Substance Abuse by Nurses

profileFinance & Econ


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®


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


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- tance with reentry to work (Quinlan, 1994). It has been explained that the purpose of disciplinary action is to protect the public and not to reha- bilitate the nurse (Sullivan, Bissell, & Leffler, 1990). Although 44 state boards of nursing have implemented alte rnative-to-di sei pline approaches (American Nurses Association [ANA], 2002), research continues to show the majority of nursing educational pro- grams use dismissal in cases involv- ing substance abuse (Swenson, Fos- ter, & Champagne, 1991).

Punitive models such as zero toler- ance use "deterrence theory," which mandates punishment to control be- havior (Haack & Yocom, 2CK)2, p. 42).

Addiction was seen as willful miscon- duct as opposed to a chronic disease. This analysis implies that individuals with other chronic conditions, such as diabetes or cancer, chose to acquire them (Smith, 1991). Such a view also reñected the nursing profession's de- nial of the magnitude of the problem, while inbibiting the option of recovery through treatment and rehabilitation.

Two Paradigms of Addiction: Medical and Environmental

The preponderance of medical evi- dence shows that addiction is a seri- ous disease (American Association of Nurse Anesthetists, 2005; Leshner, 2001; McLellan, Lewis, O'Brien, & Kle- ber, 2000; Nash, 1997; Robbins, 1987; Roche, 2007). In 1956, the American Medical Association declared alcohol- ism as a disease, and in 1987, it de- cided all forms of substance abuse are to be classified as a disease (American Medical Association, 2007).

Leshner (2001 ) asserted the first use of an addictive substance is voluntary, which makes it a conceivably prevent- able behavior. Addiction emerges when the cravings for the substance become so severe that a person risks astounding consequences such as loss of family, job, and possibly life to satisfy those crav- ings (American Association of Nurse Anesthetists, 2005; Leshner, 2001; McLellan et al., 2000; Nash, 1997).

Haack (1988) outhned environ- mental precursors to addiction:

Stress combined with psycho- logical characteristics may strongly dispose some individuals towards burnout, depression, or substance abuse, (p. 126)

Therefore, within these two para- digms, or some combination thereof, there can be no distinguishable dif- ference in the outcome. The disease of addiction is fatal if left untreated.

Advocacy Movement for Nurses witb Addictions

It was only in 1980 when the Na- tional Nurses Society on Addictions established a task force on addiction that the profession finally began to recognize the prohiem among its

May 2009, Vol. 48. No. 5 273



Potential Behaviors Associated with Substance


Excessive sick calls

Repeated absences with a pattern


Frequent accidents on the job

Frequent physical complaints

Peculiar or improbable excuses for absences

Frequent absences from clinical area

Frequent trips to rest room or locker room

Long coffee or lunch breaks

Early arrival or late departure

Presence in clinical during scheduled time off

Confusion about work schedule

Request for assignments at less supervised setting


Excessive time required for recordkeeping

Assignments require more efforf or time

Difficulty recalling or understanding instructions

Difficulty in assigning priorities

Display of disinterest in work

Absentminded or forgetful

Alternate periods of high and low activity

Increasing inability to meet schedules

Missed deadlines

Frequent requests for assistance


Overreaction to criticism

Illogical or sloppy charting

Deteriorating handwriting

Poor judgment



Tendency to blame ofhers

Complaints regarding poor care

Use or Dependency


Unkempt or inappropriate clothing

Poor hygiene

Mood swings

Frequent irritability with others

Poor recall

Physical abuse

Rigidity or inability to change plans

Incoherent or irrelevant statements

Drowsiness at work

Uncooperative witii staff

Tendency toward isolation

Deteriorating relationships

Wears long sleeves all the time

Physical Signs

Hand tremors

Excessive sweating

Marked nervousness

Coming to clinical intoxicated


Frequent hangovers

Odor of alcohol

Gastrointestinal upset

Slurred speech

Increased anxiety

Unsteady gait

Excessive use of breath mints

Excessive sniffling or sneezing


Flushed face

Watery eyes


practitioners. This effort, in conjunc- tion with the ANA, led to the first position paper on impaired nurses, recommending treatment before any disciplinary action (Heise, 2003).

