Download Attachment A: Health Impairment Programs

A C I L
A L L E N
C O N S U L T I N G
REPORT TO
THE NURSING AND MIDWIFERY BOARD OF AUSTRALIA
MARCH 2015
ATTACHMENT A:
HEALTH IMPAIRMENT
PROGRAMS
REVIEW OF THE LITERATURE ON
REFERRAL, ASSESSMENT, TREATMENT
AND REHABILITATION SERVICE FOR
REGULATED HEALTH PROFESSIONALS
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ACIL ALLEN CONSULTING
C o n t e n t s
1
2
3
4
Introduction
1
1.1 Australia’s national registration scheme
1
1.2 This literature review
1
Health practitioners
3
2.1 Physical health and disability
3
2.2 Ageing
3
2.3 Mental health
3
2.4 Substance misuse and addiction
4
2.5 Risk factors
5
Impairment
7
3.1 Definition
7
3.2 Prevalence
7
3.3 Impairment versus practicing with illness or disability
8
3.4 Risks of impairment for practitioners, patients and the profession
8
Major models of impaired practitioner support services
10
4.1 Phone support line
10
4.2 Support Service
10
4.3 Case Management
11
4.4 Regulator management
11
The role of regulators
13
5.1 Type of activity
13
5.2 Information-sharing arrangements
14
6
Principles of best practice
15
7
Alignment of program and service categories with best practice
principles
18
Identification, referral and reporting of impaired practitioners
22
8.1 Identification
22
8.2 Reporting versus referral
22
8.3 Referral sources
23
8.4 Relationships between regulators and health programs/services
regarding referral and reporting
24
5
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8.5 The role of coercion
27
Assessment
29
9.1 Source of initial assessment
29
9.2 Assessment components
29
9.3 Impairment assessment
30
9.4 Role of the regulator
31
10 Treatment, rehabilitation and monitoring
33
10.1 Role of the health program
33
10.2 Program specialisation
33
10.3 Treatment types
35
10.4 Monitoring strategies
36
10.5 Work restrictions
36
10.6 Role of the regulator
37
11 Outcomes
39
11.1 Outcome types
39
11.2 Recovery from substance use disorders – rates and contributing
factors
40
11.3 Recovery from non-substance use disorder impairments
41
12 Costs
43
12.1 Costs of practitioner impairment
43
12.2 Costs to the regulator
44
12.3 Costs of health programs
45
12.4 Costs for clients
46
13 Funding
47
14 Role of other stakeholders
49
14.1 Employers
49
14.2 Medical indemnity insurers
51
14.3 Professional Colleges and Associations
51
14.4 Education Providers
53
15 Conclusions
Appendix 1
54
Methodology
57
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List of tables
Table 1
Alignment of major categories of impaired practitioner support service
with best practice principles
17
Table 2
Management programs for impaired practitioners: selected examples
20
Table 3
Management programs for impaired practitioners: key features of
interest
21
Table 4
Referral
28
Table 5
Assessment
32
Table 6
Treatment and rehabilitation
38
Table 7
Outcomes
42
Table 8
Funding sources and arrangements
48
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Abbreviations
AHPRA
Australian Health Practitioner
Regulation Agency
AHPRA
Australian Health Practitioner
Regulation Agency
CAN-EIP
College of Registered Nurses of
British Columbia – Early Intervention
Program (Health)
NHS
National Health Service
NMBA
Nursing and Midwifery Board of
Australia
NMHPV
Nursing and Midwifery Health
Program Victoria
SUD
Substance use disorder
UK-PHP
NHS Practitioner Health Program
US-HPRP
Michigan Health Professional
Recovery Program
US-PHP
US Physicians Health Program
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Introduction
1.1
Australia’s national registration scheme
In recent years, registration of health practitioners in Australia has moved from a
complex localised scheme of regulatory bodies to a National Regulation and
Accreditation Scheme (the National Scheme) with one national Board for each
health profession regulated under the scheme (Australian Health Practitioner
Regulation Agency 2011). This process involved the consolidated over 80 boards
and their associated structures. The Australian Health Practitioner Regulation
Agency (AHPRA) supports the work of 14 National Boards (some with state and
territory Boards and committees) representing 14 health professions (Australian
Health Practitioner Regulation Agency 2011). The National Scheme began on July
1 2010 (Australian Health Practitioner Regulation Agency 2011). One objective of
the scheme is to increase standardisation and consistency in health practitioner
regulation approaches, systems and standards across Australia, where a cacophony
of local differences existed previously.
Both prior to the implementation of the National Scheme and to this day,
regulatory approaches to managing impaired practitioners vary substantially
between states and territories (Siggins Miller 2012). The National Scheme has
called into question the continued government funding of health programs for
impaired practitioners in Victoria, which were previously funded by two state
Boards (namely the Victorian Doctors Health Program and Nursing and Midwifery
Health Program Victoria). Further impetus for considering these issues comes from
ongoing debate regarding the role of mandatory reporting of impaired practitioners
(Australian Health Practitioner Regulation Agency 2011) and a current formal
review of the National Scheme, planned since the outset of the scheme to assess its
effectiveness (Australian Health Workforce Ministerial Council 2014).
Other entities – including education providers, employers, health services,
professional associations and colleges, and insurers also have a role in the
identification, referral, assessment, treatment and rehabilitation of impaired
practitioners. This adds to both the opportunities and challenges of developing an
agreed and standardised approach to the issue.
In light of this context, the Nursing and Midwifery Board of Australia has
commissioned this study to explore the need for, and value of, a national referral,
assessment, treatment and rehabilitation service for regulated health professions
and the relationship between such services and the regulator. This is an opportunity
to review consistent, evidence-based models of management, referral, assessment,
treatment and rehabilitation of impaired practitioners (Australian Health
Practitioner Regulation Agency 2014a).
1.2
This literature review
This literature review explores available academic and grey literature on
practitioner impairment, and specifically, Australian and international models of
referral, treatment and rehabilitation programs for practitioners with a healthATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS
REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED
HEALTH PROFESSIONALS
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related impairment. In particular, it focuses on the role of the regulator in these
models, and the interactions and interfaces between regulators and the programs in
their jurisdictions. Where possible, it also considers issues regarding costs and
benefits, including cost effectiveness. Some discussion of the roles of other
stakeholders – including education providers, professional colleges, employers and
indemnity insurers – is also included.
This literature review is not a comprehensive analysis of all available literature, or
all health program models in place globally. Rather, it provides an overview of the
types of programs and program models found in Australia and internationally, with
particular reference to specific exemplars that represent this diversity. The review
has prioritised literature relating to nurses and midwives. Literature relating to
other health professions was used wherever nursing and midwifery-specific
research was not available.
This review is structured according to the key stages involved in managing
practitioner impairment: identification, referral and reporting; assessment;
treatment and rehabilitation; and outcomes. The literature review method is
described in more detail at Appendix 1.
ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS
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Health practitioners
The range of health conditions affecting the health practitioner population is the
same as that affecting the general population (Clode 2004, Kay and Izenour 2008).
Like many comparatively socio-economically advantaged groups, health
practitioners are healthier on average according to measures of physical health
(Shanafelt, Sloan et al. 2003, Clode 2004). They also tend to live longer than the
general population (Frank, Biola et al. 2000). However, they are not immune to
physical illnesses and disabilities that may impact on their work, including
degenerative conditions (Clode 2004, Kay and Izenour 2008). Furthermore, certain
characteristics of healthcare jobs, and the types of personalities they attract, put
practitioners at higher than average risk of certain difficulties, especially those
relating to mental health (Rucinski and Cybulska 1985, Royal Australasian College
of Physicians 2013).
2.1
Physical health and disability
Physical disabilities may be congenital, or acquired at any point in a practitioner’s
life (Kay and Izenour 2008). Examples include cerebral palsy, spinal cord injury,
epilepsy, multiple sclerosis, Parkinson’s disease, and hearing and vision loss (Kay
and Izenour 2008). Literature on physical disabilities in health professionals is
scarce. One study found that seven specific disabilities accounted for half of all
physicians who contact the American Society of Handicapped Physicians (in
decreasing order of frequency): spinal cord injury, multiple sclerosis, stroke,
arthritis/connective tissue disease, post-polio weakness, lower limb amputation and
diabetic retinopathy (Kay and Izenour 2008). However, given that the data were
obtained from the American Society of Handicapped Physicians, they are likely
skewed toward more serious and ‘visible’ physical disabilities (Kay and Izenour
2008).
2.2
Ageing
While not always technically a ‘health condition’, aging can bring about changes –
often slowly and at first subtly – that impact performance and can eventually
amount to disability (Kay and Izenour 2008). These include hearing and vision
loss, and psychomotor and cognitive slowing (Goldstein 2000). These changes may
be more difficult for colleagues to detect, and affected practitioners often deny or
minimise them (Kay and Izenour 2008).
2.3
Mental health
Overall, research suggests that practitioners are at a higher risk of mental health
issues than other professionals and the general population – although studies are
mostly limited to doctors, nurses, dentists and pharmacists (and students of these
professions) (Clode 2004, Oakley Browne, Wells et al. 2006, beyondblue 2013)
The most common mental health concerns are the experience of stress and
‘burnout’, common to caring professions (Clode 2004). Among nurses, Australian
ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS
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studies have identified higher than average levels of occupational stress across
several fields of nursing, including nursing management, mental health nursing and
emergency nursing (Lee nd, Happell, Pinikahana et al. 2003, Safe Work Australia
2010). For example, a study of 196 psychiatric nurses in Victorian acute and
forensic settings found almost 30 per cent were affected by symptoms consistent
with post-traumatic stress (Lee nd).
Among doctors and medical students in Australia, rates of two elements of burnout
—high emotional exhaustion and cynicism—have been measured at 31.6 per cent
and 34.6 per cent respectively (beyondblue 2013) Studies have found that 28 per
cent and 60 per cent of doctors show symptoms for stress (Cohen and Rhydderch
2006) and burnout (Paterson and Adams 2011) respectively at any one time.
Nurses and midwives also experience high levels of stress and burnout as a result
of their employment. For example, Adriaenssens et al. 2012 found that nurses, and
in particular emergency nurses, were confronted frequently with traumatic events
(such as death or serious injury of a child/adolescent), which has meant
approximately one-third of nurses met sub-clinical levels of anxiety, depression
and somatic complaints and 8.5 per cent met clinical levels of post-traumatic stress
disorder (PTSD). Further, British and Canadian studies have shown that the level
of PTSD among emergency nurses is around 20 per cent, this figure increases to
25-33 per cent in American studies (Helps 1997, Clohessy & Ehlers 1999, Laposa
et al 2003, Gates et al 2011, Dominguez-Gomez & Rutledge 2009).
Health practitioners are known to have higher rates of suicidal ideation and suicide
than the general population (Frank, Biola et al. 2000, Clode 2004, Hawton,
Malmberg et al. 2004, Schernhammer and Colditz 2004, beyondblue 2013).
Doctors in an Australian study were almost four times as likely to have
experienced suicidal ideation in the past 12 months compared with the general
population (10.4 per cent compared with 2.7 per cent) (beyondblue 2013). A
systematic review of international studies found that the suicide risk of male
doctors ranged from 1.1 to 3.4 times that in the general male population. The
equivalent risk in female doctors was 2.5 to 5.7 times the general female
population (Schernhammer and Colditz 2004, Kay and Izenour 2008).
2.4
Substance misuse and addiction
Health practitioners display distinctive patterns in the types of substances they use
compared with the general population (Berryman 2002, Kay and Izenour 2008,
Elliott, Tan et al. 2010). That is, they are more likely to use prescription substances
(particularly tranquilisers, sedatives and stimulants), but are less likely to use illicit
substances such as cocaine, marijuana, hallucinogens and heroin (Berryman 2002,
Clode 2004, Kay and Izenour 2008, Elliott, Tan et al. 2010). Similar patterns have
been found in doctors, nurses, pharmacists and dentists (Berryman 2002, Brown,
Trinkoff et al. 2002, Dunn 2005, Kay and Izenour 2008, Elliott, Tan et al. 2010).
The most common prescription drugs misused by doctors are opiates,
benzodiazepines, amphetamines, barbiturates and steroids (Clode 2004, Kay and
Izenour 2008, Elliott, Tan et al. 2010). There is also some evidence that nurses use
tobacco and alcohol at higher rates than the general population (Berryman 2002).
Disproportionate use of prescription medications is due in large part to easier
access through work environments and self-prescribing (Dunn 2005, Kay and
Izenour 2008). Nurses with substance use disorders (SUDs) are more likely to be
addicted to medications to which they have easiest workplace access (Trinkoff,
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Zhou et al. 2000). One US study found that among 381 internal medicine residents,
over half of those using a prescription medicine had self-prescribed by sourcing
drugs from either the sample closet, a self-written prescription or direct from
pharmaceutical representatives (Kay and Izenour 2008). The problem is amplified
by many health practitioners’ ’pharmacological optimism’ (confidence in the
ability of medications to solve problems and relieve pain), and a sense of
familiarity and mastery over medications (Buxton 1982, Dunn 2005). This can lead
many to feel they can use substances without harmful consequences (Buxton 1982,
Dunn 2005).
The compounding combination of SUDs and mental illness are also apparent in
practitioners (Trinkoff, Zhou et al. 2000, Center, Davis et al. 2003, Clode 2004).
Mental illness and SUDs are common among health practitioners who die by
suicide (Center, Davis et al. 2003, Clode 2004), with depressive symptoms shown
to reinforce substance misuse in nurses (Trinkoff, Zhou et al. 2000).
2.5
Risk factors
Factors found to predispose healthcare practitioners, in particular to drug and
alcohol misuse and mental health problems, include (Brown, Trinkoff et al. 2002,
Katsavdakis, Gabbard et al. 2004, Kay and Izenour 2008):
 reduced use of healthcare services (Gross, Mead et al. 2000, Thompson,
Cupples et al. 2001, Kay, Mitchell et al. 2004, Kay and Izenour 2008)
 easy access to prescription drugs (Trinkoff, Zhou et al. 2000, Brown, Trinkoff
et al. 2002, Kay and Izenour 2008)
 narcissistic personality characteristics (Brown, Trinkoff et al. 2002, Clode 2004,
Kay and Izenour 2008)
 abuse or mistreatment during training and work (Brown, Trinkoff et al. 2002,
Clode 2004, Kay and Izenour 2008)
 unrealistic expectations of one’s career (Brown, Trinkoff et al. 2002)
 high working hours and adverse work schedules (e.g. nightshifts and weekends
on) (Berryman 2002, Brown, Trinkoff et al. 2002, Clode 2004, Kay and Izenour
2008)
 mental health conditions, stress and burnout (Berryman 2002, Brown, Trinkoff
et al. 2002, Clode 2004, Kay and Izenour 2008)
 perfectionism, chronic self-doubt, and marked sense of responsibility (Clode
2004, Kay and Izenour 2008)
 dissatisfaction with career choice and feeling ‘trapped’ by it (Clode 2004), and
 high pressure training and work environments (Berryman 2002, Clode 2004).
Self-diagnosis and self-prescribing poses a unique risk to practitioners, who are
less likely to have a regular source of healthcare compared with the general
population (Gross, Mead et al. 2000, Thompson, Cupples et al. 2001, Clode 2004,
Kay, Mitchell et al. 2004, Marshall 2008). Self-prescribing can cloud practitioners’
judgement about their own health condition (Kay and Izenour 2008). It can also
allow them to avoid seeking professional help for longer, as they are more able to
self-medicate for symptoms (Kay and Izenour 2008).
Research on a mix of all health professional types in Britain found that they feared
being stigmatised or labelled if their colleagues knew they were affected by
addiction (73 per cent) or mental health issues (63 per cent) (Ipsos MORI 2009).
ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS
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Among doctors, a survey of 2,500 British doctors found that only 13 per cent
would seek help for mental health or addiction issues, with 87 per cent choosing
alternative paths such as self-medication or informal help (Hassan, Ahmed et al.
2009).
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3
Impairment
3.1
Definition
The Health Practitioner Regulation National Law (National Law) defines
‘impairment’ to mean ‘physical or mental impairment, disability, condition or
disorder (including substance abuse or dependence), that detrimentally affects or is
likely to detrimentally affect a registered health practitioner’s capacity to safely
practise the profession or a student’s capacity to undertake clinical training’. The
American Medical Association defines ‘impairment’ as ‘any physical, mental, or
behavioural disorder that interferes with the ability to engage safely in professional
activities’ (Kay and Izenour 2008).
The common thread is that impaired practitioners are unable to practise their
professions with reasonable skill, safety and professionalism due to mental illness,
physical illness or disability, or the misuse of substances. The term ‘impairment’ is
distinct from ‘incompetence’ and ‘unethical conduct’. Incompetence is lacking the
requisite skills, knowledge and qualities to perform effectively within the scope of
one’s professional practice (Kay and Izenour 2008). Unethical conduct is conduct
that fails to conform to moral standards or policies (Kay and Izenour 2008). While
the terms are distinct, impaired physicians commonly display incompetent or
unethical conduct (Kay and Izenour 2008).
Conditions and/or states that can lead to impairment include: (Kay and Izenour
2008)
 substance use disorders (SUDs) (including alcohol and other drugs)
 psychiatric disorders (including mood, anxiety, psychotic and personality
disorders)
 stress and ‘burnout’
 cognitive impairment (including as a result of aging), and
 physical illness or disability (including neurological, movement and sensory
impairments).
3.2
Prevalence
It is estimated that 10-15 per cent of medical practitioners will, at some time in
their careers, become ill enough for their professional performance to be impaired
(Clode 2004). For clients of the Nursing and Midwifery Health Program Victoria,
the majority are primarily treated for mental health problems (58 per cent), with 42
per cent being treated primarily for SUDs (Hamilton and Duncan 2012). Most
cases of impaired practitioners seen by Practitioner Health Programs (PHPs) in the
US (between 58 per cent and 93 per cent) are due to substance abuse and/or mental
illness.
ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS
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3.3
Impairment versus practicing with illness or
disability
Health conditions or disabilities do not necessarily equate, on their own, to
‘impairments’ in the context of practitioner performance (Kay and Izenour 2008).
For example, approximately 10 per cent of the nursing population has a substance
abuse disorder (Ponech 2000, Brown, Trinkoff et al. 2002). But of those, only 6 per
cent have a condition severe enough to interfere with their immediate ability to
practise – i.e. they are impaired (Ponech 2000). More importantly, many
practitioners practise safely with illness and disabilities (Sanderson-Mann and
McCandless 2005, Sanderson-Mann and McCandless 2006, White 2007, Altchuler
2009, Snashall 2009, DeLisa, Silverstein et al. 2011, Melnick 2011, Smith and
Allen 2011).
Practitioners with health conditions can prevent (or reverse) their health condition
or disability from becoming an impairment through various means including:
 selecting a specialty and work environment that suits their circumstances
(Dawkins, Golden et al. 2003)
 ensuring ‘reasonable adjustments’ to counter or avoid the impact of any
limitations (Dawkins, Golden et al. 2003, Kay and Izenour 2008, Kane and
Gooding 2009)
 imposing appropriate limits on their own practice (Dawkins, Golden et al.
2003), and
 accessing and complying with appropriate treatments (Kay and Izenour 2008).
Where these measures are resisted or insufficient, or where the practitioner is
attempting to hide a problem or is in denial, the health condition can cross over into
an impairment of potential regulatory interest (Kay and Izenour 2008). At this
point, the impairment may pose a risk to patients (Fletcher 2001, Dunn 2005,
Hamilton and Duncan 2012).
3.4
Risks of impairment for practitioners, patients and
the profession
The consequences of practitioner impairment can be felt by the practitioner and
those close to them, as well as their colleagues, patients, employers and society at
large (Fletcher 2001, Dunn 2005).
Risks to the practitioner: The underlying health conditions that commonly result in
practitioner impairment can result in morbidity, disability and even death (Frank,
Biola et al. 2000, Boisaubin and Levine 2001, Carr 2008, Kay and Izenour 2008,
Selby 2008). They also place practitioners at risk of contact with the criminal
justice system, strained workplace relationships and job loss, including the stress,
financial and social losses associated with these (Fletcher 2001, Galletly 2004,
Dunn 2005, Kay and Izenour 2008). When a health issue results in impairment,
further risks to the practitioner include disciplinary action by employers or
regulators, loss or restriction of practising license/registration, legal action and loss
of career (Fletcher 2001, Galletly 2004, Dunn 2005, Kay and Izenour 2008,
Hamilton and Taylor 2011). All of these impacts can generate knock-on problems
for the practitioner in family and personal relationships, social standing, reputation,
finances, and mental and physical health (Galletly 2004, Dunn 2005, Kay and
Izenour 2008, Rosen, Wilson et al. 2009, Wilson, Rosen et al. 2009).
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Risks to patients: By definition, impaired practitioners pose a potential risk to their
patients due to their inability to safely, competently and professionally practise
(Fletcher 2001, Hamilton and Duncan 2012). The claim is made in much of the
literature that impaired practitioners can and do cause direct harm to patients
(Fletcher 2001, Dunn 2005, Hamilton and Duncan 2012).
There are high-profile legal and regulatory cases where impaired practitioners have
harmed patients (Robinson 2014, Russell 2014). Drawing on Australian examples,
the harm in such cases includes major clinical errors and ‘botched’ procedures
(Robinson 2014), infection of patients with blood-borne diseases via needle re-use
(Russell 2014), and patients receiving saline or tap water instead of pain relief
following theft of drugs for personal use (News 2014). An Australian study also
found that doctors with poor psychological support, were more likely to sexually
abuse patients (Galletly 2004).
Importantly, there are almost no research studies that correlate impairment with
breaches in safe practice by health practitioners. An evaluation of Victoria’s
Nursing and Midwifery Health Program in 2012 found no such studies regarding
nurses or midwives (Hamilton and Duncan 2012). Two systematic reviews
involving multiple professions, published in 2009, also found no such evidence
(Crawford, Shafrir et al. 2009, Harvey, Laird et al. 2009). This presents a notable
and significant gap in the literature supporting formal management of health
practitioners with impairment.
The one minor exception was a US study which found that paediatric residents who
were depressed made six times as many medication errors as those who were not
(Fahrenkopf, Sectish et al. 2008). Other research supports the view that impaired
practitioners pose a danger to patients, without drawing that specific conclusion.
For example, mental illness and SUDs are known to impair judgment, memory and
concentration (Helfert and Mitchell 2003, Kay and Izenour 2008). Furthermore,
age-related changes have been shown to contribute to miscommunication, and may
impact negatively on surgical performance, hand-eye coordination, and
interpretation of test results (Goldstein 2000).
Evidence also suggests more subtle impacts of practitioner impairment on patients.
For example, it has been shown that patients are less likely to trust the advice of
doctors exhibiting signs of burnout (Royal Australasian College of Physicians
2013). There is also evidence that the health habits of practitioners are associated
with the advice they give to patients (Clode 2004). This association extends to both
mental health issues and substance misuse, where practitioner’s own difficulties
can compromise their treatment of patients with similar concerns (Clode 2004).
Risks to professions: Damage to the public’s trust in health practitioners, the
healthcare system as a whole, and practitioner regulation, is a potential impact of
impaired practitioners (Dunn 2005). In Australia, several high profile cases,
investigations and reports regarding impaired practitioners have attracted negative
public comment on complaints-handling and regulatory systems (Legal and Social
Issues Legislation Committee 2014, Robinson 2014, Russell 2014). Furthermore,
regardless of the gaps in academic literature and evidence, a UK study found that
the public view addiction among practitioners as a significant threat to patient
safety (Ipsos MORI 2009). Members of the public considered a dentist smelling of
alcohol or a GP with depression to pose a medium risk, but a surgeon with an
addiction problem to pose a high risk (Ipsos MORI 2009).
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4
Major models of impaired practitioner
support services
The types of health programs and services for practitioners identified in this review
can be broadly categorised into four types. These are: phone support line, support
service, case management and regulator management, described below. Australia
has examples of all four service categories. Most programs and services examined
in this review in Australia (Siggins Miller 2012) and the UK (General Medical
Council 2014) fall into the support line and support service categories. In contrast,
for the US (White, DuPont et al. 2007, DuPont, McLellan et al. 2009, DuPont,
McLellan et al. 2009, Pooler, Sheheen et al. 2009, Skipper and DuPont 2011) and
Canada (Brewster, Kaufmann et al. 2008, College of Registered Nurses of British
Columbia 2012), the vast majority of programs fell into the case management
category (White, DuPont et al. 2007, DuPont, McLellan et al. 2009, DuPont,
McLellan et al. 2009, Pooler, Sheheen et al. 2009, Skipper and DuPont 2011). New
Zealand had programs at both ends (Medical Council of New Zealand 2011,
Doctors' Health Advisory Service 2014).
4.1
Phone support line
Phone support line services offer ‘hotlines’ which affected practitioners and/or
concerned others can ring for support, information, and referral. Calls are typically
allowed to be anonymous. These services are typically independent of regulators –
except in limited cases where mandatory reporting applies, and may necessitate
reporting of impaired practitioners to regulators.
Strengths of this model include its potential to encourage help-seeking and promote
trust through allowing anonymity, using peer-to-peer support approaches,
independence from the regulator and specialising in health practitioners. On a
practical level, extended and/or all hours access, easy access for the geographically
isolated, comparatively low cost to funders, and low or no cost to practitioner
users, are all benefits.
Weaknesses of the phone support line approach include limited continuity and
follow-up, reliance only on caller-provided data for assessment, and inability to
provide intensive support, treatment, rehabilitation and monitoring. Another
concern is that anonymity hampers reporting of practitioners who pose a series risk
to the public.
Australian examples of these types of service include Doctors’ Health Advisory
services (NSW, ACT, Qld, NT, WA), the AMA Peer Support Services (Vic, Tas)
and CRANAplus’ Bush Support Line. International examples include the Statewide
Peer Assistance Program for Nurses (US), the Doctors’ Support Line (UK) and the
Royal College of Nurses Counselling Service (UK).
4.2
Support Service
The support service approach encompasses services whereby affected practitioners
have voluntary, brief contact with the service, which offers referral and
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occasionally limited therapeutic services such as counselling. Many are funded
through charitable organisations or employers, and offer limited counselling as
their only or main service. These services are typically independent of regulators –
except in cases where mandatory reporting applies.
Strengths of this type of service include the ability to directly offer some treatment
and rehabilitation, and a less formal and less ‘high stakes’ than other approaches which helps reduce the fear and resistance associated with more coercive
approaches. They are also comparatively low cost to funders, and low or no cost to
practitioners.
Some weaknesses of this type of service include limited-hours access, difficult
access for the geographically isolated, and limited monitoring and follow-up. In
jurisdictions where mandatory reporting is in place and clients are not protected by
special shielding arrangement, trust in the service may be hampered by fear of
reporting. In the case of Employee Assistance Programs, access is restricted to
those currently employed by a service that offers such programs.
Examples of this model include services offered by Medical Benevolent
Associations (Vic, NSW, ACT, SA), the Dr DOC Program (SA), Health for Health
Professionals (Wales) and health service Employee Assistance Programs.
4.3
Case Management
The case management approach involves affected practitioners engaging with
specialised services which manage and coordinate the practitioner’s longer-term
involvement in an intensive, formal program of assessment, treatment and
rehabilitation, monitoring and often agreed (temporary) restrictions on their
practice. Most do not offer much in-house treatment and rehabilitation, but instead
develop, coordinate and monitor treatment plans which involve referral to external
treatment services and practitioners. These services typically have formal
agreements with regulators that allow the program to operate in harmony with
regulator systems, and to shield clients from regulatory action as long as they
comply with the program. (Gray 2006, DuPont, McLellan et al. 2009)
The strengths of this approach relate to its intensity, and include extensive
assessment and individualisation, high continuity of care, long-term monitoring
and follow-up and intensive support, treatment and rehabilitation, including crisis
and inpatient options. It also promotes public protection through putting agreed
and/or voluntary work restrictions in place, enabling regulator action in cases of
serious risk and having formal agreements with the regulator. There is also goodquality evidence that these programs have high success rates, and encourage
alternative-to-discipline approaches to regulation of impaired practitioners.
Practical weaknesses of the case management approach include high costs for
practitioners and/or funders, difficult access for the geographically isolated, work
stoppages or restrictions that compromise confidentiality, and (often) large periods
of time out from practice. Some such programs have also attracted public criticism
due to perceptions of protecting and ‘hiding’ unsafe practitioners.
4.4
Regulator management
The regulator management approach encompasses cases where affected
practitioners who come to regulator’s attention are directly assisted by the regulator
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to access assessment, treatment, rehabilitation and monitoring (often through less
formally-defined processes than case management). This service is inextricably
linked to the regulator that offers it, and is often offered as an alternative-todiscipline, with non-compliance potentially leading to more punitive regulator
action (Medical Council of New Zealand 2011)
The major strengths of this approach is that it targets those at risk of, or already
affected by, regulator attention and disciplinary action, enabling regulators to take
action in cases of greatest public risk. As with case management, extensive
individual assessment and information-gathering is possible, allowing an
individualised approach which sources services and treatment providers
experienced in supporting health practitioners.
Weaknesses of this approach are that is often somewhat piecemeal, and as a result
often lacks both transparency and evidence of efficacy. Inextricable links to the
regulator can also result in distrust, fear and dishonesty on the part of practitioners,
as well as potential or actual conflicts of interest. The approach also does not
promote early intervention, taking effect only when a practitioner has come to the
regulator’s attention. Finally, this approach can attract public criticism due to
perceptions of protecting and ‘hiding’ unsafe practitioners.
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5
The role of regulators
Regulators face two major decision axes in determining the nature and extent of
their involvement with impaired practitioners. These are (a) the type of activities
they will undertake themselves; and (b) the information-sharing arrangements they
will put in place.
5.1
Type of activity
There are five main types of regulator activity in relation to the management of
impaired practitioners.
1.
Promotion and endorsement of programs and services: For example, the
Department of Licensing and Regulatory Affairs of Michigan actively
promotes the Michigan Health Professional Recovery Program on its website
(Department of Licensing and Regulatory Affairs 2014).
2.
Referral of specific practitioners to programs and services: For example, the
UK’s General Medical Council (NHS Practitioner Health Programme and
General Medical Council 2013) and General Dental Council (NHS
Practitioner Health Programme and Council 2009) both have formal
memorandums of understanding with the NHS Practitioner Health
Programme, which encourages the Councils to discuss potentially impaired
practitioners with program staff with a view to potential referral.
3.
Funding part or all of programs and services: For example the Victorian
Nursing and Midwifery Health Program was funded by the Nurses Board of
Victoria prior to the National Scheme , using funds collected from registration
fees (Standing Committee on Legal and Social Issues Legislation Committee
2013). The Nursing and Midwifery Board of Australia has agreed to fund this
program until 30 June 2016
(http://www.nursingmidwiferyboard.gov.au/News/2013-09-04-mediarelease.aspx) The College of Registered Nurses of British Columbia entirely
funds the Early Intervention Program (Health) (College of Registered Nurses
of British Columbia 2012). In the United States, The Health Professionals
Services Program (Minnesota) is 98 per cent funded by health –licensing
boards, and lastly the Washington Physicians Health Program is 65 per cent
funded by the regulator (WPHP 2015, HPSP 2015).
