By Tom Wilemon, The Tennessean
A nurse high on pot sleeps in a bathroom, neglecting her duty to care for patients in an adult psychiatric unit.
Another walks around in a surgery center with glazed eyes and blood visible on her arm from a self-administered Demerol injection.
A third nurse suspected of pilfering Percocet breaks her boss's nose upon being fired.
These incidents occurred in the Nashville area within the past year and could have been prevented if the nurses had asked for help.
Zero-tolerance policies that mandate the firing of nurses with addictions keep the problem a hushed topic and wind up endangering patients, according to a study by Todd Monroe, a post-doctoral fellow at Vanderbilt University.
"If a nurse is afraid to come forward or a student nurse is afraid to come forward, they are at risk of potentially hurting someone and themselves," Monroe said. "A non-punitive policy has been shown to increase patient safety. There is an avenue for them to get off the floor."
The public gets more protection when health-care institutions offer an alternative-to-dismissal policy, he said. Such a policy can get an impaired nurse off the job and into treatment within days to a few weeks, while documenting the proof to terminate employment can take years, according to an article Monroe recently had published in the Journal of Clinical Nursing.
Monroe looked at policies for handling nurses with addictions both nationally and internationally. Forty-five state nursing boards, including Tennessee's, have established an alternative-to-dismissal program.
Some seek treatment on their own
More than 220 nurses appeared before the Tennessee Board of Nursing in the past year because of substance abuse records, according to a review of disciplinary actions by The Tennessean. Of those, the licenses of 89 were revoked, 74 were suspended and 66 were put on probation. In almost all cases of suspension or probation, the nurses are referred to the Tennessee Professional Assistance Program.
Some nurses seek treatment before they get into trouble. Cumberland Heights offers a treatment program catering to the needs of working professionals, including nurses.
"They will go so far as take their vacation time to come to treatment," said Cinde Stewart Freeman, associate director of Cumberland Heights.
Freeman, a nurse with a graduate degree in counseling, has worked at Cumberland for 20 years. She said about 30 percent of the nurses come for treatment of their own volition, 50 percent come because of work performance issues and 20 percent come because they've been caught diverting medicine for personal use.
Although nurses know that addiction is a disease, they are still sensitive to the stigma.
"Part of what their fear is based on is they usually know at least one recovering nurse in the work environment," Freeman said. "Even though that nurse is in recovery now, they have watched sort of the distrust that co-workers have with that person."
All types of substance abuse among nurses - ranging from bingeing on booze during their off time to pilfering pills on the job - can run as high as 20 percent, Monroe wrote. But the percentage of nurses with real addictions is around 10 percent, about the same as among the general public.
Access to drugs is factor
The difference between a medical professional and others is access to drugs.
"One of the most dangerous things that raises a nurse's risk is knowledge - thinking that 'Because I know about these medications, I am not going to be at risk,' " Freeman said.
Even though state medical licensing boards encourage addiction treatment and monitoring through the Tennessee Professional Assistance Program, its director, Mike Harkreader, spends much of his time reaching out to employers.
"It runs the gamut with employers," Harkreader said. "Many times, it depends upon who the director of nursing is or the administrator is."
Policies can very greatly among locations owned and operated by the same company, he said.
The Tennessee Nurses Association founded the program that Harkreader heads in 1981. Since then, the association spun off the program to a foundation. Today, the program also serves physician assistants, physical therapists and emergency medical responders.
A total of 380 people were referred to the Tennessee Professional Assistance Program last year, compared with 365 the prior year. The program also monitored 492 nurses and 39 other health-care professionals last year to make sure they stayed sober. If they don't comply, the program notifies the Board of Nursing, which usually results in their license getting revoked.
Although nurses consistently rank among the most trusted professionals, Harkreader and Monroe worry that public discussions about nurse addiction may cause public misconceptions and negative stereotypes. The typical nurse with a substance abuse problem is not a strung-out thrill seeker.
"I've seen too many nurses come in who end up with an addiction and it all started up innocently enough with taking something for a back strain," Harkreader said.
The majority of nurses with addictions stay in recovery for the disease, Freeman said.
"Some of the most effective nurses that I know of are recovering people who have long-term recovery," she said. "They are in our hospitals right now. They are in our operating rooms and in our intensive-care rooms. They are quietly going about taking care of people. The idea that someone can't be returned to practice is an idea I'd really like to see broken down into the myth that it is."