By Megan Flaherty,OTR
Illustration by Malcolm Garris/PhotoDisc
December 7, 1998

The number of nurses disciplined by state boards of nursing each year is relatively small, but the impact of those RNs’ misdeeds can be tremendous.

In many cases, their actions have put the public-as well as their own livelihoods and reputations-at risk. The offenses prompting disciplinary action vary widely, from diverting controlled substances to incompetence.

However, some patterns emerge from the medley of transgressions, experts say. No. 1 problem Most disciplinary actions result from offenses related to chemical dependency, even in states that offer nurses rehabilitation programs in lieu of discipline, said Vickie R. Sheets, JD, RN, director for practice and accountability for the National Council of State Boards of Nursing.

In California at any time, more than 400 nurses are in the BRN’s chemical dependency and mental illness diversion program-an alternative to the disciplinary process, said Susan Brank, assistant executive officer of the BRN. The program includes confidential consultations and referrals for treatment and rehabilitation support services for chemical dependency or mental illness. However, even with the diversion program, alcohol- and drug-related offenses still account for over half of the disciplinary actions taken by the BRN, Brank said.

In 1997, the BRN revoked 75 RN licenses and placed 51 nurses on probation, according to BRN records. Seventeen nurses surrendered their licenses voluntarily while disciplinary action was pending. Common substance abuse-related offenses included diverting controlled substances for personal use, practicing unsafe nursing while under the influence of alcohol or drugs, and driving under the influence.

Destructive addictions Experts estimate that 10 percent of the general population will have a problem with alcohol or drugs at some point in their lives.

Nurses are no different, said Chris Vourakis, DNSc, RN, who until recently served on the staff of the BRN’s diversion program and is now editor of the Journal of Addictions Nursing, a publication of the National Nurses Society on Addictions geared toward nurses who treat clients with addiction problems. A complex combination of psychosocial and biological factors causes addiction in a nurse, or anyone else, she said.

Those most at risk come from backgrounds in which using substances was a way of dealing with stress and enjoying life, she said. At-risk people also have a biological hypersensitivity to chemicals, Vourakis said.

Alternative to Discipline The Diversion Program is a voluntary, confidential program for RNs whose practice may be impaired due to chemical dependency or mental illness. The goal of the program is to protect the public by early identification of impaired RNs and by providing them access to intervention programs and treatment services. When an RN is deemed safe to return to practice, he or she is closely monitored for three to five years, required to undergo random drug screenings, and subject to other stipulations.

Chemical dependency problems frequently come to a head for nurses when they are in their 30s and 40s, Vourakis said.

"Many have been using for years but seem to get into trouble around mid-life. After that many years of using, they start to slip up. They start losing time at work, or they need more of a substance, so they are less careful about when they steal it or forge prescriptions. Their need becomes increasingly salient."

A nurse who works in a critical care setting, where patient use of opioid analgesics is high and drugs are not closely monitored, may be at greater risk for substance abuse, Vourakis said. However, easy access to a drug doesn’t mean that a nurse will use it, she said. Only those with other psychosocial risk factors are likely to use it because it’s available. Errors and ethics

Disciplinary problems other than those related to chemical dependency vary widely, Sheets said. "My sense is that we’re seeing more quality of care issues than we used to," she said.

For example, nurses may be disciplined for making errors of omission or commission; for failing to assess, intervene appropriately, or summon additional help when needed; or for failing to document correctly, she said.

In some states, the increase in offenses involving quality of care is related to mandatory reporting of violations of the Nurse Practice Act, Sheets said. Nurses and nurse supervisors who are required to report in those situations sometimes face judgment calls, she said. "They obviously can’t deal with every single medication error. They are more concerned with serious incidents and patterns of behavior," she said. Nurses who are before the BRN for medication errors usually haven’t made just one, Brank agrees.

"It’s usually a pattern, not just a one-time offense," she said. The state’s nurse discipline records reveal a wide spectrum of misconduct. In California in 1997, nurses had their licenses revoked or were put on probation for offenses including patient abuse, unprofessional conduct, gross negligence and incompetence, and the embezzlement of thousands of dollars from an employer.

Other offenses included making medication errors, impersonating another nurse, falsifying records and defrauding an employer, practicing without a valid license, submitting false claims for payment, allowing unlicensed staff to perform tasks that must be performed by licensed staff, falsifying patient records, misrepresenting one’s educational level, failing to chart properly, failing to comply with an order for psychiatric evaluation, and carrying a concealed firearm with ammunition in a store.

The majority of practice-related discipline cases are due to a nurse’s lack of knowledge or inability to problem-solve effectively, Sheets said. The cases that are hardest to deal with-and exceedingly rare-involve nurses who "just don’t care," Sheets said.

"They can sit in front of you and answer every question, but they just don’t apply it. They don’t put the needs of the patients first, so maybe they’re not in the right profession. Often the best thing is to separate them from practice."