Discipline for nurses in Delaware suffering from addiction has become less punitive

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Since 2015, more than 300 nurses have been disciplined in Delaware. More than 25% stemmed from issues with drugs and alcohol. Delaware News Journal

It was 2:20 a.m. and alarms were going off in the Nanticoke Memorial Hospital patient room.

As a nurse walked in, she found another nurse already there. He was face down at the computer with a needle in his arm. He had a syringe in one hand and a bloody tissue in another. A bottle of propofol — a drug that causes sedation — was in his shirt pocket.

It took two security guards and a nurse to get him into a wheelchair so he could be taken to the emergency room.

That April 19, 2017 incident led to the man being fired from Nanticoke and his state nursing license being suspended. In its disciplinary order, the Board of Nursing described his behavior as "especially egregious.”

A number of Delaware nurses, like thousands of others in the state, struggle with addiction to drugs and alcohol. As the attitude and understanding of addiction and treatment has evolved in recent years, so has how these nurses are disciplined.

The Board of Nursing has taken a significantly less punitive approach toward these cases, The News Journal has found.

From January 2015 to October 2019, 313 nurses were disciplined by the state for a multitude of reasons. Of those, about 91 — or 28% — were disciplined for issues related to drugs or alcohol, according to an analysis by The News Journal. More than a dozen of these nurses got in trouble more than once in this time period.

Experts say long hours, the access to drugs and intense stress can make health care professionals more vulnerable to addiction. This was the case for Justin, a 34-year-old nurse who struggled with his sobriety early in his nursing career.

As result, his license was placed on both suspension and probation since 2017.

"I did allow stress to pile up and I did make a decision to lean into a profession instead of leaning into recovery," Justin said. He asked The News Journal not to publish his last name since he is still working on his sobriety through Alcoholics Anonymous.

After 2015, no licenses have been revoked by the board, according to the News Journal's analysis. Those with drug or alcohol issues often were placed on probation — allowing them to still be able to work while undergoing treatment.

Before the change, licenses often were revoked. Between 2010 to 2014, 19 nurses' licenses were revoked. Fifteen were for issues with drugs or alcohol.

The stories didn't change after 2015. Some of the disciplined nurses came to work drunk or high, while others were caught diverting medication for themselves or for others. One nurse was found overdosing on cocaine on the side of the road, after she left her shift early.

Nurses were also disciplined for conduct that occurred outside of work, such as being arrested for driving while under the influence or drug possession.

While this number of disciplined nurses makes up less than 1% of the thousands of licensed nurses in Delaware, it shows how addiction can affect people of all professions, including those who are often on the front lines of health care.

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Nurses aren't alone. In Delaware, veterinarians, doctors and physical therapists have also been disciplined by the state for substance abuse.

Addiction experts say the percentage of medical professionals with substance use disorder hovers between 10% to 15% nationally, a number that has not changed in recent years despite the growing opioid epidemic.

“There’s a misconception that medical professionals with this disease are not as talented, or dedicated,” said Carrie Kappel, associate director of the health care professionals program at Hazelden Betty Ford addiction treatment centers.

"Most of these individuals are in the top third of their class. They're talented, smart individuals, who never intended to become addicted to their substance of choice.”

Working under the influence

Since 2015, there have been at least two dozen instances of nurses being impaired by drugs or alcohol at work — or seeming to be, The News Journal found.

Their colleagues observed behavior that was in line with being under the influence, such as slurred speech, falling asleep or bumping into objects.

In some of the cases, the nurses refused to take drug tests. Many were terminated as a result.

Some instances include:

• In January 2015, a ChristianaCare nurse was observed to have an “altered mental status” during work and was seen falling asleep during conversations with patients and colleagues. A drug test was positive for meperidine, fentanyl and midazolam, according to the disciplinary order. An internal investigation found that the nurse was diverting medication intended for patients. Her license was placed on probation.
• A Genesis Rehabilitation Center nurse left work early one day in July 2018, stating she wasn’t feeling well. Later that day, police found the nurse by the side of road, exhibiting signs of an apparent overdose, according to the disciplinary order. She told paramedics that she ingested cocaine. She later told medical staff that she had been ingesting cocaine nasally for the last month. Her license was placed on probation.
• In January 2018, staff at American Surgery Center observed a nurse “improperly attempting to assist a patient getting out of bed, improperly positioning a patient, and leaving IV leads unhooked and on the floor in a patient’s room,” according to a disciplinary order. The nurse admitted to drinking the night before work, and that she had a drinking problem. Tests showed her blood alcohol content was above the legal limit. She was fired and her license was placed on probation.

Many of the disciplinary actions, including these three examples, consisted of nurses’ licenses being placed on probation — allowing them to still practice in the state — on the condition that they enroll in the Delaware Professionals' Health Monitoring Program, The News Journal found. That program looks for relapses, which often are a part of the recovery process.

If they don't follow the mandates of the program — such as regular drug testing — then their license will automatically be suspended. This has happened several times since 2015.

Run by a third-party vendor, the monitoring program does not provide the evaluations or treatment plans, said David Mangler, director of the Division of Professional Regulation. Instead, they provide a list of state-approved providers for the person to go to for care.

DOCTORS DISCIPLINED

The program monitors the random drug screenings and makes sure participants are complying with their treatment plans, Mangler said. The program will alert the licensee’s employer and regularly check in about the person’s work habits.

“That one requirement scares the holy heck out of licensees,” he said.

