INTRODUCTION
The problem of impairment among healthcare practitioners and its impact on patient safety has remained a concern since the early 1980s. The American Nurses Association (ANA) estimated that 6%-8% of nurses use alcohol or drugs to an extent that is sufficient to impair professional performance (ANA, 1984). In 1982, the ANA called out to the state nursing associations to develop "alternative to discipline" (ATD) programs to assist nursing colleagues with substance abuse and mental health conditions, disseminate information about substance abuse and mental health conditions as treatable, and conduct research (ANA, 2002). The ATD programs would also provide a nondisciplinary alternative for nurses, thus allowing impaired nurses to receive help and monitoring without license discipline.
The Florida Nurses Association (FNA) was the first state nursing association in the United States to respond to the ANA's call by initiating and lobbying for the passage of legislation to start an ATD program for Florida nurses. Since its inception in 1983, Florida's ATD, known as the Intervention Project for Nurses (IPN), has assisted over 23,000 nurses. Most nurses in IPN receive help for substance abuse and/or mental health conditions, whereas a smaller number receive assistance with physical conditions that may impact patient safety. The Florida IPN has evolved into a national model with a reputation for excellence and is often sought out by other state boards of nursing and nursing associations for consultation and assistance in program development and evaluation.
IPN's primary purpose is to protect consumers from unsafe nursing practice while assisting nursing colleagues with evaluation, treatment, referral, and coordination of support services. This approach enhances public safety while providing an avenue for the nurse's rehabilitation and retention in the nursing profession. This central mission is accomplished by way of strong partnerships with stakeholders, statewide educational (skill building) training, and case management services, along with a network of accredited evaluators/treatment programs and approved nurse support groups throughout Florida.
Like most ATD programs, IPN receives calls regarding alleged impairment from nursing employers and other referral sources on a daily basis. IPN provides consultation and evaluates each call to determine appropriateness for program entry. During this intake process, each nurse is oriented to IPN, completes initial paperwork, and undergoes a formal fitness to practice evaluation with an approved evaluator. All licensees who enter IPN execute a formal monitoring agreement after treatment. Monitoring agreements range in length from 2 to 5 years, depending on the primary and secondary diagnoses. During the monitoring process, IPN provides oversight and coordination of services by way of a comprehensive case management/monitoring process. Key components include (a) communication with each participant and with his or her support network, (b) random toxicology screening, (c) weekly attendance at a facilitated support group, (d) mutual support group meetings (such as 12 Step), (e) worksite and safety to practice monitoring, and (f) treatment provider follow-up. All IPN policies are approved annually by the Florida Department of Health (DOH) and parallel many of the National Council of State Boards of Nursing (NSCBN) guidelines for ATD programs.
The following article will highlight five areas of the Florida IPN program, which have contributed to its success and longevity. These areas include the following:
1. Maintenance of strong partnerships with stakeholders
2. Standardized accountability reporting
3. Formal approval process for evaluators/treatment programs
4. Oversight of a strong nurse support group network
5. Educational programming for skill building and stigma reduction
STRONG PARTNERSHIPS WITH STAKEHOLDERS
The establishment and maintenance of relationships built on trust is essential to an ATD program's credibility and longevity. IPN has seen, and continues to see, the importance of building and maintaining its key partnerships. Program integrity is built through ongoing communication, education, transparency, and having "words match actions." IPN staff are diligent in keeping stakeholders informed.
Building partnerships with crucial stakeholders such as regulatory agency officials, Board of Nursing members and staff, nursing association leadership, nurse executives, faculty at schools of nursing, worksite monitors, nurse support group facilitators (NSGFs), and treatment providers is time well spent. In addition, IPN has benefitted by maintaining a solid partnership with the Professional Resource Network (PRN), which provides similar services to nonnursing licensees.
IPN is present at every Board of Nursing meeting to provide consultation and build rapport with Board members. Regular reporting, conference calls, and face-to-face meetings with regulatory officials are essential to program integrity. IPN has learned that having such relationships in place and being able to pick up the telephone, request support, ask for help, provide information, and have important communication are essential to maintain trust and program stability.
IPN fosters relationships with FNA colleagues by attending FNA meetings, co-sponsoring FNA events, and contributing to FNA's newspaper, "The Florida Nurse." The Florida Organization of Nurse Executives is another important stakeholder. IPN provides education at Florida Organization of Nurse Executives' annual meetings and interacts with many of its members on a regular basis. In addition, IPN networks with and provides education to deans, directors, and faculty of Florida schools of nursing when visiting schools and attending annual meetings.
Individual case managers contact and communicate with IPN worksite monitors upon a nurse participant's return to practice. The relationship with each worksite monitor is essential in supporting both the returning nurse and his or her worksite monitor. IPN also provides education and e-learning programs on its Web site (http://www.ipnfl.org) for worksite monitors and supervisors.
