Approximately 10% of nurses have a substance use disorder (SUD), which is the same rate as the general public (Emergency Nurses Association & International Nurses Society on Addictions, 2016; Kunyk, 2015; Monroe, Kenaga, Dietrich, Carter, & Cowan, 2013). There are approximately 3 million RNs in the United States (Kaiser Family Foundation, 2017a); therefore, approximately 300,000 RNs have SUDs. As with those in other professions that involve a high level of responsibility, nurses using substances on the job could result in harm to others. Often, SUDs in nurses are not identified until compromises in patient care or other signs of impairment are identified (Kunyk, 2015; Monroe et al., 2013). Risk factors that exist for developing SUDs include genetic predisposition, early age of first use, comorbid mental health disorders, and a history of trauma or abuse (Darbro & Malliarakis, 2012).
Similar to other health care professions, a career in nursing carries some additional risk factors. Because the majority of nurses in the United States are women (83%) (Kaiser Family Foundation, 2017b), gender issues play a role in the phenomenon of SUDs in nurses. Women progress from first use to developing a dependence quicker than men and enter SUD treatment with more severe medical, psychological, and social problems (National Institute on Drug Abuse [NIDA], 2016). Other gender differences that affect women with SUDs include higher overdose death rates, brain changes from using substances, sensitivity to the effect of substances, and increased relapse rates (NIDA, 2017).
Additional risk factors specific to nursing include access to controlled medication on the job, workplace stress, lack of education about SUDs, and attitudes (Darbro & Malliarakis, 2012; National Council of State Boards of Nursing [NCSBN], 2011; Ross, Berry, Smye, & Goldner, 2017). Attitudes that can put nurses at risk for SUDs include justifying the substance use due to job stress, overconfidence in one's ability to handle substance use without it becoming a problem, and a sense of entitlement and invulnerability (Darbro & Malliarakis, 2012; Goldner et al., 2017). Similar risk factors are present in other health care professions, such as medicine, pharmacy, and dentistry (Kenna, 2010). A recent qualitative study on nurses with SUDs showed that common themes in their experience are fear, shame and guilt, poor coping, a need for control, and a belief that developing a SUD would never happen to them (Burton, 2013).
Nurses are identified and seek help for SUDs at a lower rate than the general public (Monroe et al., 2013). Often nurses do not seek help and co-workers are reluctant to address SUDs in nurses because of fear of punishment by regulatory boards (Monroe et al., 2013). Other researchers found that in a study of 4,064 nurses, 3% identified as having a SUD and 77.7% had not sought help (Kunyk, 2015). Findings from a survey by the NCSBN in 2010 showed that approximately 128 nurses per board each year are identified and potentially disciplined for SUDs (NCSBN, 2011). In the past, traditional disciplinary approaches were punitive in nature, made public, and began after a complaint was filed against a nurse. This action prompted a Board of Nursing (BON) review, investigation, hearing or proceedings, and resolution, which could include fines, monitoring, restrictions on practice, license suspension or revocation that was made public, and could take up to 2 years to enact (NCSBN, 2011).
One Nurse's Story
To gain a better understanding of what it is like to be a nurse with a SUD, a nurse was interviewed for this article. Identifying details have been changed to protect her identity.
I grew up in a good home and had a good childhood. I didn't use drugs or alcohol in high school. I went through some tough times in my 20s and 30s, and I started drinking alcohol regularly and sometimes used opioids to help me deal with stress. I decided to pursue a career in nursing, which is what I had been interested in for several years. I kept using substances all through nursing school but was still able to get good grades and pass the nursing boards. I ended up getting a job on a hospital unit.
Shortly after orientation, I began diverting opioids and injecting them on the job. At first, I thought I could handle it and justified using to help me cope with life. After a while I started having withdrawal symptoms when I didn't have any drugs, so I would often try to pick up extra shifts in order to gain access to more opioids. Two years later, I got caught using and diverting at work.
I was advised to self-report my substance use and what happened at my job to the board of nursing in order to be eligible for an ATD program. I didn't know what would happen, and I was afraid I would lose my license, but it turns out that through this program the information about what happened is kept confidential as long as I complete the program. This way I kept my license and could still work as a nurse. I work with a program contracted through the state, and I have a very supportive nurse who works with me on my recovery through my program. The first thing I had to do was complete inpatient detox and treatment, which really helped me understand this disease and how to manage it. I also have to attend support groups and submit to random drug screens over a 5-year period. I work now at a site where there are no opioids. I'm 2 years into the program, still sober, still working as a nurse and grateful for being given a second chance.
Alternative-to-Discipline Programs for Nurses with SUDS
In the early 1980s, SUDs were beginning to be understood from a disease model perspective rather than as a moral failure. In response, ATD programs for nurses with SUDS were developed (Ross et al., 2017). The first guidelines for these programs were developed by the NCSBN in 1987; they were designed to be voluntary, protect the public, and confidentially assist nurses in the recovery process so that they could return to practice (Monroe, Vandoren, Smith, Cole, & Kenaga, 2011). In 2002, the American Nurses Association (ANA) issued a position statement in support of ATD programs (Monroe et al., 2011). Recently, the ANA supported a comprehensive joint position statement by the Emergency Nurses Association and the International Nurses Society on Addictions (2016), which states that health care facilities and schools of nursing should adopt ATD approaches to treating nurses and nursing students with SUDs, with the goal of retention, rehabilitation, and re-entry into safe, professional practice. ATD programs are meant to offer treatment in an atmosphere of support that fosters early treatment and includes confidentiality and nonpunitive initiatives that serve to protect the public and assist health care workers in recovering from SUDs (NCSBN, 2011).
