Recognizing Impairment in the Workplace Nursing CE Course

2.0 ANCC Contact Hours AACN Category C


“Can you help me?  I am a nurse and I am addicted to alcohol.  I never thought this would happen to me!  I began drinking in nursing school to help ease the pressure and stress. And it worked.  I felt better.  I took my first job in critical care and soon found myself on an emotional rollercoaster of highs and lows.  And I thought nursing school was stressful!!  I needed relief, so my drinking escalated. I was working long hours, rotating between the day and night shifts and had personal issues at home.  I needed to sleep, so I self- medicated with alcohol.  And it worked until it didn’t.  I couldn’t stop.  I tried but I just couldn’t do it.  My work was beginning to suffer and I knew it.  I was frightened and unable to ask for help.  What would happen to me, a professional nurse who was an alcoholic?”

Would you be able to help a colleague with a Substance Use Disorder?  Do you have the knowledge regarding this disease to be of assistance?

Do you have the courage to report a colleague who is practicing impaired?

Have you examined your own beliefs and attitudes about addiction?

Can you provide support and compassion for a colleague who is returning from treatment for SUD?

Make no mistake about it, you will encounter a nurse colleague with substance use disorder in your career.  You are probably working with a nurse who is addicted to either alcohol or drugs.  

The following information is designed to assist you in answering each of these questions.

Substance Use Disorder (SUD) and Addiction

Substance Use Disorders, (alcohol and prescription or illicit drugs), are on the rise in the United Sates. The Substance Abuse and Mental Health Services Administration (SAMHSA) has estimated over 22 million Americans abuse either drugs or alcohol.  According to The American Nurses Association, approximately 10% of nurses use drugs or alcohol to the level of work performance impairment.   Since there are roughly 3 million nurses employed in the American workforce, this translates to approximately 300,000 nurses who are affected with a substance use disorder. To further highlight the significance of the problem, this means if you work with ten nurses, one of them is addicted to drugs or alcohol or both. 

“As the backbone of the U.S. healthcare system, nurses are essential to the quality of care and well-being of patients. Nurses with untreated addiction can jeopardize patient safety because of impaired judgment, slower reaction time, diverting drugs from patients, neglecting patients, and making mistakes, wrote Debra Dunn, RN, in an often-cited study, "Substance abuse among nurses—Defining the issue," in the October 2005 edition of the AORN Journal, which serves the Association of Peri-Operative Registered Nurses. 

Because the prevalence of drug and alcohol addiction in nursing is on the rise, nurses are faced with a major health risk and a growing crisis. 

According to the DSM-V, substance use disorders are defined as a configuration of symptoms resulting from the use of a specific substance, ranging in severity, which result in a variety of physical, social, financial and psychological consequences. 

The SUD configuration of symptoms can range from abuse, or dependency to addiction.  Addiction is defined as a treatable, significant, progressive, compulsive, chronic, life threatening disease process.  Addiction causes chemical and physical changes in the brain that cause these individuals to believe they are in control of the situation and do not have a problem.  An individual with an addiction (alcohol or drugs) cannot stop using them despite the significant consequences that occur. 

Substance Abuse and Mental Health Services Administration (SAMHSA). (1999) identifies five stages of addiction:

  • “contact (first use of intoxicant, experiences the pleasure of using)

  • experimental use (occasional, using to feel good)

  • excessive use (chasing the high, getting drunk and passing out)

  • addiction (use despite negative consequences)

  • recovery (restoring the mind, spirit and body to health and equilibrium)”

Addicted individuals experience tremendous guilt and shame, and are fearful of losing their reputations, jobs, family, and friends. Additionally, addiction is even more devastating for healthcare practitioners.  Not only is it a breach of professional ethics, it puts patients at risk as well. Nurses can be particularly hard on themselves and colleagues who may be addicted. There is a prevailing stigma in American society that addiction is a moral failure or lack of willpower rather than a disease. This stigma often prevents individuals, including nurses, from seeking much needed treatment.

Addiction affects health care institutions as well as the nurse who experiences SUD.  There are legal implications for institutions if there is a violation of state and federal regulations.  Violations in regulations lead to financial consequences for health care institutions.   This may occur in cases of drug diversion.  The reputation of the hospital is at risk when the public is informed of addicted health care workers continued employment at the institution.  Poor patient outcomes may be a consequence of addiction, especially in the areas of pain relief following a surgical procedure.  It is imperative that health care institutions have strict security measures and monitoring polices for controlled substances in place to deter tampering and diversion of medications.

