Running head: IMPAIRED NURSES 1

Impaired Nurses

Nurses who use Drugs Illegally

Paula Hasty

Chamberlain University

Transitions to Professional Nursing NUR 351

Professor Faye Silverman

IMPAIRED NURSES 2

Impaired Nurses

Nurses who use Drugs Illegally

A Licensed Practical Nurse (LPN,) who works for the local hospital for about 10 year, she

is conscientious and is respected by her peers and management. A Registered Nurse (RN), who

the LPN does not know well, was covering her; the RN was responsible to do all the intravenous

(IV) medication pushes for her. She asked the RN to give a patient some pain medications IV

push. The patient complains one hour later that he did not receive pain relief. After speaking to

some colleagues, the LPN hears from other colleagues that when this RN works the patients are

unable to receive pain relief. The LPN informs management of her concerns. After extensive

investigation, management and a few of the RN's close colleagues, who were concerned for her

health, conducted an intervention with the RN. It seemed that she had fallen into the drug

addiction trap. After injuring her back two years ago, the RN was taking prescribed Oxycontin.

The RN started needing the medication to believe she was normal. When she could not get any

more medication from her doctor, she started diverting medication from the Pyxis system at the

hospital. She and her spouse divorced and her addiction started to escalate. She worked several

shifts of overtime so that she would have access to the medications that she craved. She was in

fear of being caught and started taking the medication that was ordered for the patients. She was

ashamed and did not know where to turn when the intervention occurred.

Definitions

Nurses have a reputation as the most trusted profession in America. Nurses have taken an

oath to maintain "good moral character." In Florida, signing a "Good Moral Character" affidavit
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that explains exactly what a violation to that oath may be, is required. Nurses are entrusted with

the care of America's weakest citizen. These people are sick and debilitated. Ill people are

dependent on the care of a nurse for everything. Because of this responsibility, nurses must have

access to all types of medications. No matter how responsible a nurse is, some nurses still

succumb to temptations of drug abuse. This is a huge problem for hospitals; with the nursing

shortage the board of nursing cannot afford to lose these valuable resources. That is one reason the

Board of Nursing is turning away from punishment to treatment for this problem. Drug addiction

has become recognized as an illness in this country. Punishing people for their illnesses is not an

accepted way of dealing with the problem. Treatment is an accepted way to deal with the issue of

impaired nurses.

Nursing education does not include information on how to recognize a colleague battling

an addiction. In Nursing Forum (2009), "…specific characteristics of chemically dependent nurses

include high achievement and success orientation. These nurses often have earned advance

degrees, are in positions of responsibility, are polysubtance abusers and tend to lack support in

recovery. They often have co morbid mental health disorders, as depression, that is common in

chemically dependent nurses and should be addressed in treatment". Signs and symptoms as

frequent job changes, working frequent off shifts, history of chronic pain from an injury or recent

surgery, and patients complaining of inadequate pain relief are often indicators of an impaired

nurse. According to Jack Stem, who is the founder of the Peer Advocacy for Impaired nurses

LLC in Ohio, "The stigma that addiction is a moral failure or lack of willpower rather than a

disease is embedded in U.S. society." According to RN (2009), nurses rarely self report because

they are fearful of losing their livelihood. Drug addicts also think they are in control and will not

admit they are having a problem until they hit rock bottom. Intervention may create an "artificial
IMPAIRED NURSES 4

rock bottom" that will make the drug addicted nurse seek treatment if they may avoid losing their

license.

