A Societal Sleep Prescription.

We are suffering a global sleep-loss epidemic. The health consequences within an individual are well characterized. But does society suffer just as much? Here, I discuss how insufficient sleep erodes our societal fabric as much as it does our biological fabric, and offer some prescriptive remedies.

A Retrospective Descriptive Study of Nurses With Substance Use Disorders in Texas.

There are approximately 3.1 million nurses in the Unites States (U.S. Census Bureau, 2016), and approximately 8% of them experience substance use disorders (Kunyk, 2015). Nurses with impaired practice are referred to peer assistance programs as they seek rehabilitation. As of 2016, 348 nurses in Texas Peer Assistance Program for Nurses were actively participating in the program for substance-abuse-related offenses. Over the last 6 years (2010-2016), 1,553 nurses were referred to Texas Peer Assistance Program for Nurses specifically for substance-abuse-related problems. These represent 2% of the population of nurses in Texas. The average age of participants was 40.1 years. Women represented 75% of participants, and 76% were registered nurses. About 41% successfully completed the program without relapsing, and 32% reported at least one relapse. Varieties of drugs were abused including prescription drugs and illegal drugs. Opioids were the most frequently abused class of drugs, followed by alcohol and stimulants. Most nurses obtained their drugs by diverting from patients. Contrary to what is in the literature, nurses working in long-term care, medical-surgical units, and home health care had the highest prevalence of impaired practice. Psychiatric comorbidity was not significantly associated with relapse, but self-report status was significantly associated with gender, age category, license type, relapse, and drug of choice. There was a significant inverse relationship between time it takes to enroll and number of abstinent days. Men were also more likely to be employed while in the program.

Alcohol and the Law.

In the intersection of alcohol ingestion with the law, medical ethics, and public safety, physicians are often unsure about how to proceed. Physicians' primary focus should be on patient education with an ethical and legal duty to warn the patient of the adverse effects of alcohol. Warning third parties of potential harm related to alcohol-related impairment may involve a breach of patient confidentiality; therefore it should only be undertaken after careful analysis suggests that the risk for significant harm exceeds the burden that results to the patient from warning others. The law remains vague in this area.

Substance Use Disorders and the American Nurses Association Code of Ethics for Nurses.

Substance use disorder is a serious problem in nursing that is often invisible and not well understood or well handled. It tears at the social contract between nursing and society and disrupts the trust so essential to that contract. The American Nurses Association Code of Ethics contains clear language about a nurse's duty to take action to protect patients and to ensure the impaired nurse gets assistance. Specific interpretive statements provide useful guidance in dealing with this problem.

The Boundaries of "Good Behavior" and Judicial Competence: Exploring Responsibilities and Authority Limitations of Cognitive Specialists in the Regulation of Incapacitated Judges.

Both law and medicine rely on self-regulation and codes of professionalism to ensure duties are performed in a competent, ethical manner. Unlike physicians, however, judges are lawyers themselves, so judicial oversight is also self-regulation. As previous literature has highlighted, the hesitation to report a cognitively-compromised judge has resulted in an "opensecret" amongst lawyers who face numerous conflicts of interest. Through a case study involving a senior judge with severe cognitive impairment, this article considers the unique ethical dilemmas that cognitive specialists may encounter when navigating duties to patient, society, and the medical profession, without clear legal guidance. Systemic self-regulatory inadequacies in the legal profession are addressed, as well as challenges that arise when trying to preserve the trust and dignity of an incapacitated patient who must fulfill special duties to society. Ultimately, because of their unique neurological expertise and impartial assessments, we submit that allowing cognitive specialists to submit their assessments to an internal judiciary board may act as an additional check and balance to ensure the fair and competent administration of justice.

Assessing the health consequences of fitness to practise investigations.

Cathryn Watters of campaign group NMCWatch:registrant care argues that health problems and high attrition rates are down to the harsh treatment faced by nurses undergoing NMC investigation. cathrynwatters@mail.com.

Complaints about chiropractors, osteopaths, and physiotherapists: a retrospective cohort study of health, performance, and conduct concerns.

Background: Recent media reports have highlighted the risks to patients that may occur when practitioners in the chiropractic, osteopathy and physiotherapy professions provide services in an unethical or unsafe manner. Yet research on complaints about chiropractors, osteopaths, and physiotherapists is limited. Our aim was to understand differences in the frequency and nature of formal complaints about practitioners in these professions in order to inform improvements in professional regulation and education. Methods: This retrospective cohort study analysed all formal complaints about all registered chiropractors, osteopaths, and physiotherapists in Australia lodged with health regulators between 2011 and 2016. Based on initial assessments by regulators, complaints were classified into 11 complaint issues across three domains: performance, professional conduct, and health. Differences in complaint rate were assessed using incidence rate ratios. A multivariate negative binomial regression model was used to identify predictors of complaints among practitioners in these professions. Results: Patients and their relatives were the most common source of complaints about chiropractors, osteopaths and physiotherapists. Concerns about professional conduct accounted for more than half of the complaints about practitioners in these three professions. Regulatory outcome of complaints differed by profession. Male practitioners, those who were older than 65 years, and those who practised in metropolitan areas were at higher risk of complaint. The overall rate of complaints was higher for chiropractors than osteopaths and physiotherapists (29 vs. 10 vs. 5 complaints per 1000 practice years respectively, p < 0.001). Among chiropractors, 1% of practitioners received more than one complaint - they accounted for 36% of the complaints within their profession. Conclusions: Our study demonstrates differences in the frequency of complaints by source, issue and outcome across the chiropractic, osteopathic and physiotherapy professions. Independent of profession, male sex and older age were significant risk factors for complaint in these professions. Chiropractors were at higher risk of being the subject of a complaint to their practitioner board compared with osteopaths and physiotherapists. These findings may assist regulatory boards, professional associations and universities in developing programs that avert patient dissatisfaction and harm and reduce the burden of complaints on practitioners.