Risk factors for SUD

In 2012, the National Institute of Drug Abuse (NIDA), published a study that indicated that genetic factors account for 40-60% of an individual’s susceptibility to addiction. Vulnerability to addiction is also influenced by environmental, behavioral, social and psychological factors. 

Environmental factors may include:

  • Place of residence; inner city and rural areas have a higher rate of addiction

Behavioral factors may include:

  • Poor interpersonal relationships
  • Academic problems
  • Issues involving the criminal justice system
  • Use of a variety of substances

Social factors may include:

  • Easy access to alcohol or drugs
  • Involvement with a peer group who condone use and abuse of alcohol or drugs
  • History of substance abuse in the family
  • History of violence
  • History of psychologic and or emotional abuse

Psychological factors may include:

  • Low self esteem
  • Depression or PTSD
  • Anxiety
  • Feelings of hopelessness or helplessness
  • Feelings of loss of control
  • Resentment

Several research articles have identified risk factors for developing SUD in the general nursing population. These include:

  • Job-related stress:  staff shortages, increased patient acuity, shift rotations, long work hours, lateral violence and in some cases bullying.
  • Access:  Drugs are readily available to nurses.  Nurses also have been trained how to administer drugs with their resulting effects and side effects.  Lack of institutional controls may also make access easier.
  • Attitude:  There is a tendency to believe that since nurses are educated about the use of a variety of drugs they know enough about them and believe they are in control and will not become addicted.   The attitude of, “it won’t happen to me” is prevalent.
  • Lack of education:  Nurses are not well educated on issues of addiction.

The likelihood of nurses with SUD (alcohol and drugs) varies across the spectrum of specialties.  According to the National Council of State Boards of Nursing (2011), nurses who work in the Emergency Room, Operating Room or Mental Health areas have a higher rate of abuse than other specialties.  On the opposite end of the spectrum, nurses who are employed in pediatrics, women’s health and school nursing have the lowest rate of SUD. 

Specific behavior changes and physical signs associated with SUD

Behavior changes indicative of SUD include:

  • Change in job performance
  • Changes job frequently
  • Prefers night or off-shifts where there is less supervision and more access to medication
  • History of chronic pain
  • Increased absences
  • Frequent trips to the bathroom or off the unit
  • Consistently arriving late for work
  • Consistently making excuses for leaving work early
  • Frequent errors: medication errors as well as documentation errors
  • Increased isolation from colleagues
  • Changes in appearance (subtle)
  • Inappropriate verbal or emotional comments or responses to situations
  • Inappropriate attire designed to conceal possible needle tracks (long sleeves in the summer months)

Physical signs of SUD may include:

  • Hand tremors
  • Shakiness
  • Slurred speech
  • Diaphoresis
  • Unsteady gait
  • Runny nose
  • Pupillary changes (either dilated or constricted)
  • Alcohol on breath or excessive use of breath mints or mouthwash
  • Memory lapses
  • Confusion or trouble focusing on work
  • Diminished alertness

Specific signs of diversion

Signs of diversion are often subtle and require observation over a period of time to determine if patterns exist.  For example, a nurse who consistently makes numerous corrections on documentation regarding medication administration dosages and often has difficulty reconciling narcotic counts at the end of their shift may have a SUD.  Nurses who consistently have patients who complain of little or no pain relief despite pain med administration may be diverting narcotics.  Altered telephone or verbal orders from the primary care provider may indicate diversion. 

Another sign of diversion may be documentation of large amounts of wasted narcotics or no documentation at all of wastage.  Nurses who “volunteer” to work several extra shifts or are quick to offer pain medications to patients other than their own may also be diverting drugs.  Frequent administration of PRN pain medications to assigned patients or removing controlled substances from recently discharged patients is also a warning sign of diversion.

The highly regarded, least suspected, “Super Nurse” who is experienced, skillful and always working extra shifts despite her enormous family and personal obligations, is often the nurse who has a SUD.  

Drug diversion is a serious and frequent problem in the health care system with resulting legal and financial ramifications for the institutions, employees and patients.  Nurses need to be educated and vigilant regarding the signs of drug diversion and report them to their immediate supervisor.

Reporting responsibilities of the nurse

Nurses have a professional and ethical responsibility to report their colleagues to their immediate supervisor.  In some states, nurses have a legal requirement to report their colleague to the Board of Nursing.

