The 58 boards of nursing (BONs) in the United States take

A Review of Criminal Convictions Among Nurses 2012 2013 Elizabeth H. Zhong, PhD; Carey McCarthy, PhD, MPH, RN; and Maryann Alexander, PhD, RN, FAAN Introduction: Nurses with criminal accounted for approximately 10% of the disciplinary actions taken by state boards of nursing (BONs) between 2003 and 2013. The purpose of this study was to better understand the types of crimes for which nurses are convicted and what actions BONs are taking to protect the public. Methods: The records of nurses and nurse applicants who received disciplinary actions in the years 2012 and 2013 for a criminal conviction were extracted from the Nursys database. Information on demographic and licensure characteristics, the type of crime committed, and the actions issued by the BON were coded and analyzed. Results: 4,260 nurses and 559 nurse applicants received a board action in 2012 and 2013 due to a criminal conviction. Male nurses and licensed practical nurse/vocational nurses were overrepresented as compared to their proportion in the national nursing workforce. Driving under the influence, violation of the Controlled Substances Act, and theft were the most common crimes; probation and suspension of license were the most common BON actions. Board actions for egregious crimes and crimes involving patients were more severe. Among all nurses and applicants in this group, 18% failed to disclose a previous criminal conviction. Conclusion: Overall, the vast majority of nurses are safe practitioners. The majority of crimes reported to BONs are not patient-related. This study provides evidence that BONs diligently address criminal and evaluate whether the conviction is an indication that the individual is capable of practicing nursing safely. Keywords: Criminal, discipline, regulation, research The 58 boards of nursing (BONs) in the United States take approximately 17,000 disciplinary actions each year. In 2014, the National Council of State Boards of Nursing (NCSBN) conducted a 10-year review of disciplinary actions taken by BONs in the United States between 2003 and 2013. The two most common reasons for disciplinary actions during this period were an inability to practice safely because of alcohol or other substance abuse (11.5%) and a criminal conviction on the nurse s record (10%) (National Council of State Boards of Nursing [NCSBN], unpublished report). The topic of substance abuse among health professionals is well studied, but evidence on the relationship between the characteristics of nurses with criminal is not well known. An analysis of data from six states suggested the odds of a nurse receiving a subsequent disciplinary action for a practice-related violation were approximately four times higher if that nurse had a history of criminal conviction (Zhong, Kenward, Sheets, Doherty, & Gross, 2009). The California Board of Registered Nursing explored risk factors for recidivism in nursing practice and found a statistically significant association between recidivism and a history of criminal conviction (Waneka, Spetz, & Keane, 2011). However, a study of 47 nurses in Nebraska examining prior criminal and disciplinary actions after licensure found no correlation (Clevette, Erbin-Roesemann, & Kelly, 2007). The purpose of this study was to describe the most current demographic and licensure information on nurses with criminal, the types of crimes they committed, and the actions taken by BONs. This information will provide a better understanding of the characteristics of this small group of nurses and nurse applicants and may lead to strategies that can help BONs best protect patient safety. Research Questions The study sought to answer four questions: 1. What percentage of nurses and nurse applicants were convicted of a crime and disciplined by a BON from January 1, 2012, through December 31, 2013? 2. What types of crimes were committed, and did the age, gender, race or ethnicity, or level of nursing practice among those convicted differ from those in the general nursing workforce? 3. What types of actions were taken by the BONs in response to the criminal and what crimes led to a denial of a nursing license by a BON for a first-time applicant? 4. How many nurses and nurse applicants with criminal failed to disclose their criminal histories to the BON? www.journalofnursingregulation.com 27

