ATrain Education


Continuing Education for Health Professionals

Course Modules

  • Course Introduction
  1. Professional Impairment
  2. Substance Use Disorder
  3. Identifying SUDs and Workplace Impairment
  4. Chapters 456 and 464, Florida Statutes
  5. Barriers to Reporting
  6. Treating Impaired Nurses in Florida
  7. Employer Initiatives/Prevention
  8. Conclusion
  9. Resources and References
Return to Module View

FL: Impairment in the Workplace

  • Author:
    • Susan Walters Schmid, PhD

      Susan Schmid earned BA degrees in History and European Studies from George Mason University, a Master's degree in Public History from Appalachian State University, and a PhD in History from Arizona State University.

      In addition to her PhD she earned a Certificate in Scholarly Publishing from ASU. Susan has served as an editor for several scholarly presses. She worked as a desktop publishing specialist for Arizona State University and taught several courses for the History Department as well as "Introduction to Scholarly Publishing" and "Scholarly Editing" for the Scholarly Publishing Program.


  • Contact hours: 2
  • Pharmacotherapy hours: 0
  • Expiration date: November 1, 2020
  • Course price: $19

Course Summary

Addresses the problem of substance use disorder (SUD) in Florida, with emphasis on levels of misuse and the risks and protective factors for nurses. Identifies behaviors and signs of SUD, and workplace impairment due to SUD. Summarizes Florida laws and requirements for nurses with regard to SUD. Outlines the process for reporting workplace impairment in Florida and describes the component of the Florida Intervention Project for Nurses. Finally, discusses employer initiatives to promote safety through assistance and prevention opportunities.

The following information applies to occupational therapy professionals:

  • Target Audience: Occupational Therapists, OTAs
  • Instructional Level: Introductory

Criteria for Successful Completion

80% or higher on the post test, a completed evaluation form, and payment where required. No partial credit will be awarded.

Conflict of Interest/Commercial Support

Conflict of Interest/Commercial Support

Accredited status does not imply endorsement by ATrain Education Inc. or by the American Nurses Credentialing Center or any other accrediting agency of any products discussed or displayed in this course. The planners and authors of this course have declared no conflict of interest and all information is provided fairly and without bias. No commercial support was received for this activity.

Accreditation Information

Objectives: When you finish this course you will be able to:

  • Briefly outline the problem of substance use disorder in Florida and the United States.
  • Discuss substance use disorder in terms of levels of misuse and risk and protective factors, especially among nurses.
  • Identify behaviors and signs of substance use disorder and workplace impairment due to substance use disorder.
  • Summarize Florida laws and requirements for nurses regarding substance use disorders.
  • Explain the process for reporting workplace impairment in Florida.
  • Describe the components of the Florida Intervention Project for Nurses.
  • Discuss employer initiatives to promote safety and assistance and prevention opportunities.

Professional Impairment

The opioid crisis is familiar to most of us because it is negatively affecting individuals, families, and communities throughout our society and is a recurring topic in today’s media. Opioid misuse is one element of the broader problem of substance use disorder (SUD), which includes misuse of alcohol, prescription drugs, and illicit drugs, as well as nicotine.

The Center on Addiction (COA) estimates that 40 million Americans ages 12 and older (more than 1 in 7) abuse or are addicted to nicotine, alcohol, or other drugs (COA, 2018). Percentages can vary depending on the particular use disorder (alcohol, tobacco, cannabis, stimulant, hallucinogen, and opioid), age, gender, race, and ethnicity (US SAMHSA, 2017, 2015).

No group is immune to the possibility of substance use disorder, even those we might think would be especially knowledgeable or aware of the problem and its consequences. The American Nurses Association (ANA) has found that 6% to 8% of nurses use substances to the level that it affects their on-the-job performance; among nurse anesthetists the rate is 9.8% and it varies widely with other specialties. While rates among nurses are similar to those in the general population, nurses do have a greater risk of using prescription drugs (Smith, 2017; Cares et al., 2015).

In the most recent Gallup Poll, "More than 8 in 10 (82%) Americans describe nurses' ethics as ‘very high’ or ‘high,’” and they have received the designation “most trusted profession” for many years (Gallup News, 2017). The idea that nurses could be impaired while working is thus a difficult concept for many people to accept, but “Substance abuse occurs across all generations, cultures, and occupations, including nurses” (Thomas & Siela, 2011). And, when the signs of impairment in nurses are missed or attributed to other causes, patients’ lives can be endangered and nurses don’t receive the help they need to deal with their disorder.

Nursing work often requires practitioners to juggle many roles and actions in the course of a single work day. Their workload requires both a foundation of knowledge and an ability to focus closely on the particular task at hand. Nurses who are under the influence of drugs or alcohol cannot be counted on for focus and may be unable to carry out the day-to-day functions of their profession.

Historically, registered nurses found to be abusing drugs or alcohol were given little support; they lost their jobs, their means of financial support, and their network of professional peers, and were ostracized from the nursing profession. However, as noted recently by the National Council of State Boards of Nursing (NCSBN), “Non-disciplinary programs, offering an alternative to traditional discipline, are now used by a growing number of state boards of nursing” (NCSBN, 2018). Identifying substance abuse as a problem within professional nursing and providing alternative methods to promote and support recovery can enable many to return to work as licensed professional nurses.

Across all groups, including nurses, one of the biggest barriers to resolving this crisis is the lack of knowledge about substance use disorder—how it works, how to recognize it early, and what can be done to help those who are suffering from it. This course will address those topics along with information on relevant Florida statutes, employer initiatives, and prevention ideas.

Substance Use Disorder

The term substance use disorder (SUD) covers everything from abuse to dependency or addiction* to alcohol or drugs. Substance use disorder affects all economic classes, ages, ethnicities, genders, and any other labels. It is a progressive and chronic disease that can result in death if left untreated. However, while it cannot be cured, it can be effectively managed and treated (NCSBN, 2011; SAMHSA, 2017, 2015; Crowley et al., 2017).

*Compulsive use of chemicals, and inability to stop using them despite the myriad of negative consequences.

