JANUARY 16, 2013
Nancy Darbro, PhD, CNS, RN
New Mexico Board of Nursing
Executive Director
Why alternative and discipline
monitoring programs?
• High percentage of state board discipline
cases deal with substance use issues
(Smith & Hughes, 1996)
• Cost effective and rehabilitative option
• Provide intense scrutiny of compliance and
public protection
• Alternative programs have been
functioning for over 20 years
Why alternative and discipline
monitoring programs?
• Most nurses with substance use disorders
are not identified in the workplace
• Most nurses with substance use disorders
are not reported to regulatory agencies
• Nurse who are reported often practice for
long periods during investigation
• 10% nurses needing treatment won’t get
Why alternative and discipline
monitoring programs?
• 90% of nurses with substance use
disorders remain unidentified,
unreported, untreated and continue to
practice (Gossop et al., 2001; Tighe &
Saxe, 2006; McCabe, Cranford, West,
• Most who enter treatment do so due to
external pressure or coercion
3 General Types of programs
• Alternative to discipline with statutory
authority under Bon (57%)
• Peer assistance programs under state
nursing associations (39%)
• Discipline monitoring with consent order
or voluntary surrender of license
Types of alternative programs
• 1. Model A. statutory authority under BON
Model B. statutory authority under BON
contracted to an outside agency
Model C. Special committee of the BON
• 2. Model D. Peer assistance program of
state nursing association in
collaboration with BON
Types of alternative programs
• Model E. Peer assistance program of state
nursing association with no collaboration
with BON
• Model F. Employee assistance program
with no collaboration with BON
Types of disciplinary models
• 3. Model E. Consent order for suspension,
stayed suspension or probation
Model F. Disciplinary provision for
voluntary surrender of license to BON
What is evidence based?
• Integration of best research with clinical
expertise and patient values
• Rigorous exploration where all research
data is analyzed, synthesized and
structured into an integrative review
• Patient values and the expertise of the
clinician might overrule findings (Sackett,
et al, 2000)
Assumptions of alternative
• Reporting and identification will increase if
there is an alternative to discipline option
• Reduces time between receipt of
compliant and intervention of nurse
• Nurses are provided opportunity for
rehabilitation prior to discipline
• Public is protected via close scrutiny of
compliance, monitoring and reporting
Components of alternative
Individualized contract agreements
Treatment and aftercare monitoring
Abstinence based, no use model
Regular, random, observed drug screens
Verified support group attendance
Regular reports from self, supervisor,
therapist, prescriber
Components of alternative
• Frequent, individual assessments via
phone or face to face evaluations
• Practice restrictions and stipulations
• Prescription medication monitoring
• Intense scrutiny of compliance
• Individualized case management &
monitoring, reporting of non compliance
Responsibilities of Alternative
• To protect the public while monitoring the
nurse to ensure safe practice
• To encourage early identification, entry
into treatment, and monitoring by
• To identify and report non compliance to
BON in timely manner
Responsibilities of Alternative
• To facilitate nurses to maintain ongoing
recovery consistent with safe practice
• To educate the public and nursing
professionals and organizations
• To ensure adequate program staffing to
implement program policies and contracts
with nurses.
Purpose of Guidelines
• Practical, evidence based direction for:
• Evaluating
• Treating
• Monitoring
• Managing
• Reporting
• Educating
Eligibility Criteria: A nurse is
ineligible if:
• Has diverted for purpose of selling or
distributing to others, caused known harm
or potential to cause harm
• Is not eligible for licensure in the state
• Has a history of disciplinary action not
related to substance use
Eligibility Criteria: BON approval is
needed prior to admission if:
• Has a felony conviction or pending
criminal action
• Has caused patient harm, abuse or neglect
Eligibility Criteria: BON approval is
needed prior to admission if:
• Has been unsuccessfully discharged or
terminated from any alternative program
for non compliance
• Is receiving medication assisted treatment
• Has been prescribed controlled substances
for dual diagnosis or chronic pain
Screening and Assessment
• Initial screening to determine eligibility
and motivation
• All pertinent information related to the
case from employers, investigators, and
• All demographic is included, employment,
academic, health, psychiatric, SUD,
family/social, legal, financial history
• Written, full disclosure of requirements
reviewed and voluntary signature
• Length of contract and dates signed
• Non-disciplinary nature unless violations
• Reporting requirements, self, employer,
therapist, 12 step attendance and sponsor
Contracts continued
• Frequency and time limits of random drug
screens and reports
• Consequences of relapse and reporting of
• Appropriate waivers and releases
Recovery Monitoring
• Comprehensive requirements:
• Initial treatment
• Continuing care treatment
• Drug screens results, support group
attendance, sponsor, supervisor, therapist,
provider reports, & PMP monitoring
• Practice & work limitations
Recovery Monitoring
• Close scrutiny of compliance with all
• Face to face or phone evaluations at least
• Comparison of all reports for consistency,
and accuracy of information, signatures,
Special Considerations for Nurses
Prescribed Controlled Substances
• Dual diagnosis common and not
• Medical and psychiatric assessment,
treatment and follow up
• Neuropsychiatric, neuropsychological
evaluation as needed
• One prescriber and one pharmacy
Return to Work Guidelines
• Best outcomes include back to work
employment contract
• Supervisor/manager involvement and
accurate reporting to program
• Authority to request for cause drug screen
• Educated and informed supervisors,
managers, co-workers
Return to Work Guidelines
• Close contact, communication,
engagement with alternative program
• Work restrictions on adverse work
• No nights, overtime, agency, home health,
or shift work
Program Completion
• Must meet minimum expectations of good
compliance with all requirements
• Includes recent relapse prevention plan
• Submit request for discharge with
supporting documentation
• Most programs 3-5 years
Policies and Procedures
• Internal policies and procedures provide
standards for implementation
• Administrative and statutory authority
• Intake and admission criteria
• Case management criteria for compliance
• Identification and reporting of non
Program Education and
• Extremely important, yet undervalued
• Lack of education about substance use
disorders is major risk factor
• Education efforts should be maximized
• Education should target all stakeholders
• Via seminars, presentations, workshops,
newsletter columns, FAQs, one to one
Program Evaluation
• Annual evaluation recommended
• Include statistics about referrals,
admissions, relapse and non compliance,
successful discharges, recidivism rates
• Case loads of case managers
• Educational presentations and plans
• Number of participants
Conclusions: What we have
• Evidence based recommendations for:
• Eligibility criteria
• Screening and assessment
• Treatment and continuing care
• Contract requirements & components
• Recovery monitoring requirements
• Practice stipulations and limitations
Conclusions: What we have
• Special population contracts
• Standards for treatment programs
• Support group requirements
• Drug and alcohol testing
• Return to work guidelines
• Monitoring and reporting non compliance
Conclusions: What we have
• Program completion requirements
• Policies and procedures
• Program education and outreach
• Program evaluation criteria
What we know
• Treatment for substance use disorders
• Health care professionals have a higher
rate of recovery than lay public
• Monitoring of practice and recovery is
effective and protects the public
What we know
• Addiction is the single most disabling condition
for health care professionals (Talbott & Wright,
1987, Coombs, 1997)
Treatment and monitoring works (Ganley,et al,
2005; Graham & Schultz, 1998, NIDA, 1999)
80-90% of nurses are successful in recovery
(Hughes, T.L., Smith, L. & Howard, J.J., 200;
Shaw, et al. 2004).
Thank you
Available for download:
Substance Use Disorder in
Nursing: A Resource Manual and
Guidelines for Alternative and
Disciplinary Monitoring Programs

new guidelines - National Council of State Boards of Nursing