Running head: Impaired nurses

Impaired Nurses
Emily Mortensen
Ferris State University

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Abstract

Substance abuse in nursing is a problem that is affecting between five and 20 percent of nurses in
the United States today. Impaired nursing occurs when the nurse is unable to perform in a
manner that meets the minimum acceptable standards for her profession due to the substance that
was used (Bissonnette & Kettering-Sincox, 2010). When this occurs, ethical concerns arise
regarding moving the focus of the nurse from the patient, providing inadequate care to these
patients, and compromised patient safety. This paper will explore a theoretical base of addiction,
issues in the healthcare environment, including related policies, resources, and quality and safety
issues. Inferences and implications for care will be identified upon analysis of this issue. With
further analysis of these consequences, recommendations will be made for management of the
impaired nurse, with guidance from standards of care from the American Nurses Association
(ANA), and competencies defined by the Quality and Safety Education for Nurses (QSEN).

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Impaired Nurses

Every worthy act is difficult. Ascent is always difficult. Descent is easy and often
slippery (Devji, 2012, p. 187). The slippery path toward substance abuse is an issue that is
remarkably prevalent in the world today. In the year 2013, there had been an estimated 24.6
million Americans, at 9.4 percent of the population, that had used an illicit drug within the past
month. This has risen in prevalence from the 2002 study, where the number was at 8.3 percent
(National Institute on Drug Abuse, 2015). Among the general population of the United States, 83
percent of this countrys people use alcohol, and 24.9 percent uses tobacco. 4.76 percent of the
population has been found to utilize pain relievers for non-medical reasons, and 2.46 percent has
used cocaine (Naegle, 2006).
Nurses are a population of people in the United States that is often overlooked with the
use of illicit substances. In registered nurse continuing education programs across the country,
only two states, Delaware and West Virginia, require education on substance abuse. According to
the American Nurses Association, up to 10 percent of nurses face problems with drug or alcohol
dependence (Starr, 2015). Reports from Monroe and Kenaga (2010) show that there is a
likelihood of up to 20 percent of registered nurses with a substance abuse issue.
Among nurses, the prevalence of alcohol use matches the general population, though
there is a significant decrease in the use of illicit drugs, like cocaine and marijuana. There is a
substantial rise in the use of prescription drugs among nurses, at 6.9 percent (Naegle, 2006). This
increased prevalence can be attributed to increased access to these medications on the job, and
drug diversion, which is the transfer of a controlled substance from a legal to an illegal channel
of use (Berge, Dillon, Sikkink, Taylor & Lanier, 2012).

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When battling addiction problems, it is possible that the nurse will begin utilizing these
substances while working with patients. There are a number of signs to look for when a nurse has
been using medications in an illicit manner. First, the nurses job performance may decrease, and
she may begin showing up late to work and being inattentive to her patients. She may begin
having extended absences from units, and extended bathroom breaks during her shift as well. As
the substances will affect the nurses decision making and judgement, there may be an increase
in the number of patient care errors and medication errors made by the nurse, as well as recurring
discrepancies in narcotic counts while this specific nurse is working. The nurse may also begin
requesting to give pain medications for her coworkers, and have frequent complaints of
uncontrolled pain from her patients (Carpenter, 2014).
In the instance that a nurse is using illicit drugs while working, the nurse becomes
impaired. This means that the nurse is unable to perform in a manner that meets the minimum
acceptable standards for her profession due to the substance that was used (Bissonnette &
Kettering-Sincox, 2010). This paper is intended to address the issue of impaired nursing,
analyzing the current research on this topic through the discussion of theories, the healthcare
environment, implications and recommendations for improvement led by the American Nurses
Association (ANA) and Quality and Safety Education for Nurses (QSEN) guidelines.
Theory Base
Neuman Systems Model
Betty Neumans Systems Model was created in the idea of everybody helping each other
live (Neuman, 1995, p.675). The focus at the center of this model is the holistic idea that stress
has the ability to harm a persons health, and that the healing of a client is strengthened by