Substance use disorder has historically been seen as a problem stemming from the use/abuse of substances such as drugs or alcohol. Users were seen as lacking willpower or personal responsibility and their behavior as a “moral failing.” Medical research has advanced our knowledge of how alcohol and drugs affect the brain, temporarily and permanently, and addiction came to be understood as a “chronic, relapsing brain disease.” But that disease does not affect everyone in the same way and it operates in a complexity of factors, including behavioral and social, that need to be considered in both prevention and treatment (Crowley et al., 2017; Volkow et al., 2016; Strobbe & Crowley, 2017).

Although our understanding has changed, the older views and stigma often persist and still have the power to interfere with seeking help for drug use issues and dealing with responses from family, friends, colleagues, and society at large. Research has shown that policies and programs based on the older beliefs and attitudes are often ineffective, while newer programs that take into account the brain disease model and the web of factors have demonstrable success (Crowley et al., 2017; Strobbe & Crowley, 2017; NCSBN, 2011).

Abuse, Dependence and Addiction

The Center on Addiction (formerly the Center on Addiction and Substance Abuse [CASA] at Columbia University) defines the difference between alcohol or drug abuse and addiction as one of severity. Abuse is a mild substance problem with a person exhibiting 2 or 3 symptoms of addiction. Abusers may experience serious problems related to their substance abuse but are able to “stop using or change their pattern of use without progressing to addiction” (COA, 2018).

This follows the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) where the term substance use disorder (SUD) has replaced both substance abuse and substance dependence in the terminology and SUDs are defined as mild, moderate, or severe determined by the number of diagnostic criteria met by an individual (SAMHSA, 2015; Volkow et al., 2016).

Substance use disorders “occur when the recurrent use of alcohol and/or drugs causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school or home” (SAMHSA, 2015). Diagnosis will consider evidence of impaired control, social impairment, risky use, and pharmacological criteria (SAMHSA, 2015).

Risk and Protective Factors for SUDs

Risk factors are “characteristics at the biological, psychological, family, community, or cultural level that precede and are associated with a higher likelihood of negative outcomes.” Protective factors are those “associated with a lower likelihood of negative outcomes or that reduce a risk factor’s impact” (SAMHSA, 2015a).

Some factors remain fixed over time, while others may change. For example, genetic predispositions will not change, while factors such as income status, peer group, or employment status can vary over time. Neither risk nor protective factors exist in isolation; both operate within relationships, communities, and the larger society and can be affected by many things such as community resources, local norms and laws, and family violence or family support (SAMHSA, 2015a; HHS, 2016).

General risk factors, which tend to make any individual more susceptible to developing an SUD, include:


  • Depression
  • Anxiety
  • Low self-esteem
  • Low tolerance for stress
  • Other mental health disorders (such as learning disabilities)
  • Feelings of desperation
  • Loss of control over day-to-day circumstances
  • Feelings of resentment


  • Use of other substances
  • Aggressive behavior in childhood
  • Conduct disorder (social personality disorder, avoidance of responsibilities, impulsivity and risk-taking, alienation, and rebelliousness)
  • Reckless behavior
  • School-based academic or behavioral problems (ie, dropping out)
  • An involvement with the criminal justice system
  • Illegal behaviors
  • Poor interpersonal relationships


  • An early age of the first abuse
  • Alcohol and drug use by peers
  • Social or cultural norms condoning abuse
  • Faulty expectations about the positive effects of drugs and alcohol
  • An availability of drugs or alcohol


  • Male gender
  • Inner city or rural residence combined with a low socio-economic status
  • Lack of employment opportunities


  • Abuse of alcohol and drugs
  • A family dysfunction such as inconsistent discipline
  • A lack of positive family rituals and routines
  • Poor parenting skills
  • Family trauma (such as a death or divorce)


  • Inherited predisposition to alcohol or drug dependence
  • Deficits in natural neurotransmitters (such as serotonin)
  • An absence of aversive reactions such as flushing or palpitations (NCSBN, 2011; SAMHSA, 2015a; HHS, 2016; NCSBN, 2011).

Note: While sources essentially agree on the larger categories, they may provide variations on examples within each category.

Just as with risk factors, protective factors operate in various realms—personal, family, social, community—and in some cases will vary across a lifetime affected by gender, age, and ethnicity. Protective factors can include intelligence, easy temperament, and positive self-image; positive parenting and supportive early childhood experiences; cultural ties and participation; religious and spiritual connections; and good social relationships.

Protective factors (like risk factors) may cluster together and can lower the possibility of negative outcomes or reduce the negative impact of a risk factor, but neither protective nor risk factors are guarantees of outcome in and of themselves. Individuals, institutions, work groups, and communities can take steps to reduce risk factors and they can take steps to increase protective factors. Improving personal health and learning about risk factors, establishing organizational fairness and transparency while offering health promotion resources, team support for high standards, providing timely feedback, and colleague debriefings are among the many positive actions that can be taken (Smith, 2017; NIDA, 2016; SAMHSA, 2015a; Red Lake Chemical Health, 2013).

Risk and Protective Factors for Nurses

Nurses are, of course, subject to any of the risk and protective factors already discussed, but research shows that “risk factors unique to a nurse’s workplace can predispose them to developing a substance use disorder.” Some research even cites addiction and substance abuse as occupational hazards for healthcare professions. Certain nursing specialties, including emergency department, psychiatric, oncology, and anesthesia, have higher rates of certain types of substance use disorders, and because these higher rates are seen among physicians in those specialties as well, there may be common factors (NCSBN, 2011).

In a 2014 research project, 65% of respondents to the project survey believed that greater emphasis during nursing professional training on how to make early identification of risk factors was the most important strategy to help prevent substance abuse (Cares et al., 2014).

For nurses, risk factors include:

  • Role strain (burnout, work overload, inadequate support
  • Problems of daily living), loss of significant other, poor coping skills, insecurity, isolation
  • Enabling by peers and managers—symptoms overlooked
  • Attitudes towards drugs and drug use
  • Lack of education regarding a substance use disorder
  • Lack of controls
  • Physician prescribing practices (NCSBN, 2011)

Researchers have also identified five particular attitudes that can cause problems for nurses and increase the likelihood of developing a substance use disorder. These include:

  • Substance use is an okay way to cope with life’s problems and a means to enjoyment, comfort, and getting along
  • “Pharmacological optimism” that can come from training that emphasizes a faith in what drugs can do and seeing positive effects of them on patients
  • A sense of entitlement that one must work and substance use is an acceptable means to that end
  • Invulnerability that health care providers sometimes feel to the effects of illnesses their patients have or the inability to see themselves as the recipients of care
  • Using training to self-diagnose and self-medicate in order to keep working, with the stress and fatigue leading again to see the means justifying the end (NCSBN, 2011)

Curiously, there is often a real lack of education among nurses about how addiction works and how to recognize its signs. The occupational hazard of readily available drugs when combined with poor management (a failure to observe secure control and administration of controlled substances within a workplace) can add to the risks for nurses and other healthcare workers. Loose prescribing practices for narcotics can create an additional risk and may manifest itself as a nurse who self-diagnoses and then gets a physician friend to write a prescription.

