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

As part of an investigative series into nurse rehabilitation programs (also known as alternative-to-discipline programs), MedPage Today conducted a survey of the leaders of the 46 programs in the U.S. -- revealing high variability across a number of outcomes, including completion and relapse rates.

Completion rates ranged widely, with about 38% of administrators reporting that more than 80% of nurses complete the program, 25% reporting that 61-80% complete the program, and 31% reporting 41-60% completion rates.

In terms of the proportion of nurses who relapse, a majority (62%) of administrators said that 10% or fewer have a relapse within a year. But for 5-year rates, only 46% of administrators said 10% or fewer relapse, with 23% reporting relapse rates of 11-20% and 15% reporting rates of 21-30%.

In addition, other states reported that they don't even track this outcome, according to open-ended responses.

In terms of who runs the program, 50% are run by the state board of nursing, while 23% are run independently by program staff, and 27% are run by a separate entity, which includes professional health programs and other contractors. Less than half (43%) of programs reported being required to share overall program outcomes with another state entity.

Directors were also asked about the average monthly cost to enrollees, which ranged from free to $300. One noted that costs depend on the amount of therapy or medical intervention needed by an enrollee, as well as insurance coverage, while another noted that the cost of treatment and testing is determined by third parties.

There were some exceptions to the variability. The vast majority of programs (90%) allow nurses to maintain their license while in the program, albeit with restrictions. Also, 91% of programs allow nurses to use medication-assisted therapy. Finally, most programs (73%) have been operational for at least 20 years.

While New Jersey did not respond to the survey, the state agency charged with oversight of its Recovery & Monitoring Program (RAMP) shared some data with MedPage Today for an accompanying story.

Critics of RAMP have questioned why the program frequently stretches to its maximum of 5 years, when other programs are far shorter, such as 1 or 2 years. New Jersey, however, is not the only program that lasts 5 years. More than half of survey respondents said their programs can stretch to 5 years.

Marvin Seppala, MD, chief medical officer at the Hazelden Betty Ford Foundation in Center City, Minnesota, told MedPage Today that the alternative-to-discipline program field needs better standardization.

"Each state has kind of developed its own program, usually out of necessity and often because they had enough nurses with a [substance use disorder] that they just had to do something, and they don't necessarily seek any kind of standard," Seppala said. "Some of the older programs are just doing the same things they've done for a long period of time and no one has looked at the apparent best practice."

In a statement to MedPage Today, the National Council of State Boards of Nursing (NCSBN) essentially agreed with the need for better standardization, highlighting its own study of these monitoring programs last year.

It found program components that made the biggest difference in terms of completion included random drug testing twice per month, daily check-ins, and a minimum 3-year program length.

"There are variations in some specific components of monitoring programs from state-to-state," the statement said. "Every state makes decisions about monitoring programs based on the statutes and regulations of the state. There is no national mandate about these types of programs."

"We also agree that financial obstacles are a barrier to some nurses entering and continuing in a monitoring program and not all states subsidize the nurse's considerable costs to enroll," the statement continued.

"We hope that our study will lead to changes in monitoring programs that are based in science," NCSBN stated. "In the future, we intend to complete another study that will look at nurses in monitoring programs and then follow up with them post program to examine outcomes."

Overall, about half of program chiefs (22 of 46) responded to the MedPage Today survey (46 states and Washington, D.C. have programs; five states do not have such programs). In some cases, the state official leading the program responded; in others, the respondent was the head of the organization contracted to provide the services.

The survey was also limited because not all directors responded to every question. It included about two dozen multiple choice and open-ended questions about outcomes, costs, operations, and governance.

Cheryl Clark and Shannon Firth also contributed to this survey and report.

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