Is Your Nursing Colleague Impaired

Alcohol and Drug use in the Workplace

Part II Reporting and Rehabilitation

After completing this lesson, you will be able to:

*While much of the information in this lesson may apply to a range of health care providers,
it is focused toward licensed nurses.

While estimates vary, the American Nurses
Association (ANA) reports that 6-8% of
licensed nurses jeopardize patient care by
working while impaired by drugs and
alcohol--the most common causes of
impairment in nurses.

Some of your colleagues may be
struggling with this serious problem.

How can you help?

Indicators of drug abuse
·Errors in documentation & patient care
·Illegible handwriting
·Failure to do a narcotic count
·Uses maximum PRN dosage when other nurses use less
·Work habits deteriorate
·Prefers units with high narcotic use
·RARELY absent—needs access to drugs
·Frequently takes bathroom breaks
·Pinpoint pupils, runny nose, watery eyes, diaphoresis, etc.
·May be sleepy or hyper while working
·Offers to help give meds to other nurses’ patients
·Patients complain of no pain relief
·Prefers PMs and night shifts

Indicators of alcohol abuse
·Alcohol odor on breath
·Tremors of the hands
·Emotional instability/mood swings
·Lapses in memory or confusion
·Sleepiness or dozing off at work
·Increased tardiness & absenteeism
·Complains of personal/financial problems
·May withdraw from colleagues
·May have transportation issues if convicted of Driving While Intoxicated
·Erratic job history; multiple employers
·Slowed, thick speech
·Errors of judgment
·Excessive use of mouthwash/mints

Your Professional Responsibility

Take a moment to think about this question.

What should you do if you suspect a colleague is working while impaired by drugs or alcohol?

Here's what some nurses say...

Nate, Student
You have to do everything you can to ensure patient safety.  Even though this may be hard, you may have to report your coworker to the supervisor

Kris, MS,RN
I think that the first step is to be sure.  Have an interaction because there is a lot of stigma associated with this.  You want to have some example or something that you can use to back up your thinking.  The second thing I think you should do is look at the policies and procedures for the organization because often times this is addressed, and there is a process that you go through, a person that you identify.  Many times it's the person's supervisor, but you want to make sure that the process is done correctly so that the nurse that you suspect is impaired gets what they need both from a due process perspective and any assistance that they may need with this. 

Well, as a chief anesthetist I was very familiar with all of our patients…all of our nurses, but the thing I think there's just no…they know when I hired them that if there's any question about alcohol or drug abuse of any type, they would be released right on the spot.  They would be sent home, and then they would be investigated at that point.  I did have one nurse anesthetist that came to work with just alcohol on his breath.  He was an 11 o'clock person.  He was sent home immediately.  He was put on probation and we had no problems after that, but I think all of us are scrutinized by each other because we're a group that wants to see total patient care, and we don't want to see anything happening by one or two individuals.

Linda, MSN, APRN
That's a hard thing to do because often times your colleagues are the people that you are suspecting, and it's like ratting on your best friend when you were a child.  It is very, very hard thing to do, but I think it's important to remember that we do as nurses have a legal obligation to report suspicious behavior.  I always think of my patient's safety first, and you do have to be aware of this when you're working with colleagues who you think are impaired, and it is essential that you report suspicious behavior to the supervisor so that the behavior can stop and your patient's safety it doesn't…is not an issue then.  I also have been in situations where I an suspicious of someone's behavior and I've never seen anything concrete while I worked with them, and there have been other opportunities away from the job where I will confront an individual about their behavior and that seems sometimes a little more humane.  There's been a few times when it has made a difference in people's lives, and they have gone on and gone to EEP programs, and there's been other times where it hasn't made a bit of difference, and so I think always thinking about your patient's safety first is important, and if you do have an opportunity to confront an individual or a friend or a colleague on the side and keep it to the details, this is really important to not become emotionally involved and to place judgment but to define very clearly the details that you're concerned about.

As a licensed professional, your primary responsibility is the care and safety of patients.

“It is a nurse’s responsibility to respond to a coworker’s questionable practice as an advocate for the patient.”

You are legally and ethically required to report violations of your state’s nursing code and statutes that put patients at risk.

“Many coworkers observe unsafe behaviors but are reluctant to report nurses with whom they work closely and whose personal/professional concerns they understand.”

Example of One State's Statute

The Wisconsin Statutes and Administrative Code and Rules of Conduct (Chapter
N7) relating to the Practice of Nursing refers to the problem as follows:

N 7.03(2) “Abuse of alcohol or other drugs” is the use of alcohol or any drug
to the extent that such use impairs the ability of the licensee to safely and
reliable practice.

N 7.04 “misconduct or unprofessional conduct” means any practice or
behavior which violates the minimum standards of the profession necessary
for the protection of the health, safety, or welfare of a patient or the public.