In its comprehensive resource guide, Substance Use Disorder in Nursing, the National Council of State Boards of Nursing (NCSBN) identifies the top four risk factors for nurses in the workplace as “access, attitude, stress, and a lack of education” (NCSBN, 2011).

Protective factors for nurses have been much less well studied. Obviously, all the protective factors previously discussed can benefit nurses as well. Improving personal health and health knowledge are especially relevant, and the team and organizational protective factors are critical. Research has shown that, among nurses, beliefs in the values and norms of society, school and religious beliefs, and strong early attachment to a parent are all protective, as are work satisfaction, workplace social support, and workplace constraints regarding substance use. As will be discussed later, protective factors come into play in building an occupational environment that supports a strong recovery program for those working to overcome substance use disorder (NCSBN, 2011; Smith, 2017).

Identifying SUDs and Workplace Impairment

Many signs of SUD are non-specific and may be observed among members of any group of those afflicted by SUD. What will be observed among individuals in a personal situation may also be observed in their employment environment. Some signs are especially relevant in the workplace because they indicate an impaired ability to accomplish work tasks safely, efficiently, and correctly. Some workplace signs are especially noticeable or dangerous in the nursing field.

Complicating the issue is that signs of SUD can be conflated with those from stress (Alunni-Kinkle, 2015), or may indicate a different problem, and they vary to some extent depending on the person’s drug of choice (eg, alcohol vs. opioid). In addition, some signs will be specific to certain nursing specialties.

When considering all the various charts and checklists, it can seem as if almost anything can be a warning sign of substance use disorder. In the end it may help to look at the big picture: what is the sum of the various signs and how do they compare to the nurse’s baseline behavior? We need to observe carefully and document objectively.

As one nurse-writer observed, nurses tend to take extra care to avoid detection, and so may not manifest drug use in the same way as the disheveled street-corner addict (Paton, 2017).


  • Severe mood swings, personality changes, panic attacks, defensiveness, anger outbursts
  • Frequent or unexplained tardiness, work absences, illness or physical complaints
  • Elaborate excuses
  • Underperformance
  • Difficulty with authority
  • Poorly explained errors, accidents or injuries
  • Wearing long sleeves when inappropriate
  • Confusion, memory loss, and difficulty concentrating or recalling details and instructions
  • Visibly intoxicated – slurred speech, lack of coordination/moving unsteadily, smell of alcohol on breath; excessive use of mints, gum, mouthwash, or hand sanitizer
  • Refuses drug testing
  • Ordinary tasks require greater effort and consume more time
  • Unreliability in keeping appointments and meeting deadlines
  • Relationship discord or isolation (eg, professional, familial, marital, platonic)


  • Physical indications (eg, track marks, bloodshot eyes)
    • Shakiness and tremors
    • Dilated or constricted pupils (opioids constrict)
    • Watery eyes and nose
    • Fatigue, falling asleep, or even blackouts
    • Frequent episodes of nausea, vomiting and/or diarrhea
    • Significant weight loss or gain
  • Deterioration in personal appearance – but employed addicts may take special pains with appearance
  • Found comatose or dead

Workplace specific signs and behaviors

  • Lack of concentration, forgetfulness, and frequent errors
  • Underperformance—not carrying a full load of work
  • Frequently late, calls in sick, or leaves early
  • Always on the job, work late, extra shifts (for drug access)
  • Decreased quality of care and documentation
  • Frequent absences from the unit (eg, excessive bathroom trips)
  • Isolation from colleagues
  • Signs indicating drug diversion (see next section) (Paton, 2017; AANA, 2016; WA DoH, 2016; Stone et al., 2016; Cares et al., 2014; Alunni-Kinkle, 2015; NCSBN, 2014, 2011; Monroe & Kenaga, 2010).

Note: While sources generally agree on the larger categories, they may provide many variations on examples within each category. There is a great deal of overlap in general behavior and signs with those that are workplace critical.

Indications of Drug Diversion


  • Consistently uses more drugs for cases than colleagues
  • Frequent volunteering to count narcotics, administer narcotics, relieve colleagues of casework, especially on cases where opioids are administered
  • Consistently arrives early, stay late, or frequently volunteers for overtime
  • Frequent breaks or trips to bathroom
  • Heavy wastage of drugs
  • Drugs and syringes in pockets


  • Patient complaints of ineffective pain relief or patient has unusually significant or uncontrolled pain after anesthesia
  • Anesthesia record does not reconcile with drug dispensed and administered to patient
  • Times of cases do not correlate when provider dispenses drug from automated dispenser
  • Inappropriate drug choices and doses for patients
  • Missing medications or prescription pads
  • Drugs, syringes, needles improperly stored
  • Signs of medication tampering, including broken vials returned to pharmacy
  • Inaccuracies in controlled substances noted when a particular nurse works
  • Signatures and initials appear forged
  • Controlled substances signed out for patients with no orders
  • Excuses about shared access codes or forgetting to get witness signatures (AANA, 2016; Stone et al., 2016; Cares et al., 2014; NCSBN, 2011).

Note: As with other lists, sources display a great deal of overlap but vary in their examples. In some cases, this is due to special issues in certain practice areas such as anesthesia.

Consequences in the Workplace

“Diversion” means the transfer of a controlled substance from a lawful to an unlawful channel of distribution or use.


Uniform Controlled Substances Act (1994)

“Diversion” means “any criminal act involving a prescription drug.”

National Association of Drug
Diversion Investigators

In 2016 the American Association of Nurse Anesthetists (AANA) released a comprehensive position statement on SUD for anesthesia professionals. It includes an important discussion of the many consequences of drug diversion (drug theft) and SUD in the workplace.