Drug Diversion

According to Dictionary.com, diversion is defined as the act or an instance of diverting: as

an unauthorized rerouting or appropriation <diversion of funds>. Drug diversion is on the rise in

nursing, as drug use is in America. Diversion by nurses is not just theft from their employer, but it

is also theft from the people they are in charge of caring for. According to AORN Journal (2008),

"Most researchers believe that rates of addiction in nursing mirror the national addiction levels

10% to 12%." Drug diversion is illegal and is punishable by anti-theft laws in which the diversion

is taking place. According to Pharmacy Times, (2008) "…opioid abusers had health care costs that

were roughly 8 times higher than those of nonabusers." Per patient cost of opioid abuser were

about $16,000 per year, compared to just $1830 for non opioid abusers. These cost are high

because of the enormous cost of the physician visits, procedures, x rays, and emergency

department visits , which makes the pharmaceuticals a minuscule cost in comparison. Diversion

happens in a variety of ways. One way is to get medications is to withhold the medication from

the patient it was intended for. Another way to divert drugs is to go under someone else's

identification in the Pyxis system and take the medications out. Yet another way to divert drugs

from the hospital is to get a patient's medication and get out extra medication. Unfortunately, drug

addicts are creative in their methods to obtain their medication. According to Pharmacy Time

(2008) drug diversion cost health insurers about 72 billion dollars every year. The money is almost

never recovered and is passed on to the consumer, contributing to higher insurance costs. Another

reason for drug diversion is selling medication on the black market for large amount of money.
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Consequences

According to Journal of Addictions Nursing, "Although the need to address the problem of

nurses was recognized as early as the turn of the century, it was not until 1980 that the National

Nurses Society on Addictions (NNSA) created a task force to examine the need for professional

assistance programs." Because drug diversion is in fact, employee theft, it is punishable by law.

Nurses are sometimes arrested and prosecuted for larceny. When the nurse, is charged with a

felony, she will not be able to renew her license or practice nursing. The disciplinary approach is

designed to protect the public from harm, that an impaired nurse can do to the people she is caring

for. Unfortunately, with the discipline approach nurses receive little in the way of rehabilitation.

On top of that, according to the Journal of Addictions Nursing any hospital that hires a nurse who

has be charged with a felony may not receive payment from the federal government for the

services rendered. The punishment approach almost always includes suspension of the nursing

license, they are ineligible to work as a nurse for a period of one to five years. Nurses are then

placed on a probationary period where they are allowed to practice under contract to the board of

nurses. According to Nursing Forum (1999),"…in Florida 80-90% of disciplinary actions by the

Florida Board of Nursing were related to alcohol and substance abuse." According to the Billings

Gazette, about 50-60% of the action taken by the Board of Nursing in Montana is related to drug

diversion. Law enforcement rarely gets called when drug diversion is discovered. Facilities think

that refraining from calling law enforcement is the best way to encourage someone to go into

recovery. Some law enforcement agencies think that nurses get special treatment when theft of

narcotics and drug diversion is concerned. According to the Glacier County Attorney Larry

Epstein, "I know of no other profession exempt from criminal prosecution when they steal drugs."
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According to RN (2009), "If nurses have been involved in diverting drugs, their employers have an

obligation to report this to drug control authorities and the state Board of Nursing.

"In 1982 the American Nurses Association addressed the problem of impaired nursing

practice, promoting the use of peer assistance programs and dissemination of information

regarding impaired nursing practice within the profession" according to Nursing Forum (1999).

Since that time, disciplinary diversion programs have become popular. There are many models of

alternative programs. Forty-four states have adopted some kind of discipline diversion program;

although the standards for each program vary greatly. The oldest is the Florida Intervention Project

for Nurses (IPN), established in 1983. IPN is a diversion program that included intensive case

management, individual counseling, and strict monitoring. In the Journal of Addiction Nursing, it

defines alternative to discipline as programs that are non-compulsory and confidential. The

philosophy underlying the programs is the nurse will voluntarily seek assistance if they are allowed

to retain their livelihood and keep their treatment confidential. Once an impaired nurse chooses

this path they usually sign a contract that can be more stringent than the sanctions imposed by a

disciplinary program. A nurse will be required to refrain from practice until she may complete a

drug treatment program. When a nurse finishes either and inpatient treatment program or an

intensive outpatient program, she is allowed to return to work under the close supervision of the

administration of the hospital and her case manager. She will have a restriction on her access to

narcotics and she will be randomly frequently drug tested. She will also be required to attend a

recovery group as Alcoholics Anonymous or Narcotics Anonymous where she must have a