4.
Maintaining formal agreements with programs or services: These
agreements usually cover issues that include information-sharing and
confidentiality (Fletcher 2001, Bohigian, Croughan et al. 2002, Brown and
Schneidman 2004, Bohigian, Bondurant et al. 2005, Fletcher and Ronis 2005,
Brooks, Early et al. 2012, Krall, Niazi et al. 2012, Platman, Allen et al. 2013,
Smith 2013). For example, all US PHPs have formal agreements with relevant
regulators that provide a degree of ‘shielding’ from reporting to the regulator
and/or disciplinary action for compliant participants (DuPont, McLellan et al.
2009).
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5.
5.2
Providing part or all of programs and services: For example, as part of
administering the NSW Impaired Registrants Program, the Medical Council of
NSW often appoints a practitioner to assess potentially impaired doctors
(Medical Council of New South Wales 2010). The College of Registered
Nurses of British Columbia administers its own health program (the Early
Intervention Program (Health)) (College of Registered Nurses of British
Columbia 2012).
Information-sharing arrangements
There are three main models for information-sharing between regulators and
practitioner health programs:
No formal arrangement: Under this model, there is no formal arrangement
between the program and the regulator about the exchange of client information,
though information may still be exchanged for ethical or legal reasons (e.g.
mandatory reporting). This model is common with phone lines and support
services, such as the Medical Benevolent Association of New South Wales
(Medical Benevolent Association of New South Wales 2014).
Formal arrangement – distinct entities: Under this model, health programs have a
formal agreement with regulators (sometimes enshrined in law), which sets out
requirements for exchanging information about clients. The health program or
service is a separate legal entity operating at arms-length from the regulator.
Variations on this model are common (Fletcher 2001, Bohigian, Croughan et al.
2002, Brown and Schneidman 2004, Bohigian, Bondurant et al. 2005, Fletcher and
Ronis 2005, Brooks, Early et al. 2012, Krall, Niazi et al. 2012, Platman, Allen et
al. 2013, Smith 2013), and appear to apply to all PHPs in the US (DuPont,
McLellan et al. 2009).
Formal arrangement – same entity: Where a regulator is inextricably intertwined
with the health program or service (such as the College of Registered Nurses of
British Columbia Early Intervention Program), (DuPont, McLellan et al. 2009,
College of Registered Nurses of British Columbia 2012) an agreement governs
how information obtained in the course of administering the program will be used
(or not used) for disciplinary and regulation purposes within that same entity.
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6
Principles of best practice
One way regulators can choose between the activity and information-sharing
options described above is to consider and evaluate them against principles of best
practice for managing impaired practitioners.
Key principles common to many regulators working in this area, including the
Australian National Boards, are (Fletcher 2001, DuPont, McLellan et al. 2009,
Medical Council of New Zealand 2011, Agency 2014, College of Registered
Nurses of British Columbia 2014, General Medical Council 2014):
1.
Protect the public from harm
2.
Maintain confidence in regulator and profession
3.
Support timely access and response
4.
Optimise recovery and rehabilitation
5.
Manage risks in proportionate manner
6.
Assist practitioners to remain in / return to the workforce
7.
Promote trust, honesty, help-seeking
8.
Ensure natural justice and fairness
9.
Minimise regulatory costs and burden
10. Evidence-based and tailored to the needs of health practitioners.
At times the above principles will be in tension or even clash directly, with each
other. Some examples are set out below.
Encouraging help-seeking vs public protection: Some measures intended to
encourage help-seeking and program compliance can clash with the desire to
protect patients and the public from impaired practitioners ( Jenkins 2013). For
example, where services allow anonymity, this may encourage impaired
practitioners to seek help who otherwise may not do so for fear of retribution,
regulatory action, stigma etc (Bosch 2000, Gastfriend 2005, Sick Doctors Trust
2014). However, anonymity blocks the potential to report practitioners who pose a
serious risk to the public.
Encouraging compliance vs ethics of coercion: Some programs shield
practitioners from regulator reporting or related action while they are compliant
with the program, but report them as a direct consequence of non-compliance
(Darbro 2009). This ‘high-stakes’ coercive arrangement is believed to be a major
contributor to the high success rates of these programs, but raises ethical questions
about natural justice, procedural fairness, and the role of coercion in informed
consent and the treatment of clients (Darbro 2009, Boyd and Knight 2012).
Public protection vs workforce retention: The tension between public protection
and maintaining practitioners in the workforce is also a consideration. This is
especially true given the significant cost to society of educating and training
practitioners, and the costs of practitioner loss and early retirement (Boorman
2009). This has led to public criticism of health programs, in both the USA and
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Australia, as ‘hiding’, ‘protecting’ or ‘being soft on’ dangerous practitioners (Swan
2005, Wohlsen 2007, Skipper and DuPont 2011, Hagan 2012).
Public protection vs discrimination: With respect to managing impaired
practitioners, there is tension between public protection, and anti-discrimination
laws and principles. There is a pocket of literature exploring these issues from the
UK and USA, with a particular focus on nursing students and practitioners, and the
concept of reasonable adjustments (Sanderson-Mann and McCandless 2005,
Sanderson-Mann and McCandless 2006, Morris and Turnbull 2007, Morris and
Turnbull 2007, Grainger 2008, Sin and Fong 2008, Schroeder, Brazeau et al. 2009,
Tee, Owens et al. 2010, Storr, Wray et al. 2011). Issues to consider include the
potential for legal challenges to regulator mandates or actions, claims of workplace
discrimination, maintaining workforce diversity, public safety, reasonable
adjustments, and employer encumbrance (Oliver, Bernstein et al. 2004, SandersonMann and McCandless 2005, Sanderson-Mann and McCandless 2006, Morris and
Turnbull 2007, Morris and Turnbull 2007, Grainger 2008, Sin and Fong 2008,
Schroeder, Brazeau et al. 2009, Tee, Owens et al. 2010, Storr, Wray et al. 2011).
The degree to which each category of program or service type aligns with selected
best practice principles is outlined in Table 1. In this report, programs have been
rated based on the subjective judgement of the reviewers using a four point Likert
scale (outlined in the Box below).
Box 1




Likert Rating scale
(1) Not applicable or limited applicability,
(2) Somewhat applicable
(3) Moderately applicable
(4) Very applicable
Source: ACIL Allen Consulting 2014
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Table 1
Alignment of major categories of impaired practitioner support service with best practice principles
Relative alignment rating for each category (out of 4)
Phone line
Support service
Case management
Regulator management
Public protection
1
↓ Low intensity
anonymity, limited
service
2
↑ Option of reporting
↓ Limited service, no noncompliance consequences
4
↑ Option for reporting,
non-compliance
consequences, strict
conditions, known high
efficacy
2
↑ Direct regulatory oversight, noncompliance consequences, strict
conditions
↓ Only for those known to
regulator), practitioners reluctant to
come forward
Supports safe
practice
1
↓ Low intensity,
anonymity
2
↑ Some treatment support
↓ Low intensity
4
↑ Re-entry & job retention
oriented, voluntary work
restrictions, intensive,
known high efficacy
2
↑ Re-entry & job retention oriented,
intensive
↓ Discourages help-seeking (fear,
non-transparency)
Natural justice and
fairness
4
↑ No coercion,
voluntary, anonymity
4
↑ Low coercion, voluntary
3
↑ Agreed treatment
contracts, transparency,
clear expectations
↓ Coercion
2
↑ Clear compliance rules for
participant
↓ Limited transparency /
accountability, coercion
Cost-effective
2
↑ Free to practitioner
↓ Limited benefit
2
↑ Free to practitioner
↓ Limited benefit
3
↑ Known high efficacy
↓ High cost to practitioner
3
↑ Minimises administrative & cost
duplication
↓ High cost to practitioner, efficacy
unclear
Evidence-based
1
↓ Limited to no
evidence
1
↓ Limited to no evidence
4
↑ Much evidence, known
high efficacy
2
↑ Some well-evidenced components
↓ Limited evidence for this model
Maintains public
confidence
1
↓ Rarely known to
public, unknown
efficacy
1
↓ Rarely known to public,
unknown efficacy
3
↑ Transparent, public
reporting, known high
efficacy
↓ Perceived to ‘hide
dangerous practitioners’
2
↑ Regulator oversight
↓ Non-transparency, rarely known
to public, limited public reporting,
perceived to ‘hide dangerous
practitioners’
Timely
4
↑ Out of hours available
2
↓ Wait list, office hours
3
↑ Most have no wait list
↓ Office hours for intake
3
↑ No wait list
↓ Office hours for intake, slow
regulator action
Proportional
2
↑ Low intensity
↓ May not report
serious risks
2
↑ Low intensity
↓ Inadequate for major
problems
4
↑ From low to very high
intensity, individualised
4
↑ Individualised
Total score
16
16
28
20
Note: ↑ indicates an advantage; a↓ indicates a disadvantage
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7
Alignment of program and service
categories with best practice principles
There is extensive research evidence regarding the high efficacy and favourable
outcomes of the case management model, which has existed in the US since the
1970s (Mansky 1996, Gray 2006, Freckelton and Molloy 2007, White, DuPont et
al. 2007, DuPont, McLellan et al. 2009, DuPont, McLellan et al. 2009, Boyd and
Knight 2012, Brooks, Early et al. 2012, Dupont and Skipper 2012, Krall, Niazi et
al. 2012, Platman, Allen et al. 2013). However, this review found little evidence on
the efficacy of phone support lines, support services (with one exception
(Cunningham and Cookson 2009)) and regulator management models, especially in
terms of client outcomes
As outlined in Table 1, the balance of available evidence from this review suggests
that the case management option is most closely aligned with the principles of best
practice for treating and rehabilitating impaired practitioners. As a result, the
remainder of this review focuses on this model, with reference to selected exemplar
programs outlined in Table 2, and detailed in subsequent tables.
As the regulator management model is the second most aligned with the principles
of best practice from this analysis, one example of this model has been included for
completeness of comparison (College of Registered Nurses of British Columbia Early Intervention Program (Health)).
The exemplars were chosen for a variety of reasons relating to: availability of
quality information, reflecting aspects of the Australian healthcare and regulatory
environment, high documented success rates, key contrasts with current approaches
in Australia and/or professions covered. The major reasons for inclusion of each
model are as follows:
 Nursing and Midwifery Health Program Victoria
 nursing and midwifery specific
 one of only two case management programs of this type in Australia (the
other is the Victorian Doctors Health Program)
 Michigan Health Professional Recovery Program
 operates in a mandatory reporting environment
 covers a wide variety of professions (25 at present)
 formal shielding agreement
 College of Registered Nurses of British Columbia - Early Intervention Program
(Health)
 nursing and midwifery specific
 regulator management model
 operates in universal healthcare environment
 NHS Practitioner Health Programme (London)
 operates in universal healthcare environment
 no formal shielding agreement
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 offers some therapeutic and rehabilitation services internally
 Hypothetical ‘archetypal’ US Physicians Health Program (PHP) (based on the
average or most common response from a national survey of 42 state programs)
 captures data from a large number of services in one data set
 programs have long histories and much accumulate evidence
 model has high demonstrated efficacy
 formal shielding agreement participants.
These exemplars form the focus for the remainder of the review, but other models
are also mentioned.
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Table 2
Management programs for impaired practitioners: selected examples
Country
Australia
US
Canada
UK
US (Archetypal)
Nursing and Midwifery Health
Program Victoria (Hamilton and
Duncan 2012, Siggins Miller
2012)
Michigan Health Professional
Recovery Program (Fletcher and
Ronis 2005, Bissonnette and Doerr
2010, Michigan Health
Professional Recovery Program
2013)
College of Registered Nurses of
British Columbia - Early
Intervention Program (Health)
(College of Registered Nurses of
British Columbia 2012)
NHS Practitioner Health
Programme (London) (National
Health Service Practitioner Health
Programme 2012)
Hypothetical “archetypal” US
Health Program, based on a
national survey of 42 state
programs (DuPont, McLellan et al.
2009)
Code used in this review
AUS-NMHP
US-HPRP
CAN-EIP
UK-PHP
US-PHP
Established
2006
1994
2012
2009
circa 1980
Private sector contractor
College of Registered Nurses of
British Columbia (regulator)
Self-administering NHS program
Administering organisation
Self-administering not-for-profit
service (company limited by
guarantee)
Self-administering independent
non-profit organisation (54% of
PHPs)
Program Name
[state medical association – 35%
licensing board – 13%t]
Nurses
Midwives
Profession(s)
25 professions (e.g. medical
practitioners, nurses, dentists,
psychologists, social workers)
Nurses
Medical Practitioners
Dentists
Medical Practitioners (100% of
PHPs)
Dentists (51%)
[veterinarians – 33% pharmacists
– 21%
Substance
misuse
✓ (42%)
✓ (50% of cases, 38% with comorbid SUD & mental illness)
✓
✓ (85% of cases)
✓ (100%of PHPs)
Alcohol (50% of cases)
Opioids (35% of cases)
Impairments
covered
Mental health
✓ (58%)
✓ (10 % of cases, 38% with comorbid SUD& mental illness)
✓
✓ (28% of cases)
✓ (85% of PHPs)
Physical
-
-
✓
✓ (17% of cases)
✓ (62% of PHPs)
Aging/ cognitive
-
-
✓
-
✓
Note: US (Archetypal) PHP data is based on most common response and/or average from national survey of PHP programs in 42 US states.[68]
Key for exemplar tables: [✓= this feature is present/applicable] [ - = this feature is not present/applicable]
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Table 3
Management programs for impaired practitioners: key features of interest
Program
Eligibility
AUS-NMHP
- Available to students, practitioners
and non-practising practitioners
- Only program of its kind in Australia
- Facilitates provision of financial and
legal advice
- Offers treatment and rehabilitation
services internally
Services
- General running costs are regulatorfunded
US-HPRP
- Very wide variety of professions
covered (25)
-
CAN-EIP
- Explicitly covers mental health,
substance misuses, physical health and
cognitive/aging issues
-
- General running costs are
government-funded
- General running costs are regulatorfunded
-
- Referral to service meets legal
mandatory reporting obligations
- Board-ordered participation order is
publicly discoverable
- Program administered by regulator
- Referral not noted on nurses’
registration record if ‘all goes to plan’
-
- Abstinence-based
Formal treatment contracts with
reporting consequences for noncompliance
- Nurse must stop work, even before
assessment. Can’t return without
medical approval (registration changed
to ‘not practicing’)
Costs
Regulation/ Legal
Approach/
Philosophy
UK-PHP
US-PHP
(For 100% of PHPs unless stated)
- Can only self-refer if from London
area
-
- Offers some treatment and
rehabilitation services internally
-
- Free for London, others access on
‘cost-per-case’
Funded by NHS
-
-
- Physically embedded within
standard general practice clinic
- Written operating agreement with state
licensing board to act on their behalf in
managing impaired practitioners
- Independent legal authority based on
state laws (59% of PHPs)
- Long-term monitoring (5 years) with
reporting to regulator
- Treatment contracts with reporting for
non-compliance
- Total abstinence required
Note: - indicates this feature is not applicable
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8
Identification, referral and reporting of
impaired practitioners
The first stage in the treatment and rehabilitation of impaired health practitioners is
the identification of those who may be at risk, followed by referral and/or reporting
to services or regulators. The features of the exemplar programs relating to referral
and reporting are outlined in Table 4.
8.1
Identification
Identification of impaired practitioners can be difficult. Compared with the general
population, health concerns in practitioners are often picked up relatively late
(Ponech 2000, Clode 2004, Dunn 2005) when the problem is already severe and
entrenched (Clode 2004, Dunn 2005). This has been attributed to denial and
minimisation of the problem (both by the practitioner and his or her peers), stigma
and shame, (Ponech, 2000, (Thompson, Cupples et al. 2001, Lillibridge, Cox et al.