FIGURE 1 Licensure Status of Subjects at the Time of Board of Nursing Disciplinary Actions (n = 4,819) Multiple licenses (5%) TABLE 1 APRN (0.1%) Applicant (12%) LPN/VN (38%) RN (45%) Type of Crime Resulting in Disciplinary Actions (n = 6,879) Type of Crime Frequency Percentage Driving under the influence 1,990 29% 1,187 17% Theft 1,082 16% Fraud 700 10% Domestic violence, aggravated 410 6% Sexual offense 110 2% Others 1,220 18% Unknown 180 3% Terminology For the purposes of this study, the terms below were defined as follows: Nursys database: A comprehensive electronic database that collects and stores the demographics, licensing, and disciplinary information on U.S. nurses. Currently, all 58 BONs enter disciplinary data into Nursys (Nebraska Advanced Practice Registered Nurse Board submits data under the Nebraska Registered Nurse Board). Fifty-five BONs enter licensure information. When deidentified, these data also allow a better understanding of the general composition and characteristics of the U.S. nursing workforce. Discipline case: A Nursys database record related to a reported violation of the state nurse practice act (NPA). A case consists of the complaint, the violation of the NPA, and the disciplinary action taken by the BON. For this study, cases selected were only those in which the action by the BON resulted in a discipline to the nurse. Discipline or disciplinary action: Sanctions administered by a BON in response to a violation of the state NPA. While there are variations in definitions/interpretations of these actions from state to state, they generally include such actions as administrative warnings (letters of concern), reprimands, practice probation (for a designated period of time), license suspension, or license revocation. Criminal conviction: A misdemeanor or felony for which a nurse licensee or applicant was convicted. Applicant: An individual who, at the time of a board action for a criminal conviction, had applied for but did not hold a nursing license. Revisions to BON actions: After initial disciplinary action by a BON, any changes to the discipline are considered revisions. Revisions were not included in this analysis. Reciprocal BON actions: Actions taken in response to the action of another BON. Reciprocal actions were not included in this study. TABLE 2 Age Distribution of RNs and LPN/VNs With Criminal Convictions Compared With National Nursing Workforce Statistics Age Licensee Group 30 31 40 41 50 > 51 RNs With criminal 14% 29% 28% 29% General workforce* 11% 20% 21% 48% LPN/VNs With criminal 16% 37% 28% 19% General workforce* 12% 20% 24% 44% Methods A retrospective review of the Nursys database was conducted to identify nurses who received a disciplinary action for a criminal conviction and nursing licensure applicants who were denied a license for a criminal conviction from January 1, 2012, through December 31, 2013. Digital records of the nurses and nurse applicants coded as violation Criminal Conduct Code 19 in 2012 and 2013 were retrieved from Nursys. Cases in which the criminal conviction was a result of a revision to an action or reciprocal action were excluded. Demographic information and disciplinary records for each nurse or nurse applicant with a criminal conviction were extracted from the Nursys record, coded, and entered into data files. The criminal conviction information was coded according to the type of crime and the disciplinary action by the BON. The criminal 28 Journal of Nursing Regulation

conviction codes and codes for BON actions were entered into a data file. Data files were merged for analysis, and a unique identifier was assigned to each case when it was entered into the system to protect the confidentiality of the study subjects. Files with missing or insufficient information in the case narratives or missing BON orders were flagged; NCSBN research staff contacted BONs directly to obtain the information. Temporary data entry clerks with legal backgrounds conducted most of the data extraction and coding; they received training on the case review process and cross-checking the coding to ensure accuracy and consistency. A pilot study was conducted to ensure the accuracy of the coding book as well as to track the estimated time for completing a case review. The Western Institutional Review Board (WIRB) granted NCSBN an institutional review board exemption