What happens next is often a matter of geography. If Ms. Green practices in Texas and is found to be diverting drugs for her own use, she can participate in the Texas Peer Assistance Program for Nurses (TPAPN), which offers recovery opportunities for nurses with chemical dependency or mental illness. Conversely, if Ms. Green practices in Connecticut, her colleagues must report her to the Connecticut Department of Public Health, which may ultimately result in the loss of her license.

The ANA, its constituent member associations (CMAs), specialty organizations like the American Association of Nurse Anesthetists (AANA) and the International Nurses Society on Addictions (IntNSA), as well as nurse substance abuse experts, are among those working hard to ensure that nurses with chemical dependencies receive treatment and support, not discipline and derision. The stigma of addiction continues to be a hurdle in achieving this goal. Society as a whole isn’t very accepting of addiction as a “brain disease” and instead views it as a moral failure or lack of willpower, say nurse experts. And when the addict is a nurse, the stigma is even greater.

“Society still has the image of the nurse in the white uniform, immune to life’s problems,” said Linda Smith, ARNP, MN, CAP, CEAP, executive director of Florida’s Intervention Project for Nurses (IPN).

Nurses also tend to expect perfection from themselves and their coworkers, because patients’ lives are in their hands. “We should care about nurses with addictions because they are our colleagues,” said Smith, a Florida Nurses Association (FNA) member. “We’d care about them if they had heart disease, fragile diabetes, or any other chronic disease.”

Roughly 3% to 6% of nurses may practice impaired because of chemical dependency or psychiatric illness, and alcohol is the number-one substance abused, according to Art Zwerling, MSN, MS, CRNA, CCRN, FAAPM, an AANA Peer Assistance Commit­tee adviser and Pennsylvania State Nurses Association member.

The Movement

As research on the nature of addiction has emerged over the past 20 years, nurse leaders have recognized the need for non-punitive, confidential programs focusing on rehabilitation and reentry into practice while ensuring public safety. Nurse experts say this approach means nurses are more likely to be reported earlier, which is a crucial factor in patient safety. And getting RNs quickly into treatment may save their lives.

In 1982, the ANA’s house of delegates passed a resolution calling for the creation of nondisciplinary, peer-assistance programs for nurses across the country. After launching educational and lobbying efforts, many CMAs and nurse leaders were successful in developing alternative programs in their states.

“Programs that are put to­gether well have an 80% or better recovery rate, with some as high as 95%,” said Diana Quinlan, MA, CRNA, chairperson of the AANA’s Peer Assist­ance Committee and FNA member.

Unfortunately, the issue has become less of a priority within the nursing community over the past several years, in part because the nursing shortage and work-place hazards have taken center stage, according to Madeline Naegle, PhD, RN, FAAN, substance abuse expert and former New York State Nurses Associa­tion president. Further, just as increasingly stressful working conditions are putting nurses at greater risk for substance-related disorders, managed care continues to erode services for people with addictions, she said.

Naegle is hopeful that action taken by the National Student Nurses Association (NSNA) and the ANA’s house of delegates in 2002 will lead to renewed commitments to increase and improve treatment programs for nurses, as well as a better understanding of chemical dependency among health care professionals.

Scarlette Kronenbitter, a former Arizona Student Nurses Association member, was instrumental in bringing the issue of student nurses with addictions to the national nursing forefront. Assisting in the effort were her husband, Ray, a nurse and Arizona Nurses Association (AzNA) member, and Dana Murphy-Parker, MS, RN, CNS, an AzNA member and faculty member who questioned school administrators’ decision to dismiss a student taking prescription medication for chronic pain.

The three crafted the 2002 NSNA resolution that calls, in part, for nursing programs to implement policies to address the needs of student nurses with addictions, as well as increase education on substance abuse and diversion programs.

 “Those of us who go into nursing want to help, care, and nurture,” said Kronenbitter, now an AzNA member, who believed the student nurse was treated unfairly. “Often nurses are told when seeking help, ‘solve your problem yourself.’”

