Financial Implications and Sustainability of Innovation

The cost of drug abuse in the United States is quite substantial, with alcohol costing $249 billion dollars and drug abuse costing $193 billion dollars annually (US Department of Health and Human Services, 2015). These costs are attributed to lost productivity, increase in health care costs, premature deaths and auto accidents. When discussing these costs related to impaired nurses, information on financial implications is limited. This could be for a number of reasons, including simply failure to report. Statistics do show that the rates of addiction and substance abuse in nursing is similar to those of the general public, roughly 10-15% of the population, so 1 in 10 (National Council of the State Boards of Nursing, 2011).

Consider also, that drug or alcohol addiction can result in unpaid or late bills, overdraft fees, loss of vehicles or housing and job loss. These things all present other financial burdens to society and to the addicts’ families and other loved ones.

From the State of Virginia’s Board of Nursing:

(Talbotcampus.com,2018)

Sustaining Innovation

As discussed in my previous post, there are a few new technological innovations that have been made to help assist those with addictions, not just nurses. These innovations include apps that help support recovery and in-hospital protective devices to promote accountability and  prevent diversion. Despite the technological advances in this field, the primary way to sustain innovation is by preventing substance abuse from happening in the first place (SAMHSA, 2017).

Prevention of substance abuse in nursing can be done by building a network of stakeholders, in our case state boards of nursing, those who employ nurses, nurses and other medical field personnel, who can come together to develop effective prevention strategies (SAMHSA, 2017). This could involve education, diversion tactics and improvement in de-stigmatizing addiction in nursing.  Below is the SAMHSA model for sustainability, many of the other concepts should be familiar to you from our previous courses.

By involving the community in addressing addiction, it can provide large amounts of support and provide education to those who may not be familiar with the needs of those in recovery. Assessment is a concept that will need to be visited often in order to continually address gaps in the prevention process. Capacity allows for addressing needs and gaps. Planning is a process that will need input from all stakeholders in order to successfully implement any changes. Finally, evaluation of the process in needed to continue growth and maintain relevancy.

Following the SAMHSA model, or another successfully used innovation model, can help assist those with addictions and those who are affected by addiction by guiding change and encouraging education and prevention.

 

References

Heitz, D. (2018). Nurses Nationwide Increasingly Disciplined for Drug, Alcohol Violations. Retrieved from https://talbottcampus.com/nurses-nationwide-increasingly-disciplined-for-drug-alcohol-violations/

National Council of State Boards of Nursing, & National Council of State Boards of Nursing. (2011). Substance use disorder in nursing: A resource manual and guidelines for alternative and disciplinary monitoring programs. Chicago, IL.

Substance Abuse and Mental Health Services Administration. (2017). Planning for Sustainability. Retrieved from https://www.samhsa.gov/capt/tools-learning-resources/planning-sustainability

Technology Innovation in Chemical Dependency and Nursing

While there are not many technological innovations directly related to nurses with chemical or opioid dependency, there are several technological innovations for the general public. I will briefly touch on the few that are related to nursing first and then discuss those that are applicable to all.

In the hospital, one of the biggest developments in technology is the use of the Pyxis and the need for fingerprint identification. The purpose of this is to not only keep track of who is taking out what, but to have accountability in the removal and waste of narcotics and other controlled substances by requiring a witness using second fingerprint identification. Cameras are also put into use in some hospitals and other inpatient settings. These are often in place to monitor narcotic or other addictive substances and can be placed temporarily when investigating potential diversion by an employee.

There are several new advancements in technology and chemical dependency- mostly in the world of phone apps and online technology. There are several phone apps out there that are available to addicts, including:

• ReSet: this is an app that can be used on your computer or on the phone and is made available by prescription only. It is the only FDA approved app for chemical dependency on the market. 
• Nomo : Nomo is an app that connects addicts with support from other addicts in the form of an SOS button and text messages. It contains a Sobriety clock, gives chips and provides distracting activities for times when the person feels on edge. 
• WEConnect – helps create routines and activities for the addict to check in to that helps them stay focused in their recovery. They can share their routines with people and earn rewards (theguardianrecoverynetwork.com).
• There is also Squirrel Recovery and Sober Grid, Squirrel Recovery is similar to NoMo in that it helps create a sober circle and contains a Sobriety clock. It also sends texts to your recovery circle when the patient is feeling tempted and contains inspirational quotes.
• Finally Sober Grid is like a Facebook for sobriety, creating a social circle of sober friends anywhere you go. It uses GPS to find sober people around you that allows for messaging, sending and receiving support and an SOS button (Parkinson, 2016).

