Alternative Approaches to Traditional Discipline

New models for approaching chemical dependency in nurses were introduced during the 1970s and 1980s that combined aspects of both the traditional discipline process and the preventive peer assistance approach. As knowledge increased about the disease of addiction and alternative approaches provided services with improved outcomes, more states moved toward the alternative model (ANA, 1990).

Nonpunitive disciplinary options vary from established peer assistance committees that advocate for the impaired nurse to the state board of nursing issuing a charge letter that offers the nurse an opportunity to negotiate a settlement prior to a full evidentiary hearing. In the second case, the license is suspended or revoked but with a stay of action that places the individual on probation. As long as the nurse complies with the terms of probation (treatment and aftercare), the stay protects the license. Nurses may actually return to work with the stay in place under close monitoring. This is another example of a nonpunitive approach that serves both the public and the professional (Dorsey and Scheer, 1987).

Alternative Programs

Alternative programs are recognized by the appropriate state regulatory board, such as a board of nursing, and offer a voluntary, nonpublic opportunity for healthcare professionals whose practice is potentially impaired. This is done with close monitoring by program staff in lieu of formal disciplinary action on the professional license. Where these programs function, legislative authority has generally been granted by the state and approved by the board of nursing to conduct such activity. The nonpublic aspect of this approach maintains monitoring and licensure activity in closed files that are usually purged after five years of successful recovery. Public disciplinary approaches publish in the board of nursing newsletter the name of the nurse, the nurse's town of residence, and action on license indicating substance abuse.

Recently the public has questioned the fairness of nondisclosure, especially in states operating under the "sunshine law." If the process for investigation and action by the legislatively approved alternative program is well established, consistent, and well documented internally, and outcomes are tracked objectively, there should be less cause for alarm by the public. An interim report on a study conducted by Yocom and Haack (1996) that compared the two regulatory approaches--traditional discipline versus alternative--revealed that the retention rate after reentry for the alternative model was almost twice that of the disciplinary approach (68 percent versus 37 percent). This presumably is attributed to the quality of aftercare during monitoring.

By 2000, 60 percent of states offered formal legislation or alternative programs that permitted treatment without an adverse judgment upon the license. At present, even the states with some advocacy offer a variety of models for alternatives to disciplinary proceedings. Each may have a different legal or professional provision since the state maintains the authority to decide which model best serves the public. Therefore, a consensus within nursing does not exist. That translates to differences in discipline, treatment, monitoring, and reentry for the addicted nurse based solely on geography.

There currently is a movement of national advocacy groups, including the AANA Peer Assistance Advisors Committee (PAAC), to urge nursing to take a consensus approach to impaired practice. Many state boards are hesitant to offer an alternative to discipline, citing duty to patient safety. These organizations fail to see that the alternative approach actually provides better patient safety because it identifies chemically dependent (CD) nurses sooner and removes them from practice within hours to days. The traditional discipline method often requires six to 18 months of documentation, investigation, and hearings before the nurse is removed from practice. Within the same time frame, a CD nurse can often be identified, treated, and reentered to safe practice under a rigid monitoring program.

The saying, "Nursing is an army that shoots its wounded," has been used many times by those exasperated with the lack of progress within nursing. While it is hoped that advocacy groups can turn this tide, it ultimately will take the concerted effort of countless nurses to petition their own state boards or state legislators to create and fund alternative programs. It will also take the cooperation of colleagues to urge appropriate policies and guidelines within their workplaces that provide advocacy and support.

It is hoped that positive results with alternative programs will lead all boards of nursing to eventually take an uniformed approach to chemical dependency among nurses. To date it has been a tedious process, and this slow response by the nursing profession has contributed to the continued and often permanent loss of skilled nurses to a treatable disease.

It would be wise for CRNAs to know the provisions for disciplinary action related to impaired practice within the states in which they hold licensure. Information on disciplinary action is provided to other states so that multiple licensures will be affected by the action on one license. A CRNA who has the misfortune to become addicted in a state with no alternative discipline, despite being licensed in other states with less punitive approaches, will be disciplined by the state in which the activity occurs. Therefore, it would benefit the nurse to work toward an ideal model that affords the disciplinary alternatives, access to evaluation and treatment, monitoring contracts, and reentry assistance. With at least one in 10 CRNAs statistically at risk, every anesthetist in this country will be involved in some manner with a colleague needing this service. How it is handled impacts the entire department as well as the addict. One can best be prepared by supporting legislation that provides the best alternative program for the practice area and by creating or revising departmental chemical dependency policies.

Reference
Quinlan, D. Peer Assistance - Part 2. In: A Professional Study and Resource Guide for the CRNA. Foster S, Faut-Callahan M, eds. Park Ridge, Ill: AANA Publishing, Inc.; 2001; 460-462.

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