1. Evaluate the thesis statement note whether the author’s thesis.docx

1. Evaluate the thesis statement: note whether the author’s
thesis and overall representation of these particular articles are
clearly stated. Make suggestions to help with the wording if
you think it will help the author’s clarity.
Hazel, you have a great thesis statement, and you work in
mentioning your articles nicely. Great job!
2. Share any concerns you have about the accuracy of the
author’s sources. You can also suggest other sources that would
help the author to have the most comprehensive understanding
of his or her particular topic.
Did you use the same SUO sources we found last week A couple
of them don’t look that way. They all look like they would be
accurate though because they were either from the SUO library
or from a .edu website, and they are all timely.
3. Note whether the organization of the essay is effective.
Suggest an alternate organizational strategy if you think one is
needed or would be useful.
Your organization is wonderful. You start with the nature side
of the debate, followed by the nurture side, then followed by
articles that are sort of neutral. This is a great way to go over
the information from your sources because you’re not jumping
around all over the place.
4. Note whether this short essay convinces you that the author
has located sufficient materials to be knowledgeable about his
or her topic for the final essay and, therefore, is ready to
proceed to taking a stand on the issue, which is our next step in
the research process.
I believe that you have found sufficient material to be
knowledgeable about your topic. You look at both sides of the
debate and have very interesting information. I think you’re
ready to take a stand on the issue and continue to the next step
of the process.
5. Offer corrections to errors in in-text citations and references.
We want to have a discussion about how to correctly format

citations and references so that this aspect of writing is also
made clear in the process of writing.
Regarding your in text citations, I noticed there were a couple
of places where you included a quote, but you didn’t address the
author or the year. Remember when including quotes to end it
with (author, year) to prevent yourself from plagiarizing.
Regarding your references, I believe you have done them
correctly. Great job! I always forget to do the hanging indent.
Hopefully, I’ll remember for my final draft.
Home Study Program NOVEMBER 2005, VOL 82, NO 5
Substance abuse among nurses—
Intercession and intervention
he article “Substance abuse among nurses—Intercession and
interven-
tion” is the basis for this AORN Journal independent study. The
behav-
ioral objectives and examination for this program were prepared
by
Rebecca Holm, RN, MSN, CNOR, clinical editor, with
consultation from
Susan Bakewell, RN, MS, BC, education program professional,
Center for
Perioperative Education.
Participants receive feedback on incorrect answers. Each
applicant who suc-
cessfully completes this study will receive a certificate of
completion. The deadline
for submitting this study is Nov 30, 2008.

Complete the examination answer sheet and learner evaluation
found on pages
803-804 and mail with appropriate fee to
AORN Customer Service
c/o Home Study Program
2170 S Parker Rd, Suite 300
Denver, CO 80231-5711
or fax the information with a credit card number to (303) 750-
3212.
You also may access this Home Study via AORN Online at
http://www.aorn.org/journal/homestudy/default.htm.
BEHAVIORAL OBJECTIVES
After reading and studying the article on substance abuse among
nurses, nurs-
es will be able to
1. discuss how a nurse should report a colleague suspected of
substance abuse,
2. explain the nurse manager’s role in counseling and
intercession with a sub-
stance abusing employee,
3. identify outcome options for an intercession with a nurse
suspected of sub-
stance abuse,
4. identify return-to-work issues in regard to keeping the
suspected nurse in the

workforce, and
5. explain how staff member acceptance can enhance treatment
program
success.
Home Study Program
This
program
meets criteria
for CNOR
and CRNFA
recertifica-
tion, as well
as other
continuing
education
requirements.
A minimum
score of 70%
on the
multiple-
choice
examination
is necessary
to earn 4.7
contact hours
for this
independent
study.
Purpose/Goal:
To educate
perioperative

nurses about
the problem
of substance
abuse among
nurses.
T
AORN JOURNAL • 775
MMAANNAAGGEEMMEENNTT
Dunn NOVEMBER 2005, VOL 82, NO 5
Debra Dunn, RN
Editor’s note: This is the second article in a
two-part series on substance abuse among
nurses. Part I was published in the October
2005 issue of the AORN Journal.
Drug and alcohol addictions areprimary, chronic,
progressive,and often fatal health problems,
but many nurses choose to remain
silent about a colleague who may have
a substance abuse problem. It is not
easy to report a coworker because of
friendship, loyalty, fear of being a hyp-
ocrite, guilt, or fear of jeopardizing a
colleague’s license to practice.
It is helpful to remember, however,

that the reason for reporting inappro-
priate nursing behavior is to protect
patients, not punish the caregiver. It is
the responsibility of the person who
discovers a problem to report this situ-
ation via appropriate channels. This
article discusses how to confront and
report a nurse suspected of having a
substance abuse problem and the
nurse manager ’s role in counseling
and intercession. Available remedial
programs, return-to-work issues, and
the continuing need for education
regarding substance abuse among
nurses also are presented.
REPORTING A PEER
If a nurse suspects that a colleague
has a substance abuse problem, it is
best that he or she first talk to the nurse
about the situation discreetly and in a
nonconfrontational manner because
there may be a reasonable explanation
for the suspicious behavior. The con-
cerned person should take the suspect-
ed nurse aside and let him or her know
that patient care might be jeopardized
by the suspected nurse’s actions.1 The
individual should express concern for
the nurse’s well-being. Examples of
statements of concern are, “You aren’t
as clear in your charting today as you
usually are,” or, “You made three mis-
takes in your charting today. Is some-

thing wrong?”
Initiating communication in an hon-
est and concerned manner will set the
stage for frankness in future dialogues.
Although, in the short run, being direct
can cause the substance-dependent
nurse to make greater efforts to hide his
or her substance abuse; it also can
become the first step in the rehabilita-
tion process.2
If the suspected nurse admits to hav-
ing a problem with substance abuse, the
initial intervention is to listen and let
the nurse talk about his or her concerns
and problems. A friendly, open conver-
sation is an appropriate beginning. If
the listener feels that the nurse current-
ly is impaired, he or she should guide
the nurse to meet with a manager
Home Study Program
• IT IS NOT EASY to report a coworker who
may have a substance abuse problem, so many
nurses choose to remain silent about this issue.
• THIS ARTICLE PROVIDES suggestions for
staff nurses about how to confront a peer, docu-
ment inappropriate nursing behaviors related to
substance abuse, and report these issues to a man-

ager. The manager’s role in counseling and inter-
cession with a substance abusing employee also is
detailed.
• REMEDIATION AND SUPPORT programs are
addressed along with return-to-work issues and
the need for education about this debilitating dis-
ease. AORN J 82 (November 2005) 777-799.
ABSTRACT
778 • AORN JOURNAL
NOVEMBER 2005, VOL 82, NO 5 Dunn
immediately. An impaired nurse should
not be allowed to continue to practice. If
this nurse is not currently impaired, the
listener should help him or her set up a
meeting with the manager to discuss
the problem. This nurse needs to be
strongly encouraged and guided to
obtain professional help. This is some-
thing the manager can arrange. A staff
nurse should not accept the suspected
nurses’s confession and promise to seek
help on his or her own; follow-through
is paramount.
If, however, the suspected nurse
denies accountability for his or her
actions, the concerned individual
should report the suspected nurse while

adhering strictly to established policies
and protocols.3 Reporting a colleague or
staff member who is suspected of sub-
stance abuse requires evidence not sup-
positions or gossip. Hearsay or subjec-
tive information should be eliminated,
and the focus should be placed on the
facts only.3
Accurate, clear documentation of
evidence is imperative to ensure that an
innocent person is not accused unjustly.
Narrative summaries or journal entries
are forms of documentation that can be
used, or an incident report can be gen-
erated.3 Documentation should be con-
fidential; objective; specific; detailed
with dates, times, and places; and
should describe in detail what was
observed.2 If another coworker also has
witnessed an event, that person should
countersign the entry, if possible.3
Obtaining corroboration from col-
leagues can be helpful during the
reporting process. Inappropriate or sus-
picious behavior also can be document-
ed. The information should be first-
hand, and the tone should not be sar-
castic, blaming, judgmental, or nega-
tive.2 The nurse’s job performance is the
focus at all times. Table 1 provides a list
of rules for reporting.
The concerned individual first
should report the suspected nurse to
the manager and then to other admin-

istrators if the manager does not inter-
vene.1 The concerned individual
should allow the manager or adminis-
trator the chance to change the situa-
tion before considering filing a com-
plaint with the state board of nursing
or going public with more extreme
measures (eg, providing negative
information to the print and broadcast
media). It is best not to risk damaging
the reputation of a health care facility
with negative publicity, if possible.
TABLE 1
Rules for Reporting a Colleague
Who May Have a
Substance Abuse Problem1,2
Be knowledgeable—Know the signs and symptoms of
impairment.
Document facts clearly, concisely, and with dates.
Do not assume that it will be possible to remain
anonymous as the reporter.
Do not be surprised if some colleagues retaliate (eg,
the cold shoulder, overt harassment, increased work-
load, denigration of personal competency or integrity).
Do not gossip—Malicious gossip can tarnish the
nurse’s reputation.
Focus on the disclosure, not on the personality of the
person being reported, by providing objective data;

personalizing disclosures could result in a lawsuit for
libel or slander.
Have other professionals verify the information, if
possible, to lend objectivity.
Maintain confidentiality.
Use institutional channels of communication before
considering going public.
Write a clear, short summary of the information and
provide the source of the information.
1. “Blowing the whistle on incompetence: One nurse’s
story,” Nursing 19 (July 1989) 47-50.
2. A Taylor, “Support for nurses with addictions often
lacking among colleagues,” The American Nurse 35
(September/October 2003) 10-11.
Copies of any correspondence should
be kept for the reporting party’s protec-
tion should retaliation result. If the
report is written in good faith, the
reporter is protected from reprisals,1 and
an employer cannot take action against
the reporting nurse, even if the allega-
tions turn out to be false.4 It is important,
however, not to malign another person’s
name in speech or in writing, and this

could result in a defamation of character
lawsuit.4 Most importantly, fear should
not stop the concerned person from
being a patient advocate.5,6
THE NURSE
MANAGER’S ROLE
Nurse managers are responsible for
ensuring that staff members assigned to
their units provide at least a minimal
level of care. Managers need to develop
an educated eye and a proactive
approach to confronting nurses suspect-
ed of substance abuse. In reality, however,
nurse managers often are not prepared to
confront nurses who may be involved in
potentially unsafe practices. It is espe-
cially stressful to confront a nurse who is
a valued employee. To ensure the provi-
sion of quality nursing care, nurse man-
agers must learn to detect behaviors that
warrant action.7,8 It is incumbent on
nurse managers to be knowledgeable
about chemical dependency and to learn
its signs and symptoms. Nurse man-
agers need to raise their index of suspi-
cion for this illness.2
Managers should support the nurses
on their units and emphasize their eth-
ical duty to report unusual behaviors or
patterns. Reporting is critical—no one
can correct a problem unless a report-
ing mechanism is solidly in place. Staff
members also should be empowered to