Because nurses have a duty to protect their patients’ safety and work unimpaired, a failure to do so can have far reaching consequences for patients, the nurse, other colleagues, families and friends, the facility, and even the wider community. Impaired practice can poison a work environment with mistrust that potentially affects patient care on a larger scale.

The AANA identified the following categories of consequences:


  • Undue pain, anxiety, side effects from improper dosing
  • Allergic reactions to substituted drugs
  • Infections from contaminated needles or drugs
  • Victim of medical errors (eg, medication, procedural)
  • Loss of trust in the healthcare system

Impaired professional

  • Adverse health effects (respiratory depression, organ failure, death)
  • Chronic health effects (liver impairment, heart disease
  • Infections from unsterile drugs, needles, injection techniques
  • Accidents resulting in physical harm
  • Familial and financial problems
  • Loss of social statues
  • Decline in work performance and professional instability
  • Felony prosecution, prison, civil malpractice
  • Actions against license
  • Billing or insurance fraud


  • Injury or infection from improperly stored equipment (needlesticks)
  • At risk for medical/legal secondary liability
  • Stress from increased workload
  • Disciplinary action for failure to report or false witness


  • Costly investigations
  • Loss of revenue from diverted drugs or reimbursement for adverse events
  • Poor quality work and need to compensate for other employees
  • Civil liability re: drug diversion
  • Civil liability for patient harm
  • Damaged reputation
  • Increased worker’s compensation cost costs (AANA, 2016)

Similar concerns and risks have been raised on the Centers for Disease Control and Prevention (CDC) Safe Healthcare Blog (CDC, 2014, 2014a) and found in ongoing research at the Mayo Clinic (Berge et al., 2012). While some may think that drug diversion is a victimless crime, it is in reality a multi-victim crime. It can harm diverters themselves but also their patients and co-workers and can affect the reputation of their employer (Berge et al., 2012).

The CDC identifies several types of patient harm that can result from drug diversion including:

  • Substandard care delivered by an impaired healthcare provider,
  • Denial of essential pain medication or therapy, or
  • Risks of infection (eg, with hepatitis C virus or bacterial pathogens) if a provider tampers with injectable drugs.

The CDC is especially concerned with the possibilities of disease outbreak due to drug diversion activities. Between 1983 and 2013 it identified 9 outbreaks—4 bacterial and 5 of Hepatitis C virus—directly tied to drug diversion activities of healthcare professionals, 3 of them nurses. These incidents each demonstrated gaps in prevention, detection, or response to drug diversion at the relevant facilities and indicate the need for stronger controls and prevention measures (CDC, 2017).

Chapters 456 and 464, Florida Statutes

The Florida Statutes are organized into 58 Titles, each with a number of Chapters. Title XXXII—Regulation of Professions and Occupations—contains 39 chapters.

Chapter 456 covers general provisions relating to health occupations and professions, and Section 456.076 specifically addresses impaired-practitioner programs. That section lays out the structure and elements of these programs, including requirements for providers within the programs, services to be offered, and details of confidentiality requirements and disciplinary actions.


Access to Chapter 456 References

Entire Chapter 456:

Section 456.076:


Chapter 464 specifically focuses on nursing and certified nursing assistants and contains regulations on the practice of nursing in the state of Florida. This chapter is divided into two parts:

  • Part I: Nurse Practice Act
  • Part II: Certified Nursing Assistants

The laws contained in Chapter 464, Part I, provide safe parameters within which to work, as well as provisions intended to protect patients from unprofessional and unsafe nursing practice. Florida nurses and certified nursing assistants covered by this chapter are responsible for understanding the laws and rules that govern and define their scope of practice.


Access to Chapter 464 References

Chapter 464, Part I:

Chapter 464, Part II: h


Of particular importance to this course is Chapter 464: “Section 464.018, Disciplinary actions” is referred to as Florida’s mandatory reporting law and it contains the following:

  1. The following acts constitute grounds for denial of a license or disciplinary action…:
    1. Being unable to practice nursing with reasonable skill and safety to patients by reason of illness or use of alcohol, drugs, narcotics, or chemicals or any other type of material or as a result of any mental or physical condition. In enforcing this paragraph, the department shall have, upon a finding of the State Surgeon General or the State Surgeon General’s designee that probable cause exists to believe that the licensee is unable to practice nursing because of the reasons stated in this paragraph, the authority to issue an order to compel a licensee to submit to a mental or physical examination by physicians designated by the department. If the licensee refuses to comply with such order, the department’s order directing such examination may be enforced by filing a petition for enforcement in the circuit court where the licensee resides or does business. The licensee against whom the petition is filed shall not be named or identified by initials in any public court records or documents, and the proceedings shall be closed to the public. The department shall be entitled to the summary procedure provided in s. 51.011. A nurse affected by the provisions of this paragraph shall at reasonable intervals be afforded an opportunity to demonstrate that she or he can resume the competent practice of nursing with reasonable skill and safety to patients.
    2. Failing to report to the department any person who the licensee knows is in violation of this part or of the rules of the department or the board. However, a person who the licensee knows is unable to practice nursing with reasonable skill and safety to patients by reason of illness or use of alcohol, drugs, narcotics, chemicals, or any other type of material, or as a result of a mental or physical condition, may be reported to a consultant operating an impaired practitioner program as described in s. 456.076 rather than to the department.
    3. Knowingly violating any provision of this part, a rule of the board or the department, or a lawful order of the board or department previously entered in a disciplinary proceeding or failing to comply with a lawfully issued subpoena of the department.
    4. Failing to report to the department any licensee under chapter 458 or under chapter 459 who the nurse knows has violated the grounds for disciplinary action set out in the law under which that person is licensed and who provides health care services in a facility licensed under chapter 395, or a health maintenance organization certificated under part I of chapter 641, in which the nurse also provides services.

Paragraphs (p) and (q) address additional items specific to practice for advanced practice registered nurses and psychiatric nurses.

Florida Administrative Code Requirements

Administrative codes are intended to assist state departments and divisions in carrying out certain duties mandated in statute and are organized by department/division/chapter/rule. Administrative code provides a place to codify details to help a department carry out specific activities and does not necessarily cover every item contained in the statute. Important to the discussion at hand are those that concern continuing education requirements (Florida Statutes Chapter 464) and the impaired practitioners program (Florida Statutes Chapter 456).

