Nursing a Habit

**The first of two parts on Texas nurses battling substance abuse problems. (Part two is here.)

Texas nurses with substance abuse problems — including showing up to work drunk or high, stealing narcotics meant for patients, and forging doctor signatures on prescriptions for pain-killers — are often not punished for their acts for months or even years and continue to practice in the meantime, according to a Texas Tribune review of state nursing disciplinary records.

The reason? Nurses often fight the allegations against them, hiring lawyers, asking for a postponement, and demanding administrative hearings, which can take up to three months to schedule. The State Office of Administrative Hearings gets two months after that to issue its findings, Texas Board of Nursing General Counsel Dusty Johnston said; the nurse gets another 25 days to file a response. And the nursing board only meets four times a year to determine nurses' fates. Under due process proceedings, nurses can continue to practice while they're awaiting a ruling, Johnston said, unless they fail a drug test in the meantime. 

"It does take time to build a body of evidence," Johnston said. "We have to demonstrate the violation through a preponderance of the evidence."

A Texas Tribune review of Texas Board of Nursing disciplinary records found 117 nurses were punished for drug offenses over a three-month period last summer — a third of all actions taken against nurses. Thirty-five nurses with substance abuse problems had their licenses revoked for their actions. The nurses make up just a tiny portion of the state’s 300,000 licensed and registered nurses. But drug problems are hardly rare in the profession; every year, a third of the roughly 1,500 nurses reprimanded by the board are cited for drug or alcohol abuse. 

The actual number of nurses with substance abuse problems is likely higher. Nurses who self-enroll in rehab programs — or are shepherded there by their colleages — generally don’t get reported to the nursing board unless they fail to finish the programs. And the records the Tribune reviewed raise questions about how frequently nurses are even caught. In at least a dozen instances in the three-month window, nurses abused or stole drugs on the job for months, and in several cases for years, before they were punished for it.

Experts say drug abuse is common among nurses because they have such physically demanding and stressful jobs. Leanne Malone, the clinical supervisor for the state’s nursing rehabilitation program — and a recovered addict herself — said many nurses take drugs from their workplace because of injuries sustained on the job. “A lot of nurses do very, very physical work,” she said.

They also have far more access to drugs than the average person, said the nursing board's Johnston. “Access facilitates addictive behaviors,” he said. Some nurses “see the relief their patients get. You have people who treat their pain, whether emotional or physical, with the same type of medication.”

The Tribune’s research follows a national review of nurse disciplinary records by the investigative news non-profit Pro Publica. Pro Publica, in conjunction with the Los Angeles Times, published a series of articles last summer on nursing infractions in California, including nurses who skipped dozens of drug screens, stole drugs on the job, and tested positive for drugs at work before getting their licenses revoked.

The most common nurse substance abuse offenses in Texas? Getting caught drug-impaired while caring for patients; dispensing narcotics for patients, then taking them for themselves; and forging doctor signatures on prescriptions for heavy-duty pain meds like Vicodin and Morphine.

Some of the nurses engaged in all three activities over the course of multiple years. Others had been given second chances, and were enrolled in or had recently finished the state’s nurse rehabilitation program when they slipped back into bad habits.

The same stories appear repeatedly in state nursing board records:

• A Waco nurse showed up to work in 2007 drugged with Xanax — she acted jittery, fell asleep while attending to a patient and was unable to identify routine medications. She failed to perform a fetal heart tone procedure on a patient, which the nursing board determined “was likely to injure the patient.” She surrendered her license — but not until two years later, in 2009.

• A Center family practice nurse forged her physician employer’s signature on more than 50 prescriptions for narcotics and muscle relaxants over a nine-month period. She lost her license in 2009, after failing to finish a treatment program.

• In mid-2008, a Bay City nurse showed up to work high on sleeping pills and antidepressants, with slurred speech and an inability to walk or complete basic nursing tasks. She injected a patient with a drug, then later told her supervisor she couldn’t remember doing it. She was given a warning in 2009.

• An Arlington pediatric nurse showed up intoxicated at work once in 2002 and twice in 2005 before being sent to a nurse rehabilitation program. Even after the program, she failed drug screens twice in 2007. She was suspended in 2009.

• A Rusk nurse showed up to work in 2008 completely incapacitated; her speech was slurred, she was unable to count, and it took her 10 minutes to read a 30-second report on two patients sent to the emergency room. She was given a warning.

Other nurses included in the Tribune’s review were so addicted or incapacitated they couldn’t even make it to work. In one 2006 case, a Fort Worth on-duty nurse got so high on methamphetamines that he had to call 911 for his own overdose. He wasn’t suspended until 2009. And in 2007, an Irving nurse tried to kill herself by overdosing on narcotics. EMS workers found her home closet stocked with pharmaceuticals and needles. In 2009, the nursing board punished her with a warning. 

The bureaucracy behind state administrative hearings isn't the only reason nurses aren't punished immediately after their infractions. By state law, nurses with substance abuse problems are often referred directly to the state’s confidential nursing rehab program — and never reported to the board. Traditionally, the nursing board would only find out about the drug problem if the nurse didn’t pass the program or was reported for another violation. After the 2007 legislative session, nurses were also reported to the board if they committed a substance abuse-related error at work, but not all of them do.

And if a nurse commits a drug-related crime, the board might not find out until the next time the nurse has to report it on a license renewal, Johnston said. That could be two years away. Even then, nurses don’t always report honestly. 

Johnston said the nursing board takes drug abuse extremely seriously, and that the national nursing shortage doesn’t ever tempt the board to keep drug-addicted nurses in their jobs.

“Nurses and their lawyers often make that argument,” he said. “But the fact that there’s a nursing shortage can’t influence proper discipline.”

—Rachel Kraft contributed to this report.