Alternative-to-Discipline Programs for Nurses

How they work

The incidence of substance use disorders among nurses tends to parallel rates in the general population, falling somewhere in the range of 10-15 percent. The American Journal of Nursing estimates that 3-6 percent of registered nurses have an active drug or alcohol addiction at any given time. Traditional workplace discipline is typically punitive and may lead to dismissal and loss of nursing licensure.

To address this issue, 43 states have created substance use disorder monitoring programs for nurses called "alternative-to-discipline" (ATD) programs. Nurses with substance use disorders are three times more likely to admit their problem in states with ATD programs than in states with traditional discipline programs. ATD programs provide nurses with a structured process for a better outcome: After completing addiction treatment, they go through monitored reintegration into the workforce.

A study published in Nursing Research concluded that alternative-to-discipline programs for nurses potentially have a greater impact on protecting the public than disciplinary programs because ATD programs identify and/or enroll more nurses with substance use problems, thereby initially removing more nurses with active substance use problems from direct patient care.1

Effective Monitoring Programs

Successful monitoring programs include the following key elements:

Authorization and funding
Diversion boards, as they are called, are established by state statute and are associated with state boards of nursing. Usually these monitoring agencies are funded by nurse licensure fees and not state general funds.

Broad support
Success depends on support and cooperation of local nurse unions, state health departments, and health care organizations that employ nurses.

A nurse may voluntarily participate (self-refer) in a monitoring program or enter by referral from the nurse's employer or possibly the state board of nursing. In all cases, participation remains confidential as long as the nurse completes the program.

Public protection
Under regulations governing diversion boards, the participating nurse may be asked to cease practice, and his or her license may be restricted or suspended until treatment is successfully completed. The primary goal here is to protect the public from contact with an impaired nurse who might divert patient medication for personal use or is at risk of making a mistake that may adversely impact a patient.

Monitoring Program Services

The goal of monitoring programs is to help a nurse with a substance use disorder successfully complete treatment, maintain sobriety, and effectively reintegrate into career and home life.

Processes and resources
Many ATD programs provide the following services to professionals who help nurses:

  • Schedule an assessment to determine whether a nurse has a substance use and/or mental health disorder
  • Arrange detoxification services if needed
  • Provide referrals to addiction treatment programs
  • Develop a treatment plan

Return-to-work monitoring
Upon successful completion of addiction treatment, the nurse participates in a return-to-work plan. Components of this plan include random drug tests, continuing care (support groups), and ongoing consultation with the nurse's supervisor to ensure a safe and smooth transition back to nursing practice. Monitoring continues for 36 months or longer. A key component of success is ongoing encouragement, support, and guidance provided to nurses by other nurses.

Success factors
When a nurse with a substance use disorder participates in key elements of an ATD program, the likelihood of success is increased, and the chance of relapse is reduced. Success factors include:

  • Successful completion of addiction treatment
  • Participation in peer-group support meetings with health care professionals, particularly other nurses
  • Regular attendance at Twelve Step support groups
  • Extended post-treatment monitoring
  • Reentry into a safe work environment
  • Open and honest discussion and planning with the nursing supervisor

The American Association of Nurse Anesthetists reported in 2005 that a well-designed rehabilitation/diversion program for nurses will have a success rate of greater than 80 percent.2

Addiction and recovery programs for medical professionalsHazelden Betty Ford Foundation's Nurse Professionals Program
The Hazelden Betty Ford Foundation has specialized addiction treatment programs for health care professionals, including a nurses' program. The nurses' program includes return-to-work support. For more information, go to or call 1-866-831-5700. We offer a free, confidential consultation and phone-based assessment.
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