approval for the study. Descriptive analyses were performed using SAS Enterprise 6.1 to derive means, frequencies, percentages, and standard deviations on variables reported. Missing data were treated as missing at random; however, some subanalysis was limited because of the extent of missing data. An n used for each subanalysis was listed. In certain instances, the NCSBN 2015 National Nursing Workforce Survey statistics (Budden, Moulton, Harper, Brunell, & Smiley, 2016) and the NCSBN National Nursing Database statistics (NCSBN, 2015) were used to derive samples of the general U.S. nursing workforce for comparison. Results Research Question 1 What percentage of nurses and nurse applicants were convicted of a crime and disciplined by a BON from January 1, 2012, through December 31, 2013? A total of 4,819 nurses and nurse applicants from 53 BONs received initial BON disciplinary actions for criminal in 2012 and 2013. The cases that met the study criteria represented less than 0.1% of all nurses in the U.S. population. In this group, 4,260, or 88%, held nursing licenses; the remaining 559 were nurse applicants. Among the 88% licensed study subjects, 45% held a registered nurse (RN) license, 38% held a licensed practical nurse/vocational nurse (LPN/VN) license, and 0.1% held an advanced practice registered nurse (APRN) license. (See Figure 1.) Of these nurses, 5% held more than one license. (All license categories are coded separately; one person belongs to only one category.) Research Question 2 What types of crimes were committed, and did the age, gender, race or ethnicity, or level of nursing practice among those convicted differ from those in the general nursing workforce? The 4,819 subjects committed a total of 6,879 crimes that resulted in disciplinary actions. (See Table 1.) More than one third (n=1,624) received a disciplinary action for more than TABLE 3 Gender Distribution of RNs and LPN/VNs in the Study Group Compared With National Nursing Workforce Statistics Licensee Group Male Female RNs With criminal 25.0% 75.0% (n = 1,564) General workforce* 8.0% 92.0% LPN/VNs With criminal 20.0% 80.0% (n = 1,554) General workforce* 7.5% 92.5% TABLE 4 Type of Crime by Gender Type of Crime Female Male Driving under the influence 26% (1,094) 31% (432) 18% (769) 16% (217) Theft 18% (769) 10% (136) Fraud 12% 488) 7% (97) Domestic violence, aggravated 5% (230) 8% (116) Sexual offense < 1 (18) 4% (60) Others 17% (732) 21% (297) Unknown 3% 126) 3% (36) TABLE 5 Ethnicity Distribution of RNs and LPN/VNs in the Study Group Compared With National Nursing Workforce Statistics White Black/African American Licensee Group RNs With criminal 70% 6% 8% 14% 1% 2% General 80% 6% 4% 7% < 1% 3% workforce* LPN/VNs With criminal 65% 19% 13% 1% 1% 2% General 68% 15% 6% 5% 1% 4% workforce* Hispanic/Latino Asian American Indian/Alaskan Multiple, Other www.journalofnursingregulation.com 29

TABLE 6 Licensure Status of RNs and LPN/VNs in the Study Group Compared With National Nursing Workforce Statistics Group RN LPN/VN Total Study group 54% 46% 4,001 (2,158) (1,843) General RN workforce* 81% (3,762,704) 19% (901,398) 4,664,102 *Data source: National Nursing Database (National Council of State Boards of Nursing, 2015). TABLE 7 Type of Crime by Licensure Status Type of Crime RN LPN Applicant Driving under the 34% (1,014) 25% (657) 24% (209) influence 18% 543) 17% (452) 15% (134) Theft 13% (383) 19% (487) 18% (158) Fraud 9% 274) 11% (281) 11% (100) Domestic violence, 6% (170) 6% (156) 7% (61) aggravated Sexual offense 3% (75) 1% (30) < 1% (3) Others 16% (478) 19% (500) 19% (165) Unknown 2% (56) 3% (70) 6% (53) TABLE 8 Type of Crime by Age-Group Age Type of Crime 30 31 40 41 50 > 51 Driving under the influence (n = 1,638) (n = 960) 19% (304) 16% (152) Theft (n = 843) 12% (99) Fraud (n = 534) 9% (48) Domestic violence, aggravated (n = 311) 10% (32) Sexual offense (n = 102) 10% (10) 29% (483) 35% (336) 32% (273) 40% (212) 35% (109) 24% (24) 26% (432) 28% (268) 32% (273) 30% (162) 32% (100) 31% (32) 26% (419) 21% (204) 23% (198) 21% (112) 23% (70) 35% (36) General nursing workforce* 11% 20% 22% 47% one crime. Driving under the influence (DUI) was the most frequently reported crime (29%). It was followed by violation of the Controlled (17%), theft (16%), and fraud (10%). At the time of disciplinary action, the mean age of the study subjects was 41 (SD = 