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Recognizing Impairment in the Workplace Nursing CE Course

3.0 ANCC Contact Hours

About this course:

This nursing activity aims to outline the challenging yet crucial issue of identifying and responding to interactions with potentially impaired coworkers in the workplace. The evidence regarding the indicators, diagnosis, reporting responsibilities, investigation, treatment, and return-to-work process for impaired healthcare workers is discussed to promote education and decrease the stigma associated with this critical issue.

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Recognizing Impairment in the Workplace

Disclosure Statement

              This nursing activity aims to outline the challenging yet crucial issue of identifying and responding to interactions with potentially impaired coworkers in the workplace. The evidence regarding the indicators, diagnosis, reporting responsibilities, investigation, treatment, and return-to-work process for impaired healthcare workers is discussed to promote education and decrease the stigma associated with this critical issue.

After this activity, the nurse should be prepared to:

  • recognize the statistics regarding substance use disorder (SUD) in the United States and among healthcare providers specifically
  • discuss the identified risk factors and effective methods for preventing SUD
  • highlight the indicators of SUD and drug diversion that a healthcare provider should be watchful for in the workplace
  • clarify the professional, ethical, and personal responsibilities of a nurse with concerns regarding the potential impairment of a coworker
  • briefly review the investigation and intervention steps that should occur when SUD is suspected in a healthcare provider
  • describe the diagnostic criteria and the treatment options available to healthcare providers diagnosed with SUD, including alternative-to-discipline programs (ATDs or ADPs), residential programs, and outpatient programs
  • discuss the return-to-work procedures for healthcare providers diagnosed with SUD

The National Institute on Drug Abuse (NIDA, 2018) defines tolerance to medication as the gradual need over time for an increased dose of a particular substance to obtain a similar effect. The development of tolerance varies significantly based on the individual and medication due to the brain’s ability to adapt to its environment physically. This phenomenon is not limited to pain medication or illicit drugs but also occurs with other substances and circumstances. Physical dependence is the physiological adaptation to a medication that develops with consistent and regular use, contributing to addiction. The medication becomes necessary for normal homeostasis and functioning. Physical dependence correlates with opposing withdrawal symptoms if the medication is no longer used. Misuse of prescription drugs is ingesting or utilizing these medications in a manner, at a dose, or by an individual outside of the prescribed context. This includes taking another person's medication or using pain medication to induce feelings of euphoria. The medical terms of substance abuse and substance dependence have been replaced in recent years by substance use disorder (SUD). This may refer to an individual addicted to nicotine, alcohol, prescription medications, or illicit drugs. Addiction involves a combination of physical dependence and compulsive drug-seeking behaviors despite significant negative repercussions (NIDA, 2018). The Emergency Nurses Association and the International Nurses Society on Addictions (ENA & IntNSA, 2016) clarify that addiction is a primary, chronic disease affecting the reward, motivation, memory, and related brain circuitry that leads to characteristic biological, psychological, social, and spiritual manifestations.

Substance Use Disorder in the United States

The physiologic changes that affect individuals who abuse substances vary but may include a brain response (a temporary increase in dopamine), increased workload on the heart, acute kidney injury that may progress to chronic kidney disease with prolonged abuse, a decrease in the liver’s blood supply related to scar tissue, and increased risks for integumentary complications such as rashes, sores, ulcers, extravasations, and infection (Lockhart & Davis, 2017).

The Substance Abuse and Mental Health Services Administration (SAMHSA, 2022) conducts the National Survey on Drug Use and Health (NSDUH) regarding substance use in the United Stateswhich was last performed in 2021. This survey includes self-reported data on over 69,850 noninstitutionalized Americans over 11, targeting all 50 states and the District of Columbia. It does not include data on residents of long-term care facilities, people who are incarcerated, or individuals experiencing unsheltered homelessness (SAMHSA, 2022).

SAMHSA estimates 133.1 million Americans used alcohol in the last month, including over 5.9 million people under 21 years old. Of those Americans who report alcohol use, 60 million report binge drinking, and over 16 million report heavy drinking. Prescription pain reliever misuse in the past year was reported by 3.1% of respondents (a slight decrease from the 2018 survey results), or nearly 9 million Americans. Sixty-four percent of these users report abusing prescription pain medication to relieve pain, and 44.9% obtained the medication from a relative or friend. The estimated usage in the last month of cocaine; prescription sedatives, tranquilizers, or other central nervous system (CNS) depressants; prescription stimulants; hallucinogens; methamphetamine (meth); and inhalants is provided in Table 1 (SAMHSA, 2022).

