Running head: Running Head: ETHICS AND IMPAIRED NURSES
Ethics and Impaired Nurses
Jill Collins, RN BSN
Washburn University
Emergency Department Charge Nurse
St. Francis Health Center
Topeka, KS 66606
December 14th, 2009
Northeast Kansas ENA Chapter 447
jccgcollins@yahoo.com
1
Running Head: ETHICS AND IMPAIRED NURSES
2
Abstract
Impaired nursing practice is a very prominent issue faced by the nursing profession today. This
issue can cause great moral distress for the nurse suspecting his/her coworker and/or friend of
practicing impaired. The nurse often has to choose between protecting the patient and risking a
friendship as well as causing detriment to his/her coworker by reporting him/her. The purpose of
this article is to educate nurses on signs of impaired nursing practice and give a brief explanation
of what drives a nurse to impairment. The article will also assist nurses in realizing that not only
do nurses, as a profession, have an obligation to ensure the safety of the patients being cared for
by impaired nurses but the profession also has an obligation to its peers to assist them in
recovery and return to the workforce.
Running Head: ETHICS AND IMPAIRED NURSES
3
Introduction
What would you do if you discovered or even suspected that you were working with a
nurse that was impaired by either drugs or alcohol? Add to the equation the same nurse is either
a close co-worker or a very good friend. It is a situation most nurses will probably find
themselves in sooner or later. It is a situation which causes a great deal of moral distress which
occurs when one faces a challenge about how to maintain his/her integrity or the integrity of the
profession (Purtilo, 2005). Estimates suggest that approximately 20% of nurses are chemically
dependent and working while impaired. That is 1 out of every 5 nurses. (Monroe, Pearson, &
Kenaga, 2008) Many times recognizing the signs of an impaired nurse is a difficult task. This
task becomes even more difficult when one considers friendships, the fact nurses naturally want
to help everyone and nurses tend to enable the behaviors at hand. One of the most difficult parts
of suspecting impairment is deciding what to do with the information and how to handle the
situation. This is the source of the moral distress. It requires either reporting the coworker
putting his/her credibility, job and livelihood at risk or continuing to look the other way while
putting patients’ lives at risk. It seems there should be a way, as a profession, we can
report/confront our coworker in such a manner that it does not jeopardize his/her career and
livelihood yet protects our patients from the potential effects of the impaired nurse.
Discussion
Impaired nursing practice is the inability of a nurse to perform essential functions of
his/her job with reasonable skill or safety secondary to chemical dependency on drugs or alcohol,
or due to mental illness (Dunn, 2005). The chemically dependent/impaired nurse may not
necessarily be easy to recognize. Many times this nurse is very cheerful and outgoing, is willing
to pick up hard to fill shifts, will volunteer to pick up medications from the pharmacy, and will
Running Head: ETHICS AND IMPAIRED NURSES
4
volunteer to take those “difficult” patients who are in a lot of pain. Unless one recognizes these
signs as being indicators of drug addiction, this nurse may be difficult to pick out. There are
several other signs of drug and/or alcohol addiction which can include but are not limited to:
requesting jobs in less supervised settings, volunteering to count narcotics, patients complaining
of ineffective pain relief, frequent unwitnessed medication wasting, failing to obtain
cosignatures, signing out more controlled substances than coworkers, frequent trips to the
bathroom, increasing or unexplained tardiness or absenteeism, increased forgetfulness, showing
up when not scheduled and around departmental drug supply, and gradual and subtle
deterioration of routine work performance (Dunn, 2005), (Quinlan, 2003). One must also
consider that “suspicion of substance dependency should not be presumed by a single sign or
symptom, but rather by changes in behavior” (Quinlan, 2003). It is important for facilities to
educate their staff on awareness of these symptoms.
One of the biggest questions surrounding impaired nurses is why and how one gets to the
point of being addicted to drugs and/or alcohol so much so that one is willing to jeopardize
his/her career, reputation, families and livelihood. There are several factors which are inherent
to the occupation that contribute to dependency. Some of these factors are: demanding, highpressure, stressful work environments, burnout, decreased staffing, overwork, sleep deprivation,
increased workloads, mandatory overtime, and rotating shifts. Those nurses that work in critical
care areas such as the ICU and ER also deal with: an unpredictable work pace, increased
frequency of dealing with death, the immediacy of the nursing intervention, reliance on
pharmocological agents, and ready access to controlled substances (Dunn, 2005). These factors
all contribute to fatigue and stress which can ultimately lead to chemical dependancy. Other
factors including family history, issues at home, financial difficulty, and simply the fact
Running Head: ETHICS AND IMPAIRED NURSES
5
medications are readily available in the workplace and are seen as desireable methods to cure
people also contribute to dependency and impairment (Dunn, 2005). It is rather easy to see how
one could become chemically dependant.
There are many ethical principles surrounding the impaired nurse and the patient. The
first principle to consider is nonmaleficence. Nonmaleficance considers one should “do no
harm” as well as preventing harm, removing harm when it is being inflicted, and bringing about
a positive good (Purtilo, 2005). According to this principle, it is a nurse’s duty to report an
impaired coworker in order to prevent the potential harm he/she poses to patients when working
under the influence of drugs or alcohol. This principle could also be applied to the impaired
nurse. It is also our duty as a profession to help the impaired nurse with her addiction to prevent
further harm to himself/herself.
