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The issue at the core of the constructive paper by Monroe and Kenaga (2011) is the value of ‘Alternative-to-discipline (ATD)’ strategies and programs, both for keeping the public safe and for retaining nurses in workforce. The authors note, with optimism, that ATD peer support programs operate in the majority of states of the USA. They make a very clear argument in principle for the continuation and growth of such programs.

However, our review of existing policy and program guidelines in US, UK and Australia, suggests a less optimistic picture. We perceived muted support for many programs and a current trend away from ATD programs for impaired nurses. For this reason we want to extend the arguments put forward and add a call to policy and research action.

We agree that policy in the UK has not shifted towards ATDs with peer elements. Instead, in its policy statement on drug screening, the Royal College of Nursing (2005) defers to the National Workplace Initiative and the Drug Action Teams, to assess and broker treatment for a nurse. As in many countries, UK nurses may then get support along the generic line of Employee Assistance Programs (EAPs), run for profit by counselling and human resources agencies. These programs are not attuned to the contexts of nurses, such as recognising distinct nursing workplace pressures, or nurses’ access to narcotics. Also these programs may not function independently from employer sanctions, or from processes of public disclosure.

In the USA, where ATD peer programs are strongest, there are problems with sustainability of peer volunteer models. Some programs function with a skeleton of peer contacts. They are, therefore, limited in support provided and liable to refer quickly on to profit-oriented rehabilitation. Other programs have stronger history and backing at the state industrial level. A minority of organisations, such as SPAN of the New York State Nurses Association, provide a wide range of services: prevention, education, seminars, peer support and referral.

Recent changes in the Australian context are also instructive: the Victorian Nurses’ Health Program (VNHP) is identified by Monroe and Kenega as an example of an ATD in an underdeveloped landscape. The VNHP and the Victorian Doctors’ Health Program are the only two such agencies in Australia, staffed to provide confidential treatment, peer support and monitoring and importantly funded through professional registration fees. In the new 2010 National regulatory environment, there are no plans to establish a ATD program for impaired health workers. Instead, policy guidance provided by the newly formed regulating bodies (the Nursing and Midwifery Board of Australia and the Australian Health Practitioner Regulation Agency) promotes mandatory notifications of impairment (NMBA 2010, AHPRA 2010). The future of VNHP, VDHP and ATD peer programs in Australia is uncertain.

There have been few reports of ATD program outcomes. The small study by Smith and Hughes (1996) cited good results for the peer support, in terms of return to work and abstinence. We call for urgent study of the components of current ATD programs, to strengthen the evidence base. Contemporary work is needed, to push back the trend for monitoring and even punitive responses, with just minimal support, in this climate of risk aversion and cost savings.

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