Created in the Fall of 1992, the American Association of Colleges of Nursing's (AACN) Substance Abuse Task Force was charged with developing a policy statement to address the problem of substance abuse in the nursing education community. AACN's Board of Directors recognized that nursing education reflects the society in which schools of nursing exist and that substance abuse is a universal health problem that affects all segments of society, including students, faculty, and staff in schools of nursing.
Substance abuse and its sequelae, addictive illness, can lead to serious physical, psychological, and social problems ranging from loss of employment to death. High school and college students are in the segment of the population most at risk: of the 13.9 million illicit drug users in the United States, the highest rate of use is for those between the ages of 16-20, the same age group that includes the highest rate of heavy drinkers (Substance Abuse and Mental Health Services Administration, 1997). It is estimated that in 1995 alcohol abuse costs imposed a $166.5 billion burden on the U.S. economy. In addition, drug abuse costs are estimated at $109.8 billion (National Institute on Drug Abuse, 1998). The cost of human suffering is inestimable.
Substance abuse is a major issue for nursing students, faculty, and staff, and can compromise the learning environment. Because an affected student, faculty member or staff person may have impaired judgement and skills, appropriate management of abuse and addiction is critical for nursing education and practice.
The complexities inherent in addressing substance abuse in nursing education are multiplied by the different needs and interests of those involved. A substance abuse policy must include consideration of legal, ethical, professional, financial, and academic issues including:
- Confidentiality of records and privacy (42 USCA Secs 290ee-3 and 290dd-3);
- Collective bargaining, union, civil service, and tenure;
- Anti-discrimination laws and agencies [American with Disabilities Act (ADA) (PL 101-336) 42 USCA Sec. 12101 et seq., Equal Employment Opportunity Commission (T. VII, 42 USCA Sec. 2000e), Secs. 503 and 504 of the Rehabilitation Act of 1973, 29 USCA Sec. 701 et seq.);
- Drug Free Workplace Act of 1988 (41 USCA Sec. 701 et seq.) that requires a drug free workplace for recipients of federal funds;
- Safety laws (Occupational Safety and Health Act, 29 USCA Sec. 651 et seq.)
- State requirements;
- Requirements of accrediting bodies, licensing agencies, and professional organizations;=
- Campus police and law enforcement agencies;
- Policies of the school of nursing's parent institution and clinical training and practice sites;
- Institutional and individual liability;
- Health insurance coverage.
2. Assumptions and Principles
The general assumptions and principles used by the Task Force in developing this Policy and Guidelines on substance abuse are that:
- Substance abuse compromises both the educational process and patient care and must be addressed by schools of nursing;
- Academic units in nursing have a commitment to and a unique role in the identification of abuse, intervention, referral for treatment, and monitoring of recovering individuals;
- Addicted persons need help to recognize the consequences of their substance use;
- Addiction is a treatable illness, and rehabilitative and therapeutic approaches are effective in facilitating recovery;
- Individuals with addictive illnesses should receive an opportunity for treatment in lieu of, or before, disciplinary action.
Attention should be given to education, identification, intervention, treatment, and re-entry. The process instituted by the policy should be clear and simple, with specific mechanisms to ensure confidentiality at all stages of the process. Referrals, the goals of treatment, and follow-up for each participant should be specific, realistic and practical. The procedures and requirements should be reviewed periodically to examine current scientific evidence and policy workability.
1. Education and Prevention
Management of substance abuse depends upon education. Education should be provided to nursing students, faculty and staff. Substance abuse content should be included in the nursing curriculum. Information about substance abuse should be supplemented with information on the consequences of impairment due to abuse and addiction. Furthermore, faculty should be sensitive to cultural differences and the needs of today's diverse student populations.
Acceptance of a policy will be enhanced if the policy is developed with input from those likely to be affected: students, faculty, and employees as well as individuals in clinical sites and the parent institution. Dissemination of the formal, written policy must be thorough and highly visible for maximum understanding. Information about how recovering individuals will be accommodated, which is required for employees by the Americans with Disabilities Act, (PL 101-336) also should be provided.