Rules for Meeting Chapter 464—Continuing Education Requirements

Chapter 64B9-5 Continuing Education Requirements

(under the Department of Health/Board of Nursing)

Rule No. 64B9-5.002 states that, effective August 1, 2017 nurses must complete a 2-hour course on Recognizing Impairment in the Workplace and must do so every other biennium thereafter in order to maintain their licenses.

Rule No. 64B9-5.014 states that the course must cover, at a minimum, the following areas:

  1. Identifying the signs of impairment in the workplace;
  2. Employer initiatives to promote safety and provide assistance;
  3. The essential steps to make a report or referral;
  4. Mandatory reporting law, Section 464.018, F.S.;
  5. Treatment programs for impaired practitioners, Section 456.076, F.S.; and,
  6. Impairment treatment.

Rules for Meeting Chapter 456—Impaired Practitioners Program

Chapter 64B31 Impaired Practitioners Program

(under the Department of Health)

Rule No. 64B31-10.001 contains the following

  1. Definitions:
    1. An Approved Impaired Practitioner Program is designated by the department through contract with a consultant to initiate intervention, recommend evaluation, and refer impaired practitioners to treatment providers or treatment programs and monitor the progress of impaired practitioners in treatment. Approved impaired practitioner programs do not provide medical services.
    2. Consultants operate approved impaired practitioner programs which receive allegations of licensee impairment, personally intervene or arrange intervention with licensees, refer licensees to approved treatment programs or treatment providers, evaluate treatment progress, and monitor continued care provided by approved programs and providers.
    3. A treatment program is approved by a designated impaired practitioner program and must be a nationally accredited or state licensed residential, intensive outpatient, partial hospital or other program with a multidisciplinary team approach with individual treatment providers treating licensees depending on the licensee’s individual diagnosis and treatment plan that has been approved by an approved impaired practitioner program. A treatment provider is approved by a designated impaired practitioner program and must be a state licensed or nationally certified individual with experience treating specific types of impairment.
  2. The Department designates Intervention Project for Nurses (IPN) and Professionals Resource Network (PRN) as the Approved Impaired Practitioner Programs. Approved impaired practitioner programs also serve as consultants.

American Nurses Association Code of Ethics

The American Nurses Association (ANA) Code of Ethics directly addresses impaired practice in two subsections of Provision 3, which reads:

The nurse promotes, advocates for, and protects the rights, health, and safety of the patient.

In subsection 3.5, Protection of Patient Health and Safety by Acting on Questionable Practice, the Code’s interpretive statement says:

Nurses must be alert to and must take appropriate action in all instances of incompetent, unethical, illegal, or impaired practice or actions that place the rights or best interest of the patient in jeopardy.

It further notes that nurses must be familiar with the ANA Code of Ethics, standards of practice, all relevant laws and regulations, and their employer’s policies and procedures (ANA, 2015).

In subsection 3.6, Patient Protection and Impaired Practice, the guidelines note that

Nurses must protect the patient, the public, and the profession from potential harm when practice appears to be impaired.

Nurses must follow the policies of their employer as well as professional guidelines and the law. In situations of impaired practice, they must advocate for fair treatment of and support for colleagues in recovery. If impaired practice threatens the safety of patients, self, or others, a nurse must report this to the appropriate authorities (ANA, 2015).

In a 2017 presentation to the NCSBN-IRE conference, the director of the Florida Intervention Project for Nurses (IPN) emphasized certain elements in discussion of subsection 3.6:

[The need to be] vigilant in protecting patients, the public, and the profession; the duty to protect patients, and the need to assure assistance to nurses needing help.

Other writers emphasize these same ideas (Smith, 2017; Alunni-Kinkle, 2015).

Barriers to Reporting

Often nurses are uncomfortable or unsure about reporting possible substance use disorder in colleagues. Reasons for hesitancy include a lack of education about substance use disorders and how to spot them, reluctance to get someone in trouble or negatively affect their career, and not knowing how or where to make a report.

Common persistent myths about impaired nurses can also affect decisions about reporting, including the following:

  • Impaired nurses use only street drugs.
  • Impaired nurses have a long history of drug or alcohol use.
  • Impaired nurses are easy to recognize.
  • Drug addiction is voluntary.
  • Combining drugs is not harmful.
  • Addicts cannot recover and only need treatment for a couple of weeks.
  • Addicts have to want treatment and can’t be forced into it.
  • Alcoholics can sober up quickly.
  • Beer doesn’t have as much alcohol as hard liquor. (Thomas & Siela, 2011)

Self-Reporting/Barriers to Seeking Assistance

Nurses do not seek help for themselves for a variety of reasons including stigma, fear, an inability to ask for help, or an erroneous belief that they are successfully self-treating for the root problem. Denial is the usual response, and in general it takes the intervention and insistence of colleagues and/or family and friends to get a nurse to enter treatment (Smith, 2017).

In one study, fear and embarrassment and concerns about losing one’s license were the most highly rated barriers to seeking help for substance use disorder and mental illness. Other reasons included concerns about confidentiality, lack of awareness of treatment programs, too ill to seek help, lack of money to pay for treatment, lack of insurance, and not having a healthcare provider (Cares et al., 2015).

Respondent suggestions for overcoming those barriers included greater knowledge about how to seek support; steps to take to maintain one’s license; more confidentiality; support of professional colleagues, friends, and spouses; greater knowledge of treatment services; lower cost of treatment services; insurance coverage; and a confrontation or intervention by family, friends, or colleagues (Cares et al., 2015).

How to Report

Understanding the basics of substance use disorders and their potential signs and symptoms as well as knowing your ethical and legal responsibilities under Florida law will help prepare you for reporting impairment in your workplace.

If you see a practice that is unsafe or unprofessional you need to document objective information about that practice, determine the risk, share that risk with another, and take appropriate action (Smith, 2017), which will usually be to report the problem to your nurse manager or to another person specified by your facility’s policies and procedures.

Nurse managers play a critical role in this process by making sure their staff are knowledgeable about SUDs, risk factors, and signs and that they understand facility policies and procedures for reporting. Having a sense of the baseline behavior of staff members may allow the manager to more quickly notice important changes. If there is an immediate danger to a patient, action must be taken right away to remove the impaired nurse from the workplace following facility procedures.