take action without fear of reprisal. The
nurse management team must estab-
lish a culture that encourages active
reporting and corrective action and that
is not punitive.8-10 Nurse managers also
are responsible for creating a work cli-
mate in which impaired workers can
face the truth and seek treatment.
Finally, nurse managers should contact
local law enforcement officials and the
state board of nursing to learn how
impaired nurses will be treated in their
respective states.5
Early intervention is critical, as is
providing support for the nurse sus-
pected of substance abuse. Under-
standably, employers are very con-
cerned about potential
lawsuits for negligent re-
tention of impaired nurs-
es. According to an attor-
ney, “the minute you
have knowledge or per-
ceive that the person is
substance abusing. . . .
you have got to bring this
person in and confront
him [or her].”11(p38) If a
plaintiff is able to show
that a nurse manager
knew about the substance
abuse problem but failed
to act, the plaintiff also
can sue under the “theory

of negligent supervi-
sion.”12 Keeping the prob-
lem quiet is condoning
the substance abusing
nurse’s behavior, and the
manager becomes part of
the problem instead of
part of the solution.12 “By
failing to act on evidence .
. . the administrator does
not meet a professional
obligation (and, some-
times, a legal one) to safe-
guard patients.”13(p21)
Managers should not be impulsive;
rather, they should be cautious, inves-
tigate, and plan strategically before
engaging in counseling or intercession
with a suspected employee. The first
step a nurse manager must take is to
Managers should
establish a
culture that
encourages
active reporting
and one in which
impaired workers
do not fear
punishment
so they can
face the truth

and seek
treatment.
addicted nurse must reach “rock bot-
tom” before he or she will avail him-
self or herself of treatment options;
however, it also is
exceedingly rare for any chemically
addicted person to spontaneously
gain insight into the true nature of
her or his problem without the help
of an outside source presenting real-
ity in a receivable way.2(p116)
In terms of motivators, few things are
as important to the alcohol or drug
abuser as keeping his or her job.5
The manager must document all rec-
ommendations made or actions taken.
Sometimes the interaction pattern
becomes circular. In other words, the
manager confronts the impaired nurse,
the impaired nurse temporarily cor-
rects the suspected behavior or hides
the problem for a short time, the man-
ager relaxes the level of supervision,
the impaired nurse goes back to his or

her usual behaviors, and the manager
confronts again. If this occurs, there is
no advantage in continuing one-on-one
counseling.2
THE INTERCESSION
If disciplinary issues persist, the
nurse manager should arrange an inter-
cession (ie, a hearing). One person may
not be able to penetrate a chemically
dependent nurse’s strong defense
mechanisms of denial, rationalization,
minimization, and projection.2 One
researcher demonstrated that a group of
significant persons (ie, immediate fami-
ly members, employers, coworkers,
close friends, extended family mem-
bers) who present reality in a receivable
manner so that the suspected abuser
does not become defensive and close
out the information will carry more
weight and accomplish more than one
person acting alone can achieve.14
Intercessions can be peer mediated or
obtain facts and document the nurse’s
performance by reviewing recent nar-
cotic sheets and other medication
records and noting signs and symp-
toms displayed by the nurse.7 Before
meeting with the nurse, the manager
should meet with members of the
facility’s legal, employee health, and
human resources departments. If the
suspected nurse is accused of stealing

medications, hospital administrators
may be required to file
charges based on state
and federal law.7
The nurse manager
should inform the sus-
pected nurse that a meet-
ing is necessary because
of recent concerns about
his or her work perform-
ance. The manager should
meet with the nurse in a
quiet, private setting and
should confront the nurse
with facts, not accusa-
tions, that focus on specif-
ic, documented perform-
ance issues.7 The manager
should discuss where job
performance is inade-
quate, state what per-
formance is expected,
identify consequences for
continued poor perform-
ance, and make a manda-
tory referral for counsel-
ing. The impaired nurse
needs to understand that
problems exist and that he
or she is responsible for
correcting them.
The nurse manager should express
concern for the nurse and let the nurse

know that he or she is considered to
be someone with an illness for which
help is available. The manager should
describe resources available for the
nurse and help the nurse review his or
her options.7 It is a myth that an
It is a myth that
an addicted nurse
must reach
“rock bottom”
before considering
treatment
options, but
chemically
addicted people
rarely gain insight
into their
problems
spontaneously.
management oriented. Any type of
intercession requires strict confidentiality
to protect the nurse’s rights to privacy.

PEER-LEVEL INTERCESSION. With peer inter-
cession, colleagues of the same status
level in the organization are chosen from
that nurse’s department or another unit.
This group listens to the nurse’s state-
ments, and then brings the reality of the
problem behaviors back into focus for
the nurse. The approach is
direct and honest. This
forum can be beneficial
for some nurses to see
where they have gone
astray. The idea behind
this approach is that infor-
mation may be more read-
ily received by a chemical-
ly dependent nurse when
it is delivered by peers
who face the same daily
struggles rather than by a
supervisor. Hierarchical
reporting can make the
nurse defensive at the
onset, and the action can
be perceived as discipli-
nary in nature. Peer-level
intercession can be effec-
tive in persuading a nurse
with a substance abuse
problem to voluntarily enter treatment,
although the degree of leverage, typical-
ly, is decreased without the manager’s
presence.2 Before and during the inter-

cession, peers may consult with a thera-
pist trained in intercession techniques.2
MANAGEMENT-LEVEL INTERCESSION. A man-
agement intercession should include the
nurse manager, although the nurse
manager to whom this nurse reports
may be excused from this group,
depending on the circumstances; a
human resource administrator; a repre-
sentative from the facility’s employee
assistance program (EAP); and a staff
nurse. This interdisciplinary interaction
provides a broader viewpoint. The man-
ager has the power to enforce the deci-
sions rendered, which sends a strong
message to the suspected nurse.
PLANNING THE INTERCESSION. One type of
intercession includes three phases:
planning, staging, and holding a group
conference.14 Two to four people are
selected and meticulously prepared to
act as effective interceders. It is impor-
tant that the people selected are appro-
priate and effective in this role. Meeting
with a strong group of people provides
a powerful message to the nurse with a
substance abuse problem. The interces-
sion can be held with or without a man-
agerial-level person present and with
or without a therapist physically pres-
ent (ie, a therapist may not be directly
involved, but may act as a coach before-
hand).2

The goal of the intercession is to
obtain a willingness on the nurse’s part
to accept help and follow through with
a fitness-to-practice evaluation.3 It is
important to create a controlled inter-
cession during which the sole focus is
the nurse’s performance in hope that he
or she can face reality and no longer
deny the need for treatment.5
After the interceding committee has
been chosen, the committee members
should
• select a private place and time for the
meeting;
• determine seating arrangement (eg,
chairs in a circle);
• identify the preferred method to doc-
ument the intercession (eg, audio-
tape, written notes, videotape);
• nominate a leader to keep the inter-
cession on track;
• research available resources (eg,
alternative programs, EAP);
• learn state board of nursing report-
ing requirements;
• make arrangements and provide
support and assistance for entry into

treatment (eg, inpatient versus out-
patient, health insurance clearance,
Two to four
appropriate
people who
would be
effective in this
role are selected
and meticulously
prepared to act
as interceders.
work clearance, child care arrange-
ments, packing); and
• determine disciplinary actions if the
nurse fails to comply with recom-
mendations.2,3
Before the intercession occurs, a ther-
apist or social worker evaluates the data
collected and educates intercession
group members on alcoholism and
drug addiction. Participants are given
the freedom to vent anger and other
negative feelings. The group members
discuss their doubts, fears, and worst-
case scenarios. Strategies are discussed

for avoiding interruptions or unexpect-
ed outbursts and for counteracting con-
tinued resistance. Finally, the group
members rehearse by role playing and
developing an opening greeting to the
nurse.2
HOLDING THE INTERCESSION. The team
leader carefully presents an overview of
the nurse’s work record and then listens
to the nurse’s explanation of his or her
behavior. Committee members then
decide on a course of action, and the
majority rules. If the employee is not ter-
minated, he or she is required to attend
treatment. Repeat offenders do not have
the peer-review process as an option
and can be terminated.11
When the intercession begins, the
leader should adhere to the plan even if
the suspected nurse actively uses defense
mechanisms (eg, denial, rationalization,
projection). Excuses and alibis are mani-
festations of the disease and are to be
expected; however, facts presented by
the suspected nurse should be consid-
ered. In maintaining objectivity, the team
leader should request that the impaired
nurse be evaluated by a physician who
can order various diagnostic laboratory
tests. A positive report from the laborato-
ry does not automatically identify an
individual as an illegal-drug user. A
physician with knowledge of substance
abuse disorders should be responsible

for reviewing and interpreting positive
results. He or she must give the individ-
ual an opportunity to discuss a positive
result and must take into consideration
the individual’s medical history—a posi-
tive result could occur because the indi-
vidual has consumed legally prescribed
medications while off duty.15
If the employee refuses to participate
in the intercession or undergo a physi-
cian’s evaluation, the manager should
begin disciplinary procedures that
include written warnings, suspensions,
and termination with reporting to the
state board of nursing if this is deemed
necessary.2 It is hoped, however, that as
the nurse is presented with the negative
consequences and evidence of the prob-
lem, his or her “denial will . . . crack or
even visibly crumble.”2(p119) Table 2
describes some “do’s and don’ts” for an
intercession. The intercession concludes
either when the treatment plan is accept-
ed or when the intervening group
receives a refusal to comply.2
OUTCOME OPTIONS FOR AN INTERCESSION
The outcome of the intercession
could be
• a warning,
• probation,
• a mandated treatment program,

TABLE 2
Intercession Do’s and Don’ts1
Do
Prepare a plan.
Review documentation.
Request help from other departments.
Ask the nurse to listen before he or she responds to
interveners.
Focus on job performance.
Expect denial.
Report as necessary to state alternative programs or the
board of nursing.
Debrief the interveners.
Don’t
Just react.
Intervene alone.
Diagnose the problem.
Use labels.
Expect a confession.
Give up.
1. J Daprix, “The courage to care: Intervening with col-
leagues who demonstrate signs of impairment,” The
Florida Nurse 51 (September 2003) 28.
• suspension, or