10.70), ranging from 21 to 83 years. (Age information was missing on 126 study subjects.) Half of the subjects (n = 2,358) were age 40 or younger. The age distribution of RNs in the study group was roughly compatible with their proportion in the national nursing workforce; however, LPN/VNs ages 31 to 40 were overrepresented, with 37% in the study group versus 20% in the general nursing workforce. (See Table 2.) Gender information was retrieved for 3,890 study subjects; gender data were missing on 929 study subjects. The majority of the 3,890 subjects (76%) were female, and 24% were male. Among the 3,360 study subjects who had been licensed, 23% (n = 759) were male, which is more than twice their proportion (8%) in the nursing workforce. (See Table 3.) The three most common crimes did not vary by the gender of the nurse or nurse applicant. (See Table 4.) Males had higher percentages of DUI, aggravated, and sexual offense than females, and females had higher percentages of theft, fraud, and violations of the Controlled. Information on ethnicity was available in 40% (n = 1,941) of the study records. According to these data, 68% (n = 1,320) of the subjects with criminal in 2012 and 2013 were White/Caucasian; 12% were Black/African American, and 10% were Hispanic/Latino. The data revealed a similar composition of ethnic backgrounds among RNs and LPN/VNs with criminal and those in the general workforce. (See Table 5.) As noted, 88% of the subjects (n = 4,260) were licensed at the time of disciplinary action for a criminal conviction, and 12% (n = 559) were nurse applicants without previous license records. In 27% of the cases, the year of the crime was not noted. The proportion of LPN/VN licensees in the group disciplined for criminal (46%) was more than twice (19%) that in the general nursing workforce (NCSBN, 2015). (See Table 6.) The types of crimes did not differ greatly by licensure type (RN or LPN/VN) or by licensure status (licensed or applicant). (See Table 7.) RNs had a slightly higher percentage of DUIs, but the lowest of the groups in terms of theft. There were only small differences in the types of crimes when analyzed by age. (See Table 8.) The majority (92%) of criminal did not involve patients. Only 5% of the subjects (n = 216) were disciplined, for a total of 346 crimes involving patients. (See Table 9.) This information was missing in 3% of cases. Research Question 3 What types of actions were taken by the BONs in response to the criminal and what crimes led to a denial of nursing license by a BON for a first-time applicant? A total of 27 different types of disciplinary actions were imposed by BONs for criminal in the 2-year study 30 Journal of Nursing Regulation

period; probation of license and revocation of license were the most common. Because some BONs may be responding to more than one crime when they issue a disciplinary action, a subanalysis was conducted on the 975 subjects who received a single disciplinary action for a single crime. Probation of license was still the most frequent action for several types of crime. (See Table 10.) For violent crimes, BONs consistently issued more severe disciplinary action. (See Table 11.) For example, 82% (n = 32) of crimes relating to sexual offense led to termination of licensure. Within the group of 975 subjects who had received one disciplinary action for one crime, 22 cases involved patient-related crimes. (See Table 12.) In 91% (n = 20) of cases, BONs removed the nurse from nursing practice. BON actions included suspension of license, revocation of license, voluntary surrender of license, or denial of initial license or license renewal. Of the 53 BONs, 35 denied initial licensure actions to applicants for criminal conviction histories. (See Table 13.) Further review showed that 6% of the crimes that led to the denial of initial licensure involved patients (n = 25); that is, some nurse applicants were convicted of crimes involving a patient while practicing without a nursing license, presumably as a medical assistant or other health care provider. Research Question 4 How many nurses and nurse applicants with criminal failed to disclose their criminal histories to the BON? The data indicated that in 18% (n = 837) of the cases, the applicant or licensee did not disclose a criminal conviction to the BON as required. (See Table 14.) These subjects either misrepresented