B.C. nurses in recovery say punitive, dehumanizing return-to-work agreements have derailed their lives

Four times a day, in between full-time work as a nurse in a small British Columbia community and parenting her two children, Claire has to leave the room and blow into a breathalyzer.

Sometimes, she's asked for a random urine sample and must take 40 minutes out of her hectic day to provide it.

Facing challenging life circumstances, including the loss of two loved ones seven years ago, Claire began using alcohol to cope. Her drinkingbegan to affect her work and she was convicted of impaired driving.

Claire's employer told her to agree to mandatory drug testing or lose her job.

CBC News is not using Claire's real name or naming her employer because she risks losing her job if she speaks publicly.

The mandatory drug testing is part of a return-to-work plan she had to sign three years ago to keep her job as a nurse, something she hides from her family and most friends. She pays about $350 out of pocket eachmonth for testing at a local medical monitoring company, but others can pay nearly double that.

Claire is grateful to be in recovery, but says the treatment plan is traumatizing and health authorities' policies for staff who use substances are dehumanizing and coercive.

"Dignity and respect, it all gets stripped away for the sake of protecting the public," she said.

Claire is one of an unknown but significant number of nurses in British Columbia who have entered into what experts say are harmful substance-use monitoring agreements with their employer orlicensing body in order to keep their jobs.

British Columbia isn't unique. Across Canada, nurses, doctors and other workers in safety-sensitive industries are subject to similar contracts.

A coalition of nurses and experts iscalling on the B.C. Nurses' Union (BCNU) to pressure health authorities and the college to change the policies some experts say don't help keep patients safe and actually push much-needed qualified nurses from the field.

"It's based on fear, stigma and humiliation," said Candy Gorse, a board member for the non-profit Workers for Ethical Substance Use Policy (WESUP), who was forced off work as a nurse because her prescription pain medication violated her monitoring agreement.

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Jonathan Chapnick says health authorities need non-coercive and evidence-based support for nurses who use substances.

A 2019 study found that the policies mean nurses are "not afforded the same rights to quality ethical health care as other citizens."

"If people do actually want help, they're more afraid of being punished and that isolation that ensues is a driving force behind overdose deaths," said Corey Ranger, a nurse in Victoria, B.C., and president of the Harm Reduction Nurses Association.

At least 78 nurses have entered into such agreements with the B.C. College of Nurses and Midwives (BCCNM) since 2019, and as many as 60 more decided not to renew their licences "while addressing their health," the college told the CBC.

Health authorities contacted by CBC declined to provide their own numbers of agreements with employees, citing privacy concerns.

If passed, three proposed resolutions coming to the BCNU's convention next week would direct the union to advocate directly to health authorities and the college to change these policies, and to the government to expand safe supply and regulate treatment and recovery services.

The resolutions are a chance for the union to help nurses with substance use disorders be treated as well as they strive to treat patients, says WESUP co-founder and former nurse Byron Wood.

"It's singling out nurses who use substances and then subjecting them to a regulatory program that violates their bodily autonomy, takes away their right to consent to treatment and actually puts them at increased risk for overdose death," said Wood.

The CBC reached out to B.C.'s Ministry of Health for comment and did not hear back before publication.

'A last resort'

Employment agreements are issued after a nurse is diagnosed with a substance use disorder through an independent medical examination (IME) conducted by an addictions physician ordered by the college or an employer.

The physician makes recommendations to the employer or college, which can include mandatory in-patient treatment, attendance at abstinence programs like the spiritually-based Alcoholics Anonymous or 12-Stepmeetingsand drug testing for up to five years.

They also mandate abstinence from all substances, including alcohol, some over-the-counter painkillers, and even prescribed medication-assisted treatments like methadone that help people stabilize their substance use and avoid withdrawal.

If prohibited drugs are detected or the sample is blown too late, the monitoring company can mark the nurse as "non-compliant" and their agreement can be extended or their employment or licence terminated.

The B.C. College of Nurses and Midwives says the IME process and its substance use policies are designed to protect patient and worker safety.

"BCCNM attempts to strike a balance between sanctioning and deterring conduct that places patients at risk and accommodating a registrant's health condition while supporting a safe return to practice," a spokesperson wrote in an emailed statement to CBC.

But in reality they often do the opposite, a 2021 report from the BCNU found.

"These policies typically are introduced in the name of workplace safety, and they're not keeping people safe," said Jonathan Chapnick, a workplace lawyer who co-authored that report.

The assumption that people who use substances pose an extraordinary risk to workplace safety is stigma, not science, he said.

Expensive and onerous drug testing also creates shame and disrupts a nurse's life, Chapnick said, and there is no evidence that continuing to test people for years helps them maintain recovery.

The policies "don't reflect quality health care where people can decide with their chosen health-care provider what they need," said Chapnick, who has experience representing nurses facing these policies.

Advocates have also raised conflict of interest concerns as IMEs are unregulated and many of the physicians who perform them are also part-owners of the medical testing companies they mandate nurses receive testing from.

"These agreements should be a last resort, but right now it's the first thing that happens," said Wood.

'God's word'

The reliance on largely standardized recommendations by doctors whodon't know the patients means nurses have little say in their treatment plan or recourse if they are misdiagnosed.

Sarah says that as ahigh-achieving nurse in the Lower Mainland, she never thought she would have to prove she was fit to work.

She says she wasflagged on a random audit for some explainable charting inconsistencies, and heremployer ordered an IME in 2017.

Sarah has never tested positive for any substances, according to records shared with CBC News, who is not naming her because speaking publicly could jeopardize her license renewal.

But the IME physician took details out of context, Sarah said, and determined she had substance use disorder, despite vehement opposition from her family doctor of many years.

The IME reports "are like God's words," said Sarah. "It didn't matter what I said, it didn't matter what my doctor said."

Refusing to sign an agreement admitting to having a substance use disorder, Sarah spent nearly two years unable to work while she fought for a second IME.

Eventually, the BCNU agreed to pay for one, and another assessment in 2019 confirmed she did not have substance use disorder.

But Sarah had to sell her house to pay her own legal fees and says the two-year process has drained her mentally and financially.

"This took up years of my life, thousands of dollars, my job," she said. "It can put you into a pretty dark place."

In hindsight, Sarah wonders if she should have agreed to the monitoring process to avoid the fight.

She's now trying to find a jobso she can get the required number of work hours to renew her lapsed nursing licence.

"The fight that I had to fight to get this cleared up was insane," said Sarah. "I could not imagine going through it as someone who actually had a substance use disorder."

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Building safety

Ranger, Gorse,Chapnick and Wood say workplace safety needs to be looked at holistically, with robust checks and balances in place for all kinds of safety concerns, rather thansingling out people who may use substances.

Ensuring schedules are humane and staffing is adequateisparamount, Chapnick said.

And if someone does ask for help or appears in distress due to substance use, they should be offered non-coercive support without their job on the line.

"It's pretty dehumanizing to be coerced into different forms of health care and urine screening when you're just trying to do your job, in the name somehow of workplace safety," said Chapnick. "But that's not what we're accomplishing with this regime."

While Claire is now employed in a non-clinical role, she is counting down until her monitoring agreement expires later this year.

"I want to have agency for my own life and my own health," Claire said.

She is grateful to be in recovery, but says three years of daily breathalyzer testsand random urine samples have made her feel that it's aboutpunishment rather than recovery.

"They're measuring how high you jump, not how much you recover," she said. "After three years, you kind of wonder whether or not you know what price you're paying."