Misconduct includes, but is not limited to:

Administering, supplying or obtaining any drug other than in the course of
of legitimate practice or as otherwise prohibited by law;
Failing to report to the board or to the institutional supervisory
personnel any violation of the rules of this chapter by a licensee.

Why is it so hard to report a colleague--maybe even a friend?

Reporting can be difficult, but,

“This harsh approach is necessary when the
impaired practitioner puts patient care at risk.
Kindness promotes chemical dependency, and
the harsh action may be the only event that
breaks through the denial.”

What should you do?

Here’s what the ANA suggests:

What is the process for reporting in your organization?

Is it ever OK to confront the suspected nurse colleague yourself?

Colleague-to-colleague confrontation does not meet the legal & ethical requirements of the profession, although...

It can be a supportive part of the process of reporting the impaired nurse, leading the impaired nurse to self-report or seeking a reasonable explanation for suspicious behavior.

Documenting & Reporting

“If impaired practice poses a threat or
danger to self or others, regardless of
whether the individual has sought help,
the nurse must take action to report the
individual to persons authorized to
address the problem.”


You work in the Trauma Center of a busy, urban hospital. You have a growing concern that “something’s not right” with your colleague, Jane, and decide to pay closer attention to her behavior.

You should start the process that may lead to reporting and intervention with careful observation and documentation.

Documentation can be informal or formal.

First, let's talk about informal documentation.

Informal documentation...

Formal documentation...


The supervisor is also responsible for:

Leading, or arranging for, direct intervention with the suspected nurse, and

Confronting and reporting the suspected nurse according to the protocol of the organization. This may involve:

If your efforts to report within your organization are ineffective, contact your professional association or state Board of Nursing for direction on how to proceed.

An intervention is a formal, structured meeting used to confront an individual with a drug or alcohol problem.

The intervention may be led by a supervisor or a trained specialist; other colleagues, administrators, legal or law-enforcement personnel may be involved, depending on circumstances.


Although it’s hard to report a colleague, it can be a positive step because

“The consequences of not reporting concerns can be far worse that those of reporting the issue.”

Support for the Impaired Nurse

“We should care about nurses with addiction because they are our colleagues…[after all], we’d care about them if they had heart disease, fragile diabetes, or any other chronic disease.”

Support is not the same as treatment, but may include referral to treatment. Drug and alcohol treatment varies by nurse and could include inpatient, outpatient, 12-step programs, individual and/or family counseling, aftercare, follow-up, etc.

Nurses in treatment do not automatically lose their licenses; consult your state boards of nursing* for more information.

*See Resources section for National Council of State Board of Nursing web address.

Support, treatment options and legal criteria vary according to circumstances, organization and state.

Employee Assistance Programs within an organization can be a
good resource.

Some state professional associations* provide a
peer assistance program to serve as a resource for nurses, their
families, friends and employers.

Most state boards provide an alternative-to-discipline program
for licensed nurses who qualify; some states do not yet provide this
option or have programs pending.

*See Resources section for ANA web address.

Employee Assistance Programs
Employee Assistance Programs (EAPs) are company- or union-sponsored programs that serve the needs of employees/members and their families by identifying and addressing a broad spectrum of work-related or personal health, economic and social issues including substance misuse/abuse and mental health... EAP services vary across programs from those addressing only problems related to alcohol and drug use to those covering a range of problems (e.g., emotional, psychological, marital/family, job stress, alcohol, drug, legal and financial).

Peer Assistance Programs
The availability of peer assistance programs for impaired nurses varies by state; contact your state board of nursing. Peer assistance programs typically offer support and advocacy, not treatment. Here is an example from the Massachusetts Nurses Association: “The MNA Peer Assistance Program is one of advocacy and will assist nurses with substance abuse problems to explore options available to them. Contact with a supportive peer assistant can help lessen the devastation in the life of a nurse struggling with addiction, preserve a career, and return a valuable resource to the healthcare community.”

Alternative-to-discipline programs
Vary by state Regard chemical dependency as a treatable illness Offer nurse a structured approach to recovery, keeping license, and returning to work Help remove barriers to reporting because the intended outcome is rehabilitation and return-to-work Make nurse accountable for meeting specific criteria for treatment, recovery and return-to-work Monitor nurse over a designated period May include referral to a Peer Assistance Program that provides nurse with personal support of a nursing colleague May help nurse to retain license if certain criteria and conditions are met Promote patient safety through retention of a qualified and healthy nursing workforce (Trossman, 2003)

Example: Here’s a summary of the goals of the Colorado Nurse Health Program. Purpose: Our purpose is to reasonably ensure patient safety while providing the nurse an opportunity to get into treatment and recovery, keep his/her license, and go back to work. How we ensure patient safety: We require that the nurse maintain a strong recovery program, a treatment and monitoring contract, and a well planned back-to- work agreement.

