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Impaired Nursing
Cassaundra Braden
Ferris State University
This paper aims to define an impaired nurse as well as the signs and symptoms of impairment.
The goal of the author is to help the reader learn the law as it relates to impaired nurses, identify
barriers to getting help, and promote resources available for impaired nurses.

Impaired Nursing
According to the Michigan Public Health Code, Section 333.16106a, Impaired practice
means the inability or immediately imminent inability of a health professional to practice in a
manner that conforms to the minimum standards of acceptable practice for that health profession
due to the health professionals substance abuse, chemical dependency or mental illness, the
health professionals use of drugs or alcohol that does not constitute substance abuse or chemical
dependence (2014). Drug use is not the only cause for a nurse to work impaired. The
American Nurses Association (ANA) reports that a strong relationship exists between fatigue,
accidents, mistakes, and errors. Each year tens of billions of dollars are spent in correction of
medical errors. Though nurses may not feel that they are impaired, they need proper rest and
breaks to provide the best possible patient care (ANA,2014). There are numerous causes of
chemical dependence. These factors include genetic predisposition, family and peer influences,
sexual abuse in childhood, low self-esteem, and self-treatment of mental illness symptoms.
Chemical dependency affects the employer, co-workers, patients, family and community through
absences, accidents, injuries, violence, and stress-related illnesses.
Signs and Symptoms of Impairment
The following are common symptoms that are shown by someone who may have a
substance use disorder that may affect their work performance:
Work habits - Misses work or is frequently tardy because of illness or oversleeping;
doesn't keep scheduled appointments; has an unacceptable error rate.
Emotions Often irritable, defensive, jealous, easily angered, depressed, withdrawn, or
moody. These behaviors affect work and relationships at work
Personal care - Personal hygiene is deteriorating.
Observations - Smells of alcohol or observed taking drugs and often exhibits
inappropriate behavior with patients.
Defensive behaviors - Becomes angry when someone else mentions their drinking, use of
drugs or emotional instability; frequently expresses guilt about use of alcohol or drugs.
Behavioral consequences - Continues to use drugs or alcohol or exhibit inappropriate
behavior in spite of continuing negative personal, professional, family or financial
Assessment of the Health Care Environment
Opportunities for impairment
Every nurse has their own limitations and the capacity to work a certain amount of hours
before they are compromised (Singh,2012). Aside from narcotic misuse, one opportunity for
impairment is exhaustion while working. Another cause for nurses working impaired is not
getting proper rest, fluids or nutrition. This could compromise a nurses health which ultimately
could lead to working as an impaired nurse. A final example is being unaware of the effects that
prescribed medications have ones body, especially when new dosage changes are made to
medications. Nurses are not perfect health professionals. They can suffer from physical and
mental illnesses that require medications. While working under the influence of exhaustion is
more common and often swept aside, the risks associated with working while under the influence
of drugs or alcohol is more dangerous.
Barriers to Getting Help
The main barriers to nurses obtaining help are themselves or their coworkers. When
nurses are substance abusers they experience a lot of shame and guilt about their drug use.
Shame and guilt can be the biggest barriers to seeking help. A substance use disorder is a
progressive disease which untreated continues to worsen leading to the addict's deterioration
physically, psychologically, emotionally and eventually causing their death (Fleck, 2012). A
substance use disorder is a disease that also feeds and progresses on fear and shame. Nurses
struggling with impairment most likely will not seek treatment until confronted by peers, family,
nursing management, or their employment is in jeopardy. However, those with substance abuse
issues that enter and complete structured treatment programs can be successful and reenter the
profession of nursing.
Safety and Ethical Issues
The impaired nurse is putting patients at risk by their absenteeism and lack of clinical
judgment. The impaired nurse is putting their co-workers at risk by causing them to work
understaffed by taking frequent breaks and providing poor patient care that needs to be handled
by others. The company is put at risk by the impaired nurse because of possible law suits
brought on by patients and family who are affected by the nurses impairment.
The registered nurse practices ethically and reports any illegal, incompetent, or impaired
practice. The impaired nurse does not maintain a positive nurse-patient relationship, and does
not provide care in a manner that preserves patient rights. The impaired nurse does not seek
available resources to formulate ethical decisions and instead practices in a way that risk patient
Resources for Getting Help
According to Thomas & Siela, currently there are 37 states that offer some form of a
substance abuse treatment program to direct nurses toward treatment (2011).
The Health Professional Recovery Program (HPRP). HPRP was established by the
state Legislature in 1993 to meet the needs of the health professions as a confidential, non-
disciplinary approach to aide in recovery from substance abuse/chemical addiction or mental
illness. The HPRP is a supportive program that promotes recovery through evaluation of the
presence of a chemical dependency/substance abuse or mental health problem. The program
plans a monitoring agreement to address the treatment needs that are specific for the individual,
and monitors the individual's progress. The HPRP is designed to encourage impaired health
professionals to seek a recovery program before their impairment causes harm to a patient or
damages their career. The program is supported by the licensing boards, as well as professional
societies and associations throughout the state (LARA, 2014).