their criminal history during the initial or renewal licensure application process, or they failed to comply with the jurisdiction s self-reporting requirements. Discussion This study was a comprehensive retrospective review of licensed nurses and license applicants with a criminal conviction in 2012 and 2013 to better understand the number and types of crimes committed by nurses and how boards across the United States are responding. More than 4,000 cases from 53 BONs in 50 states met the study description of a criminal conviction, representing approximately 0.01% of licensed nurses in the U.S. at the time. The majority of the subjects were female, Caucasian, and between ages 30 and 44. Male nurses and LPN/VN licensees were overrepresented compared with the overall nursing workforce in the United States. Male nurses make up only 8% of the nursing workforce, but 23% of the study subjects were males. Criminal among health care professionals are a public policy issue rarely discussed in the literature. The study brings to light the small number of nurses committing crimes and highlights BONs actions in response to criminal. TABLE 9 Crimes Involving Patients (n = 346) Type of Crime Frequency (n) Percentage Theft 76 22% 73 21% Fraud 70 20% Neglect or abuse of child, adult 31 9% Driving under the influence 28 8% Sexual offense 14 4% Domestic violence, aggravated 8 2% Exploitation of vulnerable 7 2% individuals Manslaughter 3 1% Unknown 1 < 1% Other, labeled as misdemeanor 35 10% TABLE 10 Nonviolent Crime and Disciplinary Action Imposed (Single Action Against Single Crime Only) Type of Crime Action Taken % (n) Driving under the Probation of license 49% (149) influence (n = 304) Unspecified licensure action 15% (47) Violation of Suspension of license 28% (39) Controlled Probation of license 24% (33) (n = 140) Theft (n = 129) Unspecified licensure action 23% (30) Probation of license 16% (21) TABLE 11 Disciplinary Action Taken for Sexual Offense Type of Crime Action Taken % (n) Sexual offense Revocation of license 36% (14) (n = 39) Voluntary surrender of license 26% (10) Suspension of license 21% (8) Reprimand or censure 5% (2) Mirroring the national trend in criminal (FBI, 2013), the most frequent criminal among nurses and nurse applicants were DUI, violation of the Controlled Substances Act, and theft. The data further indicated that BONs often use probation for common crimes such as DUI. As expected, more www.journalofnursingregulation.com 31

TABLE 12 Disciplinary Actions Taken for Patient- Related Crimes Action Taken Termination of license (91%, n = 20) Nontermination of license (9%, n = 2) TABLE 13 TABLE 14 Self-Disclosure of Criminal Convictions on Board of Nursing Documents Disclosure % (n) Revocation of license 40.9% (9) Suspension of license 27.3% (6) Voluntary surrender of license 13.6% (3) Denial of license renewal 4.5% (1) Denial of initial license 4.5% (1) Censure 4.5% (1) Probation of license 4.5% (1) Criminal Convictions That Led to Denial of Licensure or Endorsement (n = 452) Type of Crime Frequency % Driving under the influence 116 26% Theft 73 16% 68 15% Fraud 42 9% Domestic violence, aggravated 29 6% Other, labeled as misdemeanor 74 16% Unknown 50 11% Licensed Nurses (n = 4,260) Applicants (n = 559) Total (n = 4,819) Reported criminal 81% (3,455) 92% (517) 82% (3,972) conviction Failed to report 19% (796) 7% (41) 18% (837) criminal conviction Unknown < 1% (9) < 1% (1) < 1% (10) severe disciplinary actions, such as revocation or suspension of license, are issued in cases of egregious crimes and especially for patient-related criminal activity. The data showed that about 18% of the study subjects had not disclosed their criminal conviction history to their BONs. A similar finding was reported in a prelicensure RN student study conducted in Louisiana (Smith, Corvers, Wilson, Douglas, & Bienemy, 2013). The authors reported that 18.2% of applicants with criminal histories did not disclose them. The correlation between criminal histories and practice violation has not been systematically analyzed (Priola-Surowiec et al., 2014). Clearly, not all people with criminal commit further violations (Priola-Surowiec, 2010). A high percentage (88%) of study subjects had criminal after being licensed. Thus, it may be worth considering criminal background checks (CBCs) after initial licensure. The Federal Bureau of