However, despite subsequent reso- lutions in 1982 and 1984 by the ANA that advocated treatment, many

schools and colleges of nursing contin- ued to punish students with addictions (Fletcher, 2001; Heise, 2003; Markarian & Quinlan, 1986). For example, Swen- son et al. (1991) found 53% of nursing education programs used expulsion as a punitive measure. However, in the past 15 years, the nursing literature

clearly has established that addiction is a disease requiring treatment (Ameri- can Association of Colleges of Nursing [AACNl, 1994; ANA, 2002; Fletcher, 2001; National Council of State Boards of Nursing, 2004; Quinlan, 2003; Roche, 2008; West, 2003). The National Stu- dent Nurses Association, recognizing

274 Journal of Nursing Education


TABLE (Continued)

Potential Behaviors Associated with Substance Use or Dependency

Use of Controlled Substances

Signs out more controlled substances than do other providers

Frequently breaks or spills drugs

Waits to be alone before obtaining controlled substances for assigned cases

Discrepancies between patients' charts and narcotic records

Patients pain complaints out of proportion to medication charted

Frequent medication errors

Defensive when questioned about medication errors

Frequent disappearance immediately after signing out narcotics

Unwitnessed or excessive waste of controlled drugs

Tampering with drug vials or containers

Use of infrequently used drugs

© 2007, Bernadette Roche. Adapted with permission.

research findings as well as actual con- ditions among its population, passed a resolution in 2002 urging appropriate counseling and treatment for those members struggling with substance abuse (Quinian, 2003).

Dismissal hy a school or college of nursing leaves students untreat- ed and ashamed, posing a threat to themselves by means of overdose or suicide. In addition, feeling there is no alternative to dismissal, many students continue to work impaired, potentially harming clients.

Often failure to assist students into recovery results in frequent transfers from institution to institution (Center for Substance Ahuse Treatment, 1994; Fletcher, 2001). It is only through early intervention, treatment, and reentry that niui^ing schools can help students achieve successful careers, thereby increasing client safety and decreas- ing future costs to society, Early in- tervention removes impaired students from practice and moves them into treatment quickly. This helps to pre- vent the long-term associated costs to society, including poor health, hroken famihes, and potential death resulting from overdose, suicide, or homicide.

Faculty attitudes about substance ahuse are important in establishing a comprehensive substance ahuse policy.

Most faculty favor helping chemically dependent students receive treatment: 15% reported knowing at least one stu- dent with a current drug use prohlem, and 25% reported knowing students who at one time had a substance ahuse prohlem (Bugle et al., 2003). Still, they expressed concern about their ability to recognize impairment. As such, the provision of continuing education and training for facility should be part of the substance ahuse policy at schools of nursing.

Development of a Policy at the University of Memphis

Until 2006, UMSON had relied heav- ily on the university's policy concerning substance ahuse for the general stu- dent population. However, the school's administration and faculty recognized the need for a uniform and comprehen- sive policy when four students were identified in the past 2 years with sub- stance abuse or chemical dependency prohlems. Three ofthese students were directed into treatment, and the fourth student was monitored without further incident. All four students successfully completed the baccalaureate nursing program and graduated.

The philosophy guiding the UMSON policy was derived from the 1982 and

1984 ANA resolutions recommending treatment prior to disciplinary action, the 1994 AACN Policy Guidelines for the Prevention and TVeatment of Suh- stance Abuse in the Nursing Educa- tion Community, and the ANA (2005) Code of Ethics for Nurses with Inter- pretative Statements. The University of Memphis School of Nursing made a firm commitment to the view that ad- diction was a disease and not a moral issue nor deliberate misbehavior. Ac- cording to Haack and Yocom (2002):

I Schools] of nursing that take the approach that substance use disorder is a treatable and chronic illness are more in line with the objectives put forth by the Healthy People 2010 governmental document, (p. 42) The ANA (2005) Code of Ethics for

Nurses recommended advocacy by all nurses to support colleagues or students whose practice may be im- paired, including reentry into work or school. Likewise, the ANA's (2002) professional response to the issue of impairment mandates advocacy and promotion of well-being. Disciplinary policies such as zero tolerance and dismissal, with no regard for recovery or reentry, clearly are in violation of the Code of Ethics for Nurses.

Faculty recognized the importance of input from all stakeholders to ensure

May 2009, Vol. 48, No. 5 275


Identilïcationof possible impairment,

report to Dean

Continued assessment, data colleclionand documentation

consult with Tennessee Professional Assistance

Program (TNPAP)

Determination of: (a) Substance abuse

or (b) Other problem

Insuffîcienl dala then continue data


If data supports impairment


ÄgruWw wíftiillíOH'ftr ralunarily enters

treatment and monitoring with TNPAP.

