abstinence-oriented treatment. Physicians are then required to attend 12-step outpatient programs, are randomly tested for substance use through urine sampling; and employers, state licensing boards, and insurers are issued status reports for usually five years or more (DuPont, McLellan, Carr, Gendel, & Skipper, 2009). Physicians who complete a PHP, or are still being monitored by their state PHP, have an annual rate of malpractice risk 20% lower than a matched cohort who were not monitored (Brooks et al., 2013). UPHP EVALUATION TOOLKIT 12 Nurses are allowed similar alternative-to-discipline programs for SUD, enabling impaired nurses to demonstrate to Boards of Nursing (BON) that they can retain their license by becoming and remaining sober and safe (NCSBN, n.d.). In the US, 43 states have these non-punitive programs that guide nurses with SUD into recovery and treatment programs. However, nurses cannot enter an alternative-to-discipline program if they are guilty of diverting drugs for sale or distribution, if they caused harm to a patient related to their substance abuse, or if they engaged in behavior that put a patient at risk for serious injury (Bettinardi-Angres, Pickett, & Patrick, 2012). Utah's non-punitive program, the Utah Professionals Health Program (UPHP), aims to facilitate treatment and recovery of HCPs with SUD. Unlike the Physician's Health Program, meant solely for physicians, the UPHP is available to physicians, physician assistants, nurses, pharmacists, veterinarians, podiatrists, and dentists licensed by the Division of Occupational and Professional Licensing (DOPL) (UPHP, 2021). Treatment and return-to-practice outcomes are positive for HCPs who are monitored through alternative-to-discipline programs. For example, Weenink, Kool, Bartels, and Westert (2017) conducted a systematic review examining the effects of remediation and rehabilitation programs for HCPs. At the time of follow-up in three studies included in the systematic review, 82%, 92%, and 95% of physicians were practicing medicine, and in four studies, 74%, 81%, 90%, and 90% were the return rates for nurses. Barriers for HCPs with SUD. Barriers that prevent or delay treatment for SUD or addiction in HCPs include, but are not limited to peer monitoring, access to specialized treatment, personality traits, stigma and the perceived risks of self-reporting, and lack of SUD education. UPHP EVALUATION TOOLKIT 13 The primary mechanism for identifying an impaired or incompetent nurse or physician is peer monitoring. When SUD is suspected, and a HCP cannot provide competent medical services or care, it is the responsibility of that individual's colleagues to ensure patient safety (Vayr, Herin, Jullian, Soulat, & Franchitto, 2019). One barrier to this is that nursing and medical training programs lack a curriculum on preventing prescription drug misuse and SUD in HCPs. This deficiency in training results in the hesitancy of HCPs and their colleagues to report any problems for fear of negative financial, social, legal, and professional consequences (Butler Center for Research, 2015; Carter, McMullan, & Patrician, 2019; Merlo, Singhakant, Cummings, & Cottler, 2013). Moreover, some HCPs avoid addressing SUD in their peers because they feel it is private (Sørensen et al., 2016). In a nationally representative survey of 2,938 practicing physicians in the US, 64% of participants agreed that it was part of their professional commitment to report impaired physicians. 69% of physicians felt they were ill-equipped to deal with an impaired colleague effectively. Of physicians who had direct personal knowledge of an impaired or incompetent colleague, only 67% reported that colleague; the reason for most underreporting was that these physicians assumed someone else was taking care of the problem (19%) (DesRoches et al., 2010). Stigma can be defined as a mark of disgrace or infamy; or an attribute, behavior, or socially discrediting condition (Kelly, 2016). The public and HCPs hold stigmatized views towards those who struggle with SUDs. Stigma is higher for SUD than severe psychiatric disorders and even higher for intravenous drug users (IDUs). Kelly (2016) states that no other disease is stigmatized more than addiction. Several studies have found that the public's reactions to individuals with SUD include fear, anger, and pity (Yang, Wong, Grivel, & Hasin, 2017). UPHP EVALUATION TOOLKIT 14 They also found that 71-87% of the public agree that people with SUD tend to be more dangerous than individuals with severe psychiatric disorders. Additionally, 59-67% believed that individuals with SUD were more to blame for their condition than individuals with other psychiatric disorders; this is a continued stigma. Continued stigma focuses on the fact that the first use of an addictive substance is a choice. It disregards that self-regulating impulses to use a substance become impaired in genetically predisposed individuals after introducing an addictive substance (Kelly, 2016). The stigma surrounding mental illness, including substance misuse and addiction, persists despite widespread removal attempts. HCPs with SUD may experience a range of stigmatizations. These include (Clement et al., 2015): • anticipated