Table 1

Substance users in 2021, per the NSDUH

Use of marijuana

52.5 million

Misuse of opioids, including prescribed medication and heroin

9.2 million

Use of cocaine

4.8 million

Misuse of prescription sedatives/tranquilizers/CNS depressants

4.9 million

Misuse of prescription stimulants

2.5 million

Misuse of prescription pain relievers (all types)

8.7 million

Use of hallucinogens

7.4 million

Use of methamphetamine (meth)

2.5 million

Use of inhalants

2.2 million

Use of heroin

1.1 million

(SAMHSA, 2022)

Of the nearly 9 million Americans who reported prescription pain reliever misuse in the 2021 NSDUH (SAMHSA, 2022), 44.9% obtained the pain reliever they misused from a family member or friend. Over 43% of people who misused prescription pain relievers were either prescribed the medication or stole it from the provider. Nearly 8% of people bought pain relievers from someone selling them (SAMHSA, 2022). Despite the reduction in the prevalence of opioid use disorder (OUD), the morbidity and mortality related to opioid misuse remain high. Roughly 45 US residents died daily during 2021 from prescription opioid overdose. According to the Centers for Disease Control and Prevention (CDC, 2023), almost 645,000 Americans died due to opioid overdose from 1999-2021. These deaths have come in three distinct waves in that period. The first wave of overdose deaths occurred in the 1990s and was due to an increase in the prescribing of opioids within the medical community (CDC, 2023). This timing correlates with a national initiative to bette

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r identify and manage pain as the “5th vital sign”. An article by Dr. Mitchell Max published in 1990 in the Annals of Internal Medicine, followed by a presidential address to the American Pain Society by Dr. James Campbell, started a national movement to assess and consider pain more seriously in patients. This prompted new standards published by the Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations [JCAHO]) in 2000 to improve pain management in our patients. This first increase in deaths due to OUD is now considered an adverse effect of the increased focus and new standards (Baker, 2017; Spiegel, 2019). The second wave began in 2010, largely due to increased heroin use, an illicit opioid synthesized from morphine. The third and final wave started just 3 years later, in 2013, and was comprised primarily of deaths related to synthetic opioids such as fentanyl (CDC, 2023).

SUD in Health Care Workers

The American Nurses Association (ANA) first included language regarding impaired practice in their Code of Ethics in 2001 (Monroe et al., 2011). The prevalence rate of SUD amongst healthcare workers (HCWs) mirrors that of the general population, which is roughly 8 to 13% (Merlo et al., 2022). HCWs have an increased risk of OUD due to frequent access to these medications at work (Butler Center for Research, 2015; Rhodes, 2018). The ENA and IntNSA (2016) define impaired practice as a decreased level of competence evidenced by changes in work habits, job performance, appearance, or other erratic or concerning behaviors. The ANA estimates that roughly 10 to 15% of the nursing workforce is either impaired or recovering from SUD. This is such a priority within the medical (and nursing) communities that states such as Florida have begun requiring mandatory education regarding the risks of SUD within HCWs to help medical professionals accurately identify and treat those with the condition (Lockhart & Davis, 2017).

The Butler Center for Research (2015) at the Betty Ford Organization corroborates findings that the rate of SUDs in HCWs aligns with the rate within the general population of the United States; this starkly contrasts the decreased rates of smoking and increased rates of consistent exercise within the HCW community. Their findings indicate that 10 to 15% of HCWs will misuse substances during their lifetime, and as many as one-third of disciplinary actions against nurses are substance-related (Butler Center for Research, 2015). Up to 100,000 HCWs experience SUD yearly, but this rate has decreased in the last decade among the general population and HCWs. As much as 4.4% of HCWs report heavy alcohol consumption, and 5.5% struggle with illicit drug use (Henson, 2022). Historical estimates of the prevalence of SUD in nurses extend as high as 18-20%. Recent studies show that 32% of nurses experienced increased substance use during the COVID-19 pandemic (Arble, 2023).

