麻豆果冻传媒影音

This story is part of a MedPage Today series on alternative-to-discipline nurse rehabilitation programs.

New Jersey's Recovery and Monitoring Program (RAMP) recently suspended a nurse's license for 3 months, she said, because she spoke out during a support group meeting. Andrea (whose last name is being omitted to protect her identity, at her request) could not work or even search for a nursing job during that span.

, the state's rehabilitation program for nurses, then threatened to extend Andrea's suspension after its director told her she was being manipulative when she pushed back on a phone call.

"My last 2 years in RAMP I never knew if I was going to do something wrong," she said. "I was scared."

Andrea, a long-time nurse, could only work in nursing for a combined 9 months out of the 60 she spent in the program, and her other employment options were also limited. She struggled to get by: "I was making pennies," she said. "It was [also] hard to meet the financial requirements of the program," which forces nurses to pay for services.

Such can be life as a RAMP participant, according to documents, participants, and other sources interviewed and examined by MedPage Today. While many participants enter the program seeking an on-ramp that leads back to sobriety and full-time work, some say the program often makes them feel like they've just been off-ramped onto the side of the New Jersey Turnpike.

"There's just never any positive reinforcement," one current participant said. "I can't tell you how afraid I am of retaliation."

RAMP is one of nearly 50 state-run nurse rehabilitation programs in the U.S. Most were established to boost both nurses and public health, via an alternative-to-discipline model offering nurses a carefully monitored path to continue their careers while recovering from substance abuse. But critics have questioned the effectiveness of these programs and how they treat participants.

MedPage Today conducted a survey of state program coordinators in all 50 states and the District of Columbia -- which revealed high variability across programs in terms of relapse and completion rates, and in operational procedures and governance. (See survey sidebar here.)

While state programs function differently, a look inside RAMP provides one example. Some participants have alleged that it treats nurses poorly, leading them to question whether it's designed to keep nurses with substance abuse issues away from clinical settings, rather than help them recover and return to work.

"I still fear repercussions. They would find something I did that wasn't right and they would pursue me," Andrea said. "We are professionals. We're trying, we're trying."

Is RAMP Effective?

RAMP was established as a (NJSNA) program in 2003, but is also contracted with the state nursing board "to provide monitoring services," according to RAMP's 2021 participant guide. Many nurses "do not seek or receive the help they need. RAMP's priority is the well-being of nurses and the safety of the public by supporting nurses in their wellness."

A New Jersey attorney who has represented nurses in the state since 2004 said RAMP leaders "want to say they're looking out to make sure there aren't impaired nurses out there." (The attorney asked to remain anonymous because he has clients in the program.)

How effective has RAMP been? While RAMP declined to complete the MedPage Today survey, the state's Division of Consumer Affairs, which governs RAMP, shared some data via email. All data cited below go back only as far as the Division shared:

• Enrollment increased every fiscal year from 2012 (394) to 2016 (575), then declined steadily, dipping to 468 in 2020, which was due to the pandemic, a Division spokesperson said
• The overall program completion success rate increased from 60% in 2017 to 68% in 2020
• The percentage of nurses working while in RAMP increased from 49% in 2016 to 64% in 2019, before dipping to 56% in 2020; RAMP doesn't track nurses after they've completed the program, the spokesperson said, so it's not clear how many eventually get their nursing jobs back
• RAMP does not track what percentage of nurses regain their licenses after being stripped of them when they enter RAMP, per policy; the Division did not answer a question about the average time that it takes to regain a license
• The annual relapse rate among all participants declined from 11% in 2016 to 6% in 2020

RAMP's staff includes director Terry Ivory, MSN, RN, four case managers, and three others: an intake coordinator, administrator, and communications coordinator. Ivory is a former nurse who -- -- was the NJSNA director in 2018. She is also president of . Ivory declined to speak with MedPage Today for this story.

, a Tennessee company, handles mandatory peer support meetings for RAMP participants. It does so virtually, after sources said the company was contracted to replace an NJSNA staffer who had led the meetings in-person. Birchwood CEO Elizabeth Temple declined to comment for this story.

RAMP also has subcontracted testing services to , based just outside Philadelphia. FS has about 90 clients across 36 states for all healthcare professional programs, said Shane Moes, its recovery managment director. FS has been working with nursing rehab programs for about 15 years, he estimated. The company typically bills nurses directly, Moes said, because the state programs lack funds to cover their services.