stigma (anticipation of being mistreated or perceived differently) • internalized stigma (having stigmatized views about themselves) • perceived stigma (a persons' views on how others perceive other individuals with SUD) • stigma endorsement (a persons' own held stigma towards people with SUD) • and treatment stigma (the stigma associated with seeking and receiving treatment for SUD). HCPs with SUD face the risk of feeling like a failure and being considered weak if they report their difficulties, increasing their fear and anticipated and internalized stigma (Vayr, Herin, Jullian, Soulat, & Franchitto, 2019). An even more significant deterrent is stigma endorsement, as it has been suggested that HCPs stigmatize mental illness, including SUD, more than the public (Henderson et al., 2012). In a HCP with SUD, witnessing a peer diagnosed with a SUD and how they were treated can reinforce stigma, fear, and shame. As a result, HCPs often UPHP EVALUATION TOOLKIT 15 only seek treatment when they can no longer practice in their profession and have professionally and socially isolated themselves (Vayr, Herin, Jullian, Soulat, & Franchitto, 2019). This evidence is supported by Clement et al. (2015), reporting that treatment stigma was most often associated with reduced help-seeking behavior in the meta-synthesis of studies relating to mental health-related stigma and help-seeking behaviors. They also note that HCPs have more frequent disclosure/confidentiality concerns and negative social judgment than other groups seeking treatment for mental illness. In undergraduate, medical, and all levels of training and education, there exists a lack of knowledge and insufficient curriculum time devoted to SUD education (Muzyk et al., 2019). In a nationwide cross-sectional study of 1,943 Danish physicians, just over 50% of the physicians reported their knowledge of SUD was limited or were dissatisfied with the education they had acquired on SUD throughout their education and career (Sørensen et al., 2016). This study also scored these physicians' risky alcohol and drug use and found that 18.3% of the respondents had unhealthy alcohol use, and 3.2% had unhealthy drug use. 75.4% and 82.2% of those with unhealthy alcohol use and drug use found their uses unproblematic, and 78.7% and 77.8%, respectively, found it irrelevant to seek treatment or help. These results could be due to the lack of SUD education combined with stigma and denial (Muzyk et al., 2019). Many stigmatized views are a direct result of a lack of SUD education. For example, one study found that nurses felt unprepared to identify and address SUDs (Cadiz, O'Neill, Butell, Epeneter, & Basin, 2012). Because of this lack of education on SUD and lack of awareness of available resources, HCPs avoid seeking treatment for their SUD due to their perceived risks of self-reporting, and their colleague's inability to recognize the signs of SUDs delays peer reporting. UPHP EVALUATION TOOLKIT 16 Many HCPs lack the understanding of treatments available and how to obtain assistance without losing confidentiality. Many perceive that they will lose their license and feel that their advancement opportunities will be hindered if their diagnosis/discipline is made public (Toney-Butler & Siela, 2019). Every state's Board of Nursing has disciplinary programs; only 73% of states have alternative-to-discipline programs (Monroe, Kenaga, Dietrich, Carter, & Cowan, 2013). Utah has alternative-to-discipline programs for nurses, doctors, and other HCPs (UPHP). However, Bennett and O'Donovan (2001) point out that information about HCP diversion programs is not well-publicized at the local level, leading to less self-seeking behaviors. Toney-Butler and Siela (2019) support that the unawareness of alternative-to-discipline programs is a barrier to the deterrence, identification, and treatment for HCPs with SUD. Most HCPs possess a characteristic pattern of personality traits. These include an ability to deny personal problems, independence, self-reliance, a strong drive for achievement, perseverance, and exceptional conscientiousness (Boisaubin & Levine, 2001; Butler Center for Research, 2015). These traits tend to be what drives them towards professional success. However, these traits can also become a barrier to seeking treatment causing the HCP to deny or suppress any suggestion of a substance abuse problem (Boisaubin & Levine, 2001). This self-reliant behavior can also cause HCPs with SUD to turn to self-treatment rather than their networks or colleagues for help (Sørensen et al., 2016). HCPs are also less likely to receive routine preventative care and, as a result, are less likely to seek routine medical care compared to other groups (Bennett & O'Donovan, 2001). In general, HCPs can be challenging to treat; an HCP with a SUD can be even more challenging. One reason for this is that HCPs may view themselves as somehow different from the general population. As a result, most HCPs cannot grasp their vulnerability and ignore or UPHP EVALUATION TOOLKIT 17 deny their problems, decreasing the likelihood of successful treatment (Samuelson & Bryson, 2017). In addition, HCPs often have such medical expertise and a depth of medical knowledge that they may