An objective report contains details of things you can see, hear, smell, touch or feel, and their descriptions won’t vary from one person to the next. Avoid including opinions, emotional reactions, conclusions, and theories. Include physical descriptions and focus on the ability of the person to care for patients (to do their job). Supervisors might ask themselves “Is their practice safe and professional?” In other words, focus on the person’s performance.

Remember that changes in performance or behavior that you document can have multiple causes. Your job is not to diagnose but to report signs of impairment—unsafe work practice—to prevent harm to patients and others (Smith, 2017; Alunni-Kinkle, 2015; NCSBN, 2014, 2011; Thomas & Siela, 2011).

Documentation should include:

  • Specific times and dates
  • Specific places
  • Persons involved
  • Document resources (eg, charts, labs, x-rays)
  • Actions taken
  • How participants responded
  • Outcomes (NCSBN, 2011)

When a substance use disorder is suspected, reports should be reviewed for patterns of signs and behaviors, especially negative appearance, mood changes, interpersonal problems, patient complaints, frequent unit absences, and charting review (NCSBN, 2011).

The AANA outlines a procedure in which objectively documented evidence is gathered and thoroughly reviewed and, if that evidence supports substance use disorder, an intervention is arranged to remove the person from practice. Ideally an intervention is planned ahead of time with a trained interventionist and other supporting personnel present and details worked out. Rules for privacy and confidentiality as well as facility policies must be observed (AANA, 2017).

Referral and Reporting Options

In Florida an impaired nurse can be reported to the Intervention Project for Nurses (IPN) (non-disciplinary approach) or directly to the Department of Health/Florida Board of Nursing (disciplinary approach). The IPN is Florida’s state designated impaired practitioner program, known as an alternative to discipline (ATD) program, which will be discussed in the next module. The ultimate goal of ATDs is to protect patients and return nurses to the workplace. Their use is supported by research and experience and recommended by many professional groups including the ANA, the AANA, the NCSBN, ENA, and INTNSA (Strobbe & Crowley, 2017; Alunni-Kinkle, 2015; NCSBN, 2011; Monroe & Kenaga, 2010).

Steps in the IPN process include the initial referral call, consultation/intake, intervention/evaluation, appropriate treatment, and 2 to 5 years of monitoring (Smith, 2013).

A nurse who refuses participation in the IPN, discontinues treatment, or fails to progress once in the program will be reported to the Department of Health (DOH), which is the investigative entity for the Florida Board of Nursing. The DOH will conduct an investigation of the allegations, provide the nurse an opportunity to respond or defend; if a violation is found, a hearing (informal or formal) is held and, depending on the result, a disciplinary action may be imposed.

A closer look at the process and reasoning for each step is available in this video from the NCSBN:

Treating Impaired Nurses in Florida

Intervention Project for Nurses (IPN)

Florida’s state designated impaired practitioner program for nurses only is the Intervention Project for Nurses (IPN) with a mission “to ensure public health and safety by providing education, monitoring and support to nurses in the State of Florida.” The Department of Health contracts directly with IPN, which is required to meet specific criteria and standards. Costs are paid for by license renewal fees and are part of the budget of the Florida Board of Nursing (BON) (IPN, 2018; Smith, 2017).

In the early 1980s the nursing profession realized that 67% of nurses reported and/or disciplined by Boards of Nursing in the United States had drug, alcohol, or psychiatric disorders. At the time, the Florida BON, like most, used only a disciplinary model, yet there were a variety of concerns about the results obtained with that model. Beginning in 1982 with a call from the ANA, nursing groups and states began to look for different ways to address the problem of substance abuse among nurses (Smith, 2013).

On October 1, 1983, the Florida Legislature made it possible for an alternative to discipline program in the state and it amended the Mandatory Reporting Law to its current terminology, allowing reporting of a nurse directly to IPN under certain circumstances (Smith, 2017, 2013). IPN was the first such program in the country and has become a model for other states (IPN, 2018).

Treatment Process

The steps a nurse will encounter when entering IPN are:

  • Initial referral call
  • Consultation/intake
  • Intervention/evaluation
  • Appropriate treatment
  • 2–5 years of monitoring

IPN is not itself a treatment program but a master monitoring program and a resource provider. It refers nurses to an appropriate treatment program based on the specific situation and provides a variety of services including:

  • treatment referral (approved provider network)
  • IPN Advocacy Contract
  • Structured Nurse Support groups
  • Mutual Support Groups
  • Quarterly Progress Evaluations
  • Practice-setting reports
  • Relapse prevention groups
  • Random toxicology testing

A nurse signs a contract for participation in the program and will be required to attend a variety of meetings and support groups in addition to completing their treatment program. Frequent drug testing and a daily check-in are also part of the program. The ultimate goal is for a nurse to retain his or her license and return to safe practice. Normally there will be restrictions when the nurse first returns to the workplace that will require a worksite monitor and may restrict access to work with controlled substances (Smith, 2017, 2013).

Benefits and Challenges of ATD Programs

The Florida IPN and alternative to discipline programs in general can have benefits for patients, nurses, facilities, and the community. One often cited benefit is the ability to take quick action in removing a potentially unsafe nurse from practice as opposed to the traditional investigation and discipline process that can take months and may only come into play after actual harm has taken place. Regulatory boards report the costs to administer ATD programs are lower as well (NCSBN, 2011).

For nurses the ability to obtain help while retaining their license and preserving the possibility of returning to the workplace provides significant motivation, as does the ability to keep their names from being made public (in most places). Factors typical in ATD programs such as close scrutiny of activities, high quality support situations, 12-step meetings, drug testing, and consistent reviews have been demonstrated to be protective factors supporting a successful recovery (NCSBN, 2011).

Contracts between regulatory boards and program providers need to be spelled out carefully, including how and when information is shared. Issues of confidentiality are often a critical motivator for participation in the program but some critics see this a simply creating a safe haven for nurses from public discipline rather than as timely way to get those with substance use disorders into treatment. Balancing accountability and transparency to the board and the public with the needs of participants and program operators is an ongoing consideration (NCSBN, 2011; Strobbe & Crowley, 2017).

Employer Initiatives/Prevention

Employers have an important role in combating substance use disorder and also in helping to prevent it. Proactive efforts by employers to promote safety and provide assistance can protect patients and support staff, and preserve the institution’s financial well-being and community standing.