Staff nurses are generally the first people to suspect or recognize an impaired colleague. Nurses are often reluctant to report a colleague suspected of SUD.   Sometimes, nurses just don’t know what to do; they lack the education regarding SUD and the necessity of reporting these individuals to their immediate supervisor.  Since nurses experience emotionally and physically demanding situations with little time to decompress, observations a nurse may make regarding a possible SUD situation may be regarded as a normal reaction to a stressful situation or shift.  Also, nurses develop a strong bond with each other; a friendship, a connection, a relationship that is like none other because of their shared experiences.  It is difficult to report a friend and colleague without knowing the consequences of that action.  Nurses do not want to report their colleagues for fear they will be labeled a “trouble-maker, a tattler.”  The length of time to investigate the report can sometimes be long and arduous with supervisors constantly asking for more proof, more documentation, and more evidence from the reporting nurse.  This requires a significant amount of time and energy which may take away time spent with patients.  Nurses may sometimes feel that state Boards of Nursing have become too punitive rather than supporting the nurse in her efforts to seek treatment with an opportunity for recovery.

 Although it is difficult to report a colleague, not reporting risks patient safety, institutional status, and a delay in treatment for the nurse with SUD.  But, most of all, reporting your colleague and friend may actually save her/his life.

Investigation and intervention

When there is evidence of unsafe practice and risk to patients, an investigation into the matter is warranted.  Typically, witnesses are interviewed for specific information and observations about the nurse in question.  Witness statements are then gathered to document SUD or diversion.  A multitude of documents are reviewed including patient charts, MAR’s, and narcotic count documentation for a variety of shifts.  The nurse is also referred for drug screening at this time.  It is of utmost importance that state and institutional policies and procedures regarding reporting, investigation and intervention are followed.  Once the investigation is complete and there are findings confirming SUD or diversion, an intervention is planned and scheduled.  Interventions are formal, structured meetings facilitated by a trained professional.  During the intervention, the nurse is confronted and hopefully convinced that she/he has a problem with substance use that has affected colleagues, the facility, and the patients they cared for.  The primary goal of an intervention is to give the nurse hope and assure them that help is available.

Discipline vs. non-discipline approaches (ADP) to nurses with SUD

Boards of Nursing are given the power to regulate nurses in their state. Nurse Practice Acts are designed to clearly define the scope of practice for nurses and help them in determining what is unsafe practice. The primary charge for Boards of Nursing is to protect the public from unsafe practice by nurses.

When addressing nurses with impaired practice or diversion activities, two primary approaches have been used; discipline or alternative to discipline programs (ADP).

Discipline involves due process and is typically administered by the nursing regulatory body in each state, usually, the Board of Nursing. Each Nurse Practice Act has information related to:

  • Grounds for disciplinary action
  • Investigation methods (policies and procedures)
  • Board proceedings (time frames for due process)
  • Disciplinary actions including: removal from practice, written reprimand, limited license, license revocation, probation and suspension of license

 Some state Nurse Practice Acts provide the Board of Nursing with authority to mandate a mental health and/or physical exam.  These evaluation reports include a variety of information including:

  • Family history of substance abuse
  • Prior treatment attempts by the nurse
  • Motivation to participate in treatment
  •  Employment history
  • Criminal implications of the nurses’ SUD
  • Social support system
  • Coexisting mental health problems

This information guides the Board in arriving at a decision regarding the nurse with SUD or diversion issues.  Since Boards of Nursing are not responsible to advocate for the nurse with SUD or diversion issues experts recommend that the nurse obtain legal counsel prior to any investigation.  Disciplinary proceedings are serious matters and legal counsel is necessary to protect the nurse.

If, after due process, the nurse is found guilty, the license may be suspended or revoked with no ADP or program of recovery offered.  If the nurse is terminated from his/her position, they have no access to health care which would provide treatment options.  Legal charges may be filed with loss of livelihood in cases of diversion.  If the nurse is prosecuted with resulting incarceration, this criminal record may forever prevent a nurse from practicing again.

Alternative to discipline programs, (ADP) are voluntary, non-disciplinary opportunities for nurses to recover.  These programs have been in place for over 30 years and are non-punitive with the focus of returning the nurse to work after successful treatment.  State Boards of Nursing typically enter into a contractual agreement with a third party to administer these programs.  ADP specific requirements are varied from state to state but essentially have provisions that will provide the nurse with a treatment program, establishing and documenting physical sobriety and a program for long term recovery. 

One of the advantages of ADP for Boards of Nursing is the fact that they are a good option to avoid a long period of investigation in which the nurse can still practice and place patients at risk.  An ADP is determined in a private agreement between the third party and the nurse and is not made public as the Board proceedings in disciplinary cases.  ADP provide nurses who fear the public shame and guilt of disciplinary proceedings a very helpful and humane option for treatment.  ADP give nurses the opportunity for treatment and rehabilitation. 