find it challenging to maintain the patient role and accept recommendations from their treating physician or another clinician. This critique of care is due to the misguided belief that the addicted HCP is their own best doctor, nurse, pharmacist, or counselor (Mee-Lee, 2013). Very few licensed mental health professionals with experience treating and diagnosing SUDs are trained to effectively and thoroughly treat and evaluate HCPs or safety-sensitive populations in Utah. The Utah Medical Education Council (2020a) reports an estimated 22 physicians specializing in addiction medicine in Utah, and very few are trained to treat safety-sensitive populations. In addition, 91.2% of addiction medicine physicians practice in Salt Lake County, leaving large Utah counties underserved. Due to this barrier, many HCPs with SUDs are forced to seek this specialized treatment outside Utah, causing a tremendous financial and social burden. This barrier also presents a patient safety issue as local underqualified evaluators and treaters prematurely deem an addicted HCP fit-for-duty. HCPs continue to be under and inadequately evaluated and undertreated for SUDs programs (Butler Center for Research, 2015). In addition, Mee-Lee (2013) notes that the assessment and treatment of a safety-sensitive population, like HCPs, is complicated due to a need for more extensive cognitive testing. Solutions. Investing in the health of HCPs is critical as it directly impacts public health. When HCPs are denied a non-punitive approach to their SUD, many do not receive treatment until they become criminally charged (Bettinardi-Angres, Pickett, & Patrick, 2012). Rather than waiting for a crisis to occur, early detection of impaired HCPs can save HCP's careers, helps UPHP EVALUATION TOOLKIT 18 them avoid legal battles, protects patients, and potentially saves their lives (Weenink, Kool, Bartels, & Westert, 2017). HCPs entering into alternative-to-discipline programs like UPHP have high success rates. The majority of HCPs can return to practice and provide safer care for their patients with timely appropriate treatment and monitoring. Interventions should be designed to encourage individuals with untreated SUD to initiate treatment (Yang, Wong, Grivel, & Hasin, 2017). Mee-Lee (2013) suggests that HCP addiction treatment is best executed when it contains other HCPs, specific to their professional training, licensure, and work environment. The author further suggests that this may only be accomplished through travel to a specialized facility. However, after the HCP receives the initial specialized treatment and has internalized their need for treatment and effective management of stressors, triggers, and recovery skills are addressed, the HCP can usually continue treatment in more generalized addiction care (Mee-Lee, 2013). SUD evaluators and treaters should be trained in the specifics of their patient's work environment or have direct experience in that field of work. For example, staff working with doctors should know about a doctor's work environment, training, thinking patterns, and medical rules and regulations. Evaluators and treaters must also learn to manage the dynamic defenses specific to HCPs (Mee-Lee, 2013). UPHP evaluators should be provided training on how to perform quality, timely, and thorough evaluations regarding the treatment of HCPs with SUDs; this is critical to ensure provider and patient safety. In addition, high-quality evaluations provide the opportunity for providers to gather vital background information and history to make an appropriate diagnosis and recommendations for treatment, which, as a result, can reduce the probability of adverse events (Brooks, Gendel, Early, & Gundersen, 2018;2017). UPHP EVALUATION TOOLKIT 19 Lastly, HCPs with SUDs should be treated and evaluated by clinicians with expertise in treating addiction or SUDs (American Society of Addiction Medicine Board of Directors, 2020). Also, HCP-specific treatment programs are critical for HCPs with SUDs because state medical boards require higher levels of treatment intervention (Butler Center for Research, 2015). Summary of Literature Review SUD or addiction is a neurobiological condition (Burda, 2020) in which an individual loses control of their use of alcohol, illegal or legal prescription drugs, and medications (Mayo Clinic Staff, 2017). The rate of HCPs with SUD mirrors that of the general population, which, depending on the region, is 10 to 15%. This rate of SUD is suspected to be related to the ease of access to prescription drugs, high work-related stress, exposure to death, trauma, illness, extreme work responsibilities, and sleep deprivation (Butler Center for Research, 2015; Koinis et al. et al., 2015). Being a HCP with SUD can lead to a loss of career and license, health issues, family and personal life destruction, and even death by suicide, overdose, and communicable infections. Impaired HCPs can also cause others to suffer, including their families, peers, the institutions they work for, and the patients they treat. Unhealthy substance use may impair the HCP from providing safe and adequate patient care. Failing to report or recognize impairment in HCPs can negatively affect an institution and