2002, Marshall 2008, Ipsos MORI 2009, Breen 2011) fear of consequences leading
to concealment,(Dunn 2005, Kay and Izenour 2008, Marshall 2008) and doubts
about the quality of care that will be provided (Thompson, Cupples et al. 2001,
Kay, Mitchell et al. 2004).
8.2
Reporting versus referral
In this context, there is a difference between ‘reporting’ (‘notification’ in the
Australian context) and referral. Reporting means raising a concern about a
potentially impaired practitioner with a regulator, on the understanding that
investigation and potential regulatory action may follow. Referral means
suggesting or directing that a practitioner engage with a program or service for
impaired practitioners.
All North American programs examined by this review allow regulators to refer a
reported practitioner to the practitioner health program, as an alternative to
disciplinary action (Mehendale and Goldman , Mansky 1996, Gray 2006,
Freckelton and Molloy 2007, White, DuPont et al. 2007, DuPont, McLellan et al.
2009, DuPont, McLellan et al. 2009, Boyd and Knight 2012, Brooks, Early et al.
2012, Dupont and Skipper 2012, Krall, Niazi et al. 2012, Platman, Allen et al.
2013). In some cases, legal provisions blur the line between reporting and referral.
For example, in some states and provinces, such as Michigan, practitioners are
considered to have met the legal obligation to ‘report’ impaired colleagues if they
refer them to the recognised practitioner health program (Schouten 2000,
Bissonnette and Doerr 2010).
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8.3
Referral sources
Numerous sources of referral to practitioner health programs are identified in the
literature (Fletcher 2001, DuPont, McLellan et al. 2009, College of Registered
Nurses of British Columbia 2012, Braquehais, Valero et al. 2014). They include:
 self
 treatment centres
 employers
 personal lawyer
 colleagues
 treating practitioners
 universities
 regulators (professional boards, licensing bodies)
 indemnity insurers
 employee assistance programs
 family and friends
 law enforcement officials
 health care organisations
 professional organisations
 patients and carers
 health complaints entities
 other government authorities
 judiciary (standard courts, drug courts), and
 anonymous.
Self-referral: Self-referral is widely touted as the ideal method of referral to
practitioner health programs (Kay and Izenour 2008, College of Registered Nurses
of British Columbia 2012, Hamilton and Duncan 2012). It is considered to
demonstrate reduced stigma, practitioner acceptance that they have a problem and
need help, motivation to change and faith in the quality and suitability of the
program (College of Registered Nurses of British Columbia 2012, Hamilton and
Duncan 2012). Self-referral may also pick up problems earlier, better protecting
patients and the practitioner (Dunn 2005, College of Registered Nurses of British
Columbia 2012). It is also a lower-cost option, as it bypasses the costs associated
with, for example, regulator investigation leading to referral (Hamilton and Duncan
2012). The extent of self-referral varied widely in the exemplar programs from 26
per cent for US programs to 90 per cent for NMHPV. There are examples
demonstrating that self-referral is higher for more established programs. For
example, in its first year (2012) 73 per cent of CAN-EIP cases were self-reported.
This grew to 84 per cent in 2013 (College of Registered Nurses of British
Columbia 2012).
Reporting by other practitioners: It is widely agreed that health practitioners have
an ethical obligation to report impaired colleagues who are placing patients at risk
(Dunn 2005, Farber, Gilibert et al. 2005, Raniga, Hider et al. 2005, Kay and
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Izenour 2008, DesRoches, Rao et al. 2010). This ethical obligation is sometimes,
but not always, extended to a legal obligation (mandatory reporting) (Laliotis and
Grayson 1985, Breen 2009, Jackson and Parker 2009, Breen 2011). In many
jurisdictions, including all Australian states and territories, registered practitioners
are required to report colleagues who they reasonably believe are impaired in a
way which poses a significant risk to patients (with the exception in some
jurisdictions – such as Western Australia - for treating practitioners) (Breen 2009,
Jackson and Parker 2009, Bissonnette and Doerr 2010, Breen 2011, Saunders
2012).
In part, mandatory reporting provisions were put in place to overcome some of the
many obstacles to practitioners reporting each other, including a fear of workplace
and personal retribution (Rennie and Crosby 2002, Dunn 2005) and uncertainty
about the threshold where reporting is necessary (Dunn 2005, Jackson and Parker
2009). However, there are concerns that mandatory reporting may dissuade
impaired practitioners from seeking help and support, especially where treating
practitioners are bound by reporting (Breen 2009, Whelan 2009, Breen 2011,
Saunders 2012, Siggins Miller 2012). Research is currently underway to better
understand the impact of mandatory reporting on practitioners in Australia.
Relative success by referral source: Data on rates of successful recovery and
retention/return to work, sorted by referral source, was limited. However, such data
are available for the Michigan program for the year 2000 (1090 individuals)
(Fletcher 2001). Program completions deemed ‘successful’ were highest in for
those who self-referred (39.2 per cent), followed by those referred by an employer
(33.8 per cent), regulator (27.7 per cent), colleague (26.9 per cent) and treating
practitioner (5 per cent). Overall, those who self-referred had higher rates of
program-defined success (39.2 per cent) than those from all other referral sources
(23.5 per cent)
8.4
Relationships between regulators and health
programs/services regarding referral and reporting
The review identified four existing broad models of referral and reporting between
health programs/services and regulators, taking into account the presence or
absence of (a) a formal public agreement, (b) mandatory reporting and (c)
‘shielding’ of clients.
No formal agreement without mandatory reporting: This model is seen most
commonly with phone support lines and support services in jurisdictions without
mandatory reporting, such as the Doctors’ Support Line (Miller 2002) and Sick
Doctors Trust Helpline (UK) (Sick Doctors Trust 2014). In this model, health
services are not required to refer or report practitioners, even if they pose a risk to
patient safety. However, referral or reporting can still occur (a) with the permission
of the practitioner, or (b) without permission, at the discretion of service staff or
volunteers (where the law and service policy allows it).
No formal agreement with mandatory reporting: This model was common in
Australia, for example, it is seen in the operation of the various Doctors Health
Advisory phone support lines (except WA) (Whelan 2009), and services offered by
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Medical Benevolent Associations (Medical Benevolent Association of New South
Wales 2014) and Employee Assistance programs (ACT Health 2013). Under this
model, clinicians working within the program or service are bound by mandatory
reporting requirements with respect to service/program clients, without a formal
agreement with the regulator to guide them. This leaves service operators, staff,
clients, potential clients, external treating practitioners, reporters and potential
reporters confused and uncertain about the role reporting to the regulator plays
(Whelan 2009). Inconsistent application and interpretation of reporting
requirements have been reported, with some practitioners considering program
compliance to negate the need to report, while others do not (Whelan 2009).
Formal agreement with shielding: Under this model, formal operating agreements
exist between health programs and regulators, which endow programs with a legal
mandate to manage impaired practitioners on behalf of the regulator (Fletcher
2001, Bohigian, Croughan et al. 2002, Brown and Schneidman 2004, Bohigian,
Bondurant et al. 2005, Fletcher and Ronis 2005, DuPont, McLellan et al. 2009,
Brooks, Early et al. 2012, Krall, Niazi et al. 2012, Platman, Allen et al. 2013,
Smith 2013). Among other things, these agreements cover how and when
practitioners are referred to the health program by the regulator, and impaired
practitioners are reported to the regulator by the health program (Cohen and
Rhydderch, 2006, Sanderson-Mann and McCandless, 2006, Department of
Licensing and regulatory Affairs, 2014, NHS Practitioner Health Programme and
General Medical Council, 2013, NHS Practitioner Health Programme and General
Dental Council, 2013, Smith 2013, Bohegian et al., 2013, Bohegian et al., 2002,
Platman et al., 2013, Krall et al., 2012). This model was the most common
identified in the literature - being common in Canada, and universally applied to
US PHPs (Mehendale and Goldman , Mansky 1996, Gray 2006, Freckelton and
Molloy 2007, White, DuPont et al. 2007, Brewster, Kaufmann et al. 2008, DuPont,
McLellan et al. 2009, DuPont, McLellan et al. 2009, Boyd and Knight 2012,
Brooks, Early et al. 2012, College of Registered Nurses of British Columbia 2012,
Dupont and Skipper 2012, Krall, Niazi et al. 2012, Platman, Allen et al. 2013).
‘Shielding’ gives the health program the legal right (and indeed obligation) not to
report, identify, or share information about any client as long as the client is
complying with program requirements (as set out in a personalised contract)
(Fletcher 2001, Bohigian, Croughan et al. 2002, Brown and Schneidman 2004,
Bohigian, Bondurant et al. 2005, Fletcher and Ronis 2005, Brooks, Early et al.
2012, Krall, Niazi et al. 2012, Platman, Allen et al. 2013, Smith 2013). However,
should the client break the contract, they can, and often must, be reported to the
regulator (Fletcher 2001, Bohigian, Croughan et al. 2002, Brown and Schneidman
2004, Bohigian, Bondurant et al. 2005, Fletcher and Ronis 2005, Brooks, Early et
al. 2012, Krall, Niazi et al. 2012, Platman, Allen et al. 2013, Smith 2013).
Referrals to the program by the regulator are usually presented as a directive
ultimatum (DuPont, McLellan et al. 2009, Boyd and Knight 2012). That is, the
practitioner is given the opportunity to take part in the program as an alternative to
discipline (during which time the first element of shielding will apply) (Darbro
2009, Hamilton and Taylor 2011). However, they face potential disciplinary or
licensure actions if they choose not to participate or comply (Fletcher 2001,
Bohigian, Croughan et al. 2002, Brown and Schneidman 2004, Bohigian,
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Bondurant et al. 2005, Fletcher and Ronis 2005, Brooks, Early et al. 2012, Krall,
Niazi et al. 2012, Platman, Allen et al. 2013, Smith 2013).
Under this model, a practitioner who complies with the program can seek help,
receive it, recover, and return to the workforce if appropriate, without any regulator
knowledge or intervention. This is alleged to encourage self-referral and early
intervention (Taylor & Heinjus 2013). In the USA, the long-standing nature of
these agreements (sometimes 40 years or more), and the associated high rates of
success, promote strong referral flows into the signatory health programs (Brown
and Schneidman 2004, Monroe, Pearson et al. 2008, Hamilton and Taylor 2011).
For example, 21 per cent of all referrals to US PHPs come from a regulator
(DuPont, McLellan et al. 2009). This is a notable contrast with models where no
formal shielding provisions are in place, where referrals from regulators are either
low (4 per cent for NMHPV)(Hamilton and Duncan 2012) or not recorded at all
(UK-PHP) (NHS Practitioner Health Programme 2014).
The contract between the Nursing and Midwifery Health Program Victoria
(NMHPV) and the Nursing and Midwifery Board of Australia contains some
references to operational issues, including referral and reporting (Taylor July 22
2014). However - unlike equivalent arrangements in North American programs this is not publically known, and details of the arrangement are not publically
available. Furthermore, the website for NMHPV and the associated publications
makes no mention of mandatory reporting, or how it interacts with the program
(Nursing and Midwifery Health Program Victoria 2014). As such, a lack of
transparency and clarity may contribute to similar uncertainty about the program.
This may in turn prevent nurses and midwives from seeking help.
Formal agreement without shielding: This model is seen in the UK, where it
applies to the NHS Practitioner Health Program (NHS Practitioner Health
Programme and NHS London Special Commissioning Group 2010, National
Health Service Practitioner Health Programme 2012, NHS Practitioner Health
Programme 2014). The program has a formal MOU with each of the two relevant
regulators (General Medical Council and General Dental Council) (NHS
Practitioner Health Programme and Council 2009, NHS Practitioner Health
Programme and General Medical Council 2013). The MOUs cover issues such as
referral, reporting, confidentiality and information sharing. However, neither these
agreements, nor the law, contain any provisions to shield practitioners who are
referred to, approach, or are engaged with the health program.
Indeed, the MOUs specifically provide that the regulator and health program may
exchange information about clients, and their involvement with the program, via
detailed reports (but typically not complete medical records) (NHS Practitioner
Health Programme and Council 2009, NHS Practitioner Health Programme and
General Medical Council 2013). They also allow the health program to report a
client to the regulator if they pose a risk to the public. This is usually done only
where the practitioner poses a serious risk to the public, and is not complying with
the program, treatment and/or recommendations to remain on leave from work.
As a result of the absence of shielding, many practitioners engaged with the
program are subject to parallel regulatory processes (NHS Practitioner Health
Programme 2014). However, over the first five years of the program to 2013, the
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proportion of program clients also involved in regulator processes dropped from 33
per cent to 7 per cent (NHS Practitioner Health Programme 2014). This is
attributed to the success of the program, and increasing acceptance and awareness
which encourages practitioners to seek help before regulator involvement occurs or
is necessary (NHS Practitioner Health Programme 2014).
8.5
The role of coercion
In all but the ‘no shielding’ model described above, there is an element of
ultimatum or coercion applied to impaired practitioners. That is, disciplinary action
is held up as potential consequence of not complying with rehabilitation programs
and other recommendations. This may contribute to the high recovery rates of
practitioners in these programs, as compared with the general population (White,
DuPont et al. 2007, Dupont and Skipper 2012) but does raise ethical concerns
regarding the voluntariness of consent.
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Table 4
Referral
Program
Regulator
Self
Clinical colleagues
Referral
sources
✓ (4%)
✓ (90%)
✓ (6%)
Employers
Treating professionals
Other
Legally-imposed
mandatory reporting in
jurisdiction
Terms of
formal
agreement
with
regulator
AUS-NMHP
×
×
✓ Where required by Health
Practitioner Regulation National
Law
(Victoria) Act 2009
US-HPRP
CAN-EIP
UK-PHP
US-PHP
✓
×
✓ (21% of cases)
✓ (26%)
✓ (84%)
✓ (not for out-of-area
practitioners)
✓ (26% of cases)
✓
✓
×
✓ (20% of cases)
✓
✓
×
✓ (14% of cases)
✓
✓
✓
✓
×
✓ (17% of cases)
e.g. medical schools, law
enforcement, family and
attorneys)
✓
✓ Patients, the State
✓ (Exemption for treating
practitioners)
✓ Program must report if
impaired professional chooses
not to participate and poses risk
to patients
.×
✓ All reports are received by
regulator who administers this
program
Where impaired professional
chooses not to participate
×
✓ (100% of PHPs)
Formal agreement/MOU with
program
✓ (only partial – limited
operational elements in
contract)
✓
✓
✓
Shielding and confidentiality for
compliant practitioners
. (not detailed in formal
agreement, but can occur)
✓ (Except board orders for
participation are publically
discoverable)
✓
×
Practitioners reported if they don’t
participate or comply
. (not detailed in formal
agreement, but can occur)
✓
✓
×
(31% of participants enter
through mandate from
regulatory authority)
✓ (100% of PHPs)
✓ (100% of PHPs)
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9
Assessment
After referral, the next stage is an assessment to determine the nature of the
practitioner’s illness and/or impairment (if any), and possible options for treatment,
rehabilitation and other actions (Boyd and Knight 2012). The features of
assessment processes for the exemplar programs are outlined in Table 5.