Treatment options leading to recovery

Treatment options for nurses can include residential inpatient treatment and intensive outpatient treatment sometimes called “Day Programs.”.   The State Board of Nursing ADP contracted program will determine the type of treatment necessary after an extensive evaluation to assess the extent and severity of the addiction. 

Residential treatment Programs

The primary treatment option for nurses with SUD is residential treatment.  Inpatient treatment programs provide a safe place for trained professionals to carefully monitor their progress from detox to help prevent adverse physical withdrawal symptoms, through a comprehensive treatment plan.  Generally, the treatment plan involves individual and group counseling.  Some residential facilities have specific groups for health care professionals that provide a safe place to discuss concerns unique to the health care provider. 

Topics for discussion can include:

  • Education regarding the disease of addiction
  • Relapse prevention
  • Licensure issues
  • Legal issues
  • Guilt and shame
  • Compliance with required after-care
  • Returning to work issues
  • Healthy coping skills for specific practice situations

Residential recovery programs are typically based on 12 step programs and principles.  A 12-step program is a fellowship of people helping other people with an addiction to obtain abstinence, which means no longer using mood-altering substances such as drugs or alcohol.  For example, Alcoholics Anonymous is an organization that unites people who have struggled with alcohol dependency, providing strength and faith in one another to overcome addiction.   12-Step programs promote the following fundamental beliefs:

  • Addiction is a disease
  • Addicts require the support of other recovering addicts
  • Reliance on a “power greater than one’s self” is fundamental
  • Abstaining from the addictive behavior is the basis of recovery
  • Recovery is a lifelong process
  • Supporting others in recovery is necessary for lasting commitment and stability
  • Accepting the limitations of being human is essential

12 step meetings are held frequently and attendance and participation is required.  Health care professionals, including nurses, often meet separately in Caduceus 12 step groups.  Step work is required prior to discharge to provide the nurse with the best opportunity for sobriety and long term recovery.  Additionally, nurses are often required to have a “12 step Sponsor” prior to discharge from the treatment facility.

Typically, residential treatment programs are twenty-eight days although the extent and severity of the addiction may require shorter or longer stays.

After residential treatment is completed, health care professionals are often required to continue their recovery by transferring to a half-way house or some type of therapeutic living community for several weeks or months, depending on their specific needs and the ADP requirements.  These therapeutic living environments provide additional opportunities to further develop and practice healthy living and coping skills.  Additionally, these environments provide continued individual and group counseling sessions as well as regular 12-step meetings.  This structured environment provides the nurse with additional time to integrate newly learned skills of a balanced, sober life as well as develop new, lasting relationships with other nurses and health care professionals in early recovery. 

Intensive Outpatient/Day treatment programs 

These programs do not require nurses to spend the night in a facility.  Rather, nurses are expected to spend a specified amount of time ranging from 30 days to nine months attending the treatment program.  These programs may require the nurse to spend several hours each day in treatment or just a few hours each day. 

 Topics covered in Outpatient programs typically include those similar to residential treatment programs:

  • Cognitive/behavior therapy
  • Individual Counseling
  • Group Counseling
  • 12-step meetings
  • Family Therapy
  • Relapse prevention

Outpatient programs typically have less supervision, are more flexible and allow the nurse to live at home.  Depending on the type and severity of the addiction, some nurses will benefit from this type of program.

Requirements for nurses with SUD returning to work

A study by Young in 2008 found that approximately 70% of nurses with a SUD who seek treatment successfully return to practice nursing.  However, returning to work for most nurses who have successfully completed an intensive treatment program, is stressful and frightening.  Support from colleagues as well as family and friends is paramount during the re-entry phase.  Precise, clear, and attainable monitoring policies and procedures must be in place to assist the nurse in compliance. 

Return to work contracts are developed with the nurse and the ADP to provide a legal basis for monitoring the nurses progress.  Clear parameters for work hours, work performance, any practice restrictions, record keeping, follow-up meetings with employers, work place monitors, counselors, drug screening, non-compliance consequences and Board of Nursing follow-up (if required) should be included in the contract.  This contract is mutually beneficial to the nurse and the employing agency to ensure monitoring is completed as required.

