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The impaired nurse: Would you know what to do if you suspected substance abuse?


Substance abuse occurs across all generations, cultures, and occupations, including nursing. About 1 in 10, or 10-15% of all nurses, may be impaired or in recovery from alcohol or drug addiction. Although nurses aren’t at a higher increase risk than the public sector, their overall pattern of dependency is unique because they have greater access to drugs in the work environment.

Impaired nurses can become dysfunctional in their ability to provide safe, appropriate patient care. Addiction is considered a disease, but the addicted nurse remains responsible for actions when working. Nurses should be aware of the signs and symptoms of substance abuse and know when to report a coworker suspected of substance abuse to management.

Consider the following questions and situations.

What does a substance abuse nurse look like?

“Have you seen Jane lately? She used to be so neat and clean but for the past several months she doesn’t seem to care about her appearance,” stated Polly. “I worked with Jane this week and she seemed in a daze most of the shift,” replied Tom. “If I didn’t know better I would think Jane was taking drugs or something,” Polly commented. “Drugs! Not Jane, she would never take drugs. I’ve known Jane for four years. She’s an excellent nurse,” Tom replied, “Besides Jane certainly doesn’t look like a drug user. She’s probably just tired from working the night shift or maybe she’s having some personal problems. We all deal with our problems differently.”

Would you be willing to inform management if you suspect a nurse is diverting medication?

“Sally do you have a minute? I need to talk to you about something I witnessed last week,” asked Dave. “Of course, what is it?” replied Sally. “I was working extra last week and about 9 pm. I answered a patient’s call light for Joe. The patient told me she was not getting any relief from her pain medication that Joe had administered over an hour ago. When I found Joe he was coming out of the bathroom with a syringe in his hand. I asked Joe what he was doing with the syringe in the bathroom. Joe seemed nervous telling me he was getting ready to give some Demerol to the same patient who was complaining of unrelieved pain. When I told Joe I had just talked to the patient and she supposedly had already had the pain medication, he became upset and asked me why I was questioning him. He did not talk to me the rest of the night. I don’t know if it means anything, and I don’t want to cause a problem for Joe, but I just have a feeling that something is not right,” Dave said.

Have you or a co-worker ever come to work after consuming alcohol?

“Wow you seem unusually wired tonight,” Carol said. “I know. Mark and I were at a party. I almost didn’t make it on time,” explained Megan. Who’s party was it?” asked Carol. “Oh an old friend of ours was in town so about 12 of us met at Randy’s,” Megan continued. “Isn’t that a bar?” asked Carol. “Yes, I probably had one too many drinks, but I’m fine. I can hold my liquor as well as anybody. I’ll just drink more coffee tonight!” Megan said proudly.

Reflect on your answers to the above questions. Could you recognize a nurse who might be engaged in substance abuse? Would you be able to identify medication diversion? Would you recognize impairment from alcohol in a co-worker? To be able to answer these questions, you need to understand the myths and truths about substance abuse.

Common myths and truths

Myth: Impaired nurses use only street drugs.
Truth: Many substance-abusing nurses use everyday medications encountered in the workplace as well as common street drugs. The problem may begin by simply taking a patient’s medication for a headache or back pain or to cope during a stressful shift. A substance-abusing nurse may substitute saline for injectable medications such as Demerol, morphine sulfate, and codeine, or dilute liquid medications after consuming some of it. Legal drugs are as harmful as illegal drugs.

Myth: Impaired nurse have a long history of drug or alcohol abuse.
Truth: Although many substance-abusing nurses have a history of long-term drug or alcohol abuse, a recent stressful life event such as a divorce, accident, or illness can lead to drug abuse as a coping mechanism.

Myth: Impaired nurses are easy to recognize.
Truth: There are specific signs and symptoms of a substance-abusing nurse, but the nurse may take extra precautions to avoid detection.

Myth: Drug addiction is voluntary.
Truth: Drug addiction is a compulsive behavior affecting the brain. It may be the result of an emotional or abusive family situation, poor choices, loss of support systems, excuse for behaviors, seeking an adrenaline rush, family history of addiction, enabling behavior, unstable lifestyle, denial, or other factors.

Myth: Combining drugs is not harmful.
Truth: Combining drugs can lead to disastrous consequences such as permanent physical impairment or death.