Physiotherapy clinical educators' perspectives on a fitness to practice initiative.

CONTEXT: Health practitioner registration boards require health professionals to evaluate and maintain "fitness to practice" (FTP). This encompasses the professional behavior, clinical competence, and freedom from impairment required for safe and effective service provision. We developed and implemented policies to promote student self-assessment and support of FTP that were pre-emptive and designed to be helpful and sought clinician feedback on this initiative. METHOD: An innovative student-centered FTP approach was devised with consideration of defensible ethico-legal practice. A survey explored clinical educators' perceptions of the FTP policy and the associated education and support. Closed and open survey questions were analyzed using descriptive statistics, qualitative evaluation, and thematic analysis. RESULTS: Seventy-nine physiotherapy clinical educators from 34 sites across eight Australian health services returned surveys. Educators had positive perceptions of policy components, particularly incorporating professionalism as a hurdle requirement and the attendance and incident reporting policies. CONCLUSIONS: The benefits of a student-centered FTP approach included clarity and consistency in managing FTP issues and facilitation of student awareness through active engagement in maintaining their FTP. To our knowledge, this paper is the first to report a comprehensive approach to the range of FTP issues incorporating student self-declaration of issues that may affect desirable progression through clinical placements. The policy and program of education and support are likely to be generalizable to health professional training programs that utilize workplace training.

Prevention of and dealing with poor performance: an interview study about how professional associations aim to support healthcare professionals.

OBJECTIVE: To explore how professional associations of nine healthcare professions aim to support professionals to prevent and deal with poor performance. DESIGN: Qualitative interview study. SETTING: The Netherlands. PARTICIPANTS: Representatives of professional associations for dentists, general practitioners, medical specialists, midwives, nurses, pharmacists, physiotherapists, psychologists and psychotherapists. INTERVENTIONS: During nine face-to-face semi-structured interviews we asked how associations aim to support professionals in prevention of and dealing with poor performance. Following the first interview, we monitored new initiatives in support over a 2.5-year period, after which we conducted a second interview. Interviews were analysed using thematic analysis. MAIN OUTCOME MEASURES: Available policy and support regarding poor performance. RESULTS: Three themes emerged from our data (i.e. elaborating on professional performance, performance insight and dealing with poor performance) for which we identified a total of 10 categories of support. Support concerned professional codes, guidelines and codes of conduct, quality registers, individual performance assessment, peer consultation, practice evaluation, helpdesk and expert counselling, a protocol for dealing with poor performance, a place for support and to report poor performance, and internal disciplinary procedures. CONCLUSIONS: This study provides an overview of support given to nine healthcare professions by their associations regarding poor performance, and identifies gaps that associations could follow up on, such as clarifying what to do when confronted with a poorly performing colleague, supporting professionals that poorly perform, and developing methods for individual performance assessment to gain performance insight. A next step would be to evaluate the use and effect of different types of support.

Assessment of fitness for duty of underperforming physicians: The importance of using appropriate norms.

OBJECTIVE: To determine whether population-specific normative data should be employed when screening neurocognitive functioning as part of physician fitness for duty evaluations. If so, to provide such norms based on the evidence currently available. METHODS: A comparison of published data from four sources was analyzed. Data from the two physician samples were then entered into a meta-analysis to obtain full information estimates and generate provisional norms for physicians. RESULTS: Two-way analysis of variance (Study x Index) revealed a significant main effect and an interaction. Results indicate differences in mean levels of performance and standard deviation for physicians. CONCLUSIONS: Reliance on general population normative data results in under-identification of potential neuropsychological difficulties. Population specific normative data are needed to effectively evaluate practicing physicians.

State programs assisting pharmacy professionals with substance use disorders.

OBJECTIVES: To identify which states currently have substance use disorder (SUD) programs to facilitate the return of pharmacy professionals (including technicians, interns, and student pharmacists) to active practice, to identify the operational structures used by the states in providing these services and compare them with those reported previously, and to compile the most current and accurate contact information for each state SUD program. METHODS: Information specific to each state program was identified from Internet resources including state pharmacy associations, licensing boards, and professional associations. Each state's site was evaluated for currency within 2016-2017. Direct contact by e-mail or telephone using the program information, or association, or licensing board contacts was pursued to identify the current program status. RESULTS: Five states with no program in 1990 have since developed programs, and 2 states with programs in 1990 have closed their programs. Overall, 4 states do not currently have a program, 2 of which have never had one. One of the 2 states has recent authorization from their legislature to develop a program. Three other programs are currently in transition from 1 model to another, resulting in website inaccuracies. The operational models have undergone significant shifts with a decrease in the association (± [with or without] Foundation) model toward a group health care association or organization model including other health- or all state-licensed professionals. CONCLUSION: Currently, 46 states have programs for assisting pharmacy professionals. Information presented in this article provides the most current contact information and model structure used by states with programs. Frequent updating of program information is critical for those who might decide to seek assistance. Expansion to include a central database that enables rigorous evaluation of outcomes and specific features is viewed as desirable.