NSGFs meet with IPN participants weekly and are integral as IPN advocates, participant coaches, and supporters. IPN places special emphasis on building and maintaining these relationships. It is critical that facilitators receive ongoing support, communication, education, and oversight. This can be challenging with a large numbers of facilitators; however, IPN has an in-house NSGF liaison and designated Webpage with videos and e-learning programs and conducts facilitator training. Like other stakeholders, ongoing communication is crucial to maintaining these relationships.
IPN treatment network assists with evaluation, treatment, and continuing care of nurse participants. Early in IPN development, nurses often chose treatment providers from the yellow pages or from a friend of a friend. Some provided excellent service, whereas others did not communicate or understand how ATD programs like IPN function. This made it very difficult to keep lines of communication open and develop and maintain long-term relationships. In an effort to ensure that impaired nurses receive quality care and IPN receives essential treatment information, IPN has since moved to "approving" and training providers (will be discussed further in later section). This has greatly improved services, communication, and networking with treatment providers.
Finally, networking and building partnerships with other ADP programs and national organizations like the National Organization of Alternative Programs (http://www.alternativeprograms.org), the NCSBN (http://www.ncsbn.org), and others. IPN, like many other ATD programs, has learned the importance of taking the time to intentionally develop and maintain strong partnerships with key stakeholders. IPN has learned that working in isolation will place an ATD program at risk, whereas working together via strong partnerships improves program transparency, trust, and stability.
ACCOUNTABILITY
The integration of standard accountability measures is critical to quality care and program integrity. Accountability is essential to maintaining the trust of the public, individual nurses, and the DOH/Florida Board of Nursing (FBON). The IPN has developed a comprehensive approach to accountability that ensures regulatory stakeholders of staff performance and adherence to IPN (DOH-approved) policy and procedures. This approach provides critical reports and information to the DOH/FBON leadership and offers IPN management the opportunity for change and improvement.
IPN ensures that the following accountability measures are performed and reported regularly based on Florida's Treatment programs for impaired practitioners (2014) statute: (i) monthly QA reports (performed by an independent auditor) which review random cases for staff adherence to IPN policies and procedures, (ii) monthly demographic/statistical reports, and (iii) quarterly reports on six (6) DOH standard performance measures. In addition, DOH officials make an annual site visit to IPN to review in-house processes and case management performance.
IPN staff has daily clinical staff meetings, which review cases of nonadherence to conditions of participation and/or alleged safety concerns. An appropriate plan of action is determined to assist the nurse while protecting the patient. This plan of action is based on conversations with the individual nurse and his or her network providers (worksite monitors, NSG facilitators, and treatment providers) as well as a review of in-house data.
Another program evaluation tool is available through the NCSBN. This tool can be adapted to an ADP model/structure and offer further program review to assist in identifying both program strengths and areas for improvement (NCSBN, 2011).
UTILIZING APPROVED EVALUATORS/TREATMENT PROVIDERS
Through the years, IPN has moved away from accepting evaluations from evaluators/providers whose experience with healthcare professionals is limited and who do not understand safety to practice issues or recognize how assistance and monitoring programs function. IPN experience has taught us that utilizing providers without experience in identifying primary problem areas/treatment needs and evaluating fitness to practice makes case management more complicated and challenging. Finding an avenue to improve this process was discussed and developed by IPN in partnership PRN. IPN/PRN subsequently developed a standardized approach to training, coaching, and accrediting evaluators and treatment providers. IPN/PRN review and approve completed applications from evaluators/treatment programs interested in becoming approved providers. Each application must include verification of credentialing, active and clear license, professional liability insurance on all staff, and certification/registration. IPN/PRN also review each application for solid experience in providing substance use disorder/mental health care to healthcare professionals.
Over the years, IPN/PRN has developed an approved network of evaluation and treatment providers throughout Florida and in other states. This network is used by IPN staff in making participant referrals. IPN staff provides each nurse with a minimum of three approved evaluators/providers in his or her geographical location from which to choose. Approved evaluators complete comprehensive forensic evaluations (based on IPN/PRN expectations) and recommend an appropriate level of treatment and care based on evaluation results and diagnostic formulation. Treatment varies depending on the diagnosis, severity/stage of the illness, support available, and access to resources.
The IPN-approved treatment provider network consists of approved evaluators/programs that provide a continuum of care, ranging from prevention services with education only to outpatient treatment, partial hospitalization, and residential care. Each nurse participant's treatment requirements and monitoring program are individualized to meet his or her presenting needs.
The IPN and PRN co-sponsor a treatment program/evaluator forum every year, usually in the fall. This forum is a time to provide education on hot topics, communicate and discuss expectations with providers, and provide information on any program changes. Time is well spent in these face-to-face meetings because they strengthen partnerships.
