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Policy: In order
to facilitate the management of substance abuse problems,
schools of nursing should adopt a written, comprehensive,
and equitable substance abuse policy for students, faculty
and staff. The policy should be based on: 1) the assumption
that addiction is an illness that can be successfully treated
and that individuals can be returned to a productive level
of functioning; and 2) the philosophy that schools of nursing
are committed to assisting their students and employees
with recovery. The policy should incorporate prevention
and education, identification of individuals with possible
abuse problems, evaluation and referral for treatment, and
provide for re-entry to work or to school upon successful
completion of rehabilitation. For those whose performance
is impaired and who are unable or unwilling to be rehabilitated,
disciplinary procedures are appropriate. The policy must
comply with local, state and federal laws, and should accommodate
the requirements of the parent organization and clinical
sites. The same policy generally should be applied to all,
but variations may be necessary to address tenure, collective
bargaining, civil service, licensing, professional association,
and other requirements. For maximum credibility and accessibility,
the policy should be developed with input from all those
affected as well as the human resources department, treatment
experts, and legal professionals.
A. Introduction
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.
1. Background
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.
B. General Guidelines
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.
C. Drug Testing
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.
D. Addenda
1. Disclaimer
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.
References
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
Statutes
Americans with Disabilities Act of 1990, PL
101-336
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.
(Approved by Membership, March 28,
1994)
(Updated: November 13, 1998)
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