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specific nurse interventions aimed toward relieving this stress. In the instance of impaired
nursing, the impaired nurse would assume the role of the client (Turner & Kaylor, 2015).
In order to accomplish this stress relief, the nurse is trained with necessary skills to
strengthen her resilience. This helps to ensure that she will be able to withstand stressors in her
life, ensuring that her natural defense is not compromised. This training will work to allow her to
respond adequately to these stressors, decreasing the chances of her turning toward substance
abuse to cope with them in the future (Turner & Kaylor, 2015).
In order to build a nurses resilience, the program follows the model set by the levels or
prevention, beginning with primary intervention. This involves identity building at the start of
the nursing career. The new nurse begins with identifying her role in the nurse profession, and
working to recognize her strengths and weaknesses, along with coping strategies that are
effective for her. This prepares her for any stressors that she may face, and teaches her the proper
methods that she may need to utilize in order to ensure her defense lines are not broken by them
(Turner & Kaylor, 2015).
The secondary intervention tactics begin when a stressor has been identified. The nurse
will view this stressor as temporary, and become stronger in order to get past this. The strategies
in which she will be able to overcome this obstacle include seeking assistance from her
professional and personal support systems, remaining positive and turning toward her spirituality
to give her strength, and looking inward at her emotions and reflecting on herself. In the
utilization of these methods, the nurse will remain strong and able to overcome any stressors
(Turner & Kaylor, 2015).
Tertiary interventions are implemented after the stressor has occurred, and involve selfreflection. The nurse will review the stressful situation, and observe which of her coping

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mechanisms were most and least helpful. In this, she begins to modify her defense strategy to
find the perfect balance in order to ensure that she will only utilize the most effective
mechanisms with the next stressor she will face (Turner & Kaylor, 2015).
PRIME Theory
Robert West, a Professor of Health Psychology, introduced the PRIME theory to evolve
the way that addiction is observed (Redvers, 2007). This theory is centered on the human
motivational system. There are, according to this system, five levels for human motivation. The
five levels include: Plans, Responses, Impulses, Motives, and Evaluations (Wanigaratne, 2006).
Plans are self-conscious intentions; responses involves starting, stopping or modifying actions;
impulses and inhibition are the final common pathway to behaviour; motives are feeling of want
or need and evaluations are beliefs about what is good or bad (West, 2013, p. 195).
The PRIME theory focuses on the idea that with the five levels of motivation, if there is
imbalance in any of the levels, addiction can result. Each of the adjacent levels influence one
another, and an imbalance with one can have a chaotic effect that leads to addiction. If the
individual feels as though she has not accomplished what she had initially planned to by her
current stage in life in her evaluation, she may feel an imbalance in her motivation system. She
may turn to use of a mind-altering drug to off-set this imbalance and this drug may give her the
reward of escaping from the negativity in her life. With continued use of this drug, she will
become addicted to the substance, and spiral out of control due to this substance (West, 2013).
Assessment of the Healthcare Environment
Policy
Impaired nursing is an issue that can impact the safety of and quality of care provided to
patients. This issue is addressed with policies put in place to address the nurse, and ensure she is

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not endangering the patient. There are two methods of action for when a nurse is found working
under the influence: Disciplinary and alternative-to-discipline (Monroe, Pearson, & Kenaga,
2008).
The disciplinary approach is utilized by six states in the United States: Arkansas, Alaska,
Georgia, Maine, Missouri, and Mississippi. In this method, the addicted nurse is penalized for
her actions in order to protect the public. There is typically a probation period after the nurse is
caught abusing substances, and then their license is impacted, causing them to be unable to work
in the field for up to five years with a suspension, or permanently removed from the field in the
event that is revoked (Monroe, Pearson, & Kenaga, 2008).
The nurse will also, in this approach, be reported to the national practitioner databanks,
where this event will become public record. This can cause the nurse to be unable to return to
work, and be ineligible for insurance. In 69.8 percent of cases, the disciplinary approach by the
board of nursing is the largest barrier that nurses attempting to return to work can face (Monroe,
Pearson, & Kenaga, 2008).
Alternative-to-discipline programs were introduced for nurses in the 1970s. The nurse is
able to remain working in the field during their recovery. This approach allows for early
intervention, and monitoring begins quickly, allowing for patient safety to remain intact
(National Council of State Boards of Nursing, 2011).
Michigan policy is based upon an alternative-to-discipline approach under the Health
Professional Recovery Program (HPRP). In this program, the nurse can seek recovery before a
patient, or her career, is damaged. The nurse will typically report herself to the Health
Professional Recovery Committee, who is in charge of the program, upon realization that she has
a problem with substances. She may also be reported by employers because of unsafe behaviors

