Differences between Licensed Healthcare Professionals with Substance Use-Related Licensure Discipline

The impact of CARA mandates on nurse practitioner controlled substance prescribing in Oregon: a cohort study

Background

In 2017, the United States Comprehensive Addiction and Recovery Act (CARA) expanded authorization to prescribe buprenorphine for opioid use disorder (OUD) to nurse practitioners (NPs). Compared to physicians, NPs were required to complete 16 additional hours of training on controlled substance prescribing before a buprenorphine waiver application. As this differential additional education mandate was seen as a potential barrier, we evaluated the impact of this requirement on both NP waiver acquisition and prescribing of controlled substances, comparing NPs who obtained waivers to those who had not.

Methods

Through 2016–2018 Oregon Prescription Drug Monitoring Program and linked NP licensure data, we identified factors associated with waiver acquisition at baseline (2016) and evaluated changes in controlled substance prescribing before (2016) and after waiver acquisition (2018). Using chi-square and Mann-Whitney U testing, we calculated and described controlled substance prescribing types, rates, and patient level quantities including co-prescribing of benzodiazepines and opioids by NPs. Multivariable linear regression compared prescribing by waivered and non-waivered NPs for significant changes in non-buprenorphine controlled substance prescribing.

Results

Waivered NPs were more likely to have a psychiatric certification, have prior disciplinary action, and have generally higher levels of non-buprenorphine controlled substance prescribing than their non-waivered counterparts. While there was a significant increase in opioid prescriptions per patient among waivered NPs, following CARA implementation, co-prescribing of benzodiazepines and opioids significantly declined among waivered NPs relative to non-waivered NPs.

Conclusions

Although educational requirements were rescinded in 2021 for most applicants, enhanced opioid prescribing training should be incorporated into professional educational offerings regardless of regulatory mandate. We recommended continued focus on education regarding avoidance of high risk prescribing such as co-prescribing of opioids and benzodiazepines. NPs who acquire waivers may take on higher risk patients already using opioids, and these findings may represent transitions in practice and patient setting.

Disciplinary processes for nurses, from organizational supervision to outcomes: A document analysis of a regulatory authority's decisions

AIM

To explore the disciplinary processes for nurses, from organizational supervision to final decisions by the Finnish regulatory authority.

BACKGROUND

Regulatory authorities are responsible for protecting the public, by ensuring that they receive safe, competent and ethical nursing care, but little is known about the disciplinary processes for nurses.

METHODS

A retrospective document analysis of 296 disciplinary decisions by the Finnish regulatory authority from 2007-2016. The data were analysed using a quantitative design with descriptive statistics.

RESULTS

We studied 204 disciplined nurses (81.4% female) with a mean age of 43.5 years. The disciplinary process comprised organizational supervision, complaints, investigations and decisions. Nurses with substance abuse issues were more likely to face criminal investigations and receive temporary decisions. The process lasted from under one month to years and could have profound effects on nurses, colleagues and nurse managers and compromise patient safety.

CONCLUSION

This study identified key factors that could inform the disciplinary processes for nurses. More knowledge is needed about how organizations ensure patient safety when unprofessional conduct is suspected.

IMPLICATIONS FOR NURSING MANAGEMENT

Retaining nursing professionals is vital due to global shortages and more attention should be paid to organizational supervision and support for nurses during disciplinary processes.

Nurses' substance use disorder in disciplinary procedures: A retrospective document analysis

AIM AND OBJECTIVES

To describe nurses with substance use disorder (SUD) in authority disciplinary actions.

BACKGROUND

Nurses with SUD risk patient safety. Research evidence on the identification of nurses' SUD and related management procedures is currently sparse.

DESIGN

Retrospective document analysis of decisions related to SUD in nurses' disciplinary actions.

METHOD

Decisions on nurses (N = 171) made by the Finnish National Supervisory Authority for Welfare and Health in Finland during 2007-2016 were used as data. An electronic extraction sheet was developed for data collection including variables (N = 34), of which 18 were analysed in this study with descriptive statistical methods and chi-squared statistics. The study reported in accordance with the STROBE checklist for cross-sectional studies.