The next principle is autonomy which is “the capacity to have the say-so about your own
well-being” (Purtilo, 2005). One is certainly not granting the patient autonomy when he/she
allows an impaired nurses to work with him/her. Most people would not willingly put their own
lives in the hands of an impaired professional.
The third principle is that of veracity. It binds one to honesty and means one will tell the
truth (Purtilo, 2005). In an ideal world, veracity should be inherent in all health professionals
but unfortunatley it is not.
The principle of fidelity applies to both the patient and the nurse. It simply means that
one will be faithful in meeting another’s reasonable expectations (Purtilo, 2005). Reporting
impaired nurses and taking them out of active practice is being faithful to society, but as a
profession, nurses should also keep in mind that they should be faithful to our colleagues in
helping them through a very difficult time.
Running Head: ETHICS AND IMPAIRED NURSES
6
The primary concern of nurses should be the patients that they care for. Afterall, why do
nurses get into this profession and why is there even such a profession to begin with? It is
because people need to be cared for and nurses have made the choice to do so. The American
Nurses’ Association’s (ANA) code of ethics states “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” and “the nurse’s primary commitment is to the patient, whether an
individual, family, group, or community” (American Nurses Association, 2001). It is expected
of the profession to uphold these standards and not doing so can also have legal ramifications.
Any nurse who is aware of or suspects impaired nursing practice and fails to report it to the
proper authorities can be charged with negligence if a patient has a bad outcome. It is imperative
to report suspicion of impaired nursing practice for the protection of our patients. But what
about the impaired nurse?
The ANA also states “nurses in all roles should advocate for colleagues whose job
performance may be impaired to ensure that they receive appropriate assistance, treatment and
access to fair institutional and legal processes. This includes supporting the return to practice of
the individual who has sought assistance and is ready to resume professional duties” (American
Nurses Association, 2001). Part of advocating for a colleague is helping him/her to realize
he/she has a problem and he/she needs help. “Nurses should understand that if addicted nurses
are not helped, they are in danger of harming patients, the facility’s reputation, the nursing
profession, and themselves” (Dunn, 2005). Unfortunately, many times when the discovery has
been made by an institution that it has an impaired nurse working there, the nurse is immediately
terminated which begins its own vicious cycle. The nurse obviously would not want shared with
his/her colleagues why he/she was terminated and so management has an obligation to uphold
Running Head: ETHICS AND IMPAIRED NURSES
7
the nurse’s confidentiality. This makes it nearly impossible for any coworker or friend to
approach the nurse about her problem and offer to help. The nurse’s healthcare benefits are also
ceased at this time leaving him/her no coverage to seek help. The nurse then either seeks
employment elsewhere and is placed back in a position where he/she is able to continue impaired
practice or seeks other alternatives which may include suicide attempts since he/she feels
hopeless.
In an attempt to prevent the above mentioned scenario, the National Nurses Society on
Addictions, and the American Nurses Association have encouraged state nursing boards to adopt
an alternative-to-discipline program. (Monroe, Pearson, & Kenaga, 2008) These programs
encourage each state to adopt non-punitive strategies to address the disease of chemical
dependency (Monroe, Pearson, & Kenaga, 2008). The hope would be that once the impaired
nurse has been discovered, he/she would be put on a leave of absence and put into a treatment
program with the ultimate goal being the ability of the nurse to return to work in the nursing
field.
Conclusion
Confronting or reporting a nurse that one suspects of being impaired is a source of great
moral distress. It is quite hard to choose sometimes between doing what one knows is ultimately
the right thing to do or potentially causing great turmoil in the life of a friend and fellow nurse.
It is, however, a necessary step to take. Not only are nurses protecting patients from potential
harm, but in the long run the are helping the impaired nurse as well. It is in the best interest of
the nursing profession to advocate for both the patient and the impaired nurse.
Running Head: ETHICS AND IMPAIRED NURSES
8
References
American Nurses Association. (2001). Code of Ethics for Nurses with Interpretive Statements.
Washington D.C.: American Nurses Publishing.
Daniel, I. Q. (1984). Impaired professionals: responsibilities and roles. Nursing Economics ,2,
190-193.
Dunn, D. (2005). Substance abuse among nurses- defining the issue. AORN Journal ,82, 573596.
Hempstead, L. A. (2007). Narcotics diversion: a director's experience. Journal of Emergency
Nursing ,33, 175-178.
Monroe, T., Pearson, F., & Kenaga, H. (2008). Procedures for handling cases of substance Abuse
among nurses: a comparison of disciplinary and alternative programs. Journal of Addiction
Nursing ,19, 156-161.
Naegle, M. A. (2003). An overview of the American Nurses' Association's action on impaired
practice with suggestions for further direction. Journal of Addiciton Nursing ,14, 145-147.
Pullen, L. M., & Green, L. A. (1997). Indentification, intervention and education: essential
curriculim components for chemical dependency in nurses. The Journal of Continuing
Education in Nursing ,28, 211-216.
Purtilo, R. (2005). Ethical Dimensions in the Health Professions. Philadelphia, PA: Elsevier
Saunders.
Quinlan, D. (2003). Impaired nursing practice: a national perspective on peer assistance in the
U.S. Journal of Addiction Nursing ,14, 149-155.