Possible actions facilities can take include adopting open, transparent, and comprehensive policies and procedures, offering classes or seminars on substance use disorder and other topics, and creating an internal structure that supports nurses and other healthcare professionals who do the right thing. Hospitals and other facilities with custody of controlled substances have an obligation to establish policies and procedures to combat drug diversion aggressively.

Employee Assistance Programs (EAPs) are an option employers can use to address several needs. EAPs can provide a program for supplementary education for nurses and staff of all levels about substance use disorder—what it is, how to recognize it, and how to take action when it affects the workplace. EAPs can also provide connections to counseling and assistance to help employees address a myriad of problems—mental, physical, professional, personal—that might otherwise act as temptations to turn to substance use as a coping mechanism.

Onsite offerings could include exercise classes or training in stress reduction techniques. Health promotion programs can offer incentives for staff to develop new healthy habits for exercise, stress reduction, weight loss, and smoking cessation. We’ve already seen that these kinds of programs and activities act as protective factors against substance use disorder.

Healthcare facilities need to actively create an environment that encourages and supports reporting of workplace impairment with zero tolerance for retaliatory action by anyone. Managers need to be well trained in legal requirements and facility policies and procedures and they should be required to share that knowledge with those they supervise through group discussions and role-playing activities to increase comfort around recommended actions and help establish open communication between staff members.

At the same time, facilities need to establish an environment that respects nurses and provides support for those dealing with substance use disorders from the perspective that it is a disease that is treatable and there is the potential for the nurse to return to the workplace after successfully completing treatment (Strobbe & Crowley, 2017).

Depending on the community and situation a facility may find that community outreach activities to explain how the organization works, what it is doing to combat substance use disorder among all populations, and encouraging community participation in actions to reduce risks and increase protective factors will work to the benefit of everyone.

Drug Diversion Prevention

Facilities need to work with all relevant local, state, and national organizations to make sure that their drug diversion prevention activities are fully up-to-date. There is no perfect system that will catch everything, but vigilance is critical.

Writing for the CDC Safe Healthcare Blog, an investigative specialist offered this summary:

Diversion of controlled substances happens at all institutions. Because diversion can’t be stopped entirely, facilities must prevent it to the extent they can, identify cases quickly, and respond appropriately.

The essential elements of a healthcare facility diversion program include

  • Policies to prevent, detect, and properly report diversion,
  • A method of observing processes and auditing drug transaction data for diversion,
  • Prompt attention to suspicious audit results,
  • A collaborative relationship with public health and regulatory officials, and
  • Diversion education for all staff (CDC, 2014)

As we have noted previously, lack of knowledge about substance use disorder and its signs is a critical part of the challenge for nurses but it reaches everyone. Investigation of a diversion incident in New Hampshire revealed that even highly educated and well-trained staff were either not properly educated about substance use disorders or were not motivated to fully follow established policies for dealing with staff SUD problems (CDC, 2014).


Substance use disorder as a form of nursing workplace impairment is a multifaceted problem that impacts patients, nurses, colleagues, family, friends, the facility, and even the community Substance use disorders are not well understood by many, even nurses, so education about them remains a critical task for nursing education and preventive employer initiatives.

A nurse operates in the world like anyone else with all the risk and protective factors of any person for substance use disorder, but nurses have some additional risk factors specific to their profession that can vary from one nursing specialty to another.

They historical model of substance use and addiction as a moral failing has been replaced with the science that shows us it is a brain disease with multiple contributing factors, including a large genetic component. In many places the old stigma of drug addiction as a choice reflecting laziness and lack of personal responsibility is still common and can make it hard for people to ask for help or get support from colleagues, family, and friends.

Perhaps the most important thing employers can do is work to erase this from institutional thinking and train staff to support and assist nursing colleagues with substance use disorders. At the same time, support does not mean tolerance of impaired practice or a failure to meet ethical and legal responsibilities. It means that nurses taking on the challenge to deal with their substance use disorder need the support of their managers, peers, and family members to succeed.

The intersection of the legal requirements in Florida Statutes and Regulations and the ethical requirements expressed in the ANA Code of Ethics for Nurses mandates that nurses be knowledgeable about substance use disorders and aware of the signs of impaired practice in themselves and in others—and take immediate steps to address the problem while prioritizing the safety of patients.

Resources and References



Florida Board of Nursing
(850) 488-0595

Florida Intervention Project for Nurses

National / Global

American Association of Nurse Anesthetists (AANA)

American Nurses Association (ANA)

Emergency Nurses Association (ENA)

International Nurses Society on Addictions (IntNSA)

National Institute on Drug Abuse (NIDA)

Substance Abuse and Mental Health Services Administration (SAMHSA)


Alunnni-Kinkle S. (2015). Identifying substance use disorder in nursing. Nursing Management 46(12):53–54. Retrieved June 26, 2018 from

American Association of Nurse Anesthetists (AANA). (2018). Substance Use Disorder (SUD). Retrieved June 26, 2018 from

American Association of Nurse Anesthetists (AANA). (2016). Addressing Substance Use Disorder for Anesthesia Professionals: Position Statement and Policy Considerations. Retrieved June 26, 2018 from

American Nurses Association (ANA). (2018). Substance Use Among Nurses and Nursing Students: Help for Nurses and Nursing Students with Substance Use Disorder. Retrieved June 1, 2018 from

American Nurses Association (ANA). (2015). Code of Ethics for Nurses with Interpretive Statements. Retrieved June 29, 2018 from

Berge KH, et al. (2012) Diversion of drugs within health care facilities, a multiple-victim crime: Patterns of diversion, scope, consequences, detection, and prevention. Mayo Clinic Proceedings 87(7):674–82. Retrieved July 1, 2018 from

Cares A, Pace E, Denious J, Crane L. (2015). Substance use and mental illness among nurses: Workplace warning signs and barriers to seeking assistance. Substance Abuse 36(1):59–66. Retrieved June 10, 2018 from

Center on Addiction (COA). (2018). What Is the Difference between Drug or Alcohol Abuse and Addiction? Retrieved June 24, 2018 from

Centers for Disease Control and Prevention (CDC). (2017). Risks of Healthcare-associated Infections from Drug Diversion. Retrieved June 29, 2018 from