RESULTS

The mean age of the nurses was 43 years (SD 8.7). The most mentioned reasons for notifications leading to disciplinary actions were substance abuse with working while intoxicated and drug theft. The most mentioned intoxicants used were medicines and alcohol. On average, the first disciplinary decision was given at 6.4 months (SD 3.9) and the final decision was given at 17.9 months (SD 13.1). The most common decision was restriction of the right to practice.

CONCLUSION

The results supported findings from previous decades and different continents, showing similar trends are prevalent globally and continue today. In future studies, countries' registers of nurses with SUD could be used to clarify the profile of nurses and develop appropriate procedures. Qualitative studies could be conducted to investigate to shed light on concealment of the phenomenon.

RELEVANCE TO CLINICAL PRACTICE

There is a need for early identification, intervention and referral to treatment as well as effective protocols for reducing nurses' risks of disciplinary actions related to SUD. It is important to be aware of the signs and symptoms of SUD and training for this is needed.

Unprofessional conduct by nurses: A document analysis of disciplinary decisions

Background:

A small minority of nurses are investigated when they fail to meet the required professional standards. Unprofessional conduct does not just affect the nurse but also patients, colleagues and managers. However, it has not been clearly defined.

Objective:

The objective was to identify unprofessional conduct by registered nurses by examining disciplinary decisions by a national regulator.

Design:

A retrospective document analysis.

Data and research context:

Disciplinary decisions delivered to 204 registered nurses by the Finnish national regulatory authority from 2007 to 2016. The data were analysed with quantitative statistics.

Ethical consideration:

The study received permission from the Finnish National Supervisory Authority for Welfare and Health and used confidential documents that were supplied on the basis of complete anonymity and confidentiality.

Findings:

The mean age of the registered nurses who were disciplined was 44 years and 81% were female. Two-thirds had worked for their employer for 5 years or less, 53% had two or more employers and 18% had a criminal history. All the decisions included a primary reason for why the nurses were investigated, but there were also 479 coexisting reasons. In most cases, unprofessional conduct was connected to substance abuse (96%). In addition, stealing of medicine, a decreased ability to work and neglect of nursing guidelines were reported.

Discussion:

We found that the nurses were investigated for unprofessional conduct for complex combinations of primary and coexisting reasons. Our study highlighted that more attention needs to be paid to the key markers for unprofessional conduct.

Conclusion:

Unprofessional conduct is a complex phenomenon that is connected to nurses’ individual and working backgrounds and has an impact on their work performance. More research is needed to identify how nursing communities can detect, manage and limit the serious effects and consequences of unprofessional conduct.

A comparative analysis of the substance use and mental health characteristics of nurses who complete suicide

AIMS AND OBJECTIVES

To describe the substance use and mental health characteristics of nurses who complete suicide compared to non-nurses.

BACKGROUND

Nurses are at higher risk of suicide than the general population. The relationship between substance use, mental health and suicide in a large sample of nurses in the USA has not been previously described.

DESIGN

Retrospective observational quantitative analysis.

METHODS

Suicide data were retrospectively analysed in the Centers for Disease Control and Prevention National Violent Death Reporting System from 2003 to 2017. Data were compared between nurses who died by suicide (n = 2,306) and non-nurses who died by suicide (n = 185,620) using odds ratios calculations and chi-square test of proportions to detect independent risk factors of suicide completion in nurses. This study followed the STROBE guidelines.

RESULTS

Significant differences between nurses and non-nurses were found. Among decedents for whom substances were implicated as a cause of death, nurses were far more likely to be positive at the time of death for almost all substance classifications. Both male and female nurses were more likely than non-nurses to have a mental health problem reported. Among both female and male nurses, job problems were more prevalent compared to non-nurses (12.8% and 19.9% versus 7.2% and 11.9%, respectively). Female nurses were more likely to have a physical health problem compared to female non-nurses, male nurses and male non-nurses (26.2% versus 21.3%, 22% and 20.4%).

CONCLUSION

Unique relationships between substance use and mental health exist among nurses who complete suicide which may offer specific opportunities for interventions to reduce suicide.

RELEVANCE TO CLINICAL PRACTICE

Efforts to address workplace stress, facilitate self-referral for risky substance use, encourage mental health treatment and reduce the stigma associated with seeking help all offer potential interventions to reduce nurse suicide.