Impaired Professionals Procedures Program (IPP). The IPP program is governed by
Administrative Code RL7 which falls under the authority of the Department of Regulation and
Licensing (Dennik-Champion, 2009). The program has been in existence since 1991. IPP does
not provide treatment, but monitors participants progress in treatment with an approved
treatment provider. According to the Department of Regulations and Licensing, the goal of IPP
is to protect the public from professionals who practice while impaired by alcohol or other drugs.
IPP promotes early identification of chemically dependent professionals and encourages their
rehabilitation. IPP offers participants an opportunity to obtain treatment for chemical
dependency while ensuring that immediate action can be taken should a participant relapse or
drop out of treatment.
Implications and Consequences
Impairment and the Law
A multitude of events could cause a nurse to work impaired and if harm comes to a
patient as a result, disciplinary actions will be taken. State boards of nursing are responsible for
protecting the public. According to ISNA, each nursing board responds to the issue of nursing
impairment in a different way. Some boards take the nurse through the disciplinary process,
some have an alternative to discipline program, and others work with outside organizations to
provide an alternative to the disciplinary process such as rehabilitation (2009).
Michigan laws
Under Section 333.16223 of the Public Health Code, licensed/registered health
professionals are required to make good faith reports of suspected violations of the Public Health
Code to the Department of Licensing and Regulatory Affairs, Bureau of Health Care Services.
However for purposes of substance use and/or mental health disorders, a report to the HPRP
meets the legal reporting requirement (LARA, 2014).
According to the Michigan Public Health Code, Section 333.20175(5), - A health facility
or agency that employs, contracts with, or grants privileges to a health professional licensed or
registered under article 15 shall report to the Department of Community Health (HPRP, 2014).
Quality and Safety Improvements
If part of the orientation process involved education on how to spot impairment,
employees would be more inclined to report suspicions while impaired nurses would be less
likely to practice impaired due to fear of identification. Risks related to impairment from fatigue
should be covered by the employer and the quality improvement department and measures taken
to eliminate this risk. Putting restrictions on the amount of overtime a nurse can work or limiting
hours worked at once would help remove the risk for a nurse to be working while exhausted and
provide for patient safety. Fatigued nurses are more likely than well-rested nurses to make
faulty decisions that lead to decision regret, a negative cognitive emotion that occurs when the
actual outcome differs from the desired or expected outcome (Scott, Arslanian-Engoren &
Engoren, 2014). With teamwork and communication, a unit should be able to end the issues
with nursing impairment to provide a safer environment for patients.
Nursing Theory
Sister Callista Roy's Model of Adaptation
Roys theory of adaptation discusses the person as a bio-psycho-social being who is in
constant interaction with a changing environment. The impaired nurse chooses to cope with a
changing world by using drugs or alcohol. This is a negative response to stressors due to the
nurse not properly adapted to the environment. A person has four modes of adaptation:
physiologic needs, self- concept, role function and inter-dependence. The impaired nurse is in
physiologic need and self concept modes of adaptation. The rehabilitation programs goals are to
help the impaired nurse adapt positively in the four modes.
Dorothea Orems Self-Care Theory
Orems theory of self-care applies to all humans, not just patients. The individual should
be self-reliant and responsible for their own care and others in their family needing care. The
impaired nurse is suffering from a self-care deficit. The impairment causes the nurse to be
incapable or limited in the delivery of continuous effective self-care. Orem identifies methods of
helping to be guiding, supporting, and teaching. Because of the nurses impairment they are
unable to help their patients and in return need help themselves.
A nurse can be impaired due to multiple causes. There are laws in place to protect
patients and nurses from impairment. Shame and guilt often stand in the way of a nurse seeking
help. There are a number of resources available for nurses struggling with impairment to obtain
the treatment they need. Our patients and our licenses depend on the elimination of impaired
Appendix A
(Thomans & Siela, 2011)

American Nurses Association (2010) Scope and Standards of Nursing Practice,
American Nurses Association (2014). Nurse fatigue. Retrieved from
Dennik-Champion, G. (2009). Department of Regulation and Licensing submits
recommendations for revising the impaired professionals procedure program. Stat:
Bulletin Of The Wisconsin Nurses Association, 78(9), 7-8.
Connection, (31), 22-23.
Guidelines for managers of impaired nurses. (2009). ISNA Bulletin, 35(3), 8-12.
Health Professional Recovery Program (HPRP)Michigan.
LARA - Health Professional Recovery Program Brochure. (n.d.). LARA - Health Professional
Recovery Program Brochure. Retrieved June 22, 2014, from,4601,7-154-35299_63294_27648-43
Scott, L. D., Arslanian-Engoren, C., & Engoren, M. C. (2014). Association of Sleep and Fatigue
With Decision Regret Among Critical Care Nurses. American Journal of Critical care,
23(1), 13-23. Retrieved July 9, 2014, from
Singh, T. (2012). Avoid Malpractice and Protect Your License: Impaired Practice. Nevada
Rnformation, 21(1), 9.
Thomas, C., & Siela, D. (2011). The impaired nurse: Would you know what to do if you
suspected substance abuse. American Nurse Today, 6(8), Retrieved from Retrieved from