There is also virtual reality, which is fairly new to the addiction field, but is being used to place addicts in life like situations, like parties or restaurants, where they might run into their drug of choice. This allows them to develop coping mechanisms and become familiar with the feelings of cravings. While this is still new, there have been successful work done on smokers and those with post traumatic stress disorder (Lecher, 2013).

Privacy and Data Issues

Like any app or digital technology, there is always the risk of a data breach. What is done with personal information can never be predetermined. If one has an app on their phone, they run the risk of someone seeing them using it. These are all modern day problems and these particular apps are no different so they must be used with caution, as you would with any other private data containing app.

Doing research on this topic was interesting as I had no idea there were these types of apps available. In particular the Reset app, but there is not much information on it, including cost. I guess the mystery is part of the draw. I am glad that there are resources available at hand for people with addictions, it will hopefully make recovery and reaching out for a help a little bit easier.

References

Guardian Recovery Network (January, 2018). 3 advances in addiction technology. Retrieved from https://www.guardianrecoverynetwork.com/blog/2018/01/19/3-advances-addiction-recovery-technology/

Lecher, C. (2013). Can virtual reality help addiction? Retrieved from https://www.popsci.com/science/article/2013-04/addiction-therapy-and-virtual-reality

Parkinson, R. (2017). Technology’s new role in addiction recovery. Retrieved from https://health.usnews.com/health-care/for-better/articles/2017-01-03/technologys-new-role-in-addiction-recovery

The Recovery Village (2017). Using technology to stay sober. Retrieved from https://www.therecoveryvillage.com/recovery-blog/using-technology-stay-sober/#gref

Private Sector Innovation and Chemically Dependent Nurses

Nurses are the backbone of the healthcare system, with a ratio of 10 nurses to 3 physicians, per the American Medical Association. They are with patients from the start of their journey in a hospital until their discharge and also follow patients’ journeys in their homes and in clinics.  The private sector employs the majority of registered nurses, accounting for 57.7% of RN’s working in a clinical type setting, generally in hospitals (McMenamin, 2010). So it is only natural to examine the resources available to chemically dependent nurses who are employed in this environment.  The pie chart below is a graphic example of where nurses work, please note this pie chart was made in 2011 and it’s numbers vary slightly from the 2010 statistics quoted above.

 

As we have discussed in previous blogs, each individual state has a board of nursing who governs the licenses, scope of practice and other issues for nurses who have licenses in those states. The board of nursing also determines how nurses with chemical dependencies will be dealt with- whether it be license suspension, revocation or an admittance into an alternative to discipline program, if the state has one available. ( You can find a list of states with ATD programs here : https://www.ncsbn.org/alternative-to-discipline.htm) However, prior to the board of nursing, most nurses are met with some sort of complaint, either from a patient or colleague, that is given to their supervisor. It is at this level that things will vary for each individual nurse as it will depend on the amount of support their employer gives them in their first steps towards a recovery process.

One example is a private hospital here in Arizona that engages their employees to utilize their Employee Assistance Program. This program has counseling services available at no cost and access to a 24/7 online resource guide that can provide the employee with various online tools and referrals to assist in not only chemical dependency issues, but lifestyle and mental health wellness. This company has also been supportive to nurses who are actively participating in the CANDO program (Arizona’s ATD program) and has allowed nurses to continue to practice despite restrictions, with the assistance of other RN’s.

Keep in mind that not all companies are this friendly to nurses seeking help. Once a person is reported there will need to be an investigation into the complaint. If the board determines that this person is a risk they may suspend their license or if there is no alternative to discipline, they may end up with a license revocation. The nurse is also subject to the loss of their job if they have been diverting drugs, have shown up to work under the influence or have missed multiple days of work. They may also be subject to prosecution if they have been diverting or participating in other illegal activities.

