Running head: THE IMPAIRED NURSE: AN ETHICAL DILEMMA 1

The Impaired Nurse: An Ethical Dilemma for Nurse Managers

George Andrew Bandorf

California State University, Dominguez Hills

Nursing Ethics

MSN 531-08

Dr. Catherine Earl

March 18, 2018

Running head: THE IMPAIRED NURSE: AN ETHICAL DILEMMA 2

The Impaired Nurse: An Ethical Dilemma for Nurse Managers

Introduction

Nurses are often the primary care providers for patients in acute care hospitals, long-term

care facilities, in home health settings as well as other areas in the community. Nurses are

expected to be skillful, knowledgeable, and sober professionals at the ready and able to meet the

needs of their patients. When a nurse becomes addicted to alcohol or drugs the issue of impaired

nursing practice becomes evident. It places the nurse in physical