9.1
Source of initial assessment
Programs reported a variety of sources of initial assessment. Some programs
employed clinical staff such as mental health and/or addiction nurses, general
practitioners or psychologists (Boyd and Knight 2012, National Health Service
Practitioner Health Programme 2012). Others referred potential clients to external
practitioners for assessments (Boyd and Knight 2012, National Health Service
Practitioner Health Programme 2012). Assessors were usually chosen from a list of
those approved by the service, to ensure quality, understanding of the assessment
requirements and cooperation (Fletcher 2001, Bohigian, Croughan et al. 2002,
Brown and Schneidman 2004, Bohigian, Bondurant et al. 2005, Fletcher and Ronis
2005, Brooks, Early et al. 2012, Krall, Niazi et al. 2012, Platman, Allen et al.
2013, Smith 2013). Some programs (such as US-HPRP) allow client practitioners
to select from a list of acceptable options (Fletcher 2001). Ideally, the specialty of
the assessor should align with the nature of the practitioner’s impairment (e.g.
psychiatrist for suspected mental illness) (Fletcher 2001, Department of Licensing
and Regulatory Affairs 2014). In practice, practitioners who present with one
concern, are often found to have other issues, which are often less obvious
(Korinek, Thompson et al. 2009).
9.2
Assessment components
Two broad types of assessment are relevant to evaluating impaired practitioners.
These reflect the two elements of ‘impairment’ in this context – (a) that the
practitioner must have a health issue, and (b) that the health issue must impair their
performance in a way that poses a risk to patients.
Health Assessments: Methods of assessing a health issue depend on the suspected
nature of the matter. Assessment may include cognitive testing, psychiatric
evaluation, psychological profiling, and physical examination and/or medical tests
(Harrison 2008, Miller 2009, Humphrey 2010, Pham, Pronovost et al. 2013). Such
assessment can establish the existence of a health issue, but cannot necessarily
establish the existence of an impairment of professional performance (Harrison
2008, Humphrey 2010). For example, many practitioners with disabilities or health
issues can practise safely, with or without adjustments to their work practice
(Sanderson-Mann and McCandless 2005, Sanderson-Mann and McCandless 2006,
Morris and Turnbull 2007, Morris and Turnbull 2007, Grainger 2008, Sin and Fong
2008, Schroeder, Brazeau et al. 2009, Tee, Owens et al. 2010, Storr, Wray et al.
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2011). Therefore, in order to establish the existence of a health impairment,
confirming the presence of a health condition is necessary, but not sufficient.
Performance Assessments: In order to establish the existence of a health-related
impairment, it must also be demonstrated that a confirmed health issue impacts, or
has a significant pressing potential to impact, on professional practice. Methods for
assessing performance are less standardised than those for detecting the presence of
health issues (Anfang, Faulkner et al. 2005, Harrison 2008, Harrison 2008,
Norcross, Henzel et al. 2009, Dyer 2012), and tend to focus on competence or
communication concerns rather than the impact of an impairment on clinical
performance per se (Humphrey 2010).
All countries from which the exemplar programs are drawn have programs (usually
run by universities or regulators) for assessing practitioners with suspected
performance problems (Humphrey 2010). Examples include the NCAS Assessment
(National Clinical Assessment Service - UK) and the Performance Assessment
Program (Medical Council of New Zealand) (Humphrey 2010). Methods
commonly used in these programs include (Humphrey 2010):
 site visits to assess work environment
 interviews or questionnaires
 simulations
 practice-based observation
 chart review
 written knowledge test, and
 feedback from patients and peers.
It is worth noting that some assessment and remediation programs for physicians
have been criticised for failing to give due attention to broader systems and
contextual factors that impact on performance (with the exception of NCAS in the
UK) (Humphrey 2010). They were seen to focus on ‘diagnosing’ and ‘treating’
individuals, with little attention to such factors as teamwork in the workplace,
working conditions etc (Humphrey 2010).
9.3
Impairment assessment
To determine the presence (or absence) and nature of impairment, an illness must
be identified (health assessment) and shown to impact on performance in a manner
serious enough to endanger patients (performance assessment) (Pham, Pronovost et
al. 2013). Only when both of these determinations are made can a valid conclusion
be reached about whether an impairment is present. However, as outlined above,
methods for assessing these two questions, and drawing valid causal connections
between the two, are often disjointed (Humphrey 2010).
In some cases, the type of assessment used to evaluate a practitioner can skew the
interpretation of their performance issues (Korinek, Thompson et al. 2009). For
example, a performance review that does not include a cognitive-testing
component may miss the underlying cause of impairment (Korinek, Thompson et
al. 2009). Efforts are being made to produce standard models, tools and guidelines
for assessing and reporting on ‘fitness-to-practice’, as well as competence
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(Reynolds 2001, Anfang, Faulkner et al. 2005, Wall 2005, Wettstein 2005, Sin and
Fong 2007, Harrison 2008, Harrison 2008, Miller 2009, Norcross, Henzel et al.
2009, Dyer 2012, Meyer and Price 2012, Price and Meyer 2013). However, there is
yet to be wide acceptance of particular methods (Reynolds 2001, Wall 2005,
Wettstein 2005, Sin and Fong 2007, Harrison 2008, Dyer 2012, Meyer and Price
2012, Price and Meyer 2013).
Finally, it is worth noting that there a relationship between history of disciplinary
action and contact with regulators, and the presence of impairment (Holtman
2007). So there is a potential role for disciplinary and/or regulator contact history
to be considered in assessing potentially impaired practitioners.
9.4
Role of the regulator
In all exemplar models, regulators can potentially receive some information about
the findings of an assessment. However, the frequency and depth of such
information-sharing, and the circumstances under which it occurred, vary
substantially. The programs examined in this review fell into four main categories
with respect to the sharing of assessment findings:
Universal initial access: This model is seen where the regulator administers case
management programs, or uses a regulator management approach. In these cases,
full information on the outcome of the assessment is available to the regulator and
is used to determine next steps in the process (e.g. whether a practitioner ought to
be offered a health program option or not) (Medical Council of New South Wales
2010, College of Registered Nurses of British Columbia 2014). Whether or not the
regulator has access to subsequent updates on client progress and participation
varies (Medical Council of New South Wales 2010, College of Registered Nurses
of British Columbia 2014). An example of this model is CAN-EIP, which follows
a regulator management model (College of Registered Nurses of British Columbia
2014). In this case, the regulator orders and/or contracts assessments of potentially
impaired practitioners and determines eligibility for the program based on these
assessments (College of Registered Nurses of British Columbia 2014). However,
details of the assessment outcome are not recorded on the practitioners’ records if
they are fully compliant and successful with their rehabilitation.
Access upon infringement: This model is most common among case management
programs in North America which utilise treatment and/or management contracts
to formalise their expectations of clients (Fletcher 2001, Bohigian, Croughan et al.
2002, Brown and Schneidman 2004, Bohigian, Bondurant et al. 2005, Fletcher and
Ronis 2005, Boyd and Knight 2012, Brooks, Early et al. 2012, Krall, Niazi et al.
2012, Platman, Allen et al. 2013, Smith 2013). In these cases there is provision
within the formal agreement with the regulator that certain information about the
client, including certain assessment findings, may be shared with the regulator if
the client breaks the terms of their contract (i.e. is ‘non-compliant’) (Fletcher 2001,
Bohigian, Croughan et al. 2002, Brown and Schneidman 2004, Bohigian,
Bondurant et al. 2005, Fletcher and Ronis 2005, Boyd and Knight 2012, Brooks,
Early et al. 2012, Krall, Niazi et al. 2012, Platman, Allen et al. 2013, Smith 2013).
Access where mandated: This model is seen in some case management programs
(e.g. US-HPRP) where rules regarding – information-sharing vary based on the
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entry path of the client into the program (Fletcher 2001, Michigan Health
Professional Recovery Program 2013). In these circumstances, access about the
assessment outcomes of clients is automatically accessible to the regulator in cases
where a clients’ participation was mandated by an order of that regulator (Fletcher
2001, Michigan Health Professional Recovery Program 2013).
Access in case of public risk: This model is seen in jurisdictions where mandatory
reporting operates, but shielding of health program clients does not (such as UKPHP) (NHS Practitioner Health Programme and Council 2009, NHS Practitioner
Health Programme and General Medical Council 2013). Under this model, the
program reserves the right (of which clients are clearly informed) to report clients
who are believed to pose a serious risk to public and/or patient safety – typically
following non-compliance (NHS Practitioner Health Programme and Council
2009, NHS Practitioner Health Programme and General Medical Council 2013). In
such cases, certain aspects of assessment findings may be shared with the regulator.
Table 5 Assessment
Program
AUS-NMHP
US-HPRP
CAN-EIP
UK-PHP
US-PHP
Internal staff
External
(participant given
choices)
External
Internal staff
Internal staff
Physical
examination
×
✓ (where
indicated)
✓ (where
indicated)
✓ (where
indicated)
✓ (where
indicated)
Psychological
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
Participant
interview and/or
questionnaires
✓
✓
✓
✓
✓
Non-referring
colleagues
✓ (with
permission)
×
✓
×
✓
✓ Where required
by law
✓ If participation is
regulatormandated, or if
contract broken or
relapse occurs
✓ Always –
regulator decides
whether nurse
eligible for
program
✓ Program reserves
the right to report
high-risk
practitioners
✓ Only if contract
broken or relapse
occurs
Initial assessment source
Initial
assessment types
Referrer (if not the
participant)
Sources of
information
Regulator’s role
Can be given
information about
assessment
outcome
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10
Treatment, rehabilitation and
monitoring
The features of treatment and rehabilitation in each of the exemplar programs is
outlined in Table 6.
10.1
Role of the health program
It is rare for health programs to directly provide clinical treatment for impairmentrelated health conditions, with the exception of some limited in-house counselling
(usually just a few sessions). Instead they serve as coordinating, referral,
administrative and monitoring bodies. While details vary between programs,
typical treatment-related roles for case management programs include:
 using assessment findings to develop a management and treatment plan
 creating an agreement or contract with the client based on the treatment plan,
which may include agreed temporary restrictions on work
 assisting the client to arrange and coordinate the treatment plan including
referrals to appropriate treatment services (inpatient and outpatient),
practitioners, support services, peer support or mutual aid groups and advocacy
services
 monitoring compliance with treatment and management programs (for example
through receipt of reports, logs and drug test results, and worksite visits)
 developing and implement response plans when relapse or other significant
negative event occur
 negotiating alterations to treatment and management plans as appropriate
 arranging re-assessment of clients reaching the end of program participation,
and
 facilitating return-to-work efforts (Brown and Schneidman 2004, Warhaft 2004,
Hall 2007, DuPont, McLellan et al. 2009, Hambleton 2011, Skipper and
DuPont 2011, Boyd and Knight 2012, Dupont and Skipper 2012).
Thus, most programs are based on a distinct separation between co-ordination and
provision of treatment. This allows for more individualisation and flexibility in
programs (Brown and Schneidman 2004, Skipper and DuPont 2011), and helps to
protect client confidentiality (National Health Service Practitioner Health
Programme 2012).
10.2
Program specialisation
Major lines of program specialisation occurs along three axes – geographic area,
impairment type and profession
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Geographic area: There is little comment in the literature on the relative merits of
a state-based or national approach. In the US, Canada and Australia, state or
province-based programs are the norm (where they exist at all) (Fletcher 2001,
Bohigian, Croughan et al. 2002, Brown and Schneidman 2004, Warhaft 2004,
Bohigian, Bondurant et al. 2005, Brewster, Kaufmann et al. 2008, Krall, Niazi et
al. 2012, Platman, Allen et al. 2013, Smith 2013, College of Registered Nurses of
British Columbia 2014, Nursing and Midwifery Health Program Victoria 2014). In
the UK, services such as hotlines and charitable support organisations are national
(Miller 2002, Sick Doctors Trust 2014), but the only case management program
(UK-PHP) is fully and freely available to London-area practitioners (NHS
Practitioner Health Programme 2014). Out-of-area practitioners can pay a fee to
access an assessment by the program (NHS Practitioner Health Programme 2014).
Impairment type: With respect to impairment types, many programs limit the
scope of impairments that they cover. Substance misuse (where mental health
concerns are often also present) was specifically covered by all programs identified
(Bosch 2000, Fletcher 2001, Bohigian, Croughan et al. 2002, Miller 2002, Brown
and Schneidman 2004, Warhaft 2004, Bohigian, Bondurant et al. 2005, Brewster,
Kaufmann et al. 2008, Krall, Niazi et al. 2012, Platman, Allen et al. 2013, Smith
2013, College of Registered Nurses of British Columbia 2014, NHS Practitioner
Health Programme 2014, Nursing and Midwifery Health Program Victoria 2014,
Sick Doctors Trust 2014). Mental health and psychiatric concerns were frequently
covered, with all exemplar programs and 85 per cent of US PHPs covering these
concerns (Fletcher 2001, DuPont, McLellan et al. 2009, DuPont, McLellan et al.
2009, Skipper and DuPont 2011, Michigan Health Professional Recovery Program
2013, College of Registered Nurses of British Columbia 2014, NHS Practitioner
Health Programme 2014, Nursing and Midwifery Health Program Victoria 2014).
US programs have been traditionally skewed towards SUDs (DuPont, McLellan et
al. 2009, DuPont, McLellan et al. 2009, Dupont and Skipper 2012). Fewer
programs explicitly cover physical health and disability or age-related cognitive
issues (DuPont, McLellan et al. 2009, College of Registered Nurses of British
Columbia 2014, NHS Practitioner Health Programme 2014). For those that do, the
proportion of total clients with these concerns is relatively small. For example, UKPHP reports physical illness or disability as a major concern in only 17 per cent of
cases (National Health Service Practitioner Health Programme 2012).
We did not identify any programs that focused solely on physical health, cognitive
concerns (distinct from mental illness) or other disabilities.
Profession: All of the health programs examined by this review were, to some
degree, specific to health practitioners. Some were specific to only one or two
professions (such as doctors, or doctors and dentists) (NHS Practitioner Health
Programme 2014), while others were open to those working in a range of healthrelated occupations (25 occupations in the case of US-HPRP) (Michigan Health
Professional Recovery Program 2013). Services that referred clients to external
treatment or rehabilitation providers reported that they preferred services or
practitioners that they deemed ‘practitioner-patient friendly’, with whom the
program often had an established relationship (Fletcher 2001, Bohigian, Croughan
et al. 2002, Brown and Schneidman 2004, Bohigian, Bondurant et al. 2005,
Fletcher and Ronis 2005, Brooks, Early et al. 2012, Krall, Niazi et al. 2012,
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Platman, Allen et al. 2013, Smith 2013). While these practitioners often had
particular skills and experience in treating health practitioners, they generally
provided services to non-practitioner members of the public as well (Skipper and
DuPont 2011).
Research in the UK found that both healthcare practitioners and the public could
see the merit in tailored or specialised services for practitioners (Ipsos MORI
2009). However, the public strongly believed that while the service should be
tailored to the needs of practitioners, it should not be ‘better’ than mainstream
services (Ipsos MORI 2009).
10.3
Treatment types
Types of treatment to which health programs in this review refer include (Fletcher
2001, Bohigian, Croughan et al. 2002, Brown and Schneidman 2004, Bohigian,
Bondurant et al. 2005, DuPont, McLellan et al. 2009, DuPont, McLellan et al.
2009, Skipper and DuPont 2011, Dupont and Skipper 2012, Krall, Niazi et al.
2012, Platman, Allen et al. 2013, Smith 2013, NHS Practitioner Health Programme
2014, Victorian Doctors Health Program 2014):
 counselling – group, individual, family and marital/relationship
 psychology and psychotherapy
 psychiatry (inpatient and outpatient)
 addiction specialists
 occupational medicine specialists
 occupational therapists
 addiction recovery programs (inpatient and outpatient)
 general practitioners
 physical rehabilitation services, and
 peer and/or mutual aid support groups (e.g. Alcoholics Anonymous, Narcanon,
Caduceus).