Myth: Addicts cannot recover and only need treatment for a couple of weeks.
Truth: Short-term in-patient programs should be at least 21 days. It is important to have follow-up supervision for physical and emotional support. The length of treatment and the willingness of the nurse are the best predictors for success. Nurses who remain in treatment for at least a year are twice as likely to be drug free, but the struggle for recovery will last a lifetime. Impaired nurses can make a complete recovery if given support and opportunity and they have a desire to recover.

Myth: Addicts have to want treatment and can’t be forced into it.
Truth: In most cases the substance-abusing nurse resists entering a treatment program. The main reasons for entering treatment are a court order and peer, management, and family member encouragement.

Myth: Alcoholics can sober up quickly.
Truth: It takes about three hours, depending on the person’s weight, to sober up. Reporting to work after attending a party and consuming alcohol is a recipe for disaster.

Myth: Beer doesn’t have as much alcohol as hard liquor.
Truth: A 12-ounce bottle of beer has the same amount of alcohol as a shot of 80% proof liquor or 5 ounces of wine.

Signs and symptoms of a substance-abusing nurse

As nurses we care for our patients, but we don’t always care for our coworkers or ourselves. As you read the Weighted Checklist you may discover you are working with or have worked with a nurse who displays signs, symptoms, and behavioral changes that may indicate substance abuse.

The most common substances abused by healthcare professionals are alcohol, cocaine/crack, Ritalin, marijuana, inhalants, ultram, methamphetamines, ecstasy, hallucinogens and stadol, sleeping pills, antidepressants, morphine, Demerol, percodan, vicodin and codeine. However, coworkers should never underestimate the need or desire for drugs from a substance-abusing nurse. The nurse might use whatever drug is available to satisfy the addiction while at work.

As a peer you should be aware that an impaired nurse who abuses alcohol would probably drink before reporting to work, during breaks and meals. Soft drinks, coffee, mouthwash, mints, and gum can be used to mask the alcohol odor. When signs and symptoms are obvious to others the substance-abusing nurse may be in the later stages of the disease.

What to do if you suspect a nurse is a substance abuser

Nurses must educate themselves on the signs, symptoms, behaviors, myths, and truths that represent substance abuse. While it may be very difficult to suspect a co-worker of substance abuse, and the fear of reprisal may keep some nurses from action, it’s important to take the steps necessary to confront or notify the nurse manager of your suspicions.

Educate yourself on the organization’s policy and procedures for employee substance abuse and employee assistance programs. Careful documentation of any changes in the suspected impaired nurses’ behaviors is important. If you are willing, you may choose to urge the nurse to seek help. Avoid any desire to enable the impairment.

Legal aspects to report a substance-abusing nurse vary among individual states, but nurses have an ethical and moral duty to patients, colleagues, the profession of nursing, and the community to take action. Documents such as the American Nurses Association Code of Ethics for Nurses provide a framework for patient safety.

Consider the following:

  • Do not ignore poor performance.
  • Do not lighten or change the nurses’ patient assignment.
  • Do not accept excuses.
  • Do not allow yourself to be manipulated or fear confronting a nurse if patient safety is in jeopardy.


Nurses who seek treatment have a good opportunity for successful recovery. Treatment can be effective in reducing substance use and improve health, social, and occupational well-being. Many organizations offer alternative treatment programs instead of drastic action such as termination.

Currently 37 states offer some form of a substance abuse treatment program to direct nurses to treatment, monitor their re-entry to work, and continue their license according to the National Council of State Boards of Nursing. Alternative programs monitor and support the recovering nurse for safe practice. Strong recovery programs offer a comprehensive, bio-behavioral, individualized treatment plan. The phases include in-treatment or outpatient detoxification in a safe environment; education about the disease; group, individual, and family therapy; and most important a relapse prevention program. However, boards of nursing have a responsibility to safe guard the public, so they may suspend the nursing license of an identified impaired nurse if they suspect he or she may pose a danger to patients.

The American Nurses Association (ANA) is a strong supporter of alternative or peer assistance programs that monitor and support safe rehabilitation and the eventual return to the professional workforce. While relapse is high, the goals for the substance-abusing nurse is to seek treatment, reach recovery, and re-enter the workforce.