• termination with or without a report
to the state board of nursing.5
Deciding whether to randomly test
an employee for alcohol or drugs while
continuing his or her employment,
send the employee to rehabilitation,
discipline the employee, or terminate
the employee may depend on the state
in which the employee works.
Treatment should be offered in lieu of
termination, at least initially.
Regardless of the path chosen, the first
step is to remove the employee from
the work environment immediately if
he or she displays inappropriate or
questionable behaviors during the
intercession. Whether the employee is
permitted to return to work the next
day or should be suspended will
depend on the circum-
stances and the decision
made by the manager.
Suspension allows time
for the manager to con-
sult further with the
human resources depart-
ment, protects the em-
ployee and his or her
coworkers from a work-
related injury, and pro-
tects patients.11
The least helpful action

a manager can take is to
allow a quiet termination
or encourage the nurse to
resign because the nurse
can then move to another
workplace where the cycle
will repeat itself. In this
simple and quiet scenario,
the nurse does not receive
help, and the public
remains unprotected. It is
easy for a nurse who is
abusing substances to
secure another job because
of the current nursing
shortage.5
“A nurse manager ’s decision to
report [the nurse] to the state board of
nursing is an individual and difficult
one.”2(p123) It depends on whether
• the state has a mandatory reporting
law;
• the state has diversion legislation (ie, a
rehabilitation option in lieu of disci-
pline) and rehabilitation programs;
• a hazard exists that poses a threat to
public health and safety;
• the nurse admits to diverting con-
trolled substances (eg, stealing from a
patient’s medicine drawer) when
confronted;

• the nurse is motivated to seek
treatment; or
• there is evidence of satisfactory par-
ticipation in a treatment program.2
Depending on facility peer-review
The Effect of After-Work
Activities on a Career
How a nurse behaves while off-duty can significantly affect
anemployer’s handling of that employee. Employers today are
doing “whatever they can to ensure that the people they hire
will
safeguard the patients entrusted to their care.”1(p71)
Scrutinizing
and monitoring employees’ off-duty conduct, therefore, has
become increasingly acceptable. “If a nurse’s behavior off the
job
suggests that [he or] she could endanger patients in any way,
[the] employer can take disciplinary action against [the nurse],
including termination.”1(p71)
Being under the influence of alcohol or drugs while on the job
can be grounds for immediate disciplinary action or dismissal.
Abusing alcohol or drugs on a nurse’s own time while off-duty
may
have similar consequences.
Employers may receive information about employees’
inappropri-
ate off-duty activities from colleagues or from law enforcement
authorities. For example, in New Jersey, law enforcement
authorities
are required to report nurses and physicians who are charged

with
criminal activity to their respective boards. The board then may
report the issue to the employer. If a nurse is arrested, the
employ-
er can discipline or dismiss the nurse if it can be determined
that
the behavior that led to the arrest indicates the nurse poses a
dan-
ger to patients and is likely to violate patients’ rights. State
boards
can use the arrest as a springboard to launch a full investigation
into the nurse’s practice. The nurse’s medical records and other
information can be subpoenaed. When criminal charges are
resolved, the board still can pursue disciplinary action.1
1. D L Mantel, “Off-duty doesn’t mean off the hook,” RN 62
(October
1999) 71-74.
SIDEBAR
processes and state-specific board of
nursing requirements, nurses may be
reported to the state board of nursing
after termination, or they can be report-
ed if a concerned individual has a strong
suspicion, based on clues such as med-
ication errors. If a state’s board of nurs-
ing identifies rehabilitation as an option,
reporting usually is a good idea. These

alternative programs are designed to
ensure that the public’s health and safe-
ty are not jeopardized.2 Many states also
have programs that reintroduce the
nurse into the workplace under a moni-
tored system of checks and balances for
the nurse’s and patients’ protection.7
Managers have the authority and
responsibility to support, advocate for,
initiate, and direct a process for leading
colleagues to appropriate treatment
options. Treatment plans can be strong-
ly suggested or mandated as a condi-
tion of continued employment. The
real issue is not whether to treat, but
rather how many times to send a nurse
back for rehabilitation. Treating relapse
one, two, or three times is considered
acceptable; beyond this, it is consid-
ered a form of enabling.11 Conse-
quences for noncompliance should be
set forth clearly.
It is “no longer excusable [for man-
agers] to stand idly by and watch profes-
sional colleagues be destroyed. . . .”2(p119)
Written policies and procedures are
required that deal fairly, effectively, and
humanely with the issues of chemical
impairment—both before treatment and
when the nurse returns to practice.2
Suspension or revocation of the nurse’s
license by the board of nursing should be
a final action when treatment is refused
or unsuccessful.16

REMEDIATION AND SUPPORT PROGRAMS
The ultimate goal of remediation and
support is to provide nonpunitive, con-
fidential, voluntary programs focused
on rehabilitation and reentry into prac-
tice while ensuring public safety.17 Some
examples of rehabilitation programs are
psychological/behavioral modification,
aversion therapy, and detoxification.18 A
nondisciplinary approach can protect
the public from unsafe practitioners
while concurrently promoting treat-
ment and rehabilitation for the im-
paired nurse. Proponents of this
approach find it to be cost-effective and
successful.19 By treating the impaired
nurse, not only is he or she helped on a
personal level, but another nurse has
been retained in the
workforce.16 With this
approach, it is more prob-
able that nurses will self-
report and report others
earlier.17
Treatment can be per-
formed on an outpatient
or inpatient basis, depend-
ing on the degree to which
the nurse is addicted and
the type of support system
(ie, enablers versus tough
love) the individual has.

Treatment on an outpa-
tient basis can require as
many as four visits a week
for a period of one to three
months, followed by less
frequent visits each week
for a few more months or
longer. Inpatient treat-
ment can be performed
daily at first and then fol-
low the same frequency as
outpatient treatment.20
Employees should pay for
at least part of their treat-
ment in order to increase
their accountability and
commitment to the process. Three recov-
ery programs noted in the literature are
the Recovery and Monitoring Program
(RAMP), Health Professionals Recovery
Program (HPRP), and Texas Peer
Assistance Program for Nurses (TPAPN).
Remediation and
support should
include
nonpunitive,
confidential,
voluntary
rehabilitation
programs
focused on
reentry into

practice while
ensuring
public safety.
THE RAMP PROGRAM. The RAMP pro-
gram, offered in New Jersey, is designed
to encourage health professionals to
disclose their dependencies and seek
recovery with confidential oversight by
the New Jersey board of nursing. The
program offers
• addiction education,
• advocacy services for employers,
• assistance in commu-
nicating with licensing
boards,
• confidential data col-
lection to provide evi-
dence that the nurse is
maintaining recovery,
• urine testing, and
• an independent re-
source for treatment
options.

The program is available
to help those who are seri-
ous about recovering and
requires periodic reporting
from the employer. The
rate of recovery for health
care professionals who are
monitored is 80% to 90%;20
relapse is common in
unmonitored substance
abusers. The RAMP pro-
gram also provides re-
sources for those col-
leagues who are resentful
of the recovering nurse or
who no longer trust the
nurse.20
THE HPRP PROGRAM. Michi-
gan’s voluntary program,
HPRP, guarantees confi-
dentiality and allows the nurse to avoid
the licensing board’s disciplinary track.
Nurses who suspect another nurse of
abusing substances can report that nurse
to HPRP without jeopardizing the sus-
pected nurse’s livelihood. This program
encourages nurses to err on the side of
helping their colleagues rather than
ignoring the problem.21
THE TPAPN PROGRAM. The TPAPN pro-
gram is a nondisciplinary program for
nurses with chemical addictions and

some mental illnesses. The nurse manag-
er or employer can contact the program’s
24-hour helpline with concerns about a
specific nurse. The suspected nurse then
is given the option of participating in the
peer-assistance program or being report-
ed to the state board. Not surprisingly,
60% of the nurses choose to enter the pro-
gram.17 The TPAPN treatment program
lasts four weeks, and the nurse then
attends ongoing self-help meetings or
therapy and agrees to undergo random
drug testing. The addicted nurse also is
assigned a volunteer nurse advocate who
provides ongoing support. The TPAPN
participant is responsible for his or her
testing and treatment costs.17
PEER-ASSISTANCE PROGRAMS. Many states
offer peer-assistance programs to help
nurses with drug or alcohol problems.
Interestingly, married nurses have been
shown more likely to successfully com-
plete a peer-assistance program.22 This
is attributed to the support provided by
a family unit. As expected, support sys-
tems (eg, friends, family members) are
crucial for success.
Services that usually are offered with
peer-assistance programs include
• intervention,
• referral,
• education,
• peer-support groups,
• regionalized state-wide contacts,

• reentry monitoring, and
• a hotline telephone number.22
In one study, 66% of the nurses referred to
a peer-assistance program made positive
progress and completed their program.22
EMPLOYEE ASSISTANCE PROGRAMS (EAPS). An
EAP is a referral program for employees
who have personal problems that affect
their performance at work.18 The EAP
provides a counselor who is a licensed
mental health professional. Employee
assistance programs are contracted by
Employee
assistance
programs
provide a licensed
mental health
counselor who
performs an
evaluation, makes
an assessment,
and then
recommends
treatment
options.