>•:- • -- faculty advocHte

Refuses evaluation for substance abuse

Dismissal, send through university grievance or due

process procedures. Prqiare for hearing if


(¡•Chain Ii talion lor di tnuL

dependency expected )

cnt und unter IIUÛ contract with TNPAP. Reentcr clitiicui when

kTNPAP and Dean dctenninc

Evaluation is negative


TreatmtTit reluscd Renim to cihiicat i moni tonn g cymtract ' INPAPatidlJMSONund v\.\.-' ly visits with faculty

advocad: oporrgradtiation,"'' muy remain under \

contract with ^ TNPAP

Figure, Flowchart depicting the University of Memphis School of Nursing's alternative-to- dismissal policy.

clarity and transparency in the prc»œss. The policy development committee was chaired by a faculty person, under the guidance of the UMSON dean, and a doctoral student (T.M.) whose research interests included nursing students and suhstance ahuse was asked to par- ticipate in the process. After a litera- ture review, the committee drafted a policy with a set of specific ohjectives. The Figure depicts a flow chart detail- ing the components ofthe policy.

Clear Policies and Procedures that Are Fair and Objective

Clear policies show a commitment to professional standards by adminis- trators and faculty and specify what

occurs when the standards are vio- lated. Nursing students are required to sign a document stating they have read and understood the UMSON suhstance ahuse policy. Still, postsec- ondary institutions are responsible for ensuring just treatment and due process of students and employees when infractions occur (Cole, 1994).

Chemical Dependency Determined by Faculty and an Appropriate Professional

Although faculty are responsible for recognizing the signs of chemical impairment, an expert in chemical dependency also should he consulted (Asteriadis et al., 1995; Roche, 2008).

As Roche (2008) noted: The school is responsible for

identifying individuals with dete- riorating academic performance, behavioral changes, and excessive absenteeism, but is not responsible for diagnosing tbe nature of tbe problem, (p. 2) Diagnosis is achieved through inter-

vention and agreement for a suhstance abuse evaluation. The Tennessee Pro- fessional Assistance Program deter- mines an appropriate specialist in ad- dictions to conduct the evaluation. This evaluation leads to either a diagnosis of substance abuse, some other problem, or neither. Documentation that ensures confidentiality is critical (Roche, 2008).

Intervention as a Possible Option Intervention attempts to provide

an objective and factual presenta- tion of the problem to impaired stu- dents, the objective of which is to obtain their consent to undergo drug and alcohol testing. If a diagnosis of suhstance abuse is made, treatment should he offered (AACN, 1994). The policy makes provisions for students to focus on recovery prior to reentry to the nursing program.

Use of State Professional Organizations to Assist Students in the Treatment and Recovery Process

The Tennessee Professional Assis- tance Program is an altemative-to- discipline program for medical profes- sionals in Tfennessee. The program chaises an annual $15 fee to confiden- tially monitor any student found to have a substance abuse problem to ensure compliance with treatment regimens and school regulations. It also provides evidence of students' successful comple- tion of rehabilitation and recommends their reentry into the UMSON. Moni- toring includes daily calls for drug and alcohol screening, mandatory nurse support groups and 12-step recovery meetings, intensive case management, and quarterly progress notes by both students and the school.

Protection of Confidentiality All information, written or other-

wise, regarding students' suhstance ahuse is confidential and guided hy pri-

276 Journal of Nursing Education


vacy law (AACN, 1994; Roche, 2008). The UMSON keeps such documenta- tion in a secure location, separate from students' academic file, and the docu- mentation is destroyed after students successfully complete the program.

Students are assigned a faeuity advocate ÍAACN, 1994; Roche, 2008), who serves as a case manager. Faeuity advocates coordinate clinical schedules to accommodate 12-step meetings or practice restrietions, as well as after- care attendance. In addition, faculty advocates facilitate communication between the Tennessee Professional Assistance Program and the school.

Guidelines for Reentry into Nursing Program

Following successful completion of an approved treatment program, stu- dents may reenter UMSON under a conditional enrollment status, depen- dent on evidence of abstinence and the recommendation of the "Itennessee Professional Assistance Program. A contract with UMSON is required for all such students, detailing all policy requirements and the consequences of failure to meet any of the require- ments. Areentry contract may be more restrictive than the state requirements (Clark, 1999; Roche, 2008).

The Tennessee Professional Assis- tance Program and the UMSON dean determine students' level of access to controlled substances, and clinical instructors are notified of any restric- tions on practice and schedule. Con- tinuation in the program is contin- gent on documented compliance with rehabilitation. Although recogniz- ing these measures were necessary, UMSON faculty believed it was criti- cal to minimize any stigma that recov- ering students might experience, and thus recovering students are treated with respect and afforded all oppor- tunities granted to other students with disabilities. As such, the policy includes a statement of compliance with the Americans with Disabilities Act (AACN, 1994; Roche, 2008).