Risk Factors for SUD

The risk factors for SUD in HCWs can be categorized as general or group-specific. The general risk factors for SUD apply universally. They include a genetic or molecular predisposition, a family history of SUD, a personal history of substance use, a comorbid psychiatric condition such as depression or anxiety, and the early first use of tobacco or alcohol (Butler Center for Research, 2015; ENA & IntNSA, 2016; Lockhart & Davis, 2017). The SAMHSA (2022) also found an increased risk for SUD among individuals with a history of stress early in life due to poverty, abuse, or neglect. In adolescents and young adults, peer-group pressure is a well-documented risk factor for substance use (Lockhart & Davis, 2017). Group-specific risk factors apply only to HCWs and include:

  • increased access to narcotics, sedatives, and other commonly abused substances
  • increased work-related stress and multiple responsibilities
  • increased exposure to illness, death, and trauma
  • sleep deprivation due to shift work
  • personality traits common to HCWs, such as independence, resiliency, self-reliance, and perseverance
  • knowledge of pharmacology and pharmacokinetics
  • a sense of perceived invulnerability (Butler Center for Research, 2015; ENA & IntNSA, 2016; Lockhart & Davis, 2017; Merlo et al., 2022)

According to Ervin (2015), specific risk factors for SUD in nurses include a belief that substance use aids with coping and a relative lack of formal education related to SUD. HCWs who abuse substances often report doing so to relieve stress, treat pain or depression, or increase their work performance (US Drug Enforcement Administration [DEA], n.d.; Henson, 2022). It should be noted that the significant increases in substance use during the COVID-19 pandemic includes unique mediators such as anxiety and secondary trauma (Arble, 2023).

Prevention of SUD

       The CDC (Dowell et al., 2022) has published guidelines for the safe and responsible prescription and administration of controlled substances for HCWs. The CDC’s Guidelines for Prescribing Opioids for Chronic Pain identify strategies that limit the risk of opioid misuse. These guidelines aim to educate prescribers and other HCWs on strategies to reduce the risk of SUD among their patients or their patients’ friends and family. Many of these elements can be self-applied to prevent SUD in HCWs. The guidelines review various types of nonpharmacological pain management strategies, including physical (physical therapy and mobilization), direct (acupuncture and transcutaneous nerve stimulation), and indirect (music therapy and aromatherapy) methods. Before prescribing or administering a controlled substance, patients must be educated regarding the risks of dependence, addiction, and SUD. If the patient agrees to proceed with treatment despite these risks, they should be educated regarding the safe storage (locked medication cabinet) and disposal (local and national drug take-back programs) of controlled substances. They should be counseled on the potential risks of sharing medications with family and friends, such as causing physical dependence, overdose, and medication withdrawal symptoms, as well as the risk of progression to illicit drug (heroin) use (Liu, 2020; NIDA, 2018).

The SAMHSA (2016) identifies three general categories of evidence-based prevention strategies for SUD. For the general public, universal prevention strategies can increase the protective factors and reduce the risk factors for SUD amongst participants. These programs tend to have the biggest impact due to the large number of targeted individuals. Examples of universal prevention programs or policies include establishing or increasing the minimum legal drinking age and national school-based programs. Selective prevention strategies apply to a subgroup of individuals at an increased risk of developing SUD; this allows these programs to focus their efforts and resources on a smaller group of individuals but simultaneously decreases their reach. Finally, indicated prevention programs target individuals already using potentially addictive substances but have not yet developed an addiction or SUD. Team Awareness and Team Resilience are examples of prevention programs for adults that have been successful for workplace or clinic-based SUD prevention efforts and could be implemented or piloted by healthcare organizations (SAMHSA, 2016).

While the CDC (Dowell et al., 2022) supports extensive patient education before prescribing controlled substances to prevent misuse and abuse, many experts also advocate for increased education for HCWs. They point toward the potential efficacy of improved curriculum at the student level, as well as extensive education for new employees during orientation programs regarding the risk factors, indications, and possible complications of SUD (Ervin, 2015). Healthcare organizations should establish employee assistance programs as an anonymous and low- or no-cost early intervention option for at-risk employees struggling with mental health or substance use. At an individual level, nurses should be aware of self-care strategies to prevent SUD by maintaining healthy coping skills, a regular exercise regimen, enjoyable hobbies, and strong relationships with friends and family outside of the workplace (Lockhart & Davis, 2017).