health care facilities for the benefit of their
employees. The counselor performs an
evaluation that includes obtaining a sub-
stance abuse history and performing an
assessment and then recommends treat-
ment options.20 The EAP can provide
counseling or can monitor the employee’s
progress while other outside agencies
provide the counseling.
BENEFITS OF ALL PROGRAMS
Treatment programs include any or
all of the following facets:
• motivational intervention,
• detoxification,
• education,
• drug screening,
• coping skills,
• self-help recovery, and
• the Alcoholics Anonymous or Nar-
cotics Anonymous 12-step programs.
Employees should be required to sign a
letter of commitment to stay drug- and
alcohol-free, continue to attend after-
care, report to the counselor, and submit
to 20 to 40 unannounced random drug
tests in the first year.
The typical cost savings for these
programs are substantial compared to
the cost of investigation, disciplinary
actions, and incarceration of an em-
ployee added to the cost of replacing a

knowledgeable nurse.17 Employees
who are motivated to seek treatment
return to the workplace as productive
employees 85% of the time,16 and those
employees who remain sober in the
first year are likely to stay clean.11
These alternate programs allow the
nurse to begin treatment and recovery
TABLE 3
Where to Get Help
Al-Anon
A program where relatives and friends of alcoholics
can share their experiences, hope, and strength to
solve common problems. All people who are affect-
ed by another person’s drinking can use this organ-
ization to help find solutions to relationship
issues.
(800) 356-9996
http://www.al-anon-alateen.org
Alcoholics Anonymous (AA)
This program is a fellowship where men and
women can share their experiences, strengths,
and hopes with others during the recovery
period. It is a 12-step program of total absti-
nence by staying away from alcohol one
day at a time.
(212) 870-3400
http://www.alcoholics-anonymous.org
American Council on Alcoholism
The prime focus for this group is educating the
public about the effects of alcohol, alcoholism,
and alcohol abuse. The Council advocates

prompt, effective, and readily available and
affordable treatment programs. It provides sup-
port groups and news updates on relevant top-
ics. The Council works with the court system to
incorporate treatment programs for drunk-driv-
ing offenders.
(800) 527-5344
http://www.aca-usa.org
Cocaine Anonymous
The program provides support for those depend-
ent on cocaine. Although this group is not affili-
ated with AA, the AA 12-step program and ideals
are followed.
(800) 347-8998
http://www.ca.org
Institute for a Drug-Free Workplace
This coalition of businesses and individuals is
dedicated to serving the rights of both the
employer and employees in the workplace. Drug
abuse prevention with efforts to influence
national debate on these issues is the focus
of this coalition. Recognizing the pervasive
substance-abuse problems facing the United
States, this organization promotes drug testing,
user accountability, employee-assistance pro-
grams, and education.
(202) 842-7400
http://www.drugfreeworkplace.org
Nar-Anon
This is a 12-step program designed to help rela-
tives and friends of addicts recover from the
effects of dealing with this stressful illness. This
group helps those who know or have known a

feeling of desperation due to the addiction prob-
lems of someone close to them.
(310) 534-8188
http://www.nar-anon.org
in tandem with continuing to practice
as a nurse or to resume practice when
treatment is completed and the nurse is
deemed competent and fit to practice
again.23 Organizations that provide
help are listed in Table 3.
RETURN-TO-WORK ISSUES
Early in the treatment program, the
counselor, the impaired nurse, and the
nurse manager should discuss reentry
into the workforce.2 Disagreement exists
about how long a manager should wait
before allowing an employee to return
to work. A general time frame is six to 12
months, depending on the degree of
addiction, severity of signs and symp-
toms, and commitment of the nurse to
recover.2 On return to work, the newly
recovered nurse should
• not be placed in clinical settings
where there is exposure to the indi-
vidual’s drug(s) of choice;

• not be expected to handle any type of
controlled substances for the first six
months, followed by another six
months in which controlled sub-
stances are handled under direct
supervision;
• be limited to practice in areas that are
less stressful (eg, long-term care units,
ambulatory care settings, utilization
review, nursing education, interim
positions that are created to meet the
temporary needs of the facility);
• limit work hours to either part time
or full time with restrictions on
overtime (eg, none allowed) and
shift (eg, day shift and evening shift
rather than night shift);
TABLE 3
Where to Get Help
National Association for Children of
Alcoholics (NACA)
The NACA advocates for all children and families
affected by alcohol and other drug dependencies.
(301) 468-0985
National Clearinghouse for Alcohol and
Drug Information (NCADI)
Along with providing research databases and
a listing of relevant publications, NCADI pro-
vides self-help resources, resource guides, a
listing of treatment facilities, and referrals.

The NCADI covers all topics related to
alcohol and drug dependency and recovery and
includes all subgroups affected by this
illness.
(800) 729-6686
http://www.health.org
National Council on Alcoholism and Drug
Dependence Hopeline (NCADD)
The NCADD operates a network of affiliates with
advocacy, education, prevention, and treatment
programs. This agency for substance-abuse treat-
ment programs provides written information and
referrals for treatment and counseling through-
out the country. The organization advocates
using ED DIRECT for interventions:
• Empathy—adopt a warm and reflective under-
standing style.
• Directness—maintain eye contact and speak
directly about the issue.
• Data—provide feedback and state concerns
clearly.
• Identify willingness to change.
• Recommend actions and advice.
• Elicit a response.
• Clarify and confirm actions.
• Telephone referrals.
(800) 622-2255
http://www.ncadd.org
National Institute on Alcohol Abuse and
Alcoholism (NIAAA)

The NIAAA provides leadership in the national
effort to reduce alcohol-related problems using
research, collaboration with other institutes, and
the dissemination of information to health care
providers, researchers, policy makers, and the
public. Pamphlets and brochures also are provided,
clinical trials are discussed, and databases and
resource listings are available.
(202) 842-7400
http://www.niaaa.nih.gov
Substance Abuse and Mental Health
Services Administration (SAMHSA)
The SAMHSA compiles a national directory of
more than 11,000 drug abuse and alcoholism treat-
ment programs, including residential treatment
centers, outpatient treatment programs, and inpa-
tient hospital-based programs.
http://www.findtreatment.samhsa.gov
It is incumbent on the manager to
carefully analyze any new charges
against the recovering nurse. The man-
ager should ensure that the returning
nurse is treated fairly and that his or her
privacy is upheld.2 If a manager notes
odd behavior from the returning nurse
and believes the nurse may be under the
influence of substances, and if state law
and unions permit random screening

processes, the nurse should be tested.
The employee is the only
person who has the right
to know the results of the
drug screening. These
results can be shared with
the manager only if the
information is relevant to
job performance. Search-
ing employees and their
personal property (eg,
lockers, desk drawers) is
acceptable if it is written
in the facility’s policy.
Physical searches are per-
mitted but must be per-
formed with great care so
that the person perform-
ing the search is not sub-
ject to assault and battery
charges.25
Should a relapse occur,
the nurse manager must
take it seriously and deal
with it immediately by
relieving the nurse of his
or her duties and placing the nurse on
medical leave of absence until the matter
has been satisfactorily resolved. Failure
to honor commitments could result in
immediate termination without pay and
being reported to the state board of
nursing.11
In general, state boards of nursing are

abstaining from taking formal discipli-
nary actions if the nurse is willing to seek
treatment and abide by a prearranged
contract.23 If this approach proves
unsuccessful, however, disciplinary
• work only in a structured setting
under direct supervision, but never
alone; and
• submit to on-the-job, random, super-
vised drug and alcohol screening.2
Return-to-work agreements in con-
tract form should specify conditions and
expectations of continued employment
along with clearly stated consequences
of failure to adhere to the terms (Figure
1). Administrators need to provide guid-
ance to the returning chemically
dependent nurse while simultaneously
protecting the institution’s interests. The
measures taken are designed to
• enhance recovery by monitoring the
nurse’s attendance at self-help group
meetings and counseling (eg, indi-
vidual, group) sessions;
• ensure safety and decrease the
chance of relapse; and
• enforce policies by delineating the
consequences of a relapse or viola-
tion of the agreements.24

Signing a contract can emphasize the
reality and seriousness of the situation
to the impaired nurse. It is a very help-
ful tool in breaking down the nurse’s
denial and preventing enabling on the
part of the nurse manager.2
When a nurse is given appropriate
treatment, he or she should be encour-
aged and supported with reentry
issues. Nurse managers are facilitators
for recovering nurses returning to work
and should provide supportive envi-
ronments. In addition, the manager
must ensure that reentry into the work-
force is supervised and structured, par-
ticularly in the area of drug access. The
nurse manager should
• constantly evaluate the nurse’s com-
pliance with treatment recommen-
dations and the human resources
department’s program or EAP,
• ensure that the nurse is maintaining
a satisfactory job performance, and
• provide for supervised, random urine,
saliva, and/or blood sample testing.2
Signing a
return-to-work
contract can
emphasize to the
impaired nurse

the seriousness
of the situation
and can be
helpful in
breaking
down denial.
FIGURE 1
Sample Return-to-Work Agreement1
Date
Employee Name
Address
Dear _______________ (employee name):
Your return-to-work date has been designated as ________
(date). Please report to your nurse manager
on this day at ____ AM/PM (time) with this signed agreement.
Read the letter in its entirety before
signing the agreement. Your signature on this document is
required for you to return to work.
If you have any questions, please contact the human resources
department at __________ (telephone
number).
These are terms to which you will agree in order to return to
work and to retain your position at

___________________________ (facility name).
Per our agreement, I will work _____ hours per day, _____
times a week on the ____________ (day
or evening) shift. I will not ingest any substances (ie, drugs,
alcohol) that may alter my mood or
affect my performance, and I will disclose any medications
prescribed to me that may have the
potential to do so. I understand that supervised, random urine
and blood tests will be performed
to assess my compliance during my recovery period, and I agree
to such interventions performed
by the hospital. I also expect the hospital to maintain my
privacy and keep all information
obtained confidential, although I understand it may be necessary
to share the results with my
nurse manager.
I will continue to participate in my _______________________
(self-help group, peer-assistance
meetings, individual counseling sessions) ______ times each
week. I will advise my nurse manag-
er when the frequency of these meetings changes or they are
terminated (ie, when the counselor
and I agree on the final date). I give permission for my nurse
manager to contact _______________
(counselor) for updates on my progress during my treatment
regimen.
I understand that my job performance will be monitored daily
and that an evaluation will be con-
ducted on a weekly basis initially, with less frequent meetings
thereafter as determined by the
nurse manager. It is expected that my evaluation will be at least
“satisfactory” in order for me to
maintain my position.