fellow HCPs who share a patients' care. The state of Utah has a Professionals Health Program to aid in treating and recovering HCPs with SUD. Treatment and return-to-practice outcomes for HCPs in alternative-to-discipline programs are positive. Barriers that prevent HCPs from seeking treatment for their SUD or addiction include, but are not limited to peer monitoring, access to specialized treatment, personality traits, stigma and the perceived risks of self-reporting, and lack of SUD education. When HCPs are denied a non-punitive approach to their SUD, many do not receive treatment UPHP EVALUATION TOOLKIT 20 until they become criminally charged (Bettinardi-Angres, Pickett, & Patrick, 2012). Lastly, HCPs with SUDs should be treated and evaluated by clinicians with expertise in treating addiction or SUDs (American Society of Addiction Medicine Board of Directors, 2020). Theory Ronald G. Havelock's theory of change focuses on planning, managing, and monitoring a change. Havelock's approach includes six phases (Finkelman, 2018): 1) Building relationships 2) Diagnosing the need for change 3) Getting resources needed for change 4) Selecting the best option to respond to the change and implementing it 5) Establishing and accepting change 6) Maintaining and stabilizing This project's clinical problem was a lack of access to specialized treatment for HCPs with SUDs. Patient and provider safety is compromised when HCPs with SUD delay seeking help or receive inadequate treatment due to this lack of access to specialized care. The first step to creating a change was to build relationships. A relationship has been built with DOPL and UPHP, which started the change process. By making these relationships, the change agent became familiar with the environment within these two entities and uncovered signs and symptoms of a needed change. In the second phase, the change agent pinpointed the problem by observing the signs and symptoms and gave the problem a name. In this review, the problem is the lack of specialized treatment and poor evaluations for HCPs with SUD. The third phase of this change process was to come up with the resources needed for change. Several solutions were proposed by consulting with members of DOPL and UPHP; only UPHP EVALUATION TOOLKIT 21 those solutions with the resources required to bring the change to fruition were considered. In addition, it was discussed with the UPHP Executive Advisory Committee members to develop a toolkit for those professionals interested in evaluating potential UPHP participants. The fourth stage of Havelock's theory was to pick a solution. Consulting with all entities involved, the change agent decided the best solution for a change project and implemented the plan. The practical and feasible solution was creating and implementing a toolkit available to providers interested in performing evaluations for HCP's entrance into the UPHP. The UPHP manager and the Executive Advisory Committee endorsed this quality improvement (QI) project idea. In phase five, the change agent gathered feedback from the Executive Advisory Committee to determine the toolkit's effectiveness. In the final phase, the change will become permanent and the new normal. After ensuring the transition is successfully stabilized and maintained, the change agent will separate from this change. Practice Change Plan Expected Outcomes/Goals By implementing an evaluation toolkit, UPHP evaluators will better assess HCPs with SUD and suggest treatment plans tailored to the HCP's specific needs. In addition, these evaluators will have quick and straightforward access to screening tools, evidence-based literature and guidelines, an evaluation template, sample evaluations, and other resources, ensuring quality evaluations of HCPs with SUDs and the best-recommended treatment plans. Setting This project is being implemented through the UPHP. The UPHP is a professional recovery program located in Salt Lake City, Utah. The purpose of UPHP is to assist chemically dependent HCPs. UPHP is a confidential Professional Health Program provided by the Utah UPHP EVALUATION TOOLKIT 22 Department of Commerce, Division of Occupational and Professional Licensing (DOPL). As stated above, UPHP currently offers services to physicians, physician assistants, nurses, pharmacists, veterinarians, podiatrists, and dentists licensed by DOPL (UPHP, 2021). Individuals may come to the attention of UPHP by either voluntarily coming forward or as part of the investigation process of a complaint filed with DOPL (DOPL, n.d.a). DOPL's role is to protect the public and enhance commerce through licensing and regulation. DOPL is legislatively responsible for investigating all unlawful and unprofessional practices performed within their regulated occupations and professions, including healthcare professions (DOPL, n.d.b). Population This project's target population was evaluators who had a license in good standing in the following professions: physician (MD or DO), licensed mental health professional (LCSW, CMHC, etc.), psychologist, advanced practice registered nurse, and physician assistant. In addition, these professionals must have at least a master's degree and experience in assessing and diagnosing SUDs. Plan