The range of treatment options available, and the individualisation of treatment
plans, was largely consistent across the programs examined. A detailed analysis of
the effectiveness of these various treatments is outside the scope of this review.
However, the evidence does support a multi-disciplinary, individualised and
integrated approach (Mehendale and Goldman , White, DuPont et al. 2007, Skipper
and DuPont 2011, Dupont and Skipper 2012).
Notable features of the US PHP model include high utilisation of lengthy inpatient
treatment and mutual aid groups (Brown and Schneidman 2004). Sixty-nine
percent of US PHP patients are placed in inpatient care (usually for 90 days), and
95 per cent of US programs mandated mutual aid group attendance (DuPont,
McLellan et al. 2009). These fit with the overall focus on abstinence-based
approaches in US PHPs, which prohibit all non-medical use of drugs and alcohol
for those presenting with SUDs (DuPont, McLellan et al. 2009). However, it has
been suggested that the total abstinence approach may not be suitable to the
Australian context (Brown and Schneidman 2004).
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10.4
Monitoring strategies
Monitoring strategies used by health programs identified in this review include
(Knight, Sanchez et al. 2002, Warhaft 2004, Ganley, Pendergast et al. 2005, Long,
Cassidy et al. 2006, Brewster, Kaufmann et al. 2008, Carinci and Christo 2009,
Darbro 2009, Skipper and DuPont 2011, Brooks, Gendel et al. 2013, Michigan
Health Professional Recovery Program 2013):
 regular drug testing, including urine, blood, breath and hair (for up to five years
for most US PHPs)
 treating practitioner feedback
 workplace feedback (most often by an appointed workplace monitor)
 unannounced worksite visits (during transition back to work or if remaining in
work)
 documentation of mutual aid or support group attendance
 medical monitoring, and
 personal progress reports by clients.
Methods, regimes and durations of monitoring varied more widely across the
programs than did treatment options. A detailed analysis of the effectiveness of
these various treatments is outside the scope of this review. However, research has
shown that program clients believe that monitoring is cumbersome, but vital to
their recovery (Knight, Sanchez et al. 2002, Fogger and McGuinness 2009).
10.5
Work restrictions
All programs identified in this review included a role for agreed work restrictions
or stoppages as part of treatment plans, agreements and/or contracts (Fletcher 2001,
Bohigian, Croughan et al. 2002, Brown and Schneidman 2004, Warhaft 2004,
Bohigian, Bondurant et al. 2005, NHS Practitioner Health Programme and Council
2009, Krall, Niazi et al. 2012, NHS Practitioner Health Programme and General
Medical Council 2013, Platman, Allen et al. 2013, Smith 2013, College of
Registered Nurses of British Columbia 2014, Nursing and Midwifery Health
Program Victoria 2014, Victorian Doctors Health Program 2014). These
restrictions are intended to protect patient from harm, protect the practitioner from
the consequences of causing harm, allow the practitioner to focus on recovery, and
maintain regulator confidence that health programs do not place patients at undue
risk (Hughes, Smith et al. 1998, Haack and Yocom 2002, Dunn 2005). While most
are technically voluntary (in that they are not regulator-ordered), failure to abide by
such restrictions is typically considered a breach of the treatment agreement, and
can trigger a report to the regulator (Fletcher 2001, Bohigian, Croughan et al. 2002,
Brown and Schneidman 2004, Bohigian, Bondurant et al. 2005, NHS Practitioner
Health Programme and Council 2009, College of Registered Nurses of British
Columbia 2012, Krall, Niazi et al. 2012, NHS Practitioner Health Programme and
General Medical Council 2013, Platman, Allen et al. 2013, Smith 2013).
In the case of CAN-EIP, all clients must initially agree to withdraw from practice
and change their practising certificate status to ‘not practising’ until cleared for
work by a medical doctor (College of Registered Nurses of British Columbia
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2014). In all other programs where such provisions were identified, work
restrictions were not so universally applied, but were determined on an individual
basis. Some restrictions involve total withdrawal from work for a time, while
others involve specific provisions such as not handling certain medications or
working restricted hours (Hughes, Smith et al. 1998, Haack and Yocom 2002,
Dunn 2005). As part of the transition back to work, these restrictions are gradually
eased (Hughes, Smith et al. 1998, Haack and Yocom 2002, Wilson and Compton
2009, Angres, Bettinardi-Angres et al. 2010).
One difficulty of work restrictions is that they have the potential to compromise
client confidentiality. Long absences from work, the need to inform worksite
monitors, managers and other staff, and changes in work permissions and tasks,
can all bring about awareness of the practitioner’s health issues (Smith and Hughes
1996, Couser 2013).
10.6
Role of the regulator
The most common role for the regulator during the treatment and rehabilitation
stage is as the repository for reports when practitioners are non-compliant,
uncooperative or choose not to engage with the health program (Fletcher 2001,
Bohigian, Croughan et al. 2002, Brown and Schneidman 2004, Bohigian,
Bondurant et al. 2005, NHS Practitioner Health Programme and Council 2009,
College of Registered Nurses of British Columbia 2012, Krall, Niazi et al. 2012,
NHS Practitioner Health Programme and General Medical Council 2013, Platman,
Allen et al. 2013, Smith 2013). The general lack of ‘matter of course’ reporting to
the regulator is seen as an important aspect of developing and maintaining trust
between the client, their treating practitioners and the health program (Jenkins
2013).
We found only one explicit reference to the progress of compliant clients being
regularly reported to the regulator as a matter of course during the treatment,
rehabilitation and monitoring stages (Health Professional Recovery Program 2011,
Michigan Health Professional Recovery Program 2013). This occurred in USHPRP, but only for those practitioners whose participation was mandated by the
regulator (33 per cent) (Health Professional Recovery Program 2011, Michigan
Health Professional Recovery Program 2013). However, as this was not a
systematic review, other examples may exist.
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Table 6 Treatment and rehabilitation
Program
Rehab offered
internally
Rehab referred to
AUS-NMHP
US-HPRP
CAN-EIP
UK-PHP
US-PHP
Medical treatment
×
×
×
×
×
Psychological/
counselling
✓ Counselling
×
×
✓ Counselling and
psychology
×
Peer support
✓
×
×
×
×
Medical treatment
✓
✓
✓
✓
✓
Psychological/
counselling
✓
✓
✓
✓
✓
Peer support
✓
✓
✓
✓
✓
✓
✓
×
✓
✓
✓ Stop work until
return medically
approved
×
✓
✓
✓
✓
✓
✓ (100 per cent of
PHPs)
✓
✓
✓
✓
✓ (100 per cent of
PHPs)
✓ Worksite
monitor reports
✓
×
✓ (70 per cent of
PHPs)
Formal, binding treatment contracts
Formally contracted work limitations
Treating
practitioner
feedback
Drug testing
Elements of
monitoring (where
relevant)
Workplace
feedback
✓
Peer support
attendance
Other
Regulator’s role
Regulator
informed of
progress as a
matter of course
×
✓ (95 per cent of
PHPs)
✓ Personal
progress reports
✓ Medical
monitoring
×
✓ Unannounced
worksite visits
✓ Only if
participation is
regulatormandated
×
×
×
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11
Outcomes
Information on outcomes for clients of health programs is patchy, and does not
report against consistent measures. As such, meaningful comparisons are difficult.
However, a summary of available outcomes data is presented in Table 7.
11.1
Outcome types
Health program outcomes mentioned in the literature are listed below (McLellan,
Skipper et al. 2008, Skipper, Campbell et al. 2009, Health Professional Recovery
Program 2011, Skipper and DuPont 2011, Hamilton and Duncan 2012, National
Health Service Practitioner Health Programme 2012, Siggins Miller 2012, Rose,
Campbell et al. 2014). Individual clients may experience different combinations of
these outcomes.
Recovery:
 total, without relapse or major problematic event
 total, with intervening relapse or major problematic event
 no longer a risk to patients
 abstinence from substance use (DuPont, McLellan et al. 2009, DuPont,
McLellan et al. 2009)
 non-recovery, and
 death
Licence/registration:
 kept, without restrictions
 kept, with restrictions
 revoked or suspended
 surrendered, and
 converted to ‘non-practising’ (e.g. retirement)
Program completion:
 program completed
 failure to complete – voluntary exit
 failure to complete – involuntary discharge (non-compliance), and
 failure to engage at beginning
Work status (in health profession):
 remained at work
 returned to work
 able to return to work, planning to return
 able to return to work, not planning to return, and
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 unable to return to work.
11.2
Recovery from substance use disorders – rates and
contributing factors
The most commonly reported outcomes are for recovery from SUDs. This may be
because abstinence from the substance of concern (or from all non-medically
required drugs and alcohol) is a relative clear and measureable definition
(McLellan, Skipper et al. 2008, Skipper, Campbell et al. 2009, Health Professional
Recovery Program 2011, Skipper and DuPont 2011, Hamilton and Duncan 2012,
NHS Practitioner Health Programme 2014, Rose, Campbell et al. 2014).
Clients with substance use disorders in practitioner health programs recover at
much higher rates than members of the general population undergoing substance
use disorder treatment (as defined by abstinence at five years) (Domino, Hornbein
et al. 2005, DuPont, McLellan et al. 2009). Optimistic estimates of recovery rate in
the general population undergoing treatment generally range from 40 per cent to 60
per cent (McLellan, Lewis et al. 2000, Institute of Medicine 2006). Yet, for
example, the average recovery rate for US PHP’s is 88 per cent at five years. A
study of abstinence rates from the Washington Physicians Health Program showed
rates of 78 per cent after 11 years (Domino, Hornbein et al. 2005). The three-year
recovery rate for UK-PHP is 79 per cent. The risk of relapse is also lower in
practitioners (Domino, Hornbein et al. 2005).
The reasons for such high recovery rates are not entirely clear (Boyd and Knight
2012). However, several factors have been suggested in the literature.
First, the quality and intensity of health programs offered to physicians outstrips
those available to most members of the general population (Domino, Hornbein et
al. 2005, White, DuPont et al. 2007, Skipper and DuPont 2011, Boyd and Knight
2012). Health programs for practitioners tend to be intensive, coordinated, lengthy,
inter-disciplinary and individualised, which has been linked with improved
outcomes (Mehendale and Goldman , White, DuPont et al. 2007, Skipper and
DuPont 2011, Boyd and Knight 2012, Dupont and Skipper 2012).
Second, practitioners tend to have the financial and social capital resources to
engage with more intensive treatment for longer (DuPont, McLellan et al. 2009,
Boyd and Knight 2012). It is known that the risk of relapse decreases the longer a
practitioner stays in a treatment program (Domino, Hornbein et al. 2005).
Third, practitioners in health programs face a uniquely formal, structured and
‘high-stakes’ set of consequences for non-compliance, relapse, or non-engagement
with treatment (Mehendale and Goldman , White, DuPont et al. 2007, Boyd and
Knight 2012, Dupont and Skipper 2012). That is, they typically face job loss,
disciplinary action, public attention/exposure, and permanent career loss through
registration or licensure actions. Writing these potential consequences into the
treatment contract creates a clear and concrete connection between noncompliance/relapse and serious negative repercussions (Mehendale and Goldman ,
White, DuPont et al. 2007, Boyd and Knight 2012, Dupont and Skipper 2012).
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Fourth, practitioners in health programs are accessing a service specific to their
profession. That is, it is tailored to their unique needs and life circumstances in a
way that is not mirrored for the general population (Brand, Rojas et al. 2013).
It is important to note that practitioners enrolled in practitioner-specific health
programs shower higher rates of recovery than those treated through mainstream
means (DuPont, McLellan et al. 2009). This suggests that differences in recovery
rates between practitioners and the general public are at least partially explained by
the features of practitioner health programs, rather the features of practitioners as a
population group (DuPont, McLellan et al. 2009).
11.3
Recovery from non-substance use disorder
impairments
‘Recovery’ from mental health issues, physical illness, cognitive impairment,
ageing and disability are sometimes either difficult to define or not medically
possible. Therefore, data on such outcomes were sparse and vaguely described.
Data on clients with mental health issues, such as those provided by the
Massachusetts Medical Society’s Physician Health Service, tended to define
‘success’ as complete adherence to treatment contracts (Knight, Sanchez et al.
2007). While this is a positive measure, it is not the same as ‘recovery’.
For these clients, being able to remain at or return to work could perhaps be
another proxy measure of wellness considered as ‘success’. However, data on work
status outcomes for clients, broken down by presenting health issue/impairment,
were not found.
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Table 7
Outcomes
Program
AUS-NMHP
Remained at work our returned to
work
58 per cent (note:
status of 22 per
cent recorded as
unknown or N/A)
Recovery rate
CAN-EIP
UK-PHP
US-PHP
[Established in
2012, too early for
data]
77 per cent (after 3
years)
71 per cent (after 5
years)
79 per cent
88 per cent
(monitored over 5
years)
52 per cent
Deemed
recovered or
abstinent
48 per cent
Non-recovery
Practitioner satisfaction
US-HPRP
Very positive
qualitative
feedback at focus
group review
98.9 per cent ‘very’
or ‘moderately’
satisfied. Of these
81.8 per cent ‘very
satisfied.
Average rating 3.6
out of 5
4.5 per cent
(29 per cent
involved with
regulator processes
at some stage
during program
contact)
License status revoked, suspended
or surrendered at end of program
contact
Informed of
relapse, noncompliance or
broken contract
✓ Where required
by law
✓ Almost always
✓ Almost always
✓ Must report if
practitioner under
regulator
supervision or
investigation
✓ Almost always
(100 per cent of
PHPs)
✓ Can report highrisk practitioners
Role of
regulator
Informed if
practitioner
won’t engage
with program
18 per cent
✓
✓
✓ Reserves the
right to report
high-risk
practitioners
✓
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12
Costs
From a regulatory point of view, the cost effectiveness of practitioner health
programs can be understood as a balance between three major factors—the cost of
poorly treated or untreated impairment to the practitioner and the wider health
system, the cost of health programs, and the costs to the regulator (e.g. if a health
program is unsuccessful and disciplinary measures are required to protect the
public.)
Public reporting of program budgets and some publically available evaluations
provide information on the overall budgets of health programs. However,
information on costs to the health system and wider society that are prevented or
recouped—and thus the benefit received from expenditure—is very limited. This
literature review, and systematic literature reviews by others, found little or no data
on, for example:
 the cost of losing practitioners from the health workforce due to impairment
(through early retirement, removal from practice)
 the cost of clinical errors by impaired practitioners to the healthcare system, and
 the relative cost-effectiveness of different programs (due, in part, to difficulties
and tensions in defining program success).
12.1
Costs of practitioner impairment
Direct costs of practitioner impairment to healthcare systems include the costs of
sick leave, personnel cover for everyday duties and legal and managerial costs
associated with discipline, suspension, investigations, regulatory action etc.
Absenteeism: Cost estimates and other publically available data about the costs of
practitioner sick leave and absence typically do not differentiate between nonimpairment-related absence (e.g. for flu, cancer or accident recovery), from those
directly associated with impairment (e.g. for addiction or psychiatric treatment).
This renders it difficult to estimate the costs of impairment.
One analysis, sponsored by the Nursing and Midwifery Health Program Victoria
(NMHPV) and the Australian Nursing Federation (ANF), calculated the cost of lost
productivity for an impaired nurse with time off work to be between $52,000 and
$70,000 (Lorgelly 2011). This was part of a wider analysis which estimated that
NMHPV saved the health sector $7.23 million in lost productivity and other costs
(Lorgelly 2011). However, these figures have been questioned by departmental
respondents from two other states (Siggins Miller 2012).