I will not be allowed to administer or count controlled
substances. It is the nurse manager’s
responsibility to determine when it will be appropriate for me to
return to performing these job
functions.
I fully understand that if I fail the blood or urine random tests;
discontinue my counseling ses-
sions without the agreement of the counselor; fail in performing
my job as required; abuse sub-
stances (ie, drugs, alcohol); or have any disciplinary action
taken against me that I may be sus-
pended, terminated from my position, and/or reported to the
state board of nursing.
As an active participant in my recovery, I will maintain contact
and seek the support and advice
of my nurse manager if I feel I might be relapsing.
I am willingly signing this contract, recognizing my obligations
and accountability for my actions.
_______________________________________
____________________
Signature of nurse Date
_______________________________________
____________________
Signature of nurse manager/human resources manager Date
________________________________________
____________________
Signature of counselor Date
1. N B Fisk, D A Devoto, “The nurse employee who uses

alcohol/other drugs,” Nurse Managers Bookshelf 2
(December 1990) 122.
action may be warranted. Discipline
ultimately can have a positive effect be-
cause it allows the abuser time to reflect
on the preceding events and analyze
errors. Some nurses who are disciplined
are able to gain greater insight into their
past behavior, retrospectively recognize
that they wanted and needed help, and
view the violation and resultant disci-
pline as a “wake up” call.8 All nurses
should be helped with their recovery
efforts, but at some point, nurse man-
agers must recognize that the impaired
nurse’s desire to change may not be
possible. If the nurse falters is his or her
commitment, disciplinary actions must
be the next step.
STAFF MEMBER ACCEPTANCE AND SUPPORT
Often employers who retain chemi-
cally dependent nurses do not provide
formal return-to-work agreements to
help these nurses be successful. In addi-
tion, some nurses may make it difficult
for recovering nurses to be accepted
back into their roles.23 Nurses who return

to work may be greeted with mistrust
and covert anger from their coworkers.
Some nurses even display overt anger
and resentment. “The view of the addic-
tion as a moral or ‘bad’ behavior issue
rather than as a disease remains a preva-
lent one.”2(p126) Recovering nurses may be
treated with distrust, disdain, and
avoidance, especially if coworkers feel
that special contractual agreements and
differential treatment place an undue
burden on them.2 Sabotage of the recov-
ering nurse also has been known to
occur.2
If confidentiality is not an issue (ie,
the treated nurse’s colleagues are aware
of the reason for the nurse’s absence),
the team should participate in a team-
oriented training session so they can
learn how to interact with this nurse on
his or her return. Recommended steps
nurses can take to support a colleague in
recovery are noted in Table 4. The nurse
manager should let staff members
express their feelings and then actively
engage them in the nurse’s reentry
process—this will give them a sense of
control and help them feel less victim-
ized (eg, at having to work more shifts
or undesirable shifts). Open communi-
cation is the best course of action.2
GROUP COHESIVENESS
Prevention program effectiveness

requires supportive elements in the work
environment. Coworkers can have either
a positive or negative influence on
employees with alcohol or drug prob-
lems. Coworkers may either help
employees seek rehabilitation or actively
enable the impaired nurse by unwittingly
covering for that person. Intragroup rela-
tions that include the substance-abusing
employee should be considered in pre-
vention efforts. Substance abuse pro-
grams and educational efforts cannot
ignore contextual elements—focusing on
the individual alone is not as effective as
looking at group dynamics.26
Teamwork and group cohesiveness
are important for prevention and are
associated with a decreased likelihood of
alcohol problems or drinking climates.
In cohesive groups, norms dictate fair
TABLE 4
How to Support a
Colleague in Recovery1
Do not be judgmental or condescending.
Step in and help the nurse when a situation develops.
Be honest—Tell the nurse when troubling behaviors
are apparent.
Be ready to intervene.

When others alienate the nurse, discuss this behavior
with them.
Involve managers.
Ask questions and learn about recovery, addiction,
and relapse.
1. A Taylor, “Support for nurses with addictions often
lacking among colleagues,” The American Nurse 35
(September/October 2003) 10-11.
distribution of work, cooperation, inter-
dependence, and addressing rather than
avoiding problems. Cohesive groups
produce conformity and rule compliance
with minimal support for deviant behav-
ior. These factors mitigate substance
abuse in a team environment because
abuse is seen as a minority behavior and
is associated with negativity from
coworkers.25
EDUCATION
Nurse managers must
halt rumors and gossip
and take positive actions
to both inform and coun-

sel staff members when a
recovering employee re-
turns to the workplace.
The manager should
launch an educational
effort to provide employ-
ees with current perspec-
tives of substance abuse
as an illness and facilitate
discussion. The educa-
tional program should
facilitate an institution-
wide change of attitudes
and behaviors.
Education can play a
direct role in preventing
drug and alcohol problems
among nurses. Nurses
should be reminded about
the toxic effects of drugs
and alcohol on the body,
the pharmacology of sub-
stances, and the addictive process. It is
paramount that the manager focus on the
signs and symptoms of early alcohol or
drug problems and strategies for inter-
vention and assistance.22
Most importantly, nurses should be
taught how to deal with the problem
of an impaired colleague. It is especial-
ly hard to confront another nurse
when the substance is legal, such as
alcohol. Practical advice and tips for

dealing with an impaired nurse are
lacking. Questions that should be dis-
cussed with and clarified for staff
members include
• how severe must misuse of a sub-
stance be for it to be considered a
medical problem? and
• how much is too much?27
The manager should provide staff
members with handouts on effective
listening tips and guidelines for
approaching an employee who has a
problem. The manager also should
instruct staff members on how to
respond to resistance when they are
trying to encourage a colleague to get
help. The manager should make every
effort to alleviate fears of placing a
nurse’s job in jeopardy so that the
nurse will seek treatment.26 One model
to help nurses seeking advice on work-
ing with an impaired nurse is the
NUDGE model:
• notice,
• understand,
• decide,
• use guidelines, and
• encourage.26
In this model, one nurse plays the part
of the employee with a substance abuse
problem during a role play. Another
nurse nudges the impaired nurse to get

help while a third nurse observes.
Not only should education on sub-
stance abuse be presented as an inser-
vice program for all employees, it
should be on the orientation agenda
for newly hired employees. During
facility orientation, newly hired
employees at all staff levels should be
educated on the illness itself and the
facility’s fitness-for-duty policy that
clearly states what is expected of
employees in performing their duties.
The policy should present clear guide-
lines and precise steps for reporting
incidents in which substance abuse is
suspected.28 The policy also should
provide contingency plans for steps to
Nurse managers
must halt rumors
and gossip and
take positive
actions to
inform and
counsel staff
members when a
recovering
employee
returns to the
workplace.

be taken if an employee is declared
unfit for duty and stipulate negative
actions for being impaired at work.
These policies should be established,
operationalized, and implemented and
should focus on caring for the
impaired employee.2,27,28
Health care facility administrators
are responsible for increasing aware-
ness of chemical dependency, providing
education, and providing impaired
employees with assistance. Administra-
tors should ensure that a work environ-
ment exists that “encourage[s] safe, qual-
ity practice, as well as physical and psy-
chological well-being.”7(p37) Healthy work
cultures emphasize employee involve-
ment; family-friendly policies that pro-
mote work-life balances (eg, child care);
peer support; and a positive flow of
communication. Work-life balance is a
key facet for organizational wellness.26
EARLY ACTION AND EDUCATION
Institutions should have policies in
place to “treat and retain—not ignore
and release—chemically dependent
employees.”24(p56) In helping an im-

paired nurse, early action and educa-
tion are critical. Nurses should explore
and express their attitudes, beliefs, and
fears about addiction. They should be
able to discuss interventions with an
impaired nurse, and, most importantly,
they should be able to identify their
own responsibility for action.27 “Eras-
ing punitive, negative attitudes toward
impaired nurses and replacing them
with supportive, positive ones must be
a goal for [everyone].”29(p10) It is each
nurse’s responsibility to educate him-
self or herself about addiction and
recovery to increase empathy for the
substance abusing nurse.
The good news is that nurses can and
do recover from addictive illness and
return to productive lives. This recov-
ery is facilitated when coworkers and
supervisors meet their ethical (and
often legal) obligations to their col-
leagues, the public, and the profession
by identifying and intervening in cases
of impaired practice.13(p24) ❖
Debra Dunn, RN, MBA, CNOR, is the
nurse manager of the OR at St Joseph’s
Wayne Hospital, Wayne, NJ.
This article is dedicated to a nurse with
whom the author once worked in hopes that
she finds her way.

The author acknowledges Eleanor Silverman,
MLS, AHIP, St Joseph’s Wayne Hospital
Library, Wayne, NJ, for her assistance in
acquiring resources for this article.
NOTES
1. D L Mantel, “Off-duty doesn’t mean off
the hook,” RN 62 (October 1999) 71-74.
2. N B Fisk, D A Devoto, “The nurse
employee who uses alcohol/other drugs,”
Nurse Managers Bookshelf 2 (December 1990)
110-129.
3. J Daprix, “The courage to care: Inter-
vening with colleagues who demonstrate
signs of impairment,” The Florida Nurse 51
(September 2003) 28.
4. D Serghis, “Caring for the carers: Nurses
with drug and alcohol problems,” Australian
Nursing Journal 6 (June 1999) 18-20.
5. H Creighton, “Law for the nurse manag-
er: Legal implications of the impaired
nurse—Part I,” Nursing Management 19
(January 1988) 21-23.
6. “Blowing the whistle on incompetence:
One nurse’s story,” Nursing 19 (July 1989)
47-50.
7. S Ponech, “Telltale signs,” Nursing
Management 31 (May 2000) 32-37.
8. D Booth, A K Carruth, “Violations of the
nurse practice act: Implications for nurse
managers,” Nursing Management 29
(October 1998) 35-39.
9. C Dunbar, “Verifying nurses’ backgrounds:
How much should we know?” Nursing
Spectrum (Jan 26, 2004) 16-18.
10. L W Mustard, “Caring and competen-

cy,” JONAs Healthcare Law, Ethics, and
Regulation 4 (June 2002) 36-43.
11. J Gemignani, “Substance abusers.
Terminate or treat?” Business and Health 17
(June 1999) 33-39.
Healthy work cultures emphasize employee involvement;
family-friendly policies that promote work-life balance
(eg, child care); peer support; and a positive flow of
communication.
12. W A Maggiore, “Substance abuse: When
the system fails,” Journal of Emergency Medical
Services 21 (November 1996) 70-80.
13. E J Sullivan, “Impaired nursing prac-
tice: Ethical, legal, and policy perspec-
tives,” Bioethics Forum 10 (Winter 1994)
20-25.
14. V E Johnson, I’ll Quit Tomorrow, second
ed (New York: Harper & Row, 1982).
15. D M Bush, J H Autry, “Substance abuse
in the workplace: Epidemiology, effects,
and industry response,” Occupational
Medicine: State of the Art Reviews 17
(January-March 2002) 13-25.
16. H Creighton, “Legal implications of the
impaired nurse—Part II,” Nursing
Management 19 (February 1988) 20-21.
17. S Trossman, “Nurses’ addictions: Finding

alternatives to discipline,” American Journal of
Nursing 103 (September 2003) 27-28.
18. J Ossi, “Substance abuse and depend-
ence in the hospital workplace: Detection
and handling,” Perspectives in Healthcare
Risk Management 11 (Spring 1991) 21-26.
19. “National council compares two regula-
tory approaches to the management of
chemically impaired nurses: An interim
report,” Issues 18 (1997) 7, 16.
20. M Kinsley, “A helping hand to freedom:
Programs help nurses with substance abuse
problems get back on the road to recovery,”
Nursing Spectrum (Nov 15, 2004) 10-11.
21. C West, “A person who is sick deserves
the chance to get well,” Michigan Nurse
(November 1997) 4-6.
22. L Finke et al, “Nurses referred to a peer
assistance program for alcohol and drug
problems,” Archives of Psychiatric Nursing 10
(October 1996) 319-324.
23. “Voluntary programs encourage
impaired nurses to admit problem,” ED
Management 9 (December 1997) 147-148.
24. B L Peery, G W Rimler, “Chemical
dependency among nurses: Are policies
adequate?” Nursing Management 26 (May
1995) 52-56.
25. “Consider liability issues when manag-
ing drug-impaired staff,” ED Management 9
(December 1997) 148-150.
26. J B Bennett et al, “Team awareness for
workplace substance abuse prevention: The
empirical and conceptual development of a
training program,” Prevention Science 1