There are things the private sector can do to help addicted nurses including:

1. Find ways to minimize drug diversion: These would include maintaining a chain of custody, establishing an education program on signs of impairment and diversion and camera surveillance in high-risk areas (Umhoefer, 2016).
2. Be open to this wide spread problem: Addiction affects not only the patients we see, but our co-workers and their families as well. Instead of keeping this topic hidden and quiet, allow education and discourse to remove the stigma addiction carries.
3. Have a program in place for when the issue does arise. Learn from other companies that have dealt with this issue successfully and follow their lead to keep quality nurses in their jobs. Showing support for an employee who has an addiction can make it more likely that others will self-refer for help (Brown, 2012).
4. There are many types of programs out there that can adopted by a private sector facility like Peer Assistance Programs and Employee Assistance Programs that can assist with guiding a nurse towards recovery and maintaining their jobs (if possible).
5. Educating Nurse Managers: Educating nurse managers and other administrators on addiction and showing them the evidence of successful recovery programs can help them help their nurses. They are, after all, only humans and may not be familiar with all there is to offer for nurses with chemical dependencies.

 

 

References

Brown, L. (2012). Supporting a nurse’s re-entry to practice after treatment for addiction. South Carolina Nurse (Columbia, S.C. : 1994), 19(1), 11.

 

McMenamin, P. (2010). ANA Issue Brief. 2009 Registered Nurses Employment and Earnings. Retrieved from http://www.nursingworld.org/mainmenucategories/policy-advocacy/positions-and-resolutions/issue-briefs/rn-employment-earnings.pdf

 

Umhoefer, S. and Finnefrock, M. (2016). 6 Steps for Hospitals to Take to Prevent Prescription Drug Abuse, Diversion. Retrieved from https://www.hhnmag.com/articles/7199-steps-for-hospitals-to-prevent-drug-abuse

Institution and Policy Influence on Chemically Dependent Nurse Policy

The public institution that has the most influence on chemically dependent nurses related policy is the Arizona State Board of Nursing. The Board of Nursing governs and produced the CANDO (Chemically Addicted Nurses Diversion Option) program to provide safety to the public and allow nurses with chemical dependency a chance to rehabilitate while maintaining their place in the work force.  The board is made up of members who are appointed by the governor and serve 5-year terms (Davenport, 2011). The Board does repeat throughout the CANDO Agreement and other statutes that the CANDO program is only a guideline, as each person must be independently evaluated by the CANDO Program Director for their ability and desire to maintain a recovery program (azbn.gov, 2011).

The policy that has the most influence on the CANDO program is the Nurse Practice Act. The state of Arizona’s legislative body delegates enforcement of the states’ Nurse Practice Act to the Arizona State Board of Nursing (National Council of the State Boards of Nursing, 2018). The Board of Nursing is in place to not only protect the public, it’s primary objective, but to help clarify and change regulations as experience and time necessitates. As mentioned above, CANDO is in place as a guideline, as is ARS 41-1019 (B), which is Arizona’s “Alcohol and/or Drugs Investigative and Disciplinary Guidelines”. This document provides guidance on various issues that can occur related to alcohol or drug abuse including DUI’s and positive drug screens within nursing.

List of Arizona Board of Nursing members can be found here:  https://www.azbn.gov/board/board-members/

List of AZ Senate Members can be found here: https://www.azleg.gov/MemberRoster/?body=S

List of AZ House Members can be found at here: https://www.azleg.gov/MemberRoster/?body=H

References

Arizona State Board of Nursing (2010). Alcohol and/or Drugs Investigative and Disciplinary Guidelines. Retrieved from https://www.azbn.gov/media/1454/substantive-policy-alcohol-and-or-drugs-investigative-disciplinary-guidelines.pdf

Davenport, D. (2011). Performance and Audit Sunset Review: Arizona State Board of Nursing. Retrieved from https://www.azauditor.gov/sites/default/files/11-02_Report_0.pdf