This standardized approach for developing and maintaining an approved evaluator/treatment program network has proven to be a win-win for both IPN and its approved providers. It has resulted in more uniform evaluations, better clarity for treatment referrals, and a solid beginning framework and improved care and monitoring of nurses. IPN believes this process has also played an important part in enhancing public safety.
NURSE SUPPORT GROUPS: WHERE THE MAGIC HAPPENS
When IPN receives surveys from participants about which program component is liked the most, the overwhelming response is "nurse support group." It is in these groups, which offer weekly support and care, that nurses meet, share truth, and often no longer feel alone. The IPN philosophy for these groups is "what is said in the group stays in the group" unless there are immediate safety issues, relapse behaviors, or lack of attendance issues. These are exceptions that need to be communicated to IPN.
Over the years, IPN has developed a network of over 150 nurse support groups. Facilitators agree to follow IPN guidelines, maintain licensure, and obtain professional liability insurance. Facilitators receive initial as well as ongoing training on topics related to impairment, group process, suicide prevention, documentation, and intervention. Facilitators also attend IPN's annual conference and mandatory facilitator meeting. IPN provides tools to assist with skill building and help facilitators keep groups focused on recovery. The IPN Recovery Maintenance Workbook and Facilitator's Guide (Smith & LaGodna, 2010), Relapse Prevention Therapy Workbook (Gorski & Grinstead, 2010), Group Conversation Cards (Smith, 2013), and Central Recovery Press' (2015) Discover Recovery: A Comprehensive Family Guide for the Twelve Steps are only a few of the tools IPN provides its facilitators. In addition, video training sessions are available online. All content focuses on relapse prevention and recovery maintenance. Experience has shown that using recommended recovery resources in nurse support group assists in standardizing groups and keeping the groups recovery focused.
Most IPN nurses consistently report favorably about their nurse support group participation. Weekly nurse support group engagement promotes a sense of belonging, enhances problem-solving skills, and improves self-esteem. IPN believes that nurse support groups are one of the most crucial components in building and maintaining a strong ATD/nurse assistance program.
EDUCATION: BUILDING SKILLS AND REDUCING STIGMA
Educational programming, which helps build skills and reduce stigma, is an essential element of IPN's work among the nursing community. Lack of education regarding substance abuse disorders among nursing colleagues remains a challenge. An overview of the IPN program, legal and ethical responsibilities, identification of unprofessional and/or unsafe behaviors, proper documentation, and dos and don'ts of performing interventions and making appropriate referrals are only a few of the usual topics offered during IPN training. Training is available to nursing employers, nursing schools, nursing associations, and other interested parties. Educating the nursing workforce about IPN is challenging because of the sheer number of licensed nurses in Florida. As a means of reaching more nurses, IPN has developed a Web-based training for employers, which discusses many aspects of a proper workplace intervention. This Web-based tool is available on the IPN Web site (http://www.ipnfl.org). IPN also publishes articles on its various aspects in the FBON and FNA newsletters.
Another new avenue for "getting the word out" will begin next year when the FBON implements a newly approved, mandatory 1-hour continuing education for all licensed nurses. This new continuing education will focus on substance abuse among the nursing profession and an overview of how IPN can assist.
Finally, IPN has recently begun offering a 4-hour evidenced-based skill training, "Fit to Perform," for nursing directors/supervisors (Cadiz, Truxillo, & O'Neill, 2012). The impact of this training on attendees is increased confidence in managing fitness issues in the workplace and reduction of stigma. Utilizing the "Fit to Perform" curriculum (Cadiz et al., 2012) in Florida is showing very positive feedback from nursing officers, managers, and directors.
Educating nursing colleagues is a continuous process, which both enhances public safety and early identification and intervention. IPN recognizes the long-term advantage of strategic planning centered on educational programming. A focus on education that increases awareness, provides skill building, and helps decrease stigma has a positive influence on all involved in the care, support, and monitoring of nurses participating in state ATD programs.
A FINAL WORD AND LOOK TO THE FUTURE
This article highlighted five areas of strength, which have contributed to Florida IPN's success and longevity as one of the premier ATD programs in the United States. IPN recognizes that these five areas, together with sound case management services, are integral to its success and stability in assisting colleagues with substance use disorders/mental health conditions.
Florida's IPN continues to learn from other ADP programs and current literature as to new strategies for further improvement. IPN participates in a multistate research group, which is studying data of over 5000 nurse participants in ADPs. In addition, the National Organization of Alternative Programs is focusing its research efforts. The future of ATD programs depend on evaluating and refining current programming, while developing new evidenced-based strategies toward enhancing care and support for nursing colleagues and protecting public safety.
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