Indications of SUD

Compared to the general population, SUD in HCWs is under-evaluated, underdiagnosed, and undertreated. This likely results from several factors, especially a lack of peer and self-reporting due to the fear of legal, professional, social, and financial consequences of SUD diagnosis (Butler Center for Research, 2015). Although nurses in the United States are required to identify and report indications that suggest SUD in coworkers, many do not report due to fear of retribution, punishment, or causing professional damage to their colleagues. Further, many nurses choose not to self-report due to fear of termination (DEA, n.d.; ENA & IntNSA, 2016). HCWs also note that guilt, shame, and fear of tarnishing their professional reputation contribute to their decision not to self-report (Lockhart & Davis, 2017). Practicing under the influence of substances increases the risk of medical and documentation errors and decreases productivity, appearance, and general health (Merlo et al., 2022). Education on SUD for HCWs should clearly outline the advantages of reporting concerns versus the potential consequences. Ultimately, impairment in HCWs places patients at risk of harm. There is also a risk of damage to the reputation of the HCW, the health care organization, the nursing profession, and the medical field (DEA, n.d.; ENA & IntNSA, 2016). Enhanced participation in scholarly forums on addiction by all HCWs will improve the collective understanding of SUD as a treatable disease, not a moral failing or personal weakness (ENA & IntNSA, 2016).

Increasing awareness of the signs and symptoms of addiction will help HCWs identify coworkers who may be struggling with addiction. The signs and symptoms of impairment or addiction may include:

  • a lack of energy or motivation
  • drowsiness
  • changes in weight, eating habits, or bathroom habits
  • conjunctival injection (red or bloodshot eyes), glassy eyes, or pupillary changes
  • sudden change in appearance (lack of interest in clothes, grooming)
  • changes in behavior (acting inappropriately, sudden insistence on privacy, being secretive or dishonest, different friends, anxiety, irritability, mood swings, poor interpersonal relationships, social isolation)
  • changes in mental functioning with loss of memory, confusion, and poor decision-making
  • a need to use the substance regularly
  • an obsession with protecting or maintaining a steady supply of the substance
  • financial issues (spending money to obtain the substance without regard for its availability, requests for money without an explanation, reports of missing cash or valuable personal items from those around the user)
  • a decrease in performance at work, including poor reliability regarding deadlines, missing meetings, and an increase in careless mistakes
  • doing immoral, illegal, or unethical things to obtain the substance
  • engaging in high-risk behavior while under the influence of the substance, such as driving
  • increased absenteeism, tardiness, or frequent lengthy breaks
  • requests to work shifts with decreased supervision (e.g., night shift)
  • a scent of alcohol or the regular use of gum, mints, or mouthwash to reduce the smell of alcohol
  • highly variable periods of productivity (hyperactivity or hypoactivity)
  • wearing seasonally inappropriate clothing (e.g., long sleeves in hot weather)
  • consistent reports of poor behavior or attitude from colleagues and patients
  • slurred speech, tremors, excessive perspiration, or unsteady gait
  • frequent runny nose
  • frequent nausea, vomiting, or diarrhea (DEA, n.d.; Lockhart & Davis, 2017; Mayo Clinic, 2022; Rhodes, 2018).

In addition to the list above, indications of drug diversion within a healthcare setting may include the following:

  • discrepancies in medication reconciliation records
  • patients reporting that medications brought from home are missing
  • changes in verbal or telephone orders
  • poor documentation with illegible and incomplete portions or worsening handwriting
  • patients consistently reporting poor pain control or missing doses of controlled substances
  • spending long periods near the medication dispensers (overtime or volunteering)
  • increased wastage of controlled substances, broken vials, or a lack of documented witnesses for controlled substance administration in the medication administration record (MAR)
  • inappropriate or large narcotic prescriptions (for prescribers)
  • insisting on personal administration of controlled substances to patients or offering to provide PRN controlled substances to patients for other nurses
  • significantly more administration of PRN controlled substances by a particular nurse compared to other nurses on the same unit
  • inconsistent documentation (e.g., a dose of medication documented as administered when the patient was not on the clinical unit or did not have a corresponding prescription/order)
  • excessive spending
  • legal difficulties (DEA, n.d.; Lockhart & Davis, 2017; Merlo et al., 2022)

