Experts believe nurses are as likely as the general public to have substance use disorders-perhaps even more so because of their ready access to addictive drugs. It's estimated that about 10% of nurses have a substance use disorder, and that percentage may have risen during the pandemic, when research suggests more people have turned to drugs and alcohol.
ALTERNATIVE-TO-DISCIPLINE PROGRAMS
Beginning in the 1980s, boards of nursing and professional associations committed to help nurses with substance use disorders get the help they need and return to work unimpaired. In response to recurring cases of substance use, Florida altered its nurse practice act in 1983, providing an alternative to disciplining and removing nurses with substance use disorders from practice. Impaired licensees "actively participating in a board-approved program for the treatment of a physical or mental condition" need only be reported to "an impaired professionals consultant." Florida's Intervention Project for Nurses (IPN) was established and approved by the state as an alternative-to-discipline (ATD) program for nurses. Since that time, more than 40 states and the District of Columbia have put in place similar programs.
ATD programs don't provide treatment. Their primary function is to monitor and test nurses for drug and alcohol use to ensure they are able to practice safely. Nurses who agree to participate in these confidential programs may suspend their practice and seek treatment without losing their license or having a disciplinary violation recorded on their license by their state's board of nursing. Program length typically ranges from six months to five years, and nurses who remain in compliance can eventually return to work.
ATD programs are underutilized, however, according to a series of articles published last August in MedPage Today. Nurse enrollment in ATD programs in states that have the largest number of nurses is "astonishingly low," according to the authors, who spent three months investigating ATD programs in 15 states in which the number of nurses collectively represents two-thirds-more than 2.8 million-of the nation's licensed nurses. They found that far less than 1% of state licensees were taking part in ATD programs (See Figure 1).
"There needs to be more awareness among nurses and administrators that ATDs are available to licensees," says Suzanne Alunni-Kinkle, MSN, RN, CARN, director of business development for recovery management solutions at FSSolutions, a workforce screening company. Alunni-Kinkle has worked in addiction research and treatment for three decades, and while serving as director of New Jersey's ATD program, she discovered that many hospital administrators were unaware these programs were an option for impaired nurses. "They just typically fired them, or they had them arrested," Alunni-Kinkle says. At other times, coworkers and managers looked the other way. She recalls one manager telling her she thought a nurse on her staff might have been drinking but didn't report her because "we were short staffed."
The MedPage Today reporters cited these and other reasons, including a failure to educate nursing students on the risk of addiction, a climate of stigma, and the lack of positive messaging about recovery, for low program enrollment. Nurses are also reluctant to enroll because of cost. Fees for testing, monitoring, and therapy vary but can be as high as $300 a month, MedPage Today reported.
MAKING PROGRAMS BETTER
In 2017, the National Council of State Boards of Nursing (NCSBN) associate director of regulation, Kathleen Russell, JD, MN, RN, undertook an analysis of documents describing 27 state ATD programs. She found "wide variation" in their components, and a "lack of consistency and uniformity." She also found many program documents lacked clear definitions, processes, and guidelines, potentially inhibiting staff members' and participants' understanding of program expectations.
What makes a good ATD program for nurses? The NCSBN is trying to find out. Last year, it published results from the first study to examine which program elements and interventions led to higher rates of program completion. The researchers reviewed eight years of data from 13 programs. Except for one outlier, program completion rates ranged from 52% to 72%. In the study, published in the July 2020 Journal of Nursing Regulation, the researchers outline factors associated with successful program completion, including being enrolled for at least three years, daily check-ins, and most importantly, bimonthly drug testing. They recommend testing at random times and using different methods, such as sampling of hair, nails, and urine.
"The nurses that were successfully completing were those who had been tested more frequently," says Richard Smiley, MS, MA, senior statistician, nursing regulation, at the NCSBN, who led the study. This was "the key factor leading to success."
The organization will conduct a pilot study this year to test the researchers' proposed guidelines and to evaluate outcomes beyond program completion. "It's always been a tacit assumption that program completion is roughly equivalent to successful return to practice," Smiley says, "but since we didn't have the data when I did the study, I had to just take it on faith." The new study will allow researchers to follow participants after they complete ATD programs and return to practice.
STRATEGIES FOR INCREASING ENROLLMENT
In the meantime, at least two states are taking steps to increase program enrollment. The Alabama Board of Nursing administers two monitoring programs, the Voluntary Disciplinary Alternative Program (VDAP) and a probation program, for nurses who have substance use disorders. In 2017, the board launched what it called "an aggressive, proactive, multimedia campaign to ensure maximum licensee, employer, and public awareness of the availability of VDAP and to promote early identification of [substance use disorders] and admission into VDAP." Alabama Board of Nursing staff also developed four online courses on substance use disorders and drug diversion. In addition, they created a simple online form that nurses can use to self-report without fear of losing their licenses.
Since the start of the campaign, nurse self-reports and peer reports to the VDAP have doubled. As of last fall, 200 nurses were being monitored in this program and another 250 in the probation program.
In 2015, Florida's IPN began offering worksite impairment training to nursing supervisors. In 2017, the organization helped pass legislation requiring all nurses to take a two-hour course about recognizing impairment in the workplace before renewing their licenses; thereafter, they retake the course every four years.
In Alunni-Kinkle's view, employers also have an opportunity to improve program enrollment. Keeping nurses with substance use disorders on the payroll with health benefits could be a powerful incentive for impaired employees to get treatment and make enrolling in ATD programs affordable.
Such a policy could also save employers money in the long run by reducing the cost of turnover, recently estimated to be $40,038 for each bedside RN. When a nurse in a monitoring and support program returns to work, Alunni-Kinkle says, "this is the safest nurse you're going to find. They're great employees. They value their license."-Nicole Fauteux