Both Birchwood and FS have contracted with RAMP since Ivory assumed leadership, said two participants who started the program before she became director.

Ivory referred MedPage Today's queries first to the state nursing board and then the attorney general's office. The Division of Consumer Affairs, a part of that office, declined to make any RAMP or nursing board staff available to speak. A spokesperson answered the questions related to RAMP statistics via email. The Division asked MedPage Today to email other questions, but did not answer them as of press time.

How RAMP Works

RAMP staff must follow the program's , according to the document and sources.

Potential participants are referred to RAMP by themselves, colleagues and managers, and friends and family. In addition: "A Board of Nursing may refer a nurse to RAMP as a result of a complaint and/or discrepancies in a background check or profile," according to the guide.

They are also selected when new nurses -- including recent nursing school graduates -- note on licensing applications that they have had trouble with substances, even if they are currently substance-free.

The first step is a 90-day evaluation, designed on paper to determine if the nurse needs to enter RAMP. The nurse's license is suspended at this time. Independent counselors selected by RAMP conduct these evaluations and RAMP typically follows them.

Once a nurse is enrolled in RAMP, his or her license remains suspended. Each license is reinstated on a case-by-case basis.

The program -- which involves both rehabilitation and monitoring -- typically lasts 5 years, though the Division of Consumer Affairs notes it can be shorter.

Nurses are barred from working when they start the program. They may return to work with a RAMP case manager's blessing, after that manager has spoken to the nurse's new employer -- and only if an RN is on the premises supervising the nurse at all times. They are thus excluded from home care positions, sources noted.

Nurses in the program are not allowed to work more than 40 hours per week, to work for multiple employers, or be self-employed. They also cannot work in critical care settings unless RAMP approves that.

They must attend the weekly peer assistance meetings and check in daily. They are billed for all program costs, "including the application fee, costs of evaluation, peer assistance meetings, and toxicology screens."

Participants must also upload information regarding "all controlled medication prescriptions" and supporting documents into a monitoring system monthly within 24 hours of receipt. They must also respond to all RAMP communications within 24 hours; and notify RAMP about any changes in their healthcare providers, employment/supervisor, and travel plans. "Failure to inform RAMP of any changes will be considered non-compliant and may result in a review by the RAMP team."

If they relapse while enrolled, they must sign a new monitoring agreement and "voluntarily inactivate their nursing license."

Other stipulations may be included in a letter that nurses must sign to enroll, called a private letter agreement (PLA). And, as page 10 of the guide indicates in bold text: "Please note that refusal to participate in any portion of the PLA, monitoring agreement, and recommendations of RAMP is considered noncompliance and reportable to the [nursing board]." The board then typically suspends their license.

Participants who withdraw from RAMP or are dismissed are reported to the board and their employers, if they are working. The board must then approve their return.

Program cost estimates vary. Using state data, MedPage Today estimated that the annual cost per nurse ranges between $2,360 and $11,720, not including the evaluation fee.

"Insurance does not pay for the program itself, which includes lab fees, evaluation fees, peer group fees, and therapist fees. All fees must be paid up front," Ivory told Minority Nurse. "Hard medical costs, such as a lab fee or therapist, might be covered by medical insurance."

Rigid Program, Unfair Evaluations?

Two RAMP participants and the attorney who has represented more than three dozen nurses in cases against RAMP over about a decade told MedPage Today that RAMP staff treat participants poorly and seem more interested in keeping the program running than helping them -- .

"I find some RAMP personnel to be helpful, but not many," said the attorney.

The program is too long for most participants, critics said. "Why can't it be 6 months or a year?" said one of its go-to evaluators, who asked to remain anonymous because this person still works with RAMP.

"The monitoring agreement, including the length of participation in RAMP, is determined by a specific situation, recommendations of the RAMP team and the requests of the New Jersey Board of Nursing," according to the guide.

But: "RAMP can be sort of rigid in terms of what they determine," said the evaluator, who is also a clinical therapist. This person noted that having a drink while enrolled will get nurses in trouble even if an evaluator rules they do not have an alcohol disorder.

"Less flexibility in their view makes the program easier to run," the attorney said. "I've seen more flexibility in the past; it's increasingly difficult to [advocate for participants]."