The ANA (2015) Code of Ethics specifies within Provision 3 that a nurse “promotes, advocates for, and protects the rights, health, and safety of the patient” (p. 9). Well-intentioned HCWs often are unsure how to handle a situation where a colleague may be impaired or diverting controlled substances. Concerned nurses should keep detailed records regarding behaviors or events that indicate a potential issue, including the time, date, exactly what occurred, and any bystanders who could serve as potential witnesses. Many states allow anonymous reporting to the state alternative-to-discipline program (ATD or ADP; Butler Center for Research, 2015; Lockhart & Davis, 2017; Merlo et al., 2022). If possible, the concerned colleague should approach their impaired coworker directly and encourage them to seek help and treatment for their condition (ANA, 2015; DEA, n.d.; Lockhart & Davis, 2017; Rhodes, 2018). If the subject is unwilling to admit that they have a problem and seek treatment, and suspicions have been confirmed to a satisfactory degree, the colleague should discuss their concerns with the impaired coworker’s manager or supervisor (ANA, 2015; DEA, n.d.; Lockhart & Davis, 2017; Merlo et al., 2022). Alternately, concerned individuals can contact local police, organizational security, or the DEA if there is suspicion of diverted or stolen controlled substances (DEA, n.d.). Many healthcare organizations have established clear policies and procedures regarding how these concerns should be reported and investigated. A detailed record of recent events will promote the smooth functioning of this system. In addition to establishing how and to whom concerns regarding substance use should be reported, institutional policies should specify how and when pre-employment and probable cause toxicology screens (drug testing) should occur (Lockhart & Davis, 2017). It bears mentioning that inadequate staffing levels, increased patient loads, and long shifts may cause behavioral symptoms that mimic indicators of SUD, and these potential explanations should be considered and ruled out during the investigation (Brent, 2019b).

If an intervention occurs, concerns should be communicated to the subject in an objective and detailed manner with empathy and respect while avoiding blame, accusations, or arguments. Interventions should be led by a professional who is familiar with the subject’s role but is not a friend, employer, or close colleague, if possible. The intervention should include an immediate action plan with consequences clearly outlined if the plan is deviated from or declined. The subject may react to the intervention with anger, threats of legal action, resistance, or aggression. Interventions should be confidential and typically include the subject’s peers, staff, and family member(s). Only those who support the intervention and agree with the plan should participate in the intervention (Merlo et al., 2022).

Nurses should be aware of the institutional policies and procedures related to reporting concerns of SUD in colleagues and any related statutes within their state. For example, nurses in Florida can be denied a professional license and subject to disciplinary action for the following:

  • 456.072(i) Being unable to practice nursing with reasonable skill and safety to patients by reason of illness or use of alcohol, drugs, narcotics, chemicals, or any other type of material or as a result of any mental or physical condition. In enforcing this paragraph, the [Florida Department of Health] shall have, upon a finding of the State Surgeon General or the State Surgeon General’s designee that probable cause exists to believe that the nurse is unable to practice nursing because of the reasons stated in this paragraph, the authority to issue an order to compel a nurse to submit to a mental or physical examination by physicians designated by the department. If the nurse refuses to comply with such order, the department’s order directing such examination may be enforced by filing a petition for enforcement in the circuit court where the nurse resides or does business. The nurse against whom the petition is filed shall not be named or identified by initials in any public court records or documents, and the proceedings shall be closed to the public. The department shall be entitled to the summary procedure provided in section 51.011. A nurse affected by this paragraph shall at reasonable intervals be afforded an opportunity to demonstrate that she or he can resume the competent practice of nursing with reasonable skill and safety to patients.
  • 456.076(k) Failing to report to the department any person who the nurse knows is in violation of this part or of the rules of the department or the board. However, a person who the licensee knows is unable to practice nursing with reasonable skill and safety to patients by reason of illness or use of alcohol, drugs, narcotics, chemicals, or any other type of material, or as a result of a mental or physical condition, may be reported to a consultant operating an impaired practitioner program as described in section 456.076 rather than to the department (Florida Legislature, n.d.-b, para. 11 and 12).

Diagnosis of SUD

According to the American Psychiatric Association’s (APA’s) Diagnostic and Statistical Manual of Mental Disorders (DSM-5 TR; APA, 2022), SUDs are defined as a configuration of symptoms resulting from the use of a specific substance, ranging in severity, which results in a variety of physical, social, financial, and psychological consequences. The diagnosis of SUD is clinically based on a thorough patient history. The DSM-5 TR lists 11 different diagnostic criteria covering four broad categories: lack of self-control (1-4), social impairment (5-7), personal risk (8 and 9), and pharmacological criteria (10 and 11). The diagnosis of SUD is considered when a patient meets at least two of the requirements from any category. Mild SUD is diagnosed when a patient meets two or three criteria, moderate SUD is diagnosed when the patient meets four or five criteria, and severe SUD is diagnosed when six or more criteria are met (APA, 2022).