It is possible for health care professionals to return to work following treatment — in fact, a majority do, said Kappel, who oversees the health care professionals program at Hazelden Betty Ford.

A 2009 study published in the Journal of Substance Abuse Treatment found that 95% of health care professionals who completed their treatment requirements were still licensed and working in the field five years later.

For nurses who diverted drugs, Kappel said, it could be challenging for some to return to a patient’s bedside if they “can’t handle or shouldn’t handle controlled substances.”

“It’s much easier for a physician to come back because most don’t handle a lot of bedside medications,” she said. “They might be writing them but not handling them.”

Creating a less punitive, more 'just' culture

By the time he graduated high school, Justin had gone through a few treatment centers for his addiction to alcohol.

The experience helped inspire the Delawarean to become a nurse. If he could get through addiction, maybe he could help someone else get through similar experiences, Justin recalled thinking.

Yet, after graduating nursing school, Justin said he immediately struggled and relapsed. When the Board of Nursing approved his license in 2017, it was contingent on him enrolling in the state monitoring program, since he previously had issues with alcohol.

Around this time, Justin was drinking alcohol and taking opiates, though he said he never diverted medication or came to work high when he was working as a nurse.

In July 2017, Justin missed several mandatory screenings, leading to his suspension. He acknowledged his relapse to the board, which resulted in him being placed on probation again and mandatory enrollment in the monitoring program.

But less than a year later, in April 2018, Justin relapsed. He credited the relapses to "stress piling up," and focusing more on work than his recovery. The board suspended his license.

The American Society of Addiction Medicine designates health care professionals as a “special population” because they have access to addictive drugs and knowledge that can lead to “a false sense of immunity to the dangers of these drugs,” according to its public policy statement.

There’s also a significant stigma among health care professionals struggling with addiction, which makes them hesitant to admit a problem or look for help, the organization found.

In most cases, once a provider decides to accept treatment, it’s often at a later stage of the disease, Kappel said.

“This is a population that doesn’t do self-care very well,” she said. “They are great at taking care of other people, but they are not great at taking care of themselves. And they will then begin to give up pieces of themselves and their recovery to please other people to go back to work.”

While the board's first priority is to protect the public, it also recognizes that addiction is a disease — and wants to empower licensees to seek treatment, said board president Megan Williams.

Research now shows, she said, that licensees do their best if they are still "allowed to continue to work in safe capacities" while seeking treatment.

"That is their livelihood," said Williams, who has been on the board since 2014. "That is how they are supporting themselves, and sometimes their family. And so recognizing how central that is to their existence ... we try to provide a means by which our licensee, under some type of disciplinary action, (can) work."

Maia Michael feels she didn't get that kind of consideration in 2013 when her nursing license was revoked. Five years earlier, she impersonated a physician and called in five prescriptions for Xanax at three different pharmacies.

As a result, the board decided to suspend her license for five years.

Michael said she thought she was still allowed to work as a nurse. When the board learned she was working as a home health aide, it revoked her license. She tried to appeal the decision in court, but the board's decision was upheld.

Michael, who is sober, now takes "full ownership" for the mistakes she made. Then, she feared that she couldn't admit her struggles or she would be looked down on and punished more.

"It was all cookie cutter," Michael said of the disciplinary process. "It was 'This is what you're doing.' There was no individuality and person-centered plan."

DELAWARE'S OPIOID EPIDEMIC

Justin's disciplinary case, however, is one example of how the Board of Nursing is changing the way it disciplines nurses struggling with addiction.

This September, Justin sought to lift his suspension. According to hearing documents, he told the board about how, until this past year, he was not willing to "make the necessary changes to remain sober."

Justin had undergone treatment in Florida, enrolling in a program for nurses. He attends Alcoholics Anonymous several times a week, and lives with people who are also sober.

His suspension was lifted and he was put in the monitoring program. His license is on probation for three years.

The Board of Nursing, Williams said, looks to programs that are rehabilitating nurses to recommend the best course of treatment. It's stopped mandating certain requirements in disciplinary orders, such as nurses not being able to handle medication for a period of time.

When speaking of his relapses to the board, Justin felt the board had an understanding of addiction and the recovery process. He said he was "pleasantly surprised" by the board's empathy and its ability to "give me grace and see me through."

"It's the best I've been doing in a long, long time," Justin said of his life today.

Williams, who is also vice president of the Delaware Healthcare Association, said she has seen this philosophy — known as "just culture" — start to appear in Delaware hospitals. It's the idea of taking a more supportive, less punitive approach toward employees, particularly those struggling with addiction.

"When you make life and death decisions on a regular basis, I think the capacity to handle that in a healthy fashion is tested — whether you're a tractor-trailer driver, a surgeon or a nurse," Williams said. "As a result of that high stakes day-to-day that you're dealing with, it really puts a lot of stress on your coping mechanisms.

"Often folks turn to unhealthy coping mechanisms."

Although he is now allowed to practice in Delaware, Justin has chosen to work at a marketing firm. The decision is temporary, he said, while he focuses on recovery without rushing back into nursing.

When he started as a nurse a decade ago, Justin said he did his best to hide his addiction. He only told a few people at work, because he felt he would be judged.

He isn't afraid now.

“To be honest,” he said, “I kind of feel that everyone loves a comeback story."

Contact Meredith Newman at (302) 324-2386 or mnewman@delawareonline.com and on Twitter @MereNewman.

DELAWARE HEALTH