* See Resources section for sample return-to-work agreement.

They will be monitored to insure that terms of the return-to-work agreement* are met; this may include random body-fluid testing; and other requirements; They are typically assigned to areas with limited drug availability and a manageable level of stress; Their schedules are designed to allow access to the required meetings and activities needed to support recovery.

Support and rehabilitation are important because many nurses who meet and maintain the terms of treatment and recovery are able to return to work.

When they do return to work.

Linda, MSN, APRN

Well, I think that treatment is successful for many, many patients.  I do believe that nurses can be rehabilitated like any other individual regardless of their profession. Impaired nurses are not separate from the rest of the addicted…the rest of the dependent community in that a nurse, physician, lawyer, professional, homeless, someone who is homeless, they all have the same needs, which is to have access to a program that helps them move towards abstinence.

Supporting Return to Work

It may be hard to welcome the return of a nurse who worked while impaired, and “Some nurses may make it difficult for recovering nurses to be accepted back into their roles.”

Being supportive of a colleague’s return to work helps promote:

Activity about welcoming the return of impaired nurse

You know via the hospital grapevine that Jane, the new nurse on your unit, had to leave her job in the Trauma Center because she was working while impaired by alcohol. You’re concerned about how this will affect you, other nurses and the patients.

Welcome Back, Jane...

What are some of your fears about Jane’s return-to-work?

What are some positive things you can do to make it work?

Did you think about…


Case Study

Jane recovered and returned to work with the help of her state’s alternative-to-discipline program.
Let's listen to her story.
(Based on a true story)

Jane’s Story: It’s hard to say when my problems started, but things got a lot worse after my third divorce. I was just so anxious and lonely. No family, no friends. So, when I got home from my pm shift in the Trauma Center, it was just me and the wine. With the stress of working in a big city trauma center, I convinced myself that I deserved the wine—good wine, not the cheap stuff. I used it to de-stress from my job and to forget how I messed up my life. Except for my work, I was such a loser. Eventually, I was drinking two full bottles of wine every night. I knew I might not be completely sober when I showed up for work the next day. I lived in fear of being late for work, but I never was. To cover the smell of alcohol, I kept a stash of mouthwash, gum and breath mints in my car, my purse, my locker, my pocket. Then one night, things fell apart at work. A trauma case arrived just as my shift started. Honestly, I was still hung over, and combined with the stress of the case, I made the wrong dosage calculation for a major med and almost killed the patient. Another trauma nurse corrected the error and confronted me. He came right out and asked me if I was using---said I didn’t seem to be myself and that he didn’t think I could carry out my duties. And then, he demanded that I do a drug and alcohol screen. (pause) I just turned and left without even notifying my supervisor. I was about half way through my first bottle of wine when the phone rang—it was my supervisor. The trauma nurse had reported me. The supervisor said she would have to report me to the board of nursing unless I came in to talk with her in the morning--said she wanted to help me get the help I needed. What was my reply? I threatened to resign and did. But report me she did, and, as hard as it’s all been, it turned out to be the best thing she could have done. By then, I was ready to change my life. I met with the investigator from the board who presented what was called “objective information of fact finding” from my employer. Because it was my first offense and I had a good record as a nurse, she offered me a chance to be in their Alternative-to-Discipline program. I could keep my license, and work, if I met some pretty strict requirements for a year: alcohol treatment, personal counseling, AA, random body-fluid testing at work, regular reports from my supervisor. If I missed even one thing I was out. But as they say, “it works if you work it”. That was five years ago and I’m a fully functioning nurse again. Without the Alternative-to-Discipline program, who knows where I’d be? My former employer agreed to hire me back as a staff nurse on a medical unit where it was a lot less stressful. I have to say—it was pretty humbling to submit to random fluid tests and not easy to rebuild trust, but I did it. I also completed my master’s degree in public health and now work in a preventive health setting. And something else—I’m a volunteer peer counselor for other impaired nurses. Everyone deserves a second chance, right?

What If You Don’t Report?

What if YOU are working while impaired?

There is help available—ask for it.

Protect your:

Don’t wait to be reported!


“Nurses must be vigilant to protect the patient, the public and the profession from potential harm when a colleague’s practice, in any setting, appears to be impaired.”

Content Author:
Mary Jo Willis, MS; University of Wisconsin-Madison School of Nursing
Production: C.K. Worrell, BFA Visual Production
Peg Volkmann, MA Senior Editor
Jeannette McDonald, DVM, PhD Creative Director
With Support From: The Fund for The Improvement of Postsecondary Education (FIPSE) U.S. Department of Education
NEAT,   Nursing Education And Technology