In the UK, staff sickness absences are estimated to cost the National Health Service
the equivalent of AUD$3.1 billion annually (Department of Health 2010). Mental
illness-related absence of NHS staff is estimated to cost the equivalent of AUD
$2.3 billion (Department of Health 2010). Stress-related disorders alone account
for almost a third of National Health Service staff sick leave per year. However, the
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proportion of these costs which relate to conditions that meet the threshold for
impairment-related is unknown.
Presenteeism: ‘Presenteeism’ of impaired practitioners – coming to work and
performing at less than full capacity because of ill health or impairment – is also
costly. A Swedish survey found that people in the caring professions – including
healthcare workers – were among those most likely to go to work while unwell
(Aronsson, Gustafsson et al. 2000). Doctors were more than twice as likely to do
so than other workers, while nurses and midwives were three to four times more
likely (Aronsson, Gustafsson et al. 2000).
Suspensions: The UK Department of Health review estimated that suspensions due
to ill health (a somewhat better proxy for impairment than sick leave) cost Londonbased NHS institutions the equivalent of nearly AUD$10 million annually, above
and beyond normal salary paid to replacement practitioners (NHS Practitioner
Health Programme and NHS London Special Commissioning Group 2010). This
was based on an estimate of 38 doctors out of 27,640 registrants, with estimated
costs of AUD$262,000 each (composed of locum costs, management and legal
costs, but not standard salary) (National Health Service Practitioner Health
Programme 2012).
Wider costs: At the societal level, the loss of practitioners to death, disability, loss
of licence or the decision to leave the profession is a negative workforce impact
(Department of Health 2010). This is especially true given the extensive resources
invested into practitioner training (Department of Health 2010). Practitioners
leaving their profession because of impairment comprise an unknown portion of
early-retiring practitioners, who are estimated to cost UK society AUD$272
million annually in lost work potential and other costs (Boorman 2009). While
Australian data is scarce, the NMHPV-sponsored analysis, which calculated that
for the 60 per cent of impaired nurses who did not take time off, but worked under
conditions, the cost to the healthcare system was estimated at $38,000 to $40,000
(Lorgelly 2011). However, these figures have been disputed (Siggins Miller 2012).
Impaired practitioners also present costs to employers, including the costs of
additional training or supervision, locum services during periods of sick leave, and
recruitment and replacement costs if a practitioner is removed from practice.
Where practitioners are unable to work at all as a result of their impairment, this
can be costly to social welfare systems (NHS Practitioner Health Programme and
NHS London Special Commissioning Group 2010).
12.2
Costs to the regulator
At the regulator level, the introduction of health programs is associated with shifts
in the role and workload of the regulator, and the balance of practitioners in
disciplinary versus alternative-to-discipline pathways. For UK-PHP, the proportion
of clients involved in parallel regulator processes during their engagement with the
program dropped from 33 per cent to 7 per cent over the first five years of the
program (NHS Practitioner Health Programme 2014).
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Detailed breakdowns of the costs of disciplinary approaches were scarce. However,
general outlines of the types of costs incurred under a disciplinary approach are
listed below (Monroe, Pearson et al. 2008, Siggins Miller 2012):
 assessment of practitioner
 investigation
 Board sitting fees and meeting costs
 legal advice, legal representation, and court/tribunal costs, and
 salaries of staff overseeing monitoring, assessments, compliance etc.
12.3
Costs of health programs
The national survey of US PHPs found an averaging operating budget for PHPs of
AUD$572,000 (DuPont, McLellan et al. 2009). However, this varied substantially
from AUD$522,600 to AUD$1.6 million, with a median of AUD$287,500
(DuPont, McLellan et al. 2009). These budgets include program running costs, but
not treatment, rehabilitation or testing for monitoring purposes (DuPont, McLellan
et al. 2009). A breakdown of contributors to these costs is available in Table 8.
For example, the Australian Nursing and Midwifery Federation (ANMF) calculates
that funding the Nursing and Midwifery Health Program Victoria (NMHPV)
equates to a cost of $5.69 per Victorian registrant annually, all of whom can access
the program at no cost if required (Siggins Miller 2012). However, it is important
to note that this only covers the cost of case management and other assistance from
the health program, and not clinical treatment or rehabilitation to which the
program refers (Nursing and Midwifery Health Program Victoria 2014). These
costs are the responsibility of the nurse or midwife.
Medical Directors of both Hospital Trusts and Primary Care Trusts in the UK
report that before the first pilot health program in the UK (UK-PHP), employers
often met the costs for private, out-of-area treatment for practitioners with
impairment-related health issues (National Health Service Practitioner Health
Programme 2012). One Medical Director estimated that the redirection of this
money towards the PHP had saved his Primary Care Trust over AUD$911,000 in
costs from hiring locums to cover suspended clinicians, legal costs, hearings,
appeals and suspensions (National Health Service Practitioner Health Programme
2012).
Concerns about the relatively small number of practitioners benefiting from
programs aimed at impaired practitioners is raised as a potential barrier to costeffectiveness (as well as research efficacy) (Humphrey 2010). However, figures
suggest that treating even a small number of clients effectively is cost-effective.
For example, in its pilot phase, UK-PHP was funded through a block contract
worth $AUD1.82 million equivalent, to cover all doctors and dentists living in
London (National Health Service Practitioner Health Programme 2012). When
divided among all London-based Primary Care Trusts, this amounted to the
equivalent of $AUD58,320 per Trust - similar to the cost of excluding just one
doctor from work for seven weeks (AUD$52,860) (National Health Service
Practitioner Health Programme 2012).
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12.4
Costs for clients
In all programs examined in this review, a proportion of treatment, rehabilitation
and monitoring costs were covered by the client themselves. A survey of clients of
US-HPRP found that for the majority of participants, the costs of treatment,
rehabilitation, aftercare and monitoring were high, with many health insurers
offering little or no coverage. As a result, clients reported average out-of-pocket
expenses of AUD$10,650 to AUD$32,000 for a three-year program for SUD
(Michigan Health Professional Recovery Program 2013). However, these figures
should be considered with caution in the Australian context, where universal
healthcare and other differences in healthcare funding apply.
Costs to clients can include the following:
 assessments and reports
 compliance with treatment conditions on license/registration (e.g. counselling)
 compliance with monitoring conditions on license/registration (e.g. urine
testing)
 travel costs to comply with conditions
 income loss, and
 legal advice, representation and court/tribunal costs.
Costs to clients varied based on factors including the type and duration of treatment
and monitoring, the nature of the healthcare system, and the practitioner’s level of
health insurance coverage (Michigan Health Professional Recovery Program
2013).
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13
Funding
Both in Australia and internationally, programs and services are funded by a range
of sources, including regulators, impaired practitioners themselves, insurers,
employers, unions, and professional bodies. A summary of funding sources for the
exemplar programs is outlined in Table 8.
Most programs charge little or nothing to practitioners for the general running costs
of the health program. However, in the majority of programs, the practitioner (or
his or her health insurer) is responsible for the costs of treatment, rehabilitation and
monitoring aspects. The one exception of the exemplar programs is the UK-PHP,
where limited internal treatment services are funded by the NHS (but external
services are the responsibility of the client).
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Table 8 Funding sources and arrangements
AUS-NMHP
Program
US-HPRP
CAN-EIP
UK-PHP
×
×
×
×
✓ (50% of PHPs)
✓ (via
professional
registration fees)
×
✓
×
✓ (50% of total
contributions)
×
×
×
×
✓ Hospitals (9%
of total
contributions)
×
✓ Government –
Michigan
Department of
Licensing and
Regulatory Affairs
×
✓ London Clinical
Commissioning
Groups (National
Health Service
bodies)
✓
Participant fees
(16%)
State medical
association (10%)
Malpractice
companies (6%)
Other (9%)
✓ (for assessment
by external
providers)
✓
✓
✓ (for out-of-area
practitioners only)
✓
Practitioner
✓ (for initial
internal
assessment)
×
×
×
×
Regulator
Employer
×
×
×
×
×
✓ Health insurer
(79% not insured
for assessments)
✓ British
Columbia Nursing
Union
✓ London Clinical
Commissioning
Groups (NHS
statutory body)
.
✓
✓
✓
✓
Practitioner
Regulator
Employers
General program
operating costs
Other
Individual
assessment
Individual
treatment,
rehabilitation,
monitoring
US-PHP
Other
×
Practitioner
✓
Regulator
×
×
×
×
×
Employer
×
×
×
×
×
×
✓ Health insurer
(95% not insured
for drug screens,
71% not insured
for any treatment)
✓ British
Columbia Nursing
Union (travel
expenses and year
1 monitoring)
✓ London Clinical
Commissioning
Groups (treatment
internal services
only)
×
Other
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14
Role of other stakeholders
14.1
Employers
The literature identified a variety of roles for employers in the management of
impaired practitioners.
Safe work conditions: Employers can help prevent and mitigate impairment in
practitioners by providing safe working conditions, thus reducing work-related risk
factors for substance misuse and mental health issues (Medew 2008, Dwyer,
Morley et al. 2011). Examples include maintaining safe working hours, effective
supervision, and bullying prevention (Dwyer, Morley et al. 2011). For example,
these measures (among others) were adopted as part of wider context for the Royal
Melbourne Hospital support program for ‘at-risk’ junior doctors, following the
death of a surgical registrar by suicide (Dwyer, Morley et al. 2011). One report
suggested that the UK NHS could save AUD$1.83 billion per year if it followed
good practice and provided workplace health and wellbeing initiatives for staff
(Department of Health 2010). However, there is little evidence on the impact of
such initiatives on sickness absence or productivity (Department of Health 2010).
Clear policies and protocols: Clear systems and protocols for dealing with
suspected or actual physician impairment, known and applied consistently by all
staff, are vital to ensuring patient safety (Leape and Fromson 2006). Such protocols
can help address some of the barriers to help-seeking, referral and reporting
identified in this review by removing uncertainty, creating clear expectations, and
promoting a culture of patient safety (Dwyer, Morley et al. 2011). Leape and
Fromson (2006) suggest that an effective system involves four key elements –
adopting standards, requiring compliance, monitoring performance and responding
to deficiencies. An exemplar for clear policies and protocols is the Auckland
Hospital Substance Abuse Protocol (Auckland Hospital 2014). This protocol
details the formation and operation of a substance use committee, mentoring,
preventative education, self-care policies, investigation procedures, intervention
guidelines and follow-up (Auckland Hospital 2014).
Employee assistance programs: Employee Assistance Programs (EAPs) offer
another support and treatment option for impaired nurses and midwives. EAPs are
available to practitioners working in the public health system in all states and
territories in Australia (Nursing and Midwifery Board of Australia 2012, ACT
Health 2013), and to employees of certain health services in the USA and UK
(Royal United Hospital Bath 2012, UC San Diego Health System 2014). However,
coverage by EAPs is not universal for all nurses and midwives (including those in
small-scale and/or private practices), additionally data on the use of EAPS by
nurses and midwives in Australia was not available (Siggins Miller 2012). Some
nurses and midwives are concerned about confidentiality because of the EAP links
to their employer, as well as being treated by EAP counsellors who don’t share
their profession and thus do not understand their needs and situation (Siggins
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Miller 2012). There are also concerns that mandatory reporting provisions apply to
registered health practitioners (for example psychologists) working for the EAP
(Siggins Miller 2012).
Internal support and referral systems: Several educational guides for practitioners
advise that referral or reporting to in-house support is the ideal first step in
managing colleague impairment (Dunn 2005, Kay and Izenour 2008). Several
major hospitals have internal systems for managing potentially impaired
practitioners, which ideally mirror the best-practice principles of the health
programs identified in this review (Dunn 2005, Kay and Izenour 2008, Dwyer,
Morley et al. 2011). That is, they focus on encouraging early identification and
help-seeking, referral to appropriate services, and a controlled, appropriate
approach to returning to work (where appropriate). For example, the Royal
Melbourne Hospital support program for ‘at-risk’ junior doctors has systems for
identification, assessment, mentoring, referral, reporting, education and workplace
management of distressed junior doctors (Dwyer, Morley et al. 2011).
Referral and reporting to external health programs: In Australia, employers are
subject to mandatory reporting laws, including cases of practitioner impairment
(Australian Health Practitioner Regulation Agency 2014b). Employers were
responsible for a substantial portion of referrals to the health programs identified in
this review. Employer willingness to engage with health programs, and clear
understandings about when and how to do so, may be key to early intervention and
good outcomes.
Re-entry of recovering or previously impaired practitioners: Employers play a
central role in the return of recovering and previously impaired practitioners to
work (Roy I and Kenison 1994, Hughes, Smith et al. 1998, Wilson and Compton
2009, Angres, Bettinardi-Angres et al. 2010). The return to work of impaired
practitioners remains contentious, especially in the field of anaesthetics, which has
a high rate of relapse and recidivism around substance misuse (Tetzlaff and Collins
2008, Earley and Berry 2009, Wilson and Compton 2009, Hamza and Monroe
2011). Returning or retaining recovering or impaired staff requires extra resources
and careful management in the form of extra supervision, observing work
restrictions, managing confidentiality and interpersonal relationships, monitoring
and reporting on progress, and facilitating education and training (Roy I and
Kenison 1994, Hughes, Smith et al. 1998, Wilson and Compton 2009, Angres,
Bettinardi-Angres et al. 2010). An early example of work in this area in Australia
was a program at Box Hill Hospital in Victoria, which returned five anaesthetists to
work following drug addiction between 1993 and 2001. The outcome was mixed
(Hagan 2012). Known as ‘the Box Hill anaesthetists re-entry group’, four were
known to be sober and practising in 2008 (Hagan 2012). However, one had
relapsed and his whereabouts was unknown to the hospital (Hagan 2012). In 2012
this relapsed anaesthetist, Dr James Peters, was convicted of infecting 55 women
with hepatitis C at a Melbourne abortion clinic, after injecting himself with
fentanyl from syringes he then used on patients (Petrie 2012).
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14.2
Medical indemnity insurers
The literature identified some roles for medical indemnity insurers in the
management of impaired practitioners. However, public information about this was
limited. Some examples are included below.
Education: Insurers have a potential role to play in educating members about the
risks associated with practitioner impairment, and best practice methods of dealing
with it. However, extensive searches of three major medical indemnity insurer
websites from Australia – Medical Indemnity Protection Society (MIPS), Medical
Defence Australia (MDA) and Avant - found no specific mention of these issues.
Identification and referral: Medical indemnity insurers were listed as a referral
source for health programs identified in this review (Fletcher 2001, DuPont,
McLellan et al. 2009, College of Registered Nurses of British Columbia 2012,
Braquehais, Valero et al. 2014). Positive relationships between insurers and health
programs could foster referral and early intervention before patients are harmed. In
the US, medical indemnity insurers have the ability to mandate participation in
health programs (McLellan, Skipper et al. 2008). Importantly, in Australia
practitioners working for an indemnity insurer are exempt from mandatory
reporting of an impaired practitioner, if they form a belief that the practitioner is
impaired in the course of that work (Australian Health Practitioner Regulation
Agency 2014c).
Service provision: In New Zealand, a free, confidential counselling service for
health professionals is co-funded by the Medical Protection Society and the
Medical Assurance Society. Limited to members of these insurance groups, the
service is aimed at reducing stress- and mental illness-related impairment in
practitioners, with the aim of preventing resulting patient harm. The service
includes referral to face-to-face treatment by other practitioners. Participants
reported that the service was valuable overall.
14.3
Professional Colleges and Associations
The literature identified some roles for professional colleges and associations in the
management of impaired practitioners. Some examples are included below.