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that indicate this step to be necessary to continue safe practice, or by concerned family, friends,
or coworkers (Bissonnette & Kettering-Sincox, 2010).
The HPRP is a five step program that treats the addiction as a treatable mental health
problem. First, in the intake step, the presence of a problem involving impaired practice is
identified, causing the nurse to be referred to the Department of Licensing and Regulatory
Affairs. After this, referral is made to a provider in the HPRP if she meets that criteria for this
program, where a personal recovery plan is generated. Treatment is the third step, where the
nurses care is completed at levels appropriate for the problems severity. This follows an
interdisciplinary approach to treat her holistically (Department of Licensing and Regulatory
Affairs, n.d.).
After completion of treatment, the nurse and her provider create a monitoring agreement.
This is where the nurse is observed for a period of time, where she is put on a probationary
period. She may have limitations on the practice she can perform, or areas she may be employed
in, or she may require random drug screenings, support group attendance, and regular
evaluations and progress reports are completed to ensure her compliance. After the monitoring
period has been completed, the nurse is released from the HPRP. The records of the nurses
treatment are destroyed five years after completion of the program, and there are no long-term
negative effects for the nurse (Department of Licensing and Regulatory Affairs, n.d.).
Resources
The problem of addiction is one that is difficult to solve alone. In order to successfully
overcome this, the individual needs support, and there are a number of resources available to
these individuals to ensure that this obstacle is surpassed. The first resource is the Health
Professional Recovery Committee. This department is in charge of the HPRP, and was created

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exclusively to provide health care providers suffering from substance abuse problems the support
that they require (Department of Licensing and Regulatory Affairs, n.d.).
A second resource available to these nurses is the American Nurses Association. This
organization has created a resources for impaired nurses, the Impaired Nurses Resource Center.
This webpage will provide guidance to those who have confirmed problems with chemical
dependence, and for those who are questioning whether they do or not. This source acts as a
guide for the nurses ethical standpoint, addressing the obligations that the nurse has to herself
and her patients, and offers the nurse guidance on what she should do in order to address this
problem (Massachusetts Nurses Association Peer Assistance Program, n.d.).
More resources available to impaired nurses include Alcoholics Anonymous and
Narcotics Anonymous. These two programs are support groups created for all who are battling
addiction to substances. The use of peer support in these programs helps to build the participants
coping mechanisms, strength, and hope in order to remain sober from these substances, and
working to help others in the program achieve this goal of sobriety as well (Massachusetts
Nurses Association Peer Assistance Program, n.d.).
Quality and Safety Issues
In the event of drug diversion and impaired nursing in the medical field, there are a
number of quality and safety issues that arise. The first issue involves harm to herself. With
diversion of these medications to herself, she is taking a dose that was formulated for another
person, which may be unsafe for her. Due to this, she may accidentally overdose and suffer
mortality (Berge, Dillon, Sikkink, Taylor & Lanier, 2012).
A second safety issue that arises is potential harm to other healthcare workers. In the
healthcare field, trust is often found between co-workers, and this trust is often manipulated and

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abused when one worker becomes addicted. The nurse can break policies easily without being
detected by their coworkers via this manipulation. One instance in which this occurs is in the
disposal of controlled medication. Typically, with these medications, if there is any of the
medication leftover after administration of the needed amount, the nurse is required to have
another licensed registered nurse witness the disposal of this medication. There are times,
however, when the colleague may sign that they had seen the waste of this medication when in
reality they did not. This instance breaches the policy that is set in place by the institution, and
puts both nurses at risk for discipline if they are found guilty of this (Berge, Dillon, Sikkink,
Taylor & Lanier, 2012).
A third issue that is presented by this is the vast issue of patient safety. The patient that is
in the care of the impaired nurse can receive substandard and inadequate care from this practice.
The impaired nurse can be distracted, or unable to focus on the task at hand, so she may be at
risk for making errors related to patient management or medications that can cause harm to the
patient (Berge, Dillon, Sikkink, Taylor & Lanier, 2012).
Medication diversion is a problem that also causes harm to the patient. In this instance,
the patient may be receiving diluted drugs, or missing entire doses of their prescribed
medications. This will cause the patient increased pain and anxiety, or any other symptoms that
were treated by the specific medication that was diverted away from them (Berge, Dillon,
Sikkink, Taylor & Lanier, 2012).
A third patient safety issue is presented by the case of drug contamination. There was a
case of this occurring in 2009 in a Colorado hospital. In this hospital, two patients had been
newly diagnosed with Hepatitis C, despite the fact that they had not had any exposure to the
illness. These two patients had both undergone surgeries on the same day and had contracted the

