Don’t Ask, Don’t Tell Shouldn’t Apply in Nursing Either

February 17th, 2012


By , BSN, RN

Don’t ask, don’t tell may be on its way out for the military, but it is still a pretty firmly entrenched way of thinking in the world of nursing and substance abuse. With somewhere in the neighborhood of one in 10 nurses abusing illicit drugs, prescription medications, and/or alcohol, the problem is as widespread as in the public at large. The difference is nurses are the people charged with caring for the public and that becomes a dangerous proposition when the nurse is working under the influence.

As nurses we usually feel compelled to inform, to educate, and to help our patients with chronic, progressive, and often fatal health problems. Substance abuse is certainly one of those health issues yet when it involves a colleague we often stay silent. It’s not easy to report someone you work with daily, side by side. Whether out of friendship, loyalty, guilt, or fear of jeopardizing a coworker’s ability to earn a living we stay quiet. What we must keep in mind is that our primary concern as nurses is patient safety. A nurse who is practicing while impaired is a danger to his or her patients.

Filing a Complaint

In the not so distant past the only way of dealing with a nurse who was suspected of working while impaired was dismissal from the job and filing a complaint with the state board of nursing (BON). The complaint would be reviewed, the nurse given a chance to respond then the BON makes one of three decisions:

  1. If there is enough evidence indicating disciplinary action is warranted the will start the disciplinary process.
  2. They may dismiss the complaint.
  3. They may determine more information is needed and conduct and investigation.

The thing to keep in mind here is there is no guarantee that this is a speedy process. While this is happening the nurse is likely not working and earning a living. If stressors were part of the equation for leading to the substance abuse you can only imagine how stressed the RN is going through this.

Earning a license to practice nursing means that the nurse has the ability to earn a living. Therefore, the license is a form of property and cannot be taken away without giving the participant due process of the law as granted in the Fifth Amendment to the United States Constitution and made applicable to the states by the Fourteenth Amendment. Once a decision is rendered the nurse has a right to appeal, which differs from the previous hearing.

In many states regulations include certain acts that are cause for disciplinary action against the nurse. The most common are:

  • Drug diversion.
  • A positive drug screen for which there is no lawful prescription.
  • Violation of a state or a federal narcotics or controlled substances law.
  • Criminal convictions.
  • Addiction to or dependency on a habit-forming drug or controlled substance.
  • Illegal use of the drug or controlled substance.
  • Use of a habit-forming drug or controlled substance to the extent it impairs the user physically or mentally.
  • Failure to comply with the contract provisions of the nurses assistance program.

Nurses Assistance Programs

Nurses assistance programs, also known as peer assistance programs, are often alternatives to flat out being fired for working under the influence. They were created at non-punitive, confidential, and voluntary alternatives to reporting nurses to the boards of nursing. Currently, all 50 states, the District of Columbia and Puerto Rico offer assistance programs.

After reading the goals and mission statements of about 20 different states’ nurses assistance programs it is clear they all have, generally, the same aims with the first being to protect the public. Following that in some form or another they want to:

  • Identify nurses experiencing mental health, alcohol/drug problems that have been or are likely to be job impairing.
  • Assist these nurses in obtaining appropriate treatment.
  • Monitor the nurse's return to the work force.
  • Educate employers and nursing colleagues about the negative effects of addiction/mental illness in the work place and the potential for rehabilitation and return to productive work.

The Texas Peer Assistance Program for Nurses (TPAPN) is a prime example of how these programs work and the philosophies that guide them. “TPAPN adheres to a philosophy of providing an opportunity for recovery combined with protecting the public from unsafe nursing practice. Nurses who have substance use disorders or certain psychiatric disorders should be offered the opportunity for education, treatment, and recovery. This philosophy is based on the belief that recovery from substance use disorders and certain psychiatric disorders is possible, and that the return of nurses to safe nursing practice is in the best interest of the profession and society.”

When nurses volunteer for a peer assistance program they agree to several factors including abstinence, monitoring of their recovery via compliance with treatment recommendations, return-to-work restrictions, attendance at self help meetings and random drug tests. Participants are responsible for the costs of the treatments and the drug screens, but sometimes, if their employer has made it possible, their insurance will help defray the expenses.

Nurses may refer themselves to a assistance program, employers can refer the offending nurse in an effort to support and maintain their employment; and family or friends can make the recommendations. Most programs will not accept anonymous referrals.

Alternative-to-Dismissal plans

About a year ago, in February 2011 a study was published in the Journal of Clinical Nursing explaining how punitive substance abuse programs actually stop nurses from seeking recovery from an addiction. This shouldn’t really be a surprise because who turns themself in, in order to be fired. Their paper, titled “Don’t Ask, Don’t Tell: Substance Abuse and Addiction Among Nurses” supported programs that offered assistance and possibly the eventual return to work for nurses suffering from drug and alcohol addiction.

Authors Todd Monroe, PhD., RN, and Heidi Kenaga, Ph.D. provided six key elements for an effective alternative-to-dismissal (ATD) plan, citing that ATD plans can allow administrators to better protect patients while simultaneously supporting the nurse in their recovery. They are also cost effective since traditional disciplinary plans can take many months while an ATD can be much faster and more efficient. The six key elements are:

  1. Promoting open communication by discussing substance abuse in every work or school orientation.
  2. Encouraging an atmosphere more amenable for reporting by ensuring confidentiality.
  3. Providing information about the signs and symptoms of impairment.
  4. Conducting mock interventions to help allay fears or feelings of discomfort about confronting a co-worker or fellow student about suspected chemical dependency.
  5. Inviting ATD experts to speak to the hospital or school administration.
  6. Participating in scholarly forums about addiction among health care providers.

ATD programs have taken hold in this country and all the major nursing organizations support ATD strategies including the American Nurses Association, the National Council of State Boards of Nursing, the National Student Nurses Association, and the American Association of Colleges of Nursing.

Another positive aspect of ADT programs is that they allow nurses to handle a lot of the problems that come with the discovery of a substance abuse problem, such as obtaining liability health insurance after discipline. Monroe estimates approximately 9,000 nurses return to work successfully each year thanks to ADT programs.

While every state offers some kind of ATD programs, they are still not universally accepted. And, even though the state has such a program, not every hospital participates. Hospitals are not required to take part in ADT programs and some choose not to.

As I said at the beginning of this article, surveys show that one in every 10 nurses has some kind of substance use or abuse problem. What that means is you know someone who is currently working or studying to be nurse who is doing so while impaired. It is our job to protect our patients—it is also our job to protect ourselves, and our colleagues. As scary as it may be, if you suspect someone it is better to err on the side of caution. Enlist the help of a colleague, contact your manager or company’s Employee Assistance Program (EAP) and figure out the best way to help your fellow nurse.

One Response to “Don’t Ask, Don’t Tell Shouldn’t Apply in Nursing Either”

  1. Karen Stevens Says:

    I am doing a report for my bachleors program in health care administration. Can you please answer a few questions for me? Who creatd the ATD program? Was it teh nursing board? And it was created in 1995 right?

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