2. Identification, Intervention, Evaluation, Treatment and Reentry
a. Identification of impairment possibly due to substance abuse should be based on a pattern of observable, objective, quantifiable behaviors (e.g., alcohol on breath, slurred speech, motor incapacities, absenteeism) that suggest impairment of an individual's ability to meet standards of performance, competency, and safety in clinical sites, the office or the classroom. While an isolated incident may not indicate substance abuse directly, the occurrence of several incidents should be documented. It is critical to keep a balance between being vigilant and being overly suspicious. Reporting of observed behaviors does not constitute a diagnosis but is the first step in determining whether a problem exists. Observers should follow the applicable procedure for reporting observations and should not confront the individual directly. The individual receiving the report will assess the information, investigate as appropriate, and prepare for an intervention, if indicated.
b. Intervention is a structured process by which an individual is confronted with his or her reported behaviors and is asked to seek evaluation of a possible substance abuse problem. Interventions must be conducted in a confidential manner. It is strongly recommended that a health care professional with specific substance abuse training be utilized to: 1) conduct the intervention; 2) train an in-house intervenor; or 3) consult with the supervisor or team about the case. The intervention should be conducted by a trained intervenor who may be the appropriate supervisor(s) and may involve others as appropriate.
The goal of the intervention is to secure the individual's agreement to seek evaluation. If the individual agrees to the evaluation, prompt referral to a facility specializing in substance abuse treatment should be made. If the individual is unwilling to agree to an evaluation, he or she will face the consequences of the impaired performance and the usual disciplinary process should be followed. Termination as an employee or dismissal as a student may result. While there should be systems to ensure that a person unwilling to have a substance abuse evaluation receives a fair hearing (e.g., with a lay representative or counsel, meeting with ombudsman or administrative official/board), there may be cases where it will be necessary to suspend the person from work or school prior to a hearing to protect other faculty, staff, students or patients. Additionally. state law may require mandatory reporting of observed behaviors.
c. Evaluation, as an outcome of intervention, is the process by which all indicators of addiction are assessed and a diagnosis of substance abuse is determined. An evaluation is conducted by an experienced substance abuse professional, usually employed by a specialty treatment facility.
d. If a diagnosis of substance abuse is made, treatment should be provided by an organization specializing in substance abuse. The cost of treatment typically will be borne by the individual; through health insurance; in some institutions, by the student health services; or through an Employee Assistance Program. For licensed personnel and students, there may be a state board of nursing substance abuse treatment program offered by the professional organization or others. In addition, support groups (e.g., Alcoholics Anonymous) provide valuable assistance in the recovery process.
The school should allow the individual a reasonable time off for treatment. This could be an excused absence (for student) or use of sick/annual leave followed by an unpaid leave if needed (for employee). Length of treatment will vary by individual.
The fact and content of any treatment is subject to confidentiality rules. Procedures to minimize the possibility of disclosure and sanctions to penalize those who breach the rules should be implemented. Substance abuse professionals treating the individual are prohibited by law from disclosing information about that treatment to third parties (including state boards of nursing) without the individual's consent.
e. Re-entry is the process by which recovering individuals who have successfully completed a substance abuse treatment program can be returned to work or school. In this phase of recovery, it is critical that every effort be made to minimize the stigma that the recovering person feels, which is often exacerbated by the necessary restrictions and actions. The goal of re-entry monitoring is to facilitate recovery, not to police behavior. The recovering person may be expected to provide documentation of the course of specialized treatment together with the specialist's written assessment of the ability of the individual to perform work or school duties following treatment and should include any restrictions regarding the person's activities (e.g limiting access to narcotics, schedule for counseling self-help group meetings). This information should be furnished to a designated person (usually an administrator) in the school.