The monitoring plan is somewhat individualized to each nurse with an SUD returning to work.  However, common elements of these plans include:

  • Self-report/assessment regarding progress and compliance with contract requirements
  • Reports from treatment professionals such as therapists, counselors, social workers
  • Reports from work site monitors that provide any issues with work performance or attendance
  • Meeting attendance for 12 step programs as well as communication with a sponsor
  • Random drug testing at a specified testing center with required standardized protocol
  • Professional support group attendance

Although monitoring contracts can provide a structured, “safety net” for nurses with SUD returning to work, relapse may occur.  Relapse is a progressive process with clear warning signs that must be monitored as well.  Signs of relapse are often subtle at first and include: 

  • Change in participation in recovery activities including decreased attendance at 12 step meetings, lack of communication with 12 step sponsors, lack of honesty in communications
  • Failing to comply with treatment protocols
  • Changes in job performance
  • Missed drug screens or dilute urine samples
  • Labile emotional status 

If the nurse does in fact, relapse, contract requirements will determine the next course of action.  Some state Boards of Nursing have ADP that allow a nurse to relapse and return immediately to the program.  A new contract is generated and monitoring continues.  However, this process does not continue indefinitely when a nurse relapses.  Terms of the contract must be met or consequences will follow.  If patients are at risk or actual physical harm has been done, the state Board of Nursing will intervene to remove the nurse from practice. 

“I am a nurse in recovery.  I will be forever grateful to my colleague, that cared enough about me to report my behavior to my supervisor.  As bad as I thought that day was, it actually saved my life.  After a 28- day treatment designed specifically for me as a nurse and an additional 4 week stay at a half-way house, I was allowed to return to work on a very specific monitoring program.  I was assigned a caring, supportive and encouraging workplace monitor.  We met several times a week initially and then gradually decreased our meeting times.  I also was in a random drug testing program for 3 years.  But, probably the most important thing for me was regular attendance at my 12 step group and my work through the 12 steps with a very wise and supportive sponsor.  To this day, my recovery is first and foremost in my life.  I am one of the ‘lucky” ones.  I have been able to return to work and do what I love most.  Care for my patients!  Thanks for helping me.” 

Addiction is truly a cunning, powerful, baffling disease that can affect anyone regardless of socio-economic standing, educational level or job, or position in life.  Nurses are affected at nearly the same rate as the general population. But there is help, a way out, treatment that is successful in putting this chronic disease in remission.  It is a life -long process. 


Mary is a RN working in the Emergency Room.  She has never been late or missed a day of work until recently when she has called in sick at least once a week for her scheduled 12 -hour day shifts because of vague headaches and GI symptoms.  She has expressed significant marital problems and has recently lost her mother after a long illness.  Her appearance has been slightly disheveled and her breath has a “sweet” smell particularly when she arrives for her shift.  Her once neat hand writing has become sloppy and illegible.  As her colleague, you suspect possible SUD.

Questions for reflection:

  1. Examine your own beliefs and attitudes about addiction.  Are they supportive or judgmental?
  2. Would you be able to report Mary to her supervisor?  Why or why not?  What barriers do you face to reporting a colleague?
  3. Is there a mandatory reporting law in your state? 
  4. Does your state provide a nurse with a Substance Use Disorder with an opportunity to participate in an Alternative to Discipline Program?


National Institute of Drug Abuse (NIDA). (2012). Principles of drug addiction treatment: A research based guide (3rd ed.) [NIH Publication No. 12-4180]. 

Substance Abuse and Mental Health Services Administration (SAMHSA). (1999). Prevention works: Nurse training course on the prevention of alcohol and drug abuse

National Council of State Boards of Nursing (NCSBN). (2011). Substance use disorder in nursing: A resource manual and guidelines for alternative and disciplinary monitoring programs. Chicago, IL: Author.

Thomas, C. M., & Siela, D. (2011).  The Impaired Nurse.  Would you Know What to Do if You Suspected Substance Abuse? American Nursing Today, 6(8)  

Young, L. (2008). Education for Worksite Monitors of Impaired Nurses. Nursing Administration Quarterly, 32(4), 331-337. 

Kunyk, D. (2015).  Substance use disorders among registered nurses: prevalence, risks and perceptions in a disciplinary jurisdiction.  Nursing Management, (23) 54-64.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders—DSM V. New York: American Psychiatric Association, 2013.

Dunn, D. (2005). Substance use among nurses—Defining the issue. AORN Journal, 82(4), 573-596.

American Nurses Association (ANA), & International Nurses Society on Addictions (IntNSA) (2013). Addictions nursing: scope and standards of practice. Silver Spring, MD:

International Nurses Society on Addictions (IntNSA). (2015). Core curriculum of addictions nursing (3rd edition). Philadelphia, PA: Wolters Kluwer.

Monroe, T. B., Kenaga, H., Dietrich, M.S., Carter, M. A., & Cowan, R. L. (2013). The prevalence of employed nurses identified or enrolled in substance use monitoring programs. Nursing Research, 62(1), 10-15.