sponsor. She will be required to attend a nurse support group meeting weekly for the length of the

contract. She will also be required to attend regularly scheduled follow up appointments by a

therapist and psychiatrist for medication management in the treatment of any psychiatric co
IMPAIRED NURSES 7

morbidities. Her supervisor at work, the nurse support group, and her case manager quarterly will

evaluate her for the length of her contract. Contracts in Florida are usually 5 years. Nevertheless,

the discipline diversion program supports nurses in recovery and does not take action against the

nurse's license. When rehabilitation fails through treatment and recovery options, or when they fail

to be compliant to the contract they signed they may be referred for disciplinary action.

Recovery

According to Cinahl Information Sheets, relapse is common between 27-92% with family

history of substance abuse, use of major opioid, and co morbid psychiatric disorders increasing the

chances. Journals of Addiction Nurses(2008) states that one study 90% of those nurses

completing monitored treatment achieved abstinence, and research has also indicated when a nurse

is monitored for an extended length her chances of long term success is improved. Some programs

offer a statistic of 85-95% successful recovery rate. Some states as Idaho, Mississippi and

Arkansas offer statistics of 47-61% successful recovery rates, according to the Journal of Addiction

Nursing (2008).

Retention

In the time of nursing shortages, retention of nurses is a big concern. With the costs of

orientation of a nurse to a specific facility retaining a nurse affected by drug addiction is important.

Journal of Addictions Nursing (2008) reports that retention rates for nurses who are taking part in a

discipline diversion program are double from those that were disciplined. Some studies attribute

that to the shame and lack of support when nurses have been disciplined. When a nurse is under

contract from a discipline diversion program she has support and monitoring built in giving her and

the facility a good chance of recovery.

IMPAIRED NURSES 8

In conclusion, drug addiction is considered an occupational hazard in nursing. Nurses are

in high stress environments with easy access to mind altering drugs. Some nurses fall prey to the

disease of drug addiction. Treating addiction and any co morbid psychiatric illnesses, as a disease

that requires treatment, monitoring, and recovery is effective for not only the nurse but for the

facility where the nurse works. Statistics support the discipline diversion approach as the most

effective approach to treat impaired nurses. Discipline is not as effective because of the length of

time it takes to get through the disciplinary process, the retention rates and the lack of support

provided for the disciplined nurse. Discipline diversion proves effective because the nurse is

monitored closely for an extended period. This allows the nurse to develop effective coping skills

to deal with the stress and temptations of working in a drug rich environment. Supporting recovery

allows healthcare facilities to retain the precious resource of trained experienced nurses.
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References

Burke, C. (2008, March). Drug Diversion and Abuse: Rx Diversion Costing Health Insurers.

Pharmacy Times, 1-2.

Copp, M. B. (2009, April). Drug Addiction. RN, 40-44.

Griffith, J. , RN, BSN (1999, October-December). Substance Abuse Disorders in Nurses.

Nursing Forum, 34(4), 19-28.

Monroe, MSN, MS, RN, T. , Pearson, PhD, F. , & Kenaga, PhD, H. (2008). Procedures for

Handling Cases of Substance Abuse Among Nurses; a Comparison of Disciplinary and

Alternative Programs. Journal of Addictions Nursing, 19(3), 156-161.

10.1080/10884600802306024

Clinical update. Substance abuse: nurses and drugs--off the job. Nursing 1998, 9(ISSN: 0360-

4039), 66-67.

Pinto, MSW, S. , & Schub, BS, T. (2009, January 16). Substance Abuse in Healthcare

Professionals. In D. Pravikoff, RN,PhD,FAAN (Ed.), Cinahl Information Systems.

Ramer, L. M., RN, MSN, CNOR (2008, August). Using servant leadership to facillitate healing

after a drug diversion experience. AORN Journal, 2(ISSN: 0001-2092), 253-258.

Tranbarger, R. E. (1997, February). A Nurse Executive's Nightmare The Rogue Nurse. Nursing

Management, 28 No. 2(002-0443), 33-36.