Nurse Practice Act, Rules and Regulations. (2018). National Council of State Boards of Nursing. Retrieved from https://www.ncsbn.org/nurse-practice-act.htm

The statutory and regulatory mechanisms of policy concerning chemically dependent nurses

Statutory mechanisms

Chemical dependency is not a new issue, it has been around for as long as there have been mind altering substances. Ways to treat addiction in the past have included flogging, placing amethysts on cups to ward off the evil affects of drinking, imprisonment, mental institutions, and religion (Black, 2006). In today’s times, we attempt to treat those with addictions through therapy (group and individual), group meetings, religion and a focus on mental health (Black, 2006). When developing policy on a sensitive topic, like chemical dependency in nursing, it is important to remember that all policy development takes time. There are several steps involved including addressing the needs of the organization or group (in our case, nursing and the general public who use healthcare), formulating policy through agenda setting and an implementation phase that includes making the rules and defining the operation of the policy (Longest, 2010). Additionally, through feedback and assessment, the policy will be modified to address the needs of the group (Longest, 2010).

(Longest, 2010)

History

Nursing journals began to recognize the dangers of addiction (at least in written form) within their ranks in the early 1900’s. Virginia Levis cautioned nurses against the use of cocaine, Pearson wrote about his concerns that nurses may use narcotics, since they had easy access, to help ease the stress of work and Mary Reed warned fellow RN’s to abstain from alcohol (Heise, 2003). In 1972, the American Journal of Nursing ran an advertisement looking for nurses with chemical dependencies to voluntarily admit themselves to the Clinical Research Center in Kentucky as to assist with recovering from substance abuse. This program was for nurses only, but only saw 12 patients before closing (Heise, 2003).

Regulatory mechanisms

Regulatory mechanisms in policy for impaired nurses is done on a state to state basis, generally a state wide Board of Nursing, but I will give some history. In 1980, the National Nurses Society on Addictions Task Force on the Impaired Nurse was instituted and a position paper was published in 1982 (Heise, 2003). Later that year, a resolution was passed by the ANA Task Force on Addictions and Psychological Dysfunctions which asked for nationwide guidelines and acknowledgement of the struggle nurses were having treating their chemical dependencies and maintaining their livelihood. Arizona has our State Board of Nursing and they regulate the CANDO (Chemically Addicted Nurses Diversion Option) program which assists nurses by allowing them to keep their licenses and seek therapy.

We have certainly come a long way from flogging, and the more we recognize this very important issue, the easier it will be for those with this problem to come forward. No longer afraid of losing jobs or facing ridicule, we can create supportive and rehabilitative environments for our nurses to thrive in.

References

Black, C. (2006). History and Addiction. Retrieved from https://www.themeadows.com/blog/item/365-history-addiction

Heise, B. (2003). The Historical Context of Addiction in the Nursing Profession 18501982. Journal of Addictions Nursing, 2003, Vol.14(3), P.117-124, 14(3), 117-124.

Longest, B. (2009). Health policymaking in the United States (5th ed.). Chicago: Health Administration Press.

Ethics in Policy

Promoting policy change for nurses with addiction addresses two ethical components, namely autonomy and non-maleficence. Dictionary.com defines autonomy as being “free from external control or influence; independence” and per Longest also addresses privacy and individual choice (2015).  When advocating for policy change in this arena, we must remember to allow for individuals’ personal choices and preferences, not forgetting that those with addictions are allowed their privacy. Privacy is a huge piece when dealing with addiction, some people are more vocal than others at where they are in their recovery and it is this human factor that should help guide us in change. We do not want to impede an individuals progress in recovery by forcing them to go public, but we can also not allow them to be alone in the process.

Nonmaleficience is the concept of “doing no harm”. In policy, this could mean making policy changes that do not harm those who are seeking help for their addiction, but it primarily focuses on nurses (or providers or nursing assistants, etc..) not causing harm to the public they serve. It is policy makers responsibility to look at the best interest of those they serve and ensure that the changes being made do not cause harm or hardship. In this scenario, we would want to instill policy that would allow the nurse to work in a safe, monitored way which would allow the nurse to maintain their livelihood and protect the patient from harm. Monroe and Kenga point out that ANA Code of Ethics for Nurses calls for “workplace advocacy and promotion of well-being” and that policy that includes punishment could endanger the public even more because it would make reporting a colleague or asking for help less appealing because it could lead to job loss (2010).