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same strain of the infection. It was brought to attention that a surgical technician had been
dismissed due to probable narcotic drug diversion. It had been found that in the two local
hospitals she had worked in, she had stolen prefilled syringes of fentanyl from unattended
anesthesia carts, replacing them with syringes of normal saline. She self-injected these
medications, and then refilled the same syringes with the saline, in order to substitute it out for
her next fentanyl dose. In this practice, this technician had exposed 5,970 patients to hepatitis C,
with confirmed transmission to 18 patients. She was then prosecuted and sentenced to 30 years in
prison (Warner, 2015).
Assumptions can be made about the medical profession and hospitals that are involved in
cases of drug diversion and impaired health care professionals practicing. The cases in which
incidents become known by the public can have a profound effect on the medical profession and
the institution involved in the incident. In the event of the Colorado incident, those around the
area have lost their trust in this institution, which will likely cause these people to seek medical
care in other institutions from that one, causing the facility to lose financial support from
insurance providers. This limits the care that can be given to the patients that are receiving
treatment there, and will result in substandard care provision to these clients (Berge, Dillon,
Sikkink, Taylor & Lanier, 2012).
Inference and Implications
With impaired nursing, there are a number of inferences and implications that can result.
First are the consequences faced by the nurse. The nurse may lose her job and her license due to
her unethical practices. She has sacrificed the safety of her clients by performing nursing care
while under the influence, stolen medications from her clients and the facility, and she has also
broken numerous policies in the facility as a result of her actions. Even in an alternative-to-

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discipline program, with these actions, the nurse will likely be fired from the facility in which
she is employed.
The patient experience is also negatively impacted by the impaired nurse. The nurse has
jeopardized the safety of her patients by neglecting her care responsibilities. She will also
commit more errors in the management of her patients, and the medications that are administered
to them by diverting her focus from the patient to her addiction. The patient will be dissatisfied
by this care, and this patients outcomes may be compromised.
This research shows that substance abuse among nurses is a significant problem in the
field that not many are aware of. The nurses working amongst those struggling with substance
abuse do not know of the prevalence of this problem around them. These nurses may fail to
recognize the signs that a nurse is struggling with addiction. This is an issue, nurses facing
problems with addiction may not receive the treatment that they need, as their problems are
continuing without being reported.
Quality and Safety Improvement Recommendations
In order to address the issue of impaired nursing, there are a number of recommendations
that can be made to address quality and safety concerns. There are 16 Standards of Practice that
have been outlined by the American Nurses Association. Out of these standards, three that are
highlighted to address this issue are ethics, quality of practice, and professional practice
evaluation.
Standard 7: Ethics states, The registered nurse practices ethically (American Nurses
Association, 2010, p. 54). Ethical practice is a foundation for nursing practice, and this
foundation is brought into question when a nurse begins to have problems with substance abuse.
When a nurse is fighting addiction, she will be unable to perform her job to care for her patients