Further Disciplinary Action The UMSON understood that

in some situations, dismissal of substance-abusing students would

be necessary. Reasons included, but were not limited to;

• Failure to notify the school ofan arrest or charge for a drug offense.

• Failure to provide a written consent for a drug screen.

• Refusal to submit a specimen for a drug screen or allow a property search.

• Refusal to have an evaluation for substance abuse.

• Failure to complete treatment. • Loss of licensiire as an RN

(graduate students).

Ongoing Education and Training in the Problem of Substance Abuse

Coleman et al. (1997) and Haack and Harford (1984) stated only 1 to 5 hours of content was covered in schools of nursing, and many have inadequate content on chemical de- pendency. The policy at UMSON now incorporates coursework on substance abuse into the nursing curriculum. In addition, recovering nurses are invited to apeak to the school on the disease and recovery process, and a Ttennessee Professional Assistance Program rep- resentative conducts an annual pre- sentation about peer assistance.

Adoption and Implementation of the Policy

The policy was presented first to tenured faculty in UMSON and sub- sequently to the dean, the faculty student affairs committee, and the Tennessee Professional Assistance Program for feedback and questions. Ameeting with the university's gener- al counsel included discussions about due process and discipline measures.

A revised draft was presented to the dean, faeuity student affairs com- mittee, dean of judicial affairs, se- lected nursing students, American Association of Nurse Anesthetists Na- tional Peer Advisors, and Concentra Diagnostic Laboratories for additional clarification. Afler the final draft was approved by the faculty student affairs committee, it was resubmitted to gen- eral counsel and the judieial review board of the university. Finally, the policy was approved by the Tfennessee Board of Regents in February 2007.

Advantages of the UMSON poUcy include a uniform approach to deal- ing with substance abuse and chemi- cal dependency, involving early de- tection, intervention guidelines, and treatment plans. These measures will provide a safer environment for clients and simultaneously öfter students a greater chance to recover and gradu- ate. Emphasis is on continued recov- ery through monitoring and aflereare programs, and thus students will have ongoing exposure to professionals well vereed in substanee abuse diagnosis and treatment. Reeords will be con- fidential as long as students remain compliant with the rehabilitation plan. Students are ensured monitor- ing contracts through the Ttennessee Professional Assistance Program.

Consequences of the UMSON pol- icy include the financial burden in- curred by students for drug testing, treatment eosts, and aftercare servic- es; mandatory reporting to the Ten- nessee Board of Nursing if disciplin- ary action is warranted; and possible criminal charges resiilting from the diversion of nareotics from clinical fa- cilities. These charges could be initi- ated by hospitals or clinical affiliates, not UMSON. A noteworthy concern was how to transport suspected im- paired students for drug testing, but this was resolved by having the drug testing company come to students and faculty members if necessary.

The UMSON recognized that over time the policy statement might be modified; development and implemen- tation of an evaluation component to assess the eftectiveness of the new policy would be helpful in this process. Ideally, process evaluations will include both changes in attitudes about sub- stance abuse and chemical dependency, and increased knowledge among facul- ty, staff, and students (Murphy, 1989).

Conclusion A uniform policy for the preven-

tion and management of substance abuse and chemical dependency such as that adopted by the UMSON will be a valuable asset for students, fac- ulty, clients, hospitals, and the com- munity. Through early identification

May 2009, Vol. 48, No. 5 277


and prompt movement into treat- ment, the UMSON pohcy can help to decrease the prevalence of one of the most devastating diseases in the nursing profession.

It also is beheved that both faculty and students will be more likely to in- tervene and report impairment with a supportive altemative-to-dismissal pohcy in place. Likewise, with an altemative-to-dismissal pohcy, it is hoped that any student desiring as- sistance will be more likely to ask for help.

By removing impaired students from practice quickly, the policy helps to ensure client safety while promot- ing students' well-being. Nursing education programs that offer some type of supportive and confidential substance abuse policy remain more humanistic in their approach to stu- dents with the disease of chemical dependency.

References American Association of Colleges of Nurs-

ing. (1994). Position statement: Policy and guidelines for prevention and man- agement of substance abuse in the nurs- ing education community. Washington, DC: Author.

American Association of Nurse Anesthetists. (2005). Wearing masks: The potential for addiction in anesthesia [Motion picture]. Hampstead, NH: Rainbow Productions.

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