The study Treating Nurses and Students with Chemical Dependency: Revising Policy in the United States for the 21st Century calls for a database that evaluates state to state rehabilitation programs’ effectiveness in treatment and maintaining nurses in the profession as well as consistent state to state policy that provides rehabilitation, aftercare, assistance with employment re-entry or if necessary, transition to another profession (Monroe and Pearson, 2010). Below is a table that compares punitive and alternative to discipline key concepts form Monroe and Pearson:

Summary of key concepts in each paradigm

Alternative-to-discipline	Disciplinary
Confidential	Publically reported
Not reported to national data banks	Reported to national data banks
Board, peer, or privately managed	Board managed
More case management	Minimal case management
Usually fees attached to licensees	No additional fees to licensees
Can provide services to students	Provides no assistance to students
Always have monitoring contracts	Usually have monitoring contracts
Always have drug screening	May not require drug screening
Fast movement into treatment	Time to treatment may be delayed
Removal from practice quickly	Removal from practice up to years
Not all nurses eligible for alternative program	All nurses eligible for discipline
No civil penalty fee	Must pay a civil penalty
Fewer nurses with drug convictions	More nurses with drug convictions
High completion rate	High completion rate
Higher retention rate	Lower retention rate
More assistance with reentry	Minimal assistance with reentry

Finally, there are many nurses and people from all professions who have been successful in rehabilitation and we as future policy change advocates could benefit from their input.

References

Monroe, T., & Kenaga, H. (2011). Don’t ask don’t tell: Substance abuse and addiction among nurses. Journal of Clinical Nursing, 20(3-4), 504-9.

Monroe, T., Pearson, F., & Kenaga, H. (2010). Erratum to: Treating Nurses and Student Nurses with Chemical Dependency: Revising Policy in the United States for the 21st Century. International Journal of Mental Health and Addiction, 8(3), 525.

The Beginning

Chemical dependency and substance abuse are not new concepts to any of us in nursing. Chances are we have had patients with this issue, know family members, friends or you may even be dealing with addiction yourself.  Between 2013 and 2014, there were roughly 177,000 Arizonans who were dependent on illicit drugs. This problem can be challenging to those who work in healthcare, particularly in nursing, where easy access to narcotics in the hospital setting can be problematic.

As a Registered Nurse and soon to be provider, I feel this issue is incredibly relevant to our profession as we will soon be prescribers who must consider the very serious consequences that prescribing narcotics can lead to. We will also be working with RN’s who may have chemical dependency problems and it is important to not only recognize signs of those who might be in the midst of an addiction, but know how to support those who have sought help.

Presently, the Arizona State Board of Nursing has the CANDO program, which stands for Chemically Addicted Nurses Diversion Option. This program is a 3 year voluntary monitoring agreement that allows nurses to keep their licenses (although with restrictions) and is a nondisciplinary option of providing safety for the public who we serve and allow the nurse to maintain their livelihood. CANDO includes random drug testing (paid for by the participant), mandatory AA/NA meeting attendance and Nurse Recovery meeting attendance. You can read all the information about CANDO here https://www.azbn.gov/discipline-complaints/cando/

I am hoping to continue to learn and discuss policy about chemical dependency in nursing in this blog as there is much to learn and always room for change. This is a very personal topic for me, I have been in the company of several amazing nurses who are chemically dependent. Some have been successful in their “battle” (I hate using that word, but it fits) and some have not. I think it’s important to find ways that we can improve success rates as there is nothing more important to me than being a nurse, I have no idea what I would do if that were taken away from me, and I would like to help prevent that from happening to others.

 

References

Behavioral Health Barometer, Arizona 2015. Substance Abuse and Mental Health Administration. Retrieved from https://www.samhsa.gov/data/sites/default/files/2015_Arizona_BHBarometer.pdf

The Journey Begins

Thanks for joining me!

Good company in a journey makes the way seem shorter. — Izaak Walton