Take one nurse who moved to New Jersey from another state a few years ago, for example. She had recently kicked an alcohol problem, she said, but when another state nursing board reported it to the New Jersey nursing board, she was forced into RAMP even though her $300 evaluation did not cite alcoholism. She was required to sign a 5-year contract; no negotiation was permitted.

The Division told MedPage Today that the cost of evaluations ranges from $250 to $2,000 depending on the type of evaluation: psychological, neurological, substance use, etc.

RAMP often refers nurses to the same two evaluators, according to sources, including the aforementioned one. "There are two of us they like, and I don't know why," one said, noting the program typically accepts their recommendations.

The other evaluator declined to speak with MedPage Today. "I do not discuss any aspects of my private practice with the media in any of its forms," the evaluator emailed.

"A lot of people get a diagnosis that they don't deserve," the attorney said. "I've always felt they are biased in the evaluations because they get all this business from RAMP. ... Why can't you go to a licensed qualified person who may be covered by your insurance?"

But perhaps it could be worse, hinted the evaluator who spoke to MedPage Today: "I don't follow RAMP guidelines to a 'T,' because I don't always feel they are fair," the evaluator said.

Nurses are also tested too often in the program, critics charged. One participant was asked to get tested three consecutive days in May, for example, according to an email originating from FSSolutions shared with MedPage Today. This included two urine tests and a blood test. "This is what they consider 'random' testing," she wrote. "I am now up to approx. $300 in testing in 3 days."

Participants were ordered to get tested in-person even during the worst of the pandemic, one said.

Alternative Option

The board requires selected nurses to enroll in RAMP even though a separate program offers similar services and has a better reputation, sources said. The Professional Assistance Program of New Jersey ( is run By Louis Baxter, MD, a former addiction psychiatrist, but the program is not sanctioned by the nursing board.

Regardless, many nurses enroll in PAPNJ because it is deemed more effective and because they fear RAMP, said a licensed New Jersey therapist who has worked with the board for 20 years. (This person asked to remain anonymous to protect that relationship.)

"They run a different program and view themselves as advocates for licensees. They're actually trying to treat these people and help," the attorney said of PAPNJ. RAMP, on the other hand, views its role as keeping "problem nurses" out of healthcare.

Baxter declined to speak to MedPage Today, via a PAPNJ spokesperson.

In Defense of RAMP

Director Terry Ivory told in 2018 that RAMP "is important because it supports impaired nurses and protects their licenses so they will be able to work again with monitoring once they have completed evaluation and treatment. What makes the program special is that nurses are taking care of nurses who understand the challenge of being a nurse."

"RAMP is highly individualized; some complete it in less than 5 years, while others may relapse and take longer," the Division of Consumer Affairs spokesperson wrote. "RAMP tracks relapses as they occur and implements appropriate interventions based on the participant's time in RAMP and what has occurred."

Helene Burns, DNP, RN, president-elect of the Organization of Nurse Leaders of New Jersey () and chief nursing officer of Jefferson Health in New Jersey, noted that the program is voluntary.

"What I like about the program is it works with nurses individually, but it also works with the board of nursing and employers," she said. "We see this RAMP program as a wonderful opportunity for nurses to seek assistance in lieu of discipline."

Burns said she has never heard anything negative about RAMP in the 13 years she has worked in New Jersey.

"Programs are as good as the individual who decides to go into the program and benefit from it," Burns said. "If you're not going into it wanting to improve, you may not get the benefits of it."

Overall, Moes said of RAMP: "If anything, they're very engaged and interested." RAMP requests the most operational data out of all his clients, he said.

Regarding the random testing: "Outcomes tend to be better the more healthcare professionals are drug tested," Moes said. Nurses programs overall have increased testing frequency in recent years, he said, adding: "I think their effectiveness justifies their existence."

He favors state funding for testing. "You would be supporting public safety and supporting an individual healthcare professional," he said. A program "costs a lot for individuals at a time when they are most at need and can't pay for them, so you see dropout rates or people can't even participate."

RAMP nurses are randomly tested, the Division of Consumer Affairs wrote, on average 26 times annually.

That number is not unusual, Burns said, citing her experience working in other states as reference. "If you have someone who's back in the workforce, there has to be an ongoing process of monitoring."

But many nurses still aren't sure if such monitoring and other RAMP actions are indeed steering them to helpful on-ramps -- or if the program will ultimately off-ramp them.

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