(September 2000) 157-172.
27. J M Supples, “My colleague, my friend:
The impaired nurse,” Nursing Management
21 (August 1990) 48I-48P.
28. L E Rozovsky, F A Rozovsky, “Blowing
the whistle on incompetence,” Canadian Criti-
cal Care Nursing Journal 7 (June 1990) 12-13.
29. B E Calfee, “The state license hearing—
Information for empowerment,” Revolution—
The Journal of Nurse Empowerment 8 (Spring
1998) 20-21.
An alert issued by the Joint Commission onAccreditation of
Healthcare Organizations
(JCAHO) reports that patients undergoing chemo-
therapy to fight leukemia and lymphoma are some-
times accidentally being injected with a powerful
anti-cancer medication in an incorrect way that
results in death or permanent paralysis, according
to a July 14, 2005, news release from JCAHO. The
medication vincristine has been used widely and
successfully to treat cancer for many years, but
sometimes the medication is mistakenly adminis-
tered in the sac around the spinal cord (ie, intra-
thecal) instead of intravenously.
Intrathecal administration of vincristine can
be the result of a single error or a series of mis-
takes in a medication system, and these errors
have continued to occur despite repeated warnings
and extensive labeling requirements and standards.
The Joint Commission alert recommends that
health care organizations
• dilute the medication in such volume that it

prevents intrathecal administration;
• clearly label all vincristine syringes with the
warning that vincristine is fatal if given
intrathecally and is for IV use only;
• ensure that IV and intrathecal medications are
dispensed or administered at different times and
in different locations; and
• have at least two caregivers conduct a time out
before the patient receives vincristine to inde-
pendently confirm the correct patient, medica-
tion, dose, and route for administering the
medication.
Joint Commission Issues Alert: Mixups in Administering
Chemotherapy Drug Lead to Deaths (news release,
Oakbrook Terrace, Ill: Joint Commission on Accreditation
of Healthcare Organizations, July 14, 2005).
Chemotherapy Medication Mixup May Be Fatal
Examination NOVEMBER 2005, VOL 82, NO 5
1. Documentation about a colleague
suspected of substance abuse should
1. be confidential.
2. be objective and specific.
3. be detailed with dates, times,

and places.
4. include only facts not suspi-
cious behaviors.
a. 1 and 3
b. 2 and 4
c. 1, 2, and 3
d. 1, 2, 3, and 4
2. An employer can take action
against a reporting nurse if the alle-
gations turn out to be false.
a. true
b. false
3. When planning for a mediation, a
manager should
1. obtain facts and document the
nurse’s performance.
2. review narcotic sheets and
other medication records.
3. objectively document signs and
symptoms of substance abuse.
4. have a physician knowledgeable
about substance abuse disorders
review and interpret positive
laboratory results.
a. 1 and 3
b. 2 and 4
c. 1, 2, and 3
d. 1, 2, 3, and 4

4. One type of intercession includes
1. holding a group conference.
2. planning.
3. peer reviewing.
4. staging.
5. treating.
a. 1, 2, and 4
b. 2, 4, and 5
c. 1, 2, 3, and 5
d. 1, 2, 3, 4, and 5
5. The outcome of a hearing held
after several weeks of ongoing dis-
ciplinary issues could be
1. allowing the employee to quit.
2. a simple warning.
3. a mandatory treatment program.
4. probation.
5. suspension.
6. termination.
a. 1, 3, and 5
b. 2, 4, and 6
c. 2, 3, 4, 5, and 6
d. 1, 2, 3, 4, 5, and 6
6. The most helpful action a manager
can take is to allow a quiet termi-
nation or to encourage the nurse to
resign.
a. true
b. false

7. The ultimate goals of remediation
and support are
1. providing nonpunitive confi-
dential voluntary rehabilitation
programs.
2. facilitating reentry into practice.
3. ensuring public safety.
4. ensuring that nurses who
jeopardize patient trust
through substance abuse are
punished.
a. 1 and 3
b. 2 and 4
c. 1, 2, and 3
d. 1, 2, 3, and 4
8. Examples of rehabilitation programs
include
Examination
AORN is
accredited as
a provider of
continuing
nursing
education by
the American

Nurses
Credentialing
Center’s
Commission on
Accreditation.
AORN recog-
nizes these
activities as
continuing
education for
RNs. This
recognition
does not imply
that AORN or
the American
Nurses
Credentialing
Center
approves or
endorses
products
mentioned in
the activity.
AORN is
provider-
approved by
the California
Board of
Registered
Nursing,
Provider
Number CEP
13019. Check
with your
state board of
nursing for

acceptance of
this activity
for relicensure.
NOVEMBER 2005, VOL 82, NO 5 Examination
1. aversion therapy.
2. behavioral modification.
3. desensitization therapy.
4. detoxification.
5. psychological modification.
a. 1, 3, and 4
b. 2, 3, and 5
c. 1, 2, 4, and 5
d. 1, 2, 3, 4, and 5
9. Employees should not be required
to pay for any part of their treat-
ment because financial stress often
causes them to revert to old habits.
a. true
b. false
10. Signing a return-to-work agreement
1. emphasizes the seriousness of
the situation to the impaired
nurse.

2. is helpful in breaking down
denial.
3. helps prevent enabling on the
part of the nurse manager.
4. provides guidance to the return-
ing chemically dependent nurse.
5. protects the institution’s
interests.
a. 1 and 3
b. 2 and 4
c. 1, 2, 3, and 5
d. 1, 2, 3, 4, and 5
The Agency for Healthcare Research and Quality(AHRQ) has
launched a new program to help cli-
nicians and patients determine which medications
and other medical treatments are most effective for
certain health conditions, according to a Sept 29,
2005, news release from the AHRQ. The Effective
Health Care Program is a $15 million, three-part pro-
gram that incorporates 13 new research centers and
a center dedicated to communicating findings.
Program researchers will help provide clinicians and
patients with better information for making treat-
ment decisions by reviewing and synthesizing pub-
lished and unpublished scientific studies and identi-
fying important issues where existing evidence is
insufficient.
The program includes the following three
components.
• Developing comparative effectiveness reports—

Researchers at an existing network of 13
evidence-based practice centers will focus on
comparing the relative effectiveness of differ-
ent treatments, including medications, as well
as identifying gaps in knowledge where new
research is needed.
• Implementing a network of research centers—A
new network of 13 Developing Evidence to
Inform Decisions about Effectiveness research
centers (ie, DEcIDE centers) will carry out accel-
erated studies, including research aimed at fill-
ing knowledge gaps about treatment effective-
ness. The centers will use de-identified data
available through insurers, health plans, and
other partner organizations to answer questions
about the use, benefits, and risks of medications
and other therapies. Collectively, the DEcIDE
centers will have access to de-identified medical
data for millions of patients, including
Medicare’s 42 million beneficiaries.
• Making findings clear for different audiences—A
new Clinical Decisions and Communications
Science Center will focus on improving commu-
nication of findings to a variety of audiences,
including consumers, clinicians, payers, and
health care policy makers. The center will trans-
late findings in ways appropriate for the needs
of different stakeholders and will conduct its
own program of research into effective commu-
nication of research findings in order to improve
usability and rapid incorporation of findings
into medical practice.

AHRQ Launches New “Effective Health Care Program” to
Compare Medical Treatments and Help Put Proven
Treatments into Practice (news release, Rockville, Md:
Agency for Healthcare Research and Quality, Sept 29,
2005).
New Program Compares Medical Treatments
Answer Sheet NOVEMBER 2005, VOL 82, NO 5
Answer Sheet
lease fill out the application
and answer form on this page
and the evaluation form on
the back of this page. Tear the
page out of the Journal or
make photocopies and mail to:
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or fax with credit card information to
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Additionally, please verify by signature that you
have reviewed the objectives and read the
article, or you will not receive credit.
Signature ________________________
1. Record your AORN member identifi-
cation number in the appropriate sec-
tion below. (See your member card.)
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indicate your answers to examination
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offered
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2005
The deadline
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A score of 70%
correct on the
examination
is required
for credit.

NOVEMBER 2005, VOL 82, NO 5 Learner Evaluation
Objectives
To what extent were the following
objectives of this Home Study Program
achieved?
1. Discuss how a nurse should report
a colleague suspected of substance
abuse.
2. Explain the nurse manager’s role
in counseling and intercession with
a substance abusing employee.
3. Identify the outcome options for an
intercession with a nurse suspected
of substance abuse.
4. Identify return-to-work issues in
regard to keeping the suspected
nurse in the workforce.
5. Explain how staff member
acceptance can enhance treatment
program success.
Content
To what extent

6. did this article increase your know-
ledge of the subject matter?
7. was the content clear and organized?
8. did this article facilitate learning?
9. were your individual objectives met?
10. did the objectives relate to the over-
all purpose/goal?
Test Questions/Answers
To what extent
11. were they reflective of the content?
12. were they easy to understand?
13. did they address important points?
Learner Input
14. Will you be able to use the infor-
mation from this Home Study in
your work setting?
a. yes b. no
15. I learned of this Home Study via
a. the Journal I receive as an AORN
member.
b. a Journal I obtained elsewhere.
c. the AORN web site.
d. the AORN manager’s web site.
16. What factor most affects whether
you take an AORN Journal Home
Study?
a. need for contact hours

b. price
c. subject matter relevant to current
position
d. number of contact hours offered
What other topics would you like to see
addressed in a future Home Study
Program? Would you be interested or do
you know someone who would be inter-
ested in writing an article on this topic?
Topic(s): ___________________________
___________________________________
Author names and addresses: ________
___________________________________
Learner Evaluation
This
evaluation is
used to
determine
the extent
to which this
Home Study
Program met
your learning
needs. Rate
these items
on a scale of
1 to 5.
Purpose/Goal:

To educate
perioperative
nurses about
the problem
of substance
abuse among
nurses.
Clinical Journal of Oncology Nursing • Volume 13, Number 1
• Professional Issues 17
JeanAnne Johnson Talbert, APRN-BC, FNP, MSN, AOCN®,
DHA, is a chief clinical officer at Mountain
View Hospital in Spanish Fork, UT.
Digital Object Identifier: 10.1188/09.CJON.17-19
Substance Abuse Among Nurses
Professional issues Jeananne Johnson TalberT, aPrn-bC, fnP,
Msn, aoCn®, Dha—assoCiaTe eDiTor
DHA
Tammy is an excellent clinician. She is
fluent in oncology terminology and able
to teach patients and colleagues about
cancer care. She seemingly is dependable
and often picks up extra shifts when the
oncology unit is short staffed.