Costs of substance abuse

Substance abuse is costly to the individual nurse, their friends and families, and healthcare organizations in terms of loss of income, health, and relationships, and diminished quality of care provided to patients. While it may be difficult or uncomfortable, individual nurses can make a positive difference when they identify substance-abusing nurses so that they can get the help they need.

Substance-abusing nurses most likely will not seek treatment until confronted by peers, family, or nursing management, or their employment is in jeopardy. However, those who enter and complete structured treatment programs can be successful and reenter the profession of nursing.

Cynthia M. Thomas and Debra Siela are assistant professors of nursing at Ball State University School of Nursing in Muncie, Indiana.


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  • Christine Marton
    February 9, 2020 1:23 pm

    I have worked with a nurse manager for the last 7 months that has come into work obviously hung over from alcohol. She would openly admit she was hungover, she would start IV’s on herself and give herself fluids and antiemetics at work. Never when the Dr. could see her. She shows up at work disheveled, late on many occasions. I finally went to our upper manager, HR, and the doctor. All admitted to knowing she had a problem, but nothing was done to her. She was given a slap on the hand and continues to give patient care. In the meantime, she has sent me threatening text message, turned HR and my manager against me, and has attempted to write me up on things I did not do. This is a private surgical suite. Not hospital related. I was so overwhelmed by the daily lies and attempted write ups I was afraid she would do something to destroy my 23 year career where I have NEVER been written up.

  • If you have any problem DON’T tell anyone. Especially your employer! The first thing that will happen is you will be suspended from work. Next your license will be suspended, reprimanded, revoked or otherwise encumbered. The board of nursing will require you to do random weekly drug tests, AA/NA meetings, place limits on practice settings, require supervision for you to practice, require your employer to submit quarterly reports on your performance, mandate you go to treatment, mandate you stay in outpatient treatment indefinitely and so much more!

    Professional Nurse Assistance Programs (PNAP’s) have much to be desired. If you seek out help from these people your privilege to practice in other states pursuant to the nurse licensure compact will be taken away for the duration you are in the PNAP.

    If you need help with drug addiction…DO IT YOURSELF! Take a leave of absence from your employer and go to a treatment center far away from where you live. Don’t tell them you are a Registered Nurse. Don’t risk your career by trusting others. Addiction is a disease but boards of nursing don’t treat it like other diseases. If you suffer from diabetes they don’t require you at your expense to get a hemoglobin A1C test or monitor your blood sugar levels every day of the week and report your results to the board.

    Want to make a Professional Nurse Assistance Program fair? Treat addiction like the medical condition it is. Pay for every drug screen of the nurses in the PNAP program using the funds collected by boards of nursing during relicensure fees. Do not suspend a person’s privilege to practice in other states for voluntarily seeking help for their condition. Do not limit their practice settings. Provide the needed treatment & psychotherapy for these individuals free of charge or force the nurses employer to pay for the substance abuse treatment. Pass laws that only allow employers to terminate existing nurses (initially found practicing while impaired) if they refuse to participate in the program. If they are found practicing impaired a second time or at any time while in the program then terminate them.

    My views on this subject are the way they are because there is something fundamentally wrong with our profession. Nurses who seek help for this disease are punished. If it is discovered by other random means they are punished. When a person is diagnosed with other diseases does the board of nursing punish them?
    As a nurse I know my peers will not be “helped” if I report them to anyone. They will be punished for having a medical condition. Is treatment important? Absolutely. Do I suggest they get help? Yes, but I give them the same recommendations I wrote above. The same logic applies to ANY mental illness they may have.

  • Drug abuse is a menace the whole world is contending with, regardless of who’s affected. But when health professionals practice it, who then care for them? Nurses really need to rise up to helping colleagues who are impaired as soon as warning signs are observed. Helping them is part of fulfilling professional roles!

  • I know a nurse who voluntarily went away for alcohol. There were no work incidents involving alcohol. When the nurse returned to work after completing the program they worked for approx. one month. After this time upon entering work they were confronted by PNAP representitives and HR and told they would return to work after an investigation. Three months later and numerous tests (Drugs and alcohol), they returned to work after signing a three contract for monitoring. This is all out of pocket and random. How does this happen in this day and age. These are all facts I have just stated. I would like to know what rights this individual has after voluntarily trying to get help for a problem they recognized.