The NSNA subsequently distributed the resolution to the ANA and other nursing organizations to increase RNs’ awareness of student nurses’ needs.

In a separate action, the 2002 ANA House of Delegates passed a resolution promoting alternative-to-discipline programs submitted by several CMAs. The resolution also called for the ANA to support expansion of peer assistance to include student nurses, and efforts to educate the public and RNs in addiction and psychiatric disorders.

Alternatives To Discipline

Started in 1987 with seed money from the Texas Nurses Associa­tion (TNA) and sanctioned by the state’s board of nursing, the TPAPN is a nondisciplinary program for nurses with chemical addictions and certain mental illnesses. The program is administered by the Texas Nurses Foundation (TNF), a nonprofit arm of the TNA.

According to program director Mike Van Doren, MSN, RN, CARN, a nurse manager or employer will call the program’s 24-hour help line with concerns about a nurse’s possible chemical dependency. The nurse is given the option of participating in the peer-assistance program or the board of nursing’s disciplinary process; about 60% choose the program.

Nurses testing positive for a nonprescribed chemical substance can participate in the intensive treatment program, which usually lasts four weeks. They then must attend ongoing self-help meetings or therapy and agree to random drug testing. Nurses in recovery are also assigned to a volunteer nurse advocate who will provide ongoing support, including help in brokering a return-to-work agreement or pursuing further academic study. The entire process, which includes other requirements, takes a minimum of two years to complete, and participants are responsible for testing and treatment costs. The case managers who monitor participants’ compliance and progress in recovery are nurses with additional expertise in addictions.

The IPN, established in 1983, is the oldest alternative program and perhaps the most comprehensive. Services range from confidential consultation to daily monitoring of nurse participants to an intensive relapse-prevention program. Participants in the relapse-prevention program meet every week in one of 85 nurse support groups throughout the state to complete a 34-part series of continuing education modules on addiction and recovery.

“Those meetings help nurses see that they are not alone, which allows them to overcome their resistance to seeking help,” Smith said.

IPN staff hold training sessions several times a month for employers and nursing school staff regarding the identification of nurses or students with chemical dependency, interventions, and available resources.

Meanwhile, in Connecticut, nurse leaders are working to create a pilot alternative-to-discipline program modeled largely on Florida’s program.

“We have our mission statement, goals, and objectives, and now we’re looking for funding,” said Dede Dwyer, RN,C, chairperson of the alternative-to- discipline program of the Con­nec­ticut Nurses Associa­tion (CNA).

She said the state nursing board is willing to refer nurses to the pilot program for case management. However, CNA nurses continue to lobby policymakers to overcome their opposition to the program’s confidentiality component, which is crucial to its success.

There also are several national efforts under way to provide services to nurses and to increase awareness about addictions. For example, the AANA conducted a survey earlier this year to determine effective strategies for long-term recovery, as well as obtain hard data on the depth of the problem, Quinlan said. Additionally, the AANA and the IntNSA continue to offer many services, including an online support group for nurse anesthetists in recovery.

Naegle is working with Project Mainstream, which involves 13 interdisciplinary teams of health professionals, including RNs, collaborating to increase primary care providers’ knowledge of substance-related disorders. The ANA has been working with mental health groups to educate professionals and the public on addictions and psychiatric disorders.

Resources

ANA: ANA Bill of Rights for Registered Nurses
Buy online

Drug Testing for Health Care Workers ANA position statement

International Nurses Society on Addictions
www.intnsa.org

American Association of Nurse Anesthetists Peer Assistance Committee
www.aana.com/peer

National Organization of Alternative Programs
www.alternativeprograms.org

Florida Intervention Project for Nurses
www.ipnfl.org

Texas Peer Assistance Program for Nurses
www.tpapn.org

Susan Trossman is senior reporter for the American Nurse at the ANA.

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