One night, as the nurse comes on shift
to relieve Tammy, a patient says her pain
is a 10 on a 10-point scale. The nurse is
concerned because the medication admin-
istration record indicates that the patient
has had frequent doses of pain medication
as needed. She calls the physician to report
the severe pain the patient is experiencing
and receives an order to increase opioid
pain medication. Shortly after the nurse
administers the medication, she checks on
the patient to find her unresponsive, with
an oxygen saturation of 81% and very slow,
shallow respirations. After calling the
Rapid Response Team and administering
naloxone, the patient arouses, and her oxy-
gen saturation increases. When the patient
is stabilized, the nurse takes a minute to
reflect. What happened to the patient?
The nurse realizes that for the past
two months, every time she has followed
Tammy on shift, the patients have com-
plained of unrelieved pain, even though
the medication administration record
indicates they were being medicated fre-
quently with opioid analgesics. Further-
more, her colleagues have complained
about Tammy’s decreasing work ethic;
Tammy takes longer and more frequent
breaks and exhibits irrational behavior.
Does Tammy show signs of impaired
nursing? If so, what should the nurse do
about it?

Substance Abuse
Among Nurses
Drug and alcohol abuse is a serious
health and social problem in the United
States. Addiction and dependency affect
adolescents and older adults, all ethnici-
ties, and all socioeconomic levels. The
prevalence of alcohol and drug abuse
in the nursing population is believed to
parallel that of the general population
(Dunn, 2005). Approximately 10% of the
nursing population has alcohol or drug
abuse problems, and 6% has problems
serious enough to interfere with their
ability to practice (Ponech, 2000). The
American Nurses Association (ANA) esti-
mated that 6%–8% of nurses use alcohol
or drugs to the extent that professional
judgement is impaired (Daprix, 2003).
Impaired nursing practice is defined
as a nurse’s inability to perform essential
job functions because of chemical de-
pendency on drugs or alcohol or mental
illness (Blair, 2002). Since
the early 1970s, impairment
has been studied among the
nursing profession and has
been linked to several fac-
tors. The first factor is family
history. Nurses who have a
family history of emotional
impairment, alcoholism, drug use, or

emotional abuse, resulting in low self-
esteem, overwork, and overachievement,
are at greater risk for using or abusing
substances (Monahan, 2003). Being in
an environment with dependent family
members may lead to enabling behavior,
which often is described as “helping” be-
havior. People who fit this category may
be attracted to the nursing profession
because of the opportunity to continue
in a caregiving role.
Stress in the workplace is another rea-
son cited for nurses abusing substances.
As staffing levels decline, workloads
increase, especially with increases in acu-
ity among hospitalized patients. Rotating
shifts, working overtime, and floating
to different departments contribute to
stress, fatigue, and feelings of alienation;
substance abuse may be a way of coping.
Nurses tend to be described as “worka-
holics” and may not be able to deal with
the stress the work brings (Monahan,
2003).
The availability and accessibility of
medications also has been linked to sub-
stance abuse among nurses (Serghis,
1999). Nurses are trained that medica-
tions solve problems. Every day, nurses
administer medications to alleviate pain,
combat infections, diminish anxiety and
depression, and treat illnesses such as

cancer. Nurses administer medications
to assail side effects of other medica-
tions. The workplace of a nurse has an
intrinsic culture that accepts pharma-
cologic agents to cure ailments (Dunn,
2005). Medications are easily accessible
to nurses, who may believe erroneously
that they have the ability to control their
own medication use because of their
experience with administering medica-
tions to patients. Nurses have the ability
to obtain undiverted medications by ask-
ing a colleague to write a prescription or
by forging a prescription or may obtain
Substance abuse among nurses is a problem
that threatens the delivery of quality care
and professional standards of nursing.
ayakemovic
Text Box
This material is protected by U.S. copyright law. Unauthorized
reproduction is prohibited. To purchase quantity reprints,
please e-mail [email protected] or to request permission to
reproduce multiple copies, please e-mail [email protected]
18 February 2009 • Volume 13, Number 1 • Clinical Journal
of Oncology Nursing
medications through diverted methods
such as using medications intended for
patients.
Substance abuse among nurses is a

problem that threatens the delivery of
quality care and professional standards of
nursing. Many nurses are not identified as
having a problem until patient safety has
been compromised (Clark & Farnsworth,
2006). Substance abuse may be a primary
problem or a result of treatment for an-
other condition, such as depression or
back pain. In a study by Trinkoff and Storr
(1998), rates of substance abuse among
nurses varied by specialty, even with
controlled sociodemographics. Compared
with nurses in women’s health, pediatrics,
and general practice, emergency nurses
were 3.5 times as likely to use marijuana
or cocaine (odds ratio [OR] = 3.5; 95%
confidence interval [CI]= 1.5, 8.2); oncol-
ogy and administration nurses were twice
as likely to engage in binge drinking;
and psychiatric nurses were most likely
to smoke (OR = 2.4; 95% CI = 1.6, 3.8).
No specialty differences appeared for
prescription-type drug use. Alcohol may
serve as a coping mechanism for oncol-
ogy nurses to ease the emotional pain as-
sociated with working with patients with
cancer. Exposure to death and dying also
has been linked to substance abuse, which
is familiar to oncology nurses (Trinkoff
& Storr).
Signs and Symptoms
Many signs and symptoms of sub-
stance abuse are general, nonspecific,

and easily hidden. However, over time,
an individual’s behavior paints a clearer
picture. Nurses with substance depen-
dency often use before and during their
shifts (Ponech, 2000). Signs to watch for
include increased absenteeism, frequent
disappearances from the department or
unit, excessive amounts of time spent
in medication rooms or near medication
carts, work performance that alternates
between high and low productivity, and
inattention or poor judgement (Drug
Enforcement Administration [DEA],
2008). Other signs of substance abuse
include damaged relationships among
colleagues, friends, and patients; heavy
“wastage” of drugs; personality changes,
such as mood swings, anxiety, depres-
sion, and isolation; and increased con-
cerns voiced by patients.
In the previous scenario, the assump-
tion is that Tammy is taking medication
intended for patients for use either during
or after shifts. She may be substituting the
medications with other substances that
have similar characteristics,
such as saline, or she may be
giving patients smaller doses
than what she documents,
while keeping the remaining
medication for herself. The
decreased pain management
among her patients, her in-

creased willingness to pick up extra over-
time shifts, and the changes in her work
standards and behavior are indicators of
a substance abuse problem.
Should the Nurse
Become Involved?
Nurses usually avoid dealing with
impaired colleagues (DEA, 2008). Of-
ten, nurses who work together develop
friendships, which can be an obstacle
to recognizing and addressing problem-
atic behavior or nursing practice (Dunn,
2005). Nursing departments frequently
encourage and reinforce teamwork prac-
tices, such as helping each other during
stressful times, which also can be a bar-
rier. A study indicated that nurses may ob-
serve unsafe behaviors but are reluctant
to report nurses they consider friends
(Booth & Carruth, 1998).
In addition, nurses have a tendency
not to report other nurses for fear of ret-
ribution, creating problems in the work
environment, or being labeled as a whis-
tle-blower (Dunn, 2005). Cerrato (1988)
reported a study in which 91% of nurses
who responded to a survey stated they
would report an incident that harmed
patients or put them at risk for harm;
however, only half of the nurses actually
reported incidences they had witnessed.
Avoiding or denying the problem of sub-

stance abuse only puts patients, organi-
zations, and the profession of nursing at
greater risk. Nurses who have substance
abuse problems that are not addressed
are able to work in different organiza-
tions and settings, putting themselves
and their patients at risk for harm.
Nurses have an ethical and legal ob-
ligation to report colleagues who ex-
hibit behaviors that could be detrimental
to patients (Dunn, 2005). Patients are
vulnerable and have the “right to safe,
skilled care administered by a nurse who
is physically able” to perform his or her
duties (Sullivan, 1994, p. 21). ANA stated
that nurses are responsible to respond
to a colleague’s questionable practice
as advocates for patients. Furthermore,
nurses are acting as advocates for their
colleagues because reporting nurses who
abuse substances may save their licenses
or even their lives.
Boards of nursing are mandated to
protect the public from unsafe nursing
practices, and many states have devel-
oped treatment programs for impaired
nurses rather than taking immediate dis-
ciplinary action against nurses’ licenses
to practice (National Council of State
Boards of Nursing, 2001). In fact, most
states have adopted programs that offer
nurses treatment and recovery programs,
monitor their return to work, and prevent

their licenses from being revoked or sus-
pended (Clark & Farnsworth, 2006).
The most important intervention the
nurse can make is to report Tammy. Most
often, this means reporting her to the
nurse manager and also may involve noti-
fying the State Board of Nursing. Either op-
tion is acceptable, and the decision may be
influenced by hospital policy, the nurse’s
relationship with the nurse manager, or if
the nurse feels no action is taken. By no-
tifying the manager or the State Board of
Nursing, the nurse is advocating for the pa-
tients Tammy cares for, her organization,
her profession, and her colleague, Tammy.
More than 39 states offer programs that
provide rehabilitation without punitive
interventions. Rehabilitative programs
rely on high rates of reporting and self-
reporting among nurses (Blair, 2002).
In conclusion, substance abuse among
nurses parallels that of the general popu-
lation and places patients, the public,
organizations, the nursing profession,
and nurses in harm’s way. An estimated
6%–8% of nurses in the United States
have substance abuse problems severe
enough that their ability to practice is
compromised. Among specialty nurses,
oncology nurses are among the most
Nurses have an ethical and legal obligation
to report colleagues who exhibit behaviors

that could be detrimental to patients.
Clinical Journal of Oncology Nursing • Volume 13, Number 1
• Professional Issues 19
frequent substance users because of
the stressful demands of the job, the
exposure to death and dying, and the
accessibility to medications. Nurses are
ethically and legally responsible to re-
port coworkers who exhibit behaviors
of impairment. Nurses must be not only
patient advocates but also nurse advo-
cates. The characteristic nurses share is
a desire to help people, and a colleague
may be one of the lives nurses save during
their careers.
Author Contact: JeanAnne Johnson Talbert,
APRN-BC, FNP, MSN, AOCN®, DHA, can be
reached at [email protected]
.com, with copy to editor at [email protected]
.org.
References
Blair, P.D. (2002). Report impaired prac-
tice—Stat. Nursing Management, 33(1),
24–25, 51.
Booth, D., & Carruth, A.K. (1998). Viola-

tions of the Nurse Practice Act: Impli-
cations for nurse managers. Nursing
Management, 29(10), 35–39.
Cerrato, P.L. (1988). What to do when
you suspect incompetence. RN, 51(10),
36–41.
Clark, C., & Farnsworth, J. (2006). Program
for recovering nurses: An evaluation.
Medsurg Nursing, 15(4), 223–230.
Daprix, J. (2003). The courage to care:
Intervening with colleagues who dem-
onstrate signs of impairment. Florida
Nurse, 51(3), 28.
Drug Enforcement Administration. (2008).
Drug Addiction in Healthcare Profes-
sionals. Retrieved September 18, 2008,
from http://www.deadiversion.usdoj
.gov