A destructive repetition or habit of ingesting/administering an intoxicating substance that causes substantial anguish or drastically affects the patient’s ability to function professionally, socially, or otherwise. These effects are evidenced by two or more of the conditions listed here within one year:

  • ineffective attempts to reduce the use of the substance or a wish to do so
  • an intense need or impulse to use the substance
  • a persistent ingestion/administration of the substance even though they have experienced repeated relational challenges (i.e., with surrounding friends and family members) related to its use
  • a persistent ingestion/administration of the substance in environments where it is unsafe
  • the development of tolerance, which is a gradual reduction in the physical impact/effect of a given substance when administered at a consistent dose or amount, requiring an increase in dose or amount to achieve the prior effect
  • a persistent ingestion/administration of the substance for a longer time and at a higher dose or amount than planned
  • a considerable investment of time related to the substance, procuring it, ingesting/administering it, or recuperating from the consequences of its use
  • a persistent ingestion/administration of the substance, interfering with significant responsibilities and commitments (i.e., academic, professional, or familial)
  • a decrease in attendance or participation in significant events at work, at home, or with friends/family due to the use of the substance
  • a persistent ingestion/administration of the substance even though they are aware of a significant challenge directly related to the substance use
  • the development of withdrawal as evidenced by the signs and symptoms of withdrawal syndrome for that particular substance or the use of the substance to prevent these symptoms

(APA, 2022, p.652-3)

Treatment of SUD in HCWs

              Historically, nurses and other HCWs with SUD experienced the standard discipline mechanisms used for other practice infractions; these were facilitated by the Board of Nursing (BON) and corresponding state medical and allied health boards. These punitive policies were generally ineffective, endangering public safety by discouraging impaired HCWs from seeking help. Professional discipline typically results in a report to the Office of the Inspector General, which can complicate or preclude the HCW’s ability to obtain future liability or health insurance coverage. In the early 1980s, the ANA recommended that state BONs develop non-punitive, early intervention programs to advocate for the rehabilitation of HCWs. These ATDs (or ADPs) offer assistance instead of judgment (Butler Center for Research, 2015; Ervin, 2015; Lockhart & Davis, 2017). They advocate for protecting public safety by addressing below-standard practice, not by eliminating well-trained HCWs with a treatable illness. The ANA further stresses the importance of supporting or instituting policies and actions that promote patient safety and HCW well-being via collective bargaining. ATD programs should remain confidential and anonymous—except in instances of gross professional misconduct—to encourage willing participation by those struggling with SUD (ENA & IntNSA, 2016; Lockhart & Davis, 2017).

Most states now offer ATD programs for impaired HCWs, but it is unclear if an anonymous ATD program is available in Alaska, Georgia, or Nebraska currently (National Council of State Boards of Nursing [NCSBN], n.d.). The National Organization of Alternative Programs (NOAP, n.d.) was founded in 1999 to facilitate the multidisciplinary promotion of public safety through the rehabilitation, monitoring, research education, and standardization of ATD programs. This group emphasizes fitness to practice and the retention of trained and successfully treated HCWs in active recovery. Their primary values consist of public safety, HCW retention, education, equality, and cooperation with regulatory and professional organizations (NOAP, n.d.). In most states, the HCW must take a temporary leave of absence from medical practice while undergoing initial treatment, usually by temporarily or conditionally suspending their license to practice in that state (Lockhart & Davis, 2017). Some states allow the nurse to continue working while in treatment. When referred to an ATD program via their employer or another party, the nurse in question should accept the settlement of entrance into the ATD program from the BON without asking for a formal hearing, as this usually ensures anonymous entry. Most BON hearings are recorded publicly, breaching anonymity, and may become adversarial and expensive. This acceptance can avoid disciplinary action, which could carry legal ramifications. It typically involves signing a contract that outlines the treatment plan, conditional license terms and conditions, and any consequences for breach of contract or premature abandonment of treatment. Eligibility for ATD programs varies by state, and some disqualify nurses if they have caused patient harm or diverted controlled substances to sell to others (Brent, 2019a). Experts stress that open and forthright communication with the state BON and legal staff throughout the process is crucial (Brent, 2019b). ATD programs report a higher rate of male participants than the nursing workforce, and only a small portion (under 15%) of ATD participants are self-referred. Most ATD participants are referred by their employers (Ervin, 2015).