Investigation Criminal Justice Information Services Division has developed its Rap Back service to enable ongoing status notification of any criminal activity that occurs after initial CBCs (FBI, 2014). Many nurses do not realize that they are held to a high moral standard and crimes committed outside the workplace can have serious repercussions on their licensure and the future of their career. Educators should focus on this in prelicensure education during discussions about regulation, licensure, and policy. Nurses should read their state NPA to learn more about behaviors that lead to discipline by a BON. More research is needed related to criminal in nursing. A longitudinal study following nurses with a positive criminal background to examine which individuals go on to commit further crimes or have disciplinary issues in the workplace is warranted. Limitations Disciplinary data are submitted to the Nursys database voluntarily by the BONs. Some records are incomplete as indicated. In most cases, there was not enough background information to determine whether the crime is a misdemeanor or felony. Finally, we compared our data (2012 2013) to the 2015 National Nursing Workforce Survey statistics, under the assumption that the composition of the nursing workforce did not change significantly in 2 years. Conclusion Information concerning nurses criminal conviction histories is important to BONs because it may allow them to provide necessary support and supervision. Overall, the vast majority of nurses are safe practitioners. Most crimes reported to BONs are not patient-related. Nevertheless, even crimes such as a DUI are serious because they may be indicative of poor judgment or may be a symptom of a serious underlying problem with alcohol. All crimes need to be addressed and evaluated by a BON. CBCs provide assurance that that information gets to the BON. This study provides evidence that BONs diligently address criminal and evaluate whether the conviction is an indication that the individual is capable of practicing nursing safely. Those who are deemed to pose a risk to the public are denied licensure or have their licenses suspended or revoked. Others are put on probation and monitored by the BON for a significant period of time. 32 Journal of Nursing Regulation

References Budden, J. S., Moulton, P., Harper, K. J., Brunell, M., & Smiley, R. S. (2016). The 2015 national nursing workforce survey. Journal of Nursing Regulation, 7(1 Supplement), S1 S92. Clevette, A., Erbin-Roesemann, M., & Kelly, C. (2007). Nursing licensure: An examination of the relationship between criminal and disciplinary actions. Journal of Nursing Law, 11(1), 5 11. Federal Bureau of Investigation. (2013). Crime in the United States 2013. Retrieved from www.fbi.gov/about-us/cjis/ucr/ crime-in-the-u.s/2013/crime-in-the-u.s.-2013/persons-arrested/persons-arrested Federal Bureau of Investigation. (2014). NGI Rap Back Service. Retrieved from www.aci-na.org/sites/default/files/credentialing_-_chasity_ anderson.pdf National Council of State Boards of Nursing. (2015). The National Nursing Database: A profile of nursing licensure in the U.S. Retrieved from www.ncsbn.org/national-nursing-database.htm Priola-Surowiec, V. (2010). Does past criminal behavior predict future criminal behavior? Journal of Nursing Regulation, 1(3), 33 37. Priola-Surowiec, V., Abram, T. G., Alexander, M., Evans, S., Fullmer, S., Kunard, L., Rixey, D. (2014). Guidelines for assessing candidates with criminal histories. Journal of Nursing Regulation, 5(3), 33 37. Smith, D., Corvers, S., Wilson, W., Douglas, D., & Bienemy, C. (2013). Prelicensure RN students with and without criminal histories: A comparative analysis. Journal of Nursing Regulation, 4(1), 34 38. Waneka, R., Spetz, J., & Keane, D. (2011). A study of California nurses placed on probation. Retrieved from www.rn.ca.gov/pdfs/forms/probnurse.pdf Zhong, E. H., Kenward, K., Sheets, V. R., Doherty, M. E., & Gross, L. (2009). Probation and recidivism: Remediation among disciplined nurses in six states. American Journal of Nursing, 109(3), 48 50, 52 57; quiz 58. Elizabeth H. Zhong, PhD, is associate, Research, National Council of State Boards of Nursing, Carey McCarthy, PhD, MPH, RN, is director, Research, NCSBN. Maryann Alexander, PhD, RN, FAAN, is chief officer, Nursing Regulation, NCSBN. www.journalofnursingregulation.com 33