Dunn, D. (2005). Substance abuse among
nurses—Defining the issue. Association of
Operating Room Nurses Journal, 82(4),
573–582, 585 –588, 592–596.
Monahan, G. (2003). Drug use/misuse
Do You Have an Interesting Topic to Share?
Professional Issues provides readers with brief summaries of
nonclinical issues
relevant to oncology nurses. Length should be no more than
1,000–1,500 words,
exclusive of tables, figures, insets, and references. If interested,
contact Associate Editor
DHA, at [email protected]
mountainstarhealth.com.
among health professionals. Substance
Use and Misuse, 38(11–13), 1887–1881.
National Council of State Boards of Nursing.
(2001). National council compares two
regulatory approaches to the manage-
ment of chemically impaired nurses: An
interim report. NCSBON, 18(7), 16.

Ponech, S. (2000). Telltale signs. Nursing
Management, 31(5), 32–37.
Serghis, D. (1999). Caring for the carers:
Nurses with drug and alcohol problems.
Australian Nursing Journal, 6(11), 18–20.
Sullivan, E.J. (1994). Impaired nursing prac-
tice: Ethical, legal and policy perspec-
tives. Bioethics Forum, 10(1), 20–25.
Trinkoff, A.M., & Storr, C.L. (1998). Sub-
stance use among nurses: Differences
between specialties. American Journal
of Public Health, 88(4), 581–585.
E D U C A T I O N A L I N N O V A T I O N S
Addressing Substance Abuse Among Nursing Students:
Deveiopment of a Prototype Aiternative-to-Dismissai Poiicy
Todd Monroe, MSN, RN

ABSTRACT
Substance abuse and dependency
are health issues that require effec-
tive policies within nursing education.
In 2007, the University of Memphis
School of Nursing drafted a new sub-
stance abuse policy using the Ameri-
can Association of Colleges of Nursing's
Policy and Guidelines for Prevention
and Management of Substance Abuse
in the Nursing Education Commu-
nity. These guidelines include the as-
sumption that addiction is an illness
that can be treated and the philosophy
that schools of nursing are committed
to assisting students with recovery.
The new policy at University of Mem-
phis School of Nursing incorporated
prevention, education, identification,
evaluation, treatment referral, and re-
entry guidelines, as well as disciplin-
Received:May 1. 2007
Aeeepted; October 23, 2007
Posted: February 27. 2009
Mr. Monroe is a PiiD candidate. Univer-
sity of Tennessee Heaith Science Center,
Memphis, Tennessee.
The author thanks Dr. Katrina Meyer, As-
soeiate Professor of iHigher and Adult Edu-
cation, University of Memphis; Dr. Miehaei
Carter, University Distinguished Professor
of Nursing, and Dr. Heidi Kenaga, Research

Anaiyst, University of Tennessee Health Sei-
ence Center, for their assistanee in the prep-
aration of this manuscript. The author aiso
thanits Majorie Luttreli, Dean, and Eiizabeth
Thomas, Faeuity, University of Memphis
School of Nursing, Memphis, Tennessee.
Address correspondence to Todd Mon-
roe, MSN, RN, 4779 Eagle Crest Drive.
#2, Memphis, TN 38117; e-mail: tmonroe®
utmem.edu.
doi;10.9999/01484834-20090416-06
ary action for students unwilling to
undergo rehabilitation. It is hoped this
new substance abuse policy will serve
as a prototype for other institutions.
Jennifer is a straight "A" nursepractitioner student.
Returninghome after a stressful day, Jen-
nifer looked in her kitchen cabinet for
a glass of wine to help her relax. Not
finding any wine, she remembered
a narcotic prescription left over fi-om
recent dental surgery, thinking "This
will make me feel better, and it worked
for that procedure." Twenty minutes
after taking the medication, she felt
recharged, relaxed, and alert. She
thought no barm done because it was
her prescription. Within weeks, Jen-
nifer was addicted to pain medication,
ordering frequently from the Inter-
net and diverting from clinical facili-
ties. Although she tried several times,

she could not stop. Full of shame and
guilt, she became depressed and sui-
cidal. She was scared to ask for help.
Finally, Jennifer looked in her student
handbook to see what assistance, if
any, was available to ber. She found a
"zero-tolerance" policy. Fearful of be-
ing dismissed, she remained in clinical
experiences. In her final semester, Jen-
nifer's behavior prompted the school
to order a drug screen. She then re-
ported her addiction and her desire to
get help. Her next 45 days were spent
at an inpatient treatment facility for
alcohol and drug addiction. Because
Jennifer resided in a state that impos-
es discipline on nurses with chemical
dependency, her license was placed on
probation. She received an incomplete
in her last course, which was later
converted to a failing grade. Although
she has been in recovery since receiv-
ing treatment, Jennifer was dismissed
from the program and was inehgible to
ever complete her nursing education.
An estimated 16% of Americans
suffer from the disease of addiction,
and given that nurses have easy ac-
cess to controlled substances, this
percentage is likely to be higher in
the nursing profession (Haack, 1988;
National Council of State Boards of
Nursing, 2001). Estimates of addic-
tion rates in the nursing population in

the past decade have ranged from 6%
to 20% (Bell, McDonough, Ellison, &
Fitzhugh, 1999; New Mexico Board of
Nursing, 2008; Wennerstrom & Rooda,
1996). Coleman et al. (1997) reported
narcotic addiction was 5 to 100 times
greater among nurses than in the gen-
eral public. These statistics are alarm-
ing given the critical medical responsi-
bilities of nursing professionals.
Studies have revealed that sub-
stance abuse among nurses begins
before or while they are in school
(Bugle, Jackson, Komegay, & Rives,
2003; Coleman et al., 1997) and that
misuse of prescription drugs appears
to be especially common (Kornegay,
Bugle, Jackson, & Rives, 2004). Haack
and Harford (1984) found that 14% of
nursing students reported alcohol had
interfered with school and work, and
significant numbers of nursing stu-
dents were at risk for alcohol-related
consequences.
Research has suggested that nurs-
ing students who experience stress
and burnout are at risk for addictive
disorders and that prevention strate-
gies, such as social support and peer-
student-faculty interaction activities.
272 Journal of Nursing Education

EDUCATIONAL INNOVATIONS
should be implemented (Haack, 1988;
Haack & Harford, 1984). Peer-student-
faculty activities could include, with
each admitting class, candid discus-
sions about chemical dependency,
simulated interventions, discussion of
identifying behaviors associated with
substance abuse (Table), and dialogue
about the altemative-to-dismissal pol-
icy available (Figure).
Unfortunately, nursing education
programs in U.S. postsecondary insti-
tutions commonly neglect substance
abuse, chemical dependency, and stress-
induced problems among students, re-
sulting in inappropriate or ineffective
policies that do not adequately address
the particular challenges facing nuraing
students (Asteriadis, Davis, Masoodi,
& Miller, 1995; Haack. 1988; Murphy,
1989). A policy to effectively deal with
substance abuse among nursing stu-
dents in U.S. colleges and universities
is long overdue.
This article discusses an innovative
substance abuse policy for a school of
nursing at a large, urban university
in western Tennessee that graduates
approximately 150 nurses a year. The
development, adoption, and imple-
mentation of this policy at the Uni-

versity of Memphis School of Nursing
(UMSON) is outlined in the hope that
other institutions may consider it as a
model for addressing substance abuse
problems among nursing students in
a nonpunitive manner.
Substance Abuse Among
Nurses and Nursing Students
Since its inception in 1873, formal
nursing education has mandated that
the ideal nurse exhibit an ethical dis-
position. Early educational programs
for nurses were based on a "Florence
Nightingale model," which insisted that
nurses be of good moral character. As
explained in an 1890 primer. The Ency-
clopedia of Household Information:
There are five qualities which we
require in a nurse: Sobriety, (clean-
liness. Firmness, Gentleness and
Patience. On Sobriety: All I have to
say on this point is, if unfortunately
you cannot resist temptation, do not
come near us. (cited in Heise, 2003,
p. 119)
Still, the problem of substance
abuse among the nursing population
was recognized by the early 1900s. Is-
abel Hampton, a nurse leader, noted
that "Among my saddest experiences
are the instances, fortunately rare, in
which...[nurses I have lost their power

of self-control" (cited in Heise, 2003,
p. 119).
The situation only worsened with
the passage of the Harrison Narcotic
Act in 1914, which regulated the drug
industry and ushered in the under-
ground narcotics market, rendering
the discovery of addiction a matter for
the courts (Heise, 2003). Thus, sub-
stance abuse was not only evidence of
moral weakness, it also stigmatized
the abuser as a criminal.
Until the 1980s, state boards
of nursing and nursing education
programs almost exclusively imple-
mented discipline when substance
abuse was revealed, commonly re-
sulting in dismissal of tbe student.
State board disciplinary models
most commonly use a consent or-
der, an official civil action taken by
a board of nursing under admin-
istrative procedural law (National
Council of State Boards of Nursing,
1987). Discipline usually results in
probation, suspension, or revocation
ofthe nursing license.
The sole purpose of consent orders
is to protect the public, and with some
exceptions, they usually offer no pri-
mary preventive measures or services
for nurses, such as specific treatments,
case management, aftercare, or assis-

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