The plan was to create a toolkit for UPHP evaluators charged with assessing HCPs before their entrance into UPHP and return to practice. This toolkit better equips evaluators with the tools to perform comprehensive evaluations and meet the UPHP requirements for admission. After implementing the toolkit, more providers will be better equipped to offer specialized evaluations to HCPs with SUDs. The change agent. Implementation of this project required excellent communication between the change agent and the project team. It was essential to keep all members updated and UPHP EVALUATION TOOLKIT 23 informed. The change agent also needed to demonstrate trust. The change agent did this by keeping commitments and maintaining confidence. The change agent also demonstrated integrity by being straightforward and honest and establishing ethical standards. Lastly, the change agent was flexible in this project and adjusted and adapted to change and the organization's needs (Reavy, 2016). Implementation The pre-implementation phase involved identifying a quality gap between current practices and available effective clinical practices (Goodrich, Miake-Lye, Braganza, et al., 2020). This was done by consulting with the UPHP Executive Advisory Committee members and professional health program leaders, including Georgia, Florida, Montana, Tennessee, Michigan, and North Carolina programs. By consulting with these various programs, it became evident that Utah lacks specialized training for providers performing evaluations on HCPs with SUDs. We also identified solutions to the problem by identifying this quality gap through consultation with these other professional health programs. The Plan-Do-Study-Act (PDSA) cycle is used to start a new quality improvement project, implement any change, and work toward continuous improvement (ASQ Quality Press. n.d.). The PDSA cycle suggests beginning with a plan to ensure that all persons involved understand the QI change clearly and verify that baseline data are complete (LoBiondo-Wood & Haber, 2018). For this quality improvement project, and as a member of the UPHP Executive Advisory Committee, this change agent was charged with creating a toolkit to guide UPHP evaluators on how to perform quality SUD evaluations on HCPs. The UPHP manager Kelli Jacobsen agreed to help facilitate implementing this toolkit to equip providers interested in evaluating prospective UPHP clients. The change agent consulted UPHP EVALUATION TOOLKIT 24 Kelli Jacobsen and the UPHP Executive Advisory Committee members throughout the creation and reviewal of the toolkit before its use. Information and resources were gathered for toolkit content through virtual meetings, phone calls, and email correspondence with the UPHP Executive Advisory Committee members. A mock toolkit webpage was created and then presented to the UPHP Executive Advisory Committee and UPHP manager, Kelli Jacobsen (See appendix B). Through more virtual meetings, phone calls, and email correspondence, feedback was given and received on improving the toolkit webpage before implementation. The next step in the PDSA cycle is to "do" or to trial the change. This toolkit was initially trialed and evaluated by the UPHP Executive Advisory Committee. By trialing the toolkit on a few providers, any problems and unexpected events can easily be adjusted (IHI, 2017). After updating and refining this QI project, the toolkit was adopted and implemented by UPHP in September 2021 and was integrated into the existing UPHP website (See appendix C). During the implementation phase, the PDSA cycle suggests documenting any problems and unexpected observations. Therefore, the change agent began collecting and analyzing qualitative and quantitative data and planning for changes (IHI, 2017). Evaluation and Data Analysis Plan The third step of the PDSA cycle is to analyze the results and compare them to the initial goals. Measurements and metrics indicate whether a change is leading to improvement. Quantitative data consisted of the number of providers who evaluated the toolkit. Qualitative data included the responses and feedback collected from the evaluators. In this stage, it is good to compare the collected data to what was predicted. Lastly, a summary and reflection can be performed (Curley, 2020). In this, the fourth and final step, the new information gained in the previous actions can modify and stabilize the change or determine other improvements that can UPHP EVALUATION TOOLKIT 25 be made. Thus, the PDSA cycle can continually evaluate a change process and start from the beginning if needed (Curley, 2020). Methods The overall goal of implementing this project was to provide evaluators with the best tools to prepare a thorough, comprehensive assessment of HCPs with SUDs. Measuring this improvement required responses through virtual Google Meets and email correspondence. The feedback received was that the website is easy to navigate, increases consistency among UPHP evaluators and that it will help with accurate evaluations through provided guidelines and expectations, evaluation templates, and other resources. In addition, quantitative measures were used to determine how many participated from the UPHP Executive