Nurses and nursing students have the same rate of substance use disorders (SUDs) as the general public (Emergency Nurses Association, 2017). According to the World Health Organization, there are approximately 3.9 million nurses in the United States (Haddad & Toney-Butler, 2009). The American Association of Colleges of Nursing (2019) reports that there are approximately 500,000 nursing students. Therefore, approximately 500,000 nurses and nursing students in the United States have a SUD. Despite advances in recognizing SUD as a treatable medical condition and not a moral failure, significant barriers to treatment for nurses and nursing students still exist, which is unacceptable. Although SUDs are considered chronic disorders with relapse rates of approximately 50%, recovery is possible and achievable.
Alternative to discipline (ATD) programs are evidence-based programs for health care professionals with substance use issues to aid in their recovery. These programs focus on early intervention and nonpunitive, confidential help, which often involves continued employment. These programs have been shown to be successful in assisting nurses with SUDs so that they can retain their nursing licenses and maintain successful careers in nursing. The purpose of this editorial is to highlight the need for improved treatment for nurses and nursing students with SUDs.
Alternative to Discipline Programs
Key components to ATD programs include a forensic interview with a specialist in addictions (who may be an advanced practice nurse) who makes recommendations to a board of nursing (BON) or professionals health program (PHP) contracted with the BON. The nursing board or PHP determines components of the treatment and oversees the monitoring agreement, which can include random drug screens; work restrictions, such as shifts, hours per day, and sites without access to controlled drugs; counseling; or participation in a substance use treatment program. In most cases, nurses can work during a supervisory period, which is often 3 to 5 years. With successful completion of the program, the nurse's full license is restored.
The American Nurses Association (2016) has endorsed the joint statement of the International Nurses Society on Addictions and Emergency Nurses Association, which strongly supports ATD programs for nurses and nursing students. However, not all states have ATD programs, and there is wide variability among programs, posing significant barriers for nurses with SUDs. In some states, a PHP is contracted with the state to provide services without disclosing nurses' names to the BON or needing a full board investigation. ATD professionals gather information, determine the plan of care in accordance with standards determined by the BON, and report non-identifying data to the BON on the oversight they provide. The BON may only be notified of identifying data if a nurse is non-adherent to the recommended treatment. The benefit of this arrangement is that it has the potential to reduce fear in nurses who may be more likely to seek help early if they know their names will not go to the BON. In addition, services through an ATD can often begin much sooner than going through a BON investigation, which can take several months before a determination is made. During that time, nurses' licenses often remain in place and they continue to work, which could pose a safety risk.
Another major barrier that nurses face is the financial cost of treatment, which may not be covered or may only be covered while employed. Nurses often encounter breaks in employment during investigations of their licenses as well as during any recommended treatment. If a nurse has a restriction on his/her license, such as a probationary period, securing employment can be difficult.
Screening and Identification for Nursing Students
The problem of inadequate treatment for SUDs is worse for nursing students, which is the population that should be targeted for early identification and prevention. Many nursing programs have a zero-tolerance policy, meaning that any identified substance use results in immediate termination. Nursing students who do not seek help due to fear of termination are at risk of worsening SUD symptoms. They may attend clinical training while impaired, which has a liability risk to the student and institution. Students who are dismissed from one nursing program for a SUD–related incident could apply to another program without disclosing the incident and still obtain a license. A better approach would be to screen nursing students and identify those at risk for SUDs and offer treatment.
To encourage nursing students to self-report substance use issues and to provide quality care if a SUD is identified, the National Student Nurses' Association passed a resolution urging counseling and treatment of SUDs and encouraging nursing faculty to intervene with a nonpunitive approach and have a supportive ATD and dismissal policy in place (Monroe, Vandoren, Smith, Cole, & Kenaga, 2011). All colleges of nursing should be contracted with an ATD program to provide care for students in need. Some schools have implemented a registration fee for all students to cover the cost of an ATD program.
Standardized nationwide quality and effective care for nurses and nursing students with SUDs is long overdue. Each state should offer an ATD program that meets national standards and protocols developed by a team of nurses, administrators, addiction specialists, patient advocates, and the legal profession. States that choose to involve the BON in determining individual care for nurses suspected of SUDs should have measures in place to avoid delays in treatment. All nurses and nursing students should be offered screening and treatment when indicated for SUDs. This screening and treatment should be fair and compassionate and result in their obtaining or regaining their full license without restriction as long as they complete treatment recommendations. Although many states now include a fee for license renewal to cover ATD programs that oversee treatment for nurses with SUDs, steps should be taken through nurse associations, foundations, and other private sources to raise money to help cover the cost of treatment for nurses and nursing students when needed.
Julie Worley, PhD, FNP-BC, PMHNP-BC,
Associate Professor and Researcher, and
Doctorate of Nursing Practice Program
- American Association of Colleges of Nursing. (2019). Baccalaureate education. Retrieved from https://www.aacnnursing.org/Nursing-Education-Programs/Baccalaureate-Education
- American Nurses Association. (2016). Substance use among nurses and nursing students. Retrieved from https://www.nursingworld.org/practice-policy/nursing-excellence/official-position-statements/id/substance-use-among-nurses-and-nursing-students/
- Emergency Nurses Association. (2017). Substance use among nurses and nursing students. Retrieved from https://www.ena.org/docs/default-source/resource-library/practice-resources/position-statements/joint-statements/substanceuseamongnurses
- Haddad, L.M. & Toney-Butler, T.J. (2019). Nursing shortage. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK493175
- Monroe, T., Vandoren, M., Smith, L., Cole, J. & Kenaga, H. (2011). Nurses recovering from substance use disorders: A review of policies and position statements. Journal of Nursing Administration, 41, 415–421. doi:10.1097/NNA.0b013e31822edd5f [CrossRef]21934428