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effectively. It is her responsibility, as well as the responsibility of other nurses working around
her, to create an environment that ensures moral practice and high quality of care. When a nurse
in the environment is impaired, she is unable to ensure this environment is intact, and she may
personally be a break in it, if she is actively giving subpar care to her clients. In order to ensure
ethical care is provided to all patients, nurses should be actively assessing the environment, and
will highlight this impaired nurse. Concerns about this nurses care should be brought to the
attention of the floors supervisor in order to ensure that this nurse receives the help that she
requires (Kunyk & Austin, 2011).
Standard 10: Quality of Practice states, The registered nurse contributes to quality
nursing practice (American Nurses Association, 2010, p. 59). When a nurse is impaired, quality
of care is compromised. The nurses first concern is not thinking about the patients needs, as she
is more focused on the substance she is using. The quality of care that she provides to her
patients will diminish, and she will be unable to ensure that her patients safety remains intact
while she is focused more on herself (Berge, Dillon, Sikkink, Taylor & Lanier, 2012).
Standard 14: Professional Practice Evaluation states, The registered nurse evaluates her
or his own nursing practice in relation to professional practice standards and guidelines, relevant
statutes, rules, and regulations (American Nurses Association, 2010, p. 66). The nurse should be
aware of her unsafe practices, and upon self-evaluation, she may report herself for abusing
substances. The alternative-to-discipline approach that is present in the majority of the United
States encourages the nurse to report these behaviors without fear of punishment (Bissonnette &
Kettering-Sincox, 2010).
Competencies have been identified by The Quality and Safety Education for Nurses
(QSEN) that should be followed by the nurse to ensure quality care is provided to patients. The

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first competency that relates to impaired nursing is safety, which is define as, Minimize risk of
harm to patients and providers through both system effectiveness and individual performance
(Croenwett, Sherwood, Barnsteiner, Disch, Johnson, Mitchell, et al., 2007, p. 128). Safety is one
of the largest concerns that is presented with an impaired nurse. The nurse sacrifices the safety of
herself, her coworkers, her patients, and her institution by using these substances. The nurses
addiction should be cured as soon as it has been identified, or she should be removed from
practice if she is unwilling to comply with her treatment, in order to ensure safety is not
compromised by this nurses behavior.
A second QSEN competency that should be followed is patient-centered care, which is
defined as, Recognize the patient or designee as the source of control and full partner in
providing compassionate and coordinated care based on respect for patients preferences, values,
and needs (Croenwett, Sherwood, Barnsteiner, Disch, Johnson, Mitchell, et al., 2007, p. 123). In
the practice of drug diversion, the patient is not the center of the nurses care she is providing to
him. She will knowingly sacrifice the patients needs in order to obtain the drugs herself. One
way to ensure this competency is followed would be to follow medication administration and
waste procedures that are outlined in the facility, and ensure that all patients are receiving the
care that they require.
The third QSEN competency that should be followed in regard to impaired nursing is
quality improvement, which is defined as, Use data to monitor the outcomes of care processes
and use improvement methods to design and test changes to continuously improve the quality
and safety of health care systems (Croenwett, Sherwood, Barnsteiner, Disch, Johnson, Mitchell,
et al., 2007, p. 127). The lack of knowledge regarding impaired nurses in the healthcare system is
alarming, knowing the prevalence of this issue. With the previously stated two states that have

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education requirements for impaired nursing, while the other forty-eight do not, it is not
surprising that this issue is prevalent in the United States (Starr, 2015). Education should be
strengthened regarding this topic, and all hospital personnel should be educated on the signs that
arise with drug abuse among health care professionals, and the staff should be educated on the
risks of addiction and diversion that exist. With required education on this topic, hospital
personnel would be better able to identify when their coworkers are struggling with substance
abuse, and the likelihood that these individuals will receive the care that they need will rise,
allowing for better quality of care to be provided clients who would otherwise be affected by
this.
Conclusion
The problem of substance abuse is prevalent in the nursing community today. This
problem can cause patient safety concerns to arise with lower quality of care given to these
patients. The Neuman Systems Theory of nursing and the PRIME theory of psychology both
work to explain this problem from an interdisciplinary standpoint. Policies and resources that
concern the issue of impaired nursing were highlighted, demonstrating that these nurses have
hope for recovery after they have succumbed to this problem. Quality and safety issues and
implications for care were highlighted, demonstrating what this problem means for the nursing
field, and what can result from this. Finally, recommendations were made using the guide of
ANA standards and QSEN competencies. The issue of impaired nursing is one that nurses need
to be made aware of, and they need to be on alert for the signs that one of their peers may be
battling this issue. In working together to ensure the problem is identified, and nurses are getting
the help that they need, there is possibility that this issue may become a problem of the past.

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