Advisory Committee. Evaluation of implementation process The change agent tested this QI project numerous times as the toolkit was submitted for review and approval from various committee members. Then, through careful planning, experimenting, and observing the results, the change agent acted and adapted to what was learned and repeated the PDSA cycle. Results and Findings The UPHP executive committee reviewed and unanimously approved the evaluator toolkit and website. As a result, the toolkit was adopted by UPHP and made available on the UPHP website. Feedback from the committee included: the website was easy to navigate; it will increase consistency among UPHP evaluators; and finally, it will help with accurate evaluations for the HCP with SUD. UPHP EVALUATION TOOLKIT 26 Discussion This paper aims to present and describe the importance of this QI project, the need for specialized evaluation and treatment for HCPs with SUDs, and the implications found through the research that affect public safety. It was found that HCPs suffer from SUD at the same rates as the general population. Moreover, although stigma and shame are associated with HCPs and the general population with SUD, HCPs tend to experience more feelings of shame and guilt, which prevent them from seeking help for their SUD. While HCPs are adept at hiding behaviors of SUDs, they also can be equally adept at tackling their problems once exposed if they have the proper resources and receive adequate evaluations (Couser, 2013). Providing a toolkit to those evaluating HCPs with SUD will promote recommended treatment tailored to the HCP's specific needs, ensure quality evaluations of HCPs with SUDs, promote the UPHP, professional wellness, and patient safety. This project's objectives and goals were met from the analyzed data, as the UPHP Executive Advisory Committee felt better prepared to evaluate the HCP with SUD. Although the committee size was small due to unforeseen changes and including additional training required from the UPHP, this project was adapted to accommodate those changes and still accomplished its goals and objectives. UPHP completed its first evaluator training course on November 3, 2021, and introduced the toolkit at this training. As UPHP continues to build its program and provide its educational training for evaluators, more mental health providers will continue to utilize this toolkit and maintain sustainability (See Appendix C). Barriers to this project were gaining access and rights to guidelines and curricula, gaining support from the UPHP Executive Advisory Committee to implement this QI project, and meeting the timelines of each entity involved. In addition, ethical considerations were employed UPHP EVALUATION TOOLKIT 27 to ensure the confidentiality of PHP participants' confidentiality by redacting identifying information from all toolkit content. Other significant issues included a lack of current research on HCPs with SUD and related needs. Another challenge was recruiting an ample number of providers to participate in toolkit evaluation and utilization as well as getting feedback. Finally, the COVID-19 pandemic also created some delays in getting the toolkit developed and implemented. Recommendations In its infancy, this project has only reached a small group. As UPHP has begun formal training for potential UPHP evaluators, this toolkit is now available to the public and will be utilized by more diverse groups and populations. This toolkit will be revised as needed based on survey responses from UPHP evaluators and the changing needs of those HCPs with SUDs. In the future, the UPHP may expand to include monitoring mental health issues and SUDs. This addition of mental illness brings the opportunity for more training and education on the evaluation and treatment recommendations for HCPs with mental illness, which will lead to proliferation and revisions to the evaluation toolkit. The time frame of implementation was a continual issue with this QI project, as the organization's needs were constantly changing, resulting in later implementation dates. Therefore, it would be prudent to plan an implementation independent of other factors in the future. This improvement could be accomplished through better communication with the target organization and their specific needs and anticipating a slower process when working with the public sector. UPHP EVALUATION TOOLKIT 28 Conclusion SUD in HCPs is an issue affecting up to 15% of licensed HCPs today. Personality traits of HCPs drive them to successful careers but also hinder self-care and help-seeking behaviors. Impaired HCPs can cause significant harm to themselves, their families, colleagues, the institutions they work for, and, most importantly, the patients they care for. Nonpunitive treatment options are successful and available to HCPs, but they are underutilized, underpublicized, and lack qualified professionals to evaluate a HCPs' intake into such programs. With a delay in help-seeking, these options may not be available after a HCP has delved too deep into the world of SUD, faces criminal charges, causes patient harm or death, or loses their own life to overdose or suicide. 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