  • I am searching for information on what our duty to report is when a nurse struggling with addiction BECOMES A PATIENT. Due to the medical condition, tox screen, and H&P we know this is a person who cannot possibly be fit to take care of patients, and yet he is employed at a local nursing home. But because he is our ICU patient now, reporting him would violate HIPAA. Soooo, what are the laws and obligations around this situation?

  • to conclude my story of my life being ripped apart I was so stressed I ended up in a Psych Hospital. I was released and when my employer found out I was presented witha letter of termination. My DON was an excellant documentor and did all the catch phrases. My drug test for every possible drug was negative. I was fired the state was notified and I lost my license. My “illness” was a mental health issue…too bad cuz druggies get to go to rehab. I became a public health liability. No drugs.

  • I am sick of everything being dumped on addiction. My sister committed suicide and I had a depressive reaction at work. No not that they did not know I was in crisis I told them. I was discriminated against by other employees…even to the state being “notified” that I had committed fouls such as abuse of a patient. I was investigated found to be a highly caring compassionate humane person who also happens to be an RN. I was found innocent but the added stress of employees bullying me was awful.

  • How do I report a nurse who may be practicing under a false or fraudulent license? This woman works in Florida, and she is dangerous!

  • Yesterday, 4 of us nurses just reported a nurse coworker who comes to work on a nightly basis alcohol impaired. The D.O.N. the A.D.O.N. have been aware of this for sometime and have turned a blind eye to this nurse. I was angry at first but now am just sad for this nurse who is in total denial. She not just smells of alcohol when she comes to work she reeks of it. She is putting the residents that she takes care of in danger. I would NOT want her taking care of my loved one period.

  • I know two nurses that stay up all night partying then go into work at a nursing home. The crazy thing is they post videos and pictures of them intoxicated from the night before on Facebook and no one ever reports them. Sad that they will never get caught and no one will ever report them until something bad happens.

  • I think if they drug tested the medical field they would be surprised as to how many medical professionals would fail. (Florida)

  • @May 4, 2012. Sorry to hear this. I too am bipolar. You must must must treat it like any other medical issue (i.e. diabetes) You have to see your psychiatrist. And when all else fails, file for FMLA leave and take the time you need to keep YOUR health in check. It is unfortunate you have been terminated. I would suggest you always let your employee health department know about your diagnosis. If you run into problems, they can direct you to the right sources for help. good luck to you

  • I have been nursing for 10 years! over the last year, a lot has gone on in my life (personal)! 2 months ago I was diagnosed with bipolar disorder! my employer kept “random” drug tests! OK no one would listen when I said I am bipolar! I did begin to self medicate, but I have NEVER DONE THIS BEFORE! drug test pending & they did terminate me on the spot! Any other time, I was clean & now I have no job, license suspended til I can come up with $4000 for rehab that I do not need!

  • Chris Kennedy RN BSN
    September 13, 2011 2:00 am

    i was dismayed when i read the title to you subsection…”what does a substance abuse nurse look like” I am working in Opiate Treatment Program and I do not look like your description of a subtance abuse nurse:) Maybe rephrase it to say a subtance abusing nurse.

  • I was reported for working impaired… amazingly I have not
    worked in 5 years on SSD.
    So I drink light beer a couple
    times a week on my time.The
    State Board of nursing does not
    own me. I never gotten a DUI
    or had any police contact while
    drinking. I Do not use drugs
    and I fight to keep them out of
    my neighborhood.
    Nursing Sucks thanks to
    Pennsylvania State Board of
    Nursing . Don’t they know the
    ban on drinking ended in the

  • Cynthia Saver, RN, American Nurse Today
    August 21, 2011 8:06 pm

    Thank you for your suggestion about making this a CE program. The current article is a bit too short to do that, but that is an excellent idea for a future CE program.

  • 39 year nurse : )
    August 15, 2011 11:34 pm

    Thank-you for fulfilling this ongoing need! I hope to recommend it to my RN-BSN students. Wondering if there is a way to turn this into a c.e.u. (?)

  • This is a much needed article. So often in nursing we hesitate to do anything about a co-worker who might have an issue with drugs or alcohol. Many have no idea that this is a disease not a moral issue. Education is a must since it’s estimated that 10-20% of the population is at risk. Can you imagine going to nursing school & not learning about a disease that effects so many people? It happens; we need to raise our awareness.

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