Each state BON has power to regulate procedures for handling nurses with SUDs, including ATD programs, which vary widely from state to state. Currently, 43 states have ATD programs (Hazelden Betty Ford Foundation, 2016). Approximately one half of the ATD programs in the United States are administered by staff of a BON; the remainder are administered under contracts with the states: 11% are administered by another state agency, such as the Department of Health, and 39% are administered by an outside entity, such as a peer-assistance program or professional organization (NCSBN, 2011). Benefits of ATD programs include: the ability to take effect quickly (i.e., within 1 to 120 days), contractual agreements with the nurse, required drug testing, and criteria for evaluating treatment providers (NCSBN, 2011). Nurses can avoid BON disciplinary action if they comply with an ATD program, which usually lasts from 3 to 5 years (Bettinardi-Angres, Pickett, & Patrick, 2012). Compared to traditional discipline programs, ATD programs have been shown to increase nurse retainment in the workforce, allow nurses to maintain their licenses at a higher rate, and result in fewer criminal convictions (Haack & Yocom, 2002). Nurses in ATD programs also have better long-term recovery rates, program retention rates, and health care outcomes than those in traditional disciplinary programs (Bettinardi-Angres et al., 2012; Grauvogl, 2005; Smith, 2017). Certain factors can make a nurse ineligible for participation in ATD programs, including diverting drugs for sale or distribution or having caused harm to a patient (Bettinardi-Angres et al., 2012). Results from a study showed that in 2009, there were 9,715 nurses in ATD programs in the United States (Monroe et al., 2013). Funds to cover ATD programs generally come from nursing license renewal fees (Hazelden Betty Ford Foundation, 2016).
Barriers Nurses Face in Obtaining Treatment for Suds
For nurses who seek help or are mandated to get help for SUDs, the process can be challenging. Findings from a qualitative study of nurses who have completed ATD programs included that the process involves a transformative journey in which nurses undergo a leap of faith to seek help, experience pain related to surrendering, feel like they are drowning, and find that the experience is closely knit with their relationship with other nurses (Ervin, 2015). In a study of 119 nurses, 74% reported having worked with a nurse with a SUD, 78% believed that a nurse who voluntarily seeks recovery should not be subjected to punitive actions, 96% said they would work with a nurse in recovery, and 81% believed that nurses in recovery should be able to return to the health care profession (Cook, 2013).
The fact that each state has its own unique ATD program can be confusing as well as a barrier to care for nurses moving from one state to another. These program differences likely contribute to the fact that few nurses are knowledgeable about ATD programs (only 35% in one study [Cook, 2013]). Another barrier is the fact that although it is not made public, in many states, a nurse must go directly through the BON to access an ATD program. Some states' ATD programs are separate from the BON, and in others, nurses can avoid going through the BON if their employers have designated ATD programs in place; however, this usually is only available through large health care organizations. Ideally, to ease nurses' fears of reporting to the BON, there should be the option of working with an entity outside, but contracted with, the BON, and not having nurses' SUDs reported to the BON as long as they successfully complete an ATD program.
Another barrier nurses face to getting help is the inconsistency in available funding for ATD programs. In some states, nurses are only eligible if they remain employed or meet other stipulations, and funding for nursing students is generally not available. Those who cannot receive funding for ATD programs must go through their own insurance or resort to self-pay. If a nurse has to stop work to complete treatment or has been terminated, treatment can be unaffordable.
A key component to identification and management of SUDs in nursing is to address it early, as early as nursing school. Many colleges of nursing have zero tolerance approaches toward students with SUDs, which can have negative consequences for the school and students (Monroe & Pearson, 2009). Students might not seek help for fear of being dismissed, which could result in a worsening of their SUDs; they might attend clinical training while impaired, which could put the institution at risk; and they might transfer from one institution to another if they do not get the help they need. Dismissed students who do not receive help could be at greater risk of overdose or suicide (Monroe & Pearson, 2009). To reduce expulsion and punitive measures, the National Student Nurse Association passed a resolution in 2002 urging counseling and treatment of SUDs for nursing students (Monroe et al., 2011). Students will be more likely to self-report and faculty to intervene if a nonpunitive, supportive ATD and dismissal policy is in place (Monroe, 2009).
SUDs exist among nurses at the same rate as the general population. Recovery is possible, and the goal for nurses with SUDs is to successfully complete treatment and undergo monitoring so that they can continue in their nursing careers. All states should have funded ATD programs for all nurses and nursing students. Barriers that exist for nurses with SUDs likely result in their SUDs not being identified until a problem arises on the job. Uniformity in nurse practice acts is needed as well as a uniform, confidential approach that does not require nurses to report directly to a BON. In many cases, state nurse practice acts need to be amended to make these measures possible.
To promote early identification and treatment, colleges of nursing should have procedures in place so that nursing students can receive nonpunitive care and monitoring through an ATD program with supportive involvement from college of nursing faculty (Monroe, 2009). Lack of education about SUDs is a risk factor for nurses developing a SUD; therefore, education for nursing students and nurses in practice is needed for prevention, to better address the problem, and to facilitate early identification and treatment. Experts or nurses in recovery should be sought to inform and address nurses and nursing students on this topic (Monroe & Kenaga, 2011). Although many advances have been made, much work is needed to ensure that nurses and nursing students get the help they need for SUDs.
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