Education: Professional Colleges have a role to play in educating practitioners
about impairment and the management of impairment in self and others. This can
include activities from college publications such as newsletters (Royal Australian
College of General Practitioners 2013), to core curriculum,(Australian and New
Zealand College of Anaesthetists 2006) continuing professional development
programs (Australian and New Zealand College of Anaesthetists 2014), published
resources for practitioners (Australian and New Zealand College of Anaesthetists
2014), and presentations at conferences, forums etc (Australian and New Zealand
College of Anaesthetists 2014). For example, the Australian and New Zealand
College of Anaesthetists has a Special Interest Group for the Welfare of
Anaesthetists (Australian and New Zealand College of Anaesthetists 2014). The
group partakes in all of the activities mentioned above, as well as advocacy
(Australian and New Zealand College of Anaesthetists 2014). They have produced
a large number of publically available resource documents on issues impacting the
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welfare of anaesthetists including impairment-related issues (Australian and New
Zealand College of Anaesthetists 2014).
Help-seeking portals: The ‘Health for Health Professionals’ website (Health for
Health Professionals 2010) is a web-based portal which links UK practitioners to
information and services to assist them with health issues including mental health
and substance misuse concerns. It is a joint project of Cardiff University, the Royal
College of Psychiatrists, the Royal College of General Practitioners and the Faculty
of Occupational Medicine (Health for Health Professionals 2010). The website
makes several references to various colleges having ’well developed support
services’ (Health for Health Professionals 2010). However, no further information
could be found in the literature about these services.
Advocacy: Colleges and professional associations (such as the Australian Nursing
and Midwifery Federation) also play a role in advocating for improved
management of impaired practitioners, so that it is effective and ethical, and
protects the welfare of members of their profession. For example, the Royal
Australian College of General Practitioners provided a submission to the Medical
Board of Australia regarding the funding of external doctors’ health programs
(Royal Australian College of General Practitioners 2012). The work of the
Victorian Doctors Health Program was also mentioned by the Royal Australian and
New Zealand College of Psychiatrists in their submission to a Victorian
parliamentary inquiry into AHPRA (Royal Australian and New Zealand College of
Psychiatrists 2013).
Assessments: An international survey found that some Canadian professional
colleges administer assessment programs for practitioners with suspected
performance problems (Humphrey 2010). Examples include the Specialties
Assessment Program (College of Physicians and Surgeons of Ontario) and the
Professional Practice Enhancement (College des Medecins du Quebec) (Humphrey
2010). These assessments are intended to identify performance concerns in
practitioners, as well as provide remediation (Humphrey 2010). While geared
towards problems of competence, these programs also have regular contact with
impaired practitioners (Humphrey 2010).
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14.4
Education Providers
The literature identified the roles of education providers, particularly universities,
in the management of impaired practitioners. Some examples are included below.
Education: Inclusion of information about practitioner impairment – including
definition, prevention, causes, consequences recognition and responses – is
included in the curricula of many health practitioner training courses (Moss and
Smith 2009). For example, a study of the associate deans of 71 medical schools
across Canada and the US found that practitioner impairment (95.8 per cent) and
wellness (77.5 per cent) were addressed to some extent in their curricula (Moss and
Smith 2009). It has been suggested that teaching wellness strategies to health
practitioner students will help prevent or lessen distress or impairment, including
into the future (Estabrook 2008). There is no research to date on the effectiveness
of wellness programs in preventing future impairment, but students who partake in
these programs report experiencing benefits (Rosenzweig, Reibel et al. 2003,
Estabrook 2008).
Support services: University-wide (and sometimes faculty-specific) support
services are available at universities that educate and train health practitioner
students. Some of these are particularly relevant to the management of impairment
– such as counselling services, chaplaincy, student welfare coordinators, health
services and mentoring programs (Melbourne Medical School 2013, The
University of Sydney - Sydney Medical School 2013). However, a recent
beyondblue survey found that medical students were hesitant to use universityprovided services to seek help for mental health or substance misuse issues,
possibly due to fear of being ‘found out’ and reported to senior staff or AHPRA
(beyondblue 2013).
Referral and reporting: In Australia, education providers are subject to mandatory
reporting laws, including in cases where the suspected impaired person is a health
profession students (Australian Health Practitioner Regulation Agency, 2014b).
Education providers are also able to formally or informally refer students to an
appropriate health program.
Assessments: An international survey found that a number of universities
administer assessment programs for practitioners with suspected performance
problems (Humphrey 2010). Examples include the Remediation and Enhancement
Program (University of Saskatchewan, Canada), Physician Assessment and
Clinical Education (California, US) and Individual Support Program (Cardiff, UK)
(Humphrey 2010). These assessments are intended to identify performance
concerns, but also have regular contact with impaired practitioners (Humphrey
2010).
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15
Conclusions
This literature review aimed to provide broad evidence and insights regarding
Australian and international models for the referral, assessment, treatment and
rehabilitation of health practitioners with impairment, and the corresponding roles
of health profession regulators in these approaches.
Evidence of problem
There is an abundance of evidence that health practitioners experience health
conditions that may lead to impairment of their professional performance. Risks of
practitioner impairment discussed in the literature include risks to the practitioner,
their patients and their professions. While anecdotal reports and legal cases
abound, formal research directly correlating practitioner impairment to patient
harm is scarce. Further evidence of such harm and how it comes about are required
to better guide approaches to managing practitioner impairment.
Types of programs and services
This review identified four broad categories of services and programs for
supporting and managing impaired practitioners. These are phone support lines,
support services, case management and regulator management approaches.
Regulator interaction with programs and services
Regulators interact with these services and programs for supporting and managing
impaired practitioners in five main ways: public promotion and endorsement,
cross-referral, funding, formal agreement and program provision. Different
Australian and international models utilise various combinations of these.
Alignment with best practice principles
Of the program and service types identified, an analysis of the literature showed
that the case management approach aligns most closely with principles of best
practice. It also has the greatest volume and quality of evidence for its efficacy.
Regulator management has the next greatest alignment with best practice
principles, but scarce evidence of its efficacy. As a result, this review focused in
detail on four models of case management, and one of regulator management.
Tensions
From both an operational and regulatory perspective, tensions arise between best
practice principles, and the goals and methods of these programs and services.
These include potential clashes between the pursuit of public protection, and goals
such as encouraging help-seeking, workforce retention and anti-discrimination
concerns. Ethical matters regarding coercion as a method of encouraging program
compliance are also an issue.
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International trends – program type
International best practice trends are moving away from punitive and disciplinary
approaches in the first instance, to models which encourage engagement with
alternative-to-discipline health programs as a first option for impaired practitioners.
The most highly regarded international programs adopt a case management
approach, via practitioner health programs which run at arms-length from the
regulator.
Several well-regarded programs provide services across a range of health
professions, rather than limiting themselves to one health profession.
In most models, the health program plays only a minimal role in clinical treatment
and rehabilitation. Instead they utilise treatment contracts or plans (with varying
levels of coercion attached) to manage referral to external clinical services, and
coordinate assessment, monitoring, ‘voluntary’ work restrictions, return-to-work
provisions and other case management matters.
International trends - assessment
With respect to assessment, most case management models utilise external clinical
experts to assess the health status and impairment of practitioners. Assessments to
determine the existence of health issues and performance issues are fairly well
established separately. However, techniques and standards for connecting a health
issue with a performance problem – thus establishing impairment – are more
contentious. More literature is needed to improve clarity in this area.
International trends – information-sharing and regulator contact
Worldwide, health programs have varying arrangements regarding informationsharing between the regulator and the program. A major element that distinguishes
different models is whether a formal agreement is in place regarding informationsharing, reporting and referral. Furthermore, major differences are seen in the
nature of such agreements, including provisions regarding mandatory reporting,
sharing of client information with the regulator, coercion and ‘shielding’ of
practitioners.
The literature shows that it is common for health programs to have limited contact
with a regulator as long as a practitioner is compliant with treatment contracts
and/or program recommendations. In some models, this is formalised through a
‘shielding’ provision. In other cases, it occurred informally, through people
choosing not to report practitioners to the regulator if they are compliant with
health programs.
Costs, benefits and outcomes
Data on the outcomes of different program and services models is difficult to
compare, as it is not reported against standard measures. It is also not widely
reported. Outcomes of relevance include practitioner recovery, licence and
registration outcomes, program completion, and work status in health profession
following completion. What is known is that practitioner health programs produce
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far higher recovery rates for substance misuse than do mainstream treatments
available to the general population.
Data on the cost-effectiveness of health programs are also scarce and difficult to
compare. Detailed reviews on the costs and benefits of these programs, based on
well-evidenced estimates where hard data are not available, are needed. However,
types of costs associated with practitioner health impairment include those
associated with absenteeism, presenteeism, suspensions, legal and disciplinary
costs, as well as early retirement and/or loss of health workforce members.
Some costs associated with the disciplinary approach to impairment remain similar
when health programs are used as a first port of call instead, while others are
shifted or reduced. Clients of health programs often face very high personal costs
associated with their participation.
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Appendix 1
Methodology
This literature review, guided by the research questions and pre-determined framework, was undertaken
using an exploratory, iterative approach. As such, the review utilised a wide but not exhaustive selection of
resources to provide an overview of:
 the regulatory roles of Australian and international health profession regulators regarding the referral,
assessment, treatment and rehabilitation of health practitioners with impairment, and
 the assessment, treatment and rehabilitation models that support and manage regulated health
practitioners with impairment.
Our approach was directed towards achieving four main consecutive goals which guided selection of the
most useful material from the large volume available. These consecutive goals were to:
 identify important issues and varying features of approaches to managing impaired practitioners, and
impaired practitioner regulation
 identify an array of exemplar programs that represent an informative breadth of approaches to the issues
and features identified above
 identify (where possible) comparable information about these features and issues for the exemplar
programs, and actively seek out information to fill any gaps from initial searches, and to
 identify supplementary literature that may help in interrogating and analysing the regulatory and program
differences identified, for the purposes of determining their relative strengths and weaknesses.
Preliminary search
The preliminary search was conducted using four online databases: Medline/PUBMed, Scopus (Elsevier),
Google Scholar and Web of Science. This search, and all future searches, were limited to publications from
the year 2000 and beyond, to ensure contemporary relevance. Searches were also limited to English language
papers.
The search terms in Table A were used in varying combinations (and derivatives – for example
regulator/regulate/regulation). Some search terms were added to the initial planned list, based on useful
terminology found in the first few papers found. For example, ‘physician’ was added to better capture papers
written by American authors.
The initial searches yielded 1,763 papers. Citations for all of these papers were all downloaded into Endnote
for further analysis.
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Table 9
Search terms
Regulation/
Profession
Impairment
policies
Higher hit rate:
 Regulator
 Registration
 Licensing
 Board
 Referral
 Reporting
 Mandatory reporting
 Fitness-to-practice
Lower hit rate:
 Medical Board
 Nursing Board
 Authority
Treatment/support/
Evaluations
rehabilitation
Higher hit rate:
 Nurses
 Midwives
 Doctors
 Physicians
 Dentists
 Anaesthetists
 Pharmacists

 Lower hit rate:
 Medical Practitioners
 Psychologists
 Physiotherapists
 Chiropractors
 Occupational
therapists
 Podiatrists
 Optometrists
Higher hit rate:
 Impairment
 Addiction
 Substance abuse
 Substance misuses
 Substance abuse
disorders
 Mental health
 Mental illness
 Depression
 Anxiety
 Suicide
 Alcohol
 Drugs
 Aging
 Cognition
 Disability
Higher hit rate:
 Health program
 Treatment
 Rehabilitation
 Counselling
 Therapy
 Management
 Recovery
 Peer support
 Support group
 Assessment
Higher hit rate:
 Funding
 Evaluation
 Benefits
 Outcomes
 Success
Lower hit rate:
 Cost-benefit
 Cost-effective
 Costs
Lower hit rate:
 Phone line
 Support line

Lower hit rate:
 Degenerative
 Vision impairment
 Hearing impairment
 Dependence
Filtering – titles
First, the complete Endnote list was scanned to remove duplicates. Second, the title of all articles was
scanned to determine which papers were likely relevant to the research questions. Following these steps, 382
papers broadly met the inclusion criteria. The citations for these papers were then sorted into Endnote
‘groups’ (folders) which reflected the research questions they were likely to address, using their titles as a
guide.
The titles within each group were then re-scanned to determine which papers would be most helpful to
answering the research questions. Examining the papers in this grouped manner allowed their relative
suitability and usefulness to be compared against other papers on similar topics. Using the titles as guides,
papers were weighted based on the following criteria:
 relevance to research question
 recentness (i.e. weight given for recentness)
 study/paper type (e.g. weight given to large studies, systematic reviews)
 relevance to countries of most interest (i.e. weight given to Australia, New Zealand, UK, US and
Canada), and
 relevance to professions of most interest (i.e. weight given to nurses, midwives).
For example, in some cases, evaluations of certain programs were published every few years. In such cases,
papers for the most recent two evaluations were kept, while all others were discarded. In another example,
some papers focused on professions that were not regulated health professions in the relevant country (such
as counsellors, paramedics or massage therapists). These papers were also excluded.
Based on the above factors, the least relevant papers in each group were set aside. Where titles did not
provide sufficient information to make a judgement, the paper was progressed to the next stage. At the end of
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this stage, 161 papers remained, which we anticipated would be most valuable in addressing the research
questions.
Filtering – abstracts
Where they were not already available in the EndNote entries, abstracts were then obtained for the remaining
papers. The abstracts were then reviewed for alignment with the selection criteria, and relevance to the
research questions. Papers were sorted in tables by country, profession and research question/topic. This
helped to determine the balance of papers that had been obtained, and identify any gluts or gaps which
needed to be addressed.
Papers were excluded if:
 they were case studies based on single individuals
 they detailed regulatory frameworks, health programs or systems which have been superseded by newer
version for more than five years
 they were solely about non-work-related risk factors for substance abuse or mental illness in practitioners
(such as genetic factors and childhood trauma) or
 they fell into a ‘glut’ section of the tables, and largely duplicated data presented by other papers in the list.
Examination of the abstracts revealed that there was significant overlap between papers, as well as
substantial variation in their likely usefulness and rigour. As such, due to the sheer volume of literature on
the topic, and the limited timeframe, not all papers included at this stage could proceed to the final literature
list. Inclusion of papers was subsequently determined on a priority-based system.
Papers were afforded priority ‘points’ for each of the following criteria that applied:
 relevant to the professions of most interest
 published in or after 2009 (previous five years)
 large studies (for example, large number of participants or programs covered)
 systematic studies or reviews
 relevant to countries of interest
 novel ideas or approaches presented
 comprehensive evaluations of whole programs
 filled a gap (i.e. sole paper, or one of only a small number of papers, covering a relevant topic/country
combination)
 quantitative data provided (especially about costs and outcomes)
 pointed relevance to a specific research question.
Only papers which obtained a ‘score’ of four or higher on this priority scale were retained.
Following the application of these filtering processes, 103 papers remained.
Filtering – full text
The remaining 103 articles were obtained in full text version and manually reviewed before a final decision
was made on their inclusion. All were determined to meet the criteria for inclusion.
Additions – sourced from scholarly literature
Throughout reading of the remaining articles, relevant references were followed up. From this process, 34
more scholarly articles, and 50 other references (for example websites, government reports and consultant
reports) being identified as relevant to the review.
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Additions – sourced from grey literature searches
Based on information in the academic papers, exemplar models were chosen that best represented the
diversity of features and issues of regulatory interest in the management of impaired practitioners. Once
these exemplar models were chosen, and outlines of the tables published in this review were decided upon,
we identified gaps in information not able to be located in the scholarly literature.
This information was then specifically sought from grey literature sources, identified by the use of pointed
Google searches. This was also done where particular information was necessary to provide context for
information identified in the scholarly literature. Examples of grey literature that was included in the review
in this manner include health program websites, government data, inquiry hearings, consultant reports,
organisational position statements and newspaper articles. References identified by this process made up the
remaining 28 references included in the bibliography.
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