An effective tool to manage re-entry is the establishment of a written agreement between the individual and the institution stating the specific objectives of the re-entry process, the steps each party promises to take to facilitate successful completion, and the consequences of violating the agreement. Such agreements are usually one to two years in length. Agreements usually include:
- Individual commitment to discontinue substance use and institutional promise to facilitate re-entry if the individual meets the terms of agreement;
- A plan for follow-up treatment for a period recommended by the treatment provider;
- Regular reports of progress from staff at the treatment agency;
- Authorization for release of information regarding progress to the designated representative;
- Agreement to submit to random drug screens;
- Documentation of attendance at counseling and self-help meetings;
- Other reports of activities as recommended by the treatment provider;
- Consequences for failing to meet the terms of the agreement include warning, suspension, and dismissal;
- Institutional role in re-entry of recovering individual: reinstatement, confidentiality.
In addition, a school's "reasonable accommodation" under the ADA also may involve limiting the individual's access to drugs and allowing scheduling variations to facilitate treatment, counseling, and attendance at Alcoholics Anonymous meetings. The school must maintain the previous standard of confidentiality of records during re-entry.
Tenure may be affected by some of these requirements. The school's tenure policy already may address how tenure relates to annual, sick, or unpaid leave, as well as to dismissal for impairment or cause. Time frames for completion of student academic programs may have to be adjusted to attend treatment. Also, collective bargaining agreements may address some issues relating to substance abuse, testing, and bases for discharge, as well as other matters that are relevant to substance abuse and employment. Lastly, civil service requirements applicable to public institutions also may be relevant for public employees with substance abuse problems.
Testing of body fluids is a method of identifying recent use of alcohol or drugs; it is not a diagnosis of substance abuse or addiction. Testing is an expensive procedure most frequently used for cause and to monitor re-entering individuals. The cost of performing the tests is usually borne by the individual, for re-entering individuals, or by the institution, when tests are done for cause.
Although current testing methods are relatively accurate, results are more likely to show false negatives than false positives for use. A school should consider whether testing should be instituted. If so, when will it be done: pre-employment or pre-enrollment; after incident; to monitor recovering persons? Random mass testing is seldom recommended because of its ineffectiveness in identifying addictive problems, the expense, and potential legal pitfalls.
Test results should be kept confidential with access allowed only for those who "need to know." Strict penalties up to and including dismissal should be imposed on those who violate the requirement of confidentiality. Provisions for disclosure of information can be made with the individual's signed release, in an emergency, or otherwise when authorized by law.
Addictive illness is chronic and may involve relapse. An evaluation of potential recovery in each individual case must be made. In the case of positive drug test results, the school, in consultation with the treatment provider, determines an appropriate response (e.g., recommend return to treatment, increase counseling sessions, proceed with disciplinary procedures).
If clinical sites impose testing requirements which affect students and faculty, the school will have to decide whether to subject students to these policies, if they are contrary to those of the school, and/or whether to continue using the site for clinical experiences.
The preceding Policy and Guidelines is offered for consideration and use, but it does not constitute legal advice. The American Association of Colleges of Nursing assumes no responsibility for any actions arising as a result of an institution's following, modifying, or otherwise making use of these ideas. Due to the unique nature of each school's situation, appropriate legal or other counsel should be sought before an institution takes action with regard to management of substance abuse in its particular nursing education environment.
2. Periodic review
This Policy and Guidelines, and each school's adaptation of it, should be periodically reviewed to ensure that it reflects current scientific and treatment data on prevention and management of substance abuse.
Substance Abuse and Mental Health Services Administration. (1997). National Household Survey on Drug Abuse [on-line]. Available: www.samhsa.gov/oas/nhsda/nshda97/httoc.htm
National Institute on Drug Abuse. (1995). The Economic Costs of Alcohol and Drug Abuse in the United States-1992: Executive Summary [on-line]. Available: www.health.org/mtf/hhsfact.htm
Civil Rights Act of 1964 Title VII, 42 USCA Sec. 2000e et seq.
Drug-Free Workplace Act of 1988, 41 USCA Sec. 701 et seq.
42 USCA Sec. 290ee-3 and 290dd-3
Occupational Safety and Health Act of 1970, 29 USCA Sec. 651 et seq.
Rehabilitation Act of 1973, Secs. 503 and 504, 29 USCA Sec. 701 et seq.