Centers for Disease Control and Prevention (CDC). (2014). Drug Diversion Defined: Steps to Prevent, Detect, and Respond to Drug Diversion in Facilities. Kimberly New, JD BSN RN. Safe Healthcare Blog. Retrieved June 29, 2018 from

Centers for Disease Control and Prevention (CDC). (2014a). Drug Diversion Defined: Consequences for Hospitals and Other Healthcare Facilities. Kimberly New, JD BSN RN. Safe Healthcare Blog. Retrieved July 1, 2018 from

Crowley R, Kirschner N, Dunn A, Bornstein S. (2017). Health and public policy to facilitate effective prevention and treatment of substance use disorders involving illicit and prescription drugs: An American College of Physicians Position Paper. Annals of Internal Medicine 166(10):733–36. Retrieved June 30, 2018 from

Florida Board of Nursing. (2018). Florida Board of Nursing website. Retrieved from

Florida Intervention Project for Nurses (IPN). (2018). Intervention Project for Nurses website. Retrieved from

Florida Legislature. (2018). The 2018 Florida Statutes. Retrieved from

Gallup News. (2017). Nurses Keep Healthy Lead as Most Honest, Ethical Profession. Megan Brenan, December 26, 2017. Retrieved June 15, 2018 from

Miller T, et al. (2015). Hiring nurses re-entering the workforce after chemical dependence. Journal of Nursing Education and Practice 5(11):65–72. Retrieved June 25, 2018 from

Missouri Bureau of Narcotics & Dangerous Drugs. (2016). Drug Diversion in Hospitals: A Guide to Preventing and Investigating Diversion Issues. Retrieved June 25, 2018 from

Monroe T, Kenaga H. (2010). Don’t Ask, Don’t Tell: Substance abuse and addiction among nurses. Journal of Clinical Nursing 20:504–509. Retrieved June 5, 2018 from

National Council of State Boards of Nursing (NCSBN). (2018). Substance Use Disorder in Nursing. Retrieved June 1, 2018 from

National Council of State Boards of Nursing (NCSBN). (2017). 2017 NCSBN Annual Institute of Regulatory Excellence (IRE) Conference – A Legal and Ethical Perspective on Substance Use. Nancy Brent, JD, RN. Retrieved June 15, 2018 from Presentation, transcript, and video available.

National Council of State Boards of Nursing (NCSBN). (2017a). 2017 NCSBN Annual Institute of Regulatory Excellence (IRE) Conference – The Ups and Downs of Substance Use Disorder. Peggy Mack. Retrieved June 23, 2018 from Presentation, transcript, and video available.

National Council of State Boards of Nursing (NCSBN). (2014). What You Need to Know About Substance Use Disorder in Nursing. Retrieved June 1, 2018 from

National Council of State Boards of Nursing (NCSBN). (2014a). A Nurse Manager’s Guide to Substance Use Disorder in Nursing. Retrieved June 1, 2018 from Updated 10/16??

National Council of State Boards of Nursing (NCSBN). (2013). Substance Use Disorder in Nursing. Video. Retrieved June 15, 2018 from AND

National Council of State Boards of Nursing (NCSBN). (2011). Substance Use Disorder in Nursing: A Resource Manual and Guidelines for Alternative and Disciplinary Monitoring Programs. Retrieved June 1, 2018 from

National Institutes of Health, National Institute on Drug Abuse (NIDA). (2016). Chapter 2: Risk and Protective Factors. Principles of Substance Abuse Prevention for Early Childhood: A Research-Based Guide. Retrieved July 1, 2018 from

National Institutes of Health, National Institute on Drug Abuse (NIDA). (2015). Nationwide Trends, DrugFacts. Retrieved June 1, 2018 from

Paton F. (2017). Substance Abuse in Nursing: What Are the Signs and What To Do About It?. Nurseslabs. Retrieved June 20, 2018 from

Red Lake Chemical Health. (2013). Protective Factors Fact Sheet. Retrieved June 30, 2018 from

Smith L. (2017). Alternative to Discipline Programs: Florida’s Intervention Project for Nurses. NCSBN-IRE. Presentation slides. Retrieved June 1, 2018 from Video transcript available at Presentation video available at

Smith L, Greene M. (2015). Florida Intervention Project for Nurses: A national model for ADP and nurse assistance. Peer Assistance. Journal of Addictions Nursing 26(3):159–62. Introduction retrieved June 24, 2018 from

Smith L. (2013). Alternative to Discipline Programs: The Florida Intervention Project. NCSBN-IRE. Retrieved June 1, 2018 from

Stone L, Rice J, Hledin V. (2016). Promoting Awareness of Substance Use Disorder and Drug Diversion in the Workplace. AANA NewsBulletin. Nov 2016. Retrieved June 26, 2018 from

Strobbe S, Crowley M. (2017). Position Paper: Substance Use Among Nurses and Nursing Students. A Joint Position Statement of the Emergency Nurses Association and the International Nurses Society on Addictions. Journal of Addictions Nursing 28(2):104–106. Retrieved June 15, 2018 from

Thomas C, Siela D. (2011). The impaired nurse: Would you know what to do if you suspected substance abuse? American Nurse Today, Aug 2011, Vol 6 no 8. Retrieved May 1, 2018 from Weighted Checklist from

Trinkoff A, Storr, C. (1998). Substance use among nurses: Differences between specialties. American Journal of Public Health 88(4):581–85. Retrieved June 15, 2018 from

US Department of Health and Human Services (HHS), Office of the Surgeon General. (2016). Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. Retrieved June 26, 2018 from

U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA). (2017). Mental and Substance Use Disorders. Retrieved June 24, 2018 from

U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA). (2015). Substance Use Disorders. Retrieved June 24, 2018 from

U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA). (2015a). Risk and Protective Factors. Retrieved June 30, 2018 from

Volkow ND, Koob GF, McLellan AT. (2016). Neurobiologic Advances from the Brain Disease Model of Addiction. Review article. New England Journal of Medicine 374:363–71. Retrieved June 26, 2018 from

Washington State Department of Health (WA DoH). (2016). A Guide for Assisting Colleagues Who Demonstrate Impairment in the Workplace. Washington Health Professional Services. DOH 600-006 March 2016. Retrieved June 29, 2018 from