A Texas program that guides chemically dependent nurses through a recovery program in lieu of disciplinary action has fallen under the state budget-cutting knife and soon may be forced to turn away new referrals.

Funding cuts in the Texas Peer Assistance Program for Nurses (TPAPN), which also accepts mental illness referrals, could spell career disaster for dozens of nurses who may not get a second chance to stay in a field that's already woefully shorthanded, TPAPN proponents said.

The cuts, 7 percent for the rest of fiscal 2003 and a projected 12.5 percent for fiscal 2004 and 2005, may further strain a program that is already inundated with participants, TPAPN program director Mike Van Doren said.

"At a time when it's more critical than ever to help maintain a healthy nurse workforce, funding has decreased, and that's counterproductive, because it will end up causing more harm in the long run and probably costing taxpayers through another route," said Van Doren, who also serves as president of the National Organization of Alternative Programs.

Van Doren said TPAPN "may have to make some hard choices, like capping referrals."

For nurses like Maritia Haws who have benefited from TPAPN, such scale-backs are a disturbing prospect. Haws, a Dallas/Fort Worth-area nurse who entered the program in 1999 during a battle with substance abuse, completed the two-year program and now works as an advocate for other nurses who need someone to lean on during the often-painful rehabilitation process.

"These people need help," she said. "If it hadn't been for this program, I don't know where I'd be. TPAPN rebuilds careers and helps make people's lives whole again."

Although the 16-year-old program may be a desirable alternative to board action, it's nonetheless rigorous. Haws said she was required to undergo physician care upon entering TPAPN, enroll in an outpatient program and attend a total of 90 support-group meetings in the first 90 days of treatment.

TPAPN participants also undergo random drug testing at their own expense and fill out dozens of reports to case managers. If nurses break program rules or don't finish the two-year program, they are referred back to the state Board of Nurse Examiners or Board of Vocational Nurse Examiners for disciplinary action.

The peer assistance program later monitors the nurses when they return to work, sees to it that they have restricted access to clinical narcotics and also educates employers and colleagues about the effects of addiction/mental illness in the workplace and the potential for rehabilitation and a productive return to work.

Haws said she was re-employed as a nurse eight months after entering the program. "No one slips through the cracks here," Haws said. "In fact, a TPAPN nurse is probably the safest nurse you can have on your staff. They are accountable, they are monitored and they are tested."

Sometimes, TPAPN can help address legal issues as well. "My case manager in Austin stepped in and called the district attorney's office five times for me until she got through ... she probably kept me out of jail and truly saved my license," Haws said.

About 85 percent of those entering the program will return to work, according to TPAPN. The percentage of nurses who are considered full successes (those who have not violated rules of the program during the treatment phase or while back at work) ranges from 75 percent in RN anesthetists to about 45 percent in licensed vocational nursing, Van Doren said.

Haws believes TPAPN has become something of a national model, not only for nurse peer assistance programs but for physician and pharmacist assistance programs as well. She is now an advocate for a nurse who came from Oklahoma just to get into TPAPN.

The peer assistance program, which started in 1987, has received more than 7,000 referrals since its inception. It now has nine staff members and is annually funded through the Board of Nurse Examiners ($370,000) and the Board of Vocational Nurse Examiners ($180,000)-amounts that haven't changed since 1997, Van Doren said. Those capped monies are generated by nurse licensing fees. Excesses beyond the totals go back into a state pool.

In late January, legislative leaders told state agencies and higher education institutions they must reduce spending by at least 7 percent for the remainder of the fiscal year ending Aug. 31, suggesting that the groups eliminate out-of-state travel, capital purchases, consultant contracts and slash administrative expenses. Exempted were public schools, the Children's Health Insurance Program for low-income children and acute care Medicaid services.

The Board of Nurse Examiners, which oversees peer assistance, licensing, accreditation and enforcement for the Texas RN population, responded by cutting back its programs 7 percent across the board. Projected cuts for fiscal 2004 and 2005 are 12.5 percent.

It is not clear how the spending on peer assistance review programs would be affected by a legislative proposal to eliminate the vocational nurse examiners board and shift oversight of all nurses to the Board of Nurse Examiners.

"We had to dig deep, and everybody had to take their fair share of hits," said Mark Majek, director of operations for the board. "The downside is that peer assistance is definitely going to be limited in its intake, which may send some nurses through the discipline process instead of remediation. And that's unfortunate. But the positive side is that the Legislature could have scrapped the peer assistance program, but it didn't. They left those [funding] decisions to us."

Participants come to the TPAPN primarily through employer referrals, although about 5 percent join voluntarily.

Nationally, 38 states have programs similar to the Texas program.

However, some of those states are beginning to consider such programs expendable, especially in the flagging economy, said Randy Bryson, executive director of the National Consortium of Chemical Dependency Nurses. "We're seeing them affected in different ways," he said. "Every state is in some kind of financial crisis and a lot of legislatures are starting to see them as excess. And that's a shame, especially with the nursing shortage."

TPAPN has just four case managers, although it has 200 nurse advocates such as Haws who help support about 600 cases. "While 600 people in the program sounds like a lot, consider that there are 130,000 RNs in the state of Texas-that's less than 1 percent of the nurse population," Van Doren said. "But it's still a critical component and one that we need to retain [as nurses] if possible."

Industry studies show that for every nurse saved in the program, an employer saves the equivalent of that nurse's annual salary in costs that would have been associated with a firing and the hiring/training of a replacement, said Van Doren, who is a certified addictions-registered nurse.

Van Doren said he's already cut advocate travel expenses, staff education trips and soon may see the day when TPAPN has to cap referrals to the program. "It would be pitiful to come down to a level where we can't accept a mental health candidate," Van Doren said.

The advocates are not paid. Although they do receive continuing education classes and are reimbursed for travel and phone expenses, they will donate their expense checks back to TPAPN, Van Doren said.

Terrie Hairston, executive director of the Texas vocational nurse board, said future funding-cut projections of 12.5 percent still could change as the Legislature tinkers with budgets. "It's kind of preliminary right now."

Contact Steve McLinden at smscribe@hotmail.com

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