The Joint Position Statement on Substance Abuse Among Nurses and Nursing Students (ENA & IntNSA, 2016) outlines the following four points:

  1. Healthcare facilities [should] provide education to nurses and other employees regarding alcohol and other drug use and establish policies, procedures, and practices to promote safe, supportive, drug-free workplaces.
  2. Healthcare facilities and schools of nursing [should] adopt alternative-to-discipline (ATD) approaches to treating nurses and nursing students with substance use disorders, with stated goals of retention, rehabilitation, and re-entry into safe, professional practice.
  3. In the context of personal use, drug diversion is viewed primarily as a symptom of a serious and treatable disease and not exclusively as a crime.
  4. Nurses and nursing students are aware of the risks associated with substance use, impaired practice, and drug diversion, and have the responsibility and means to report suspected or actual concerns (p. 2).

If a nurse or other HCW has an SUD and declines to participate in the ATD rehabilitation program recommended by the state BON, then the traditional discipline process should occur with removal from practice if negligence can be proven (Brent, 2019a).

Some states require a formal evaluation by an addiction specialist to recommend a treatment plan initially (Brent, 2019b). Treatment for SUD among HCWs or laypersons should be individualized, comprehensive, and biobehavioral. Inpatient or residential programs typically facilitate detoxification in a safe environment and offer around-the-clock support, but this option naturally involves significant expense. Medications for acute withdrawal during detoxification may be utilized, especially for patients with alcohol or benzodiazepine withdrawal, such as diazepam (Valium), chlordiazepoxide (Librium), and methadone (Dolophine, which may be used for weaning patients off narcotics). Intensive outpatient or day programs are typically less costly. Either option should consist of extensive patient education (even for HCWs); ongoing individual, group, and possible family therapy; and strategies for relapse prevention. Individual psychotherapy is usually based on cognitive behavioral therapy (CBT). In a group setting, community reinforcement groups like Alcoholics Anonymous (AA) and similar 12-step programs may assist throughout recovery and prevent relapse over time. Research also supports the effectiveness of contingency management or motivational incentives, which reward participants tangibly for maintaining sobriety and abstinence (Lockhart & Davis, 2017). Participants in qualitative studies have cited the importance of participating in a support group with nurses or other HCWs struggling with SUD. They also indicate that initially, random drug screening and a highly structured program are extremely helpful (Ervin, 2015). Quantitative studies demonstrate that random drug screening is over 95% effective at assisting participants with maintaining sobriety. Treatment programs for HCWs should be more intensive and consist of a longer monitoring portion than standard SUD treatment programs (Butler Center for Research, 2015).

Barriers to recovery and sobriety maintenance include an increased problem burden (i.e., financial strain, legal ramifications, etc.), poor mental or physical health, and continued substance use (Monroe et al., 2011). To alleviate some of the problem burden, the Family and Medical Leave Act (FMLA) guarantees a period of unpaid leave for those in treatment for SUD, securing their job placement temporarily. The Mental Health Parity and Addiction Equity Act ensures equivalent coverage benefits in most insurance plans for outpatient, inpatient, or emergency care related to SUD. Finally, some professional liability products have begun covering the expense of disciplinary hearings in recent years. Many states offer legal reprieve through first offender programs (FODPs), which may facilitate treatment and offer probation to avoid a criminal conviction. If a criminal conviction is in place, this may preclude the HCW from obtaining a nursing or other state license, depending on the regulations in their particular state (Brent, 2019b). State legislatures establish the guidelines by which nurses and other HCWs can obtain SUD treatment. For example, the Florida regulation referenced above, section 456.076, establishes the Florida Impaired Practitioner Program; details can be found on the Florida state legislature’s website (Florida Legislature, n.d.-a). A small section of this legislation is highlighted below, indicating eligibility for the program, some of the confidentiality terms, and conditions of legal immunity and liability:

  • (9)(a) Except as provided in paragraph (b), when the department receives a legally sufficient complaint alleging that a practitioner has an impairment and no complaint exists against the practitioner other than impairment, the department shall refer the practitioner to the consultant, along with all information in the department’s possession relating to the impairment. The impairment does not constitute grounds for discipline pursuant to section 456.072 or the applicable practice act if:
    • 1. The practitioner has acknowledged the impairment;
    • 2. The practitioner becomes a participant in an impaired practitioner program and successfully completes a participant contract under terms established by the consultant;
    • 3. The practitioner has voluntarily withdrawn from practice or has limited the scope of his or her practice if required by the consultant;
    • 4. The practitioner has provided to the consultant, or has authorized the consultant to obtain, all records and information relating to the impairment from any source and all other medical records of the practitioner requested by the consultant; and
    • 5. The practitioner has authorized the consultant, in the event of the practitioner’s termination from the impaired practitioner program, to report the termination to the department and provide the department with copies of all information in the consultant’s possession relating to the practitioner.
      • (b) For a practitioner employed by a governmental entity who is also certified by the department pursuant to part III of chapter 401, the department may not refer the practitioner to the consultant, as described in paragraph (a), when the practitioner has already been referred by his or her employer to an employee assistance program used by the governmental entity. If the practitioner fails to satisfactorily complete the employee assistance program or his or her employment is terminated, the employer shall immediately notify the department, which shall then refer the practitioner to the consultant as provided in paragraph (a).
    • (10) To encourage practitioners who are or may be impaired to voluntarily self-refer to a consultant, the consultant may not provide information to the department relating to a self-referring participant if the consultant has no knowledge of a pending department investigation, complaint, or disciplinary action against the participant and if the participant is in compliance and making progress with the terms of the impaired practitioner program and contract unless authorized by the participant.
    • (11) In any disciplinary action for a violation other than impairment in which a practitioner establishes the violation for which the practitioner is being prosecuted was due to or connected with impairment and further establishes the practitioner is satisfactorily progressing through or has successfully completed an impaired practitioner program pursuant to this section, such information may be considered by the board, or the department when there is no board, as a mitigating factor in determining the appropriate penalty. This subsection does not limit mitigating factors the board may consider (Florida Legislature, n.d.-a, para. 30).

Roughly 9,000 nurses reenter the workforce while in recovery every year in the United States (Monroe et al., 2011). The ANA (2015) advocates for a pathway whereby nurses and other HCWs may return to work upon successfully completing their treatment program in the current Code of Ethics. Most ATD programs have established standards that must be met before an HCW can return to practice, as shown in Figure 1.

Figure 1

Standards for Re-entry into Practice


(Monroe et al., 2011, p.10)

Some states require a formal evaluation by an addiction specialist to release an HCW before they return to work or periodically for follow-up (Brent, 2019b). In most states, the HCW can return to work on an initially limited, conditional, or contingent basis. This period may include a limitation of hours or patient load, restrictions regarding the administration or prescription of controlled substances, random toxicology screenings, and mandatory ongoing treatment in the form of support groups, group therapy, or individual outpatient treatment. Research suggests colleagues welcome the HCW back without judgment or a need to regain trust. Knowing their peers and coworkers are truly glad to have them back on the team facilitates the HCW’s process of self-acceptance and overcoming feelings of guilt and shame (Lockhart & Davis, 2017). Many HCWs cite significant difficulty with stigma upon returning to work following treatment for SUD (Ervin, 2015). The three stages of recovery from SUD are often referred to as early sobriety (the first year), sustained recovery (1-5 years), and stable recovery (after 5 years). Maintaining a personal and social support system helps ensure an effective long-term recovery (Monroe et al., 2011). Targets of ongoing monitoring conditions are shown in Figure 2.

Figure 2

Desired Qualities of HCWs in Recovery


(Monroe et al., 2011, p. 11)

              A nurse in recovery during active monitoring will be supervised closely by the nurse manager on the unit. The supervising nurse manager will have an ongoing opportunity to provide feedback to the BON or ATD facilitators regarding the nurse’s conduct (Monroe et al., 2011). Unfortunately, studies have shown that HCWs with OUD are at increased risk of relapse compared to the general population. However, 81% of HCWs who complete an ATD program maintain sobriety for 5 years (Butler Center for Research, 2015). Figure 3 lists expected questions for supervising nurse managers who are working with a nurse in active recovery.

Figure 3

Safety Questions for Nurse Managers During Active or Monitored Recovery

(Monroe et al., 2011, p. 11)

For additional information on the pathophysiology, diagnosis, and treatment of SUD, please see the NursingCE continuing education activity entitled Substance Abuse and Addiction.


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Monroe, T., Vandoren, M., Smith, L., Cole, J., & Kenaga, H. (2011). Nurses recovering from substance use disorders: A review of policies and position statements. The Journal of Nursing Administration, 41(10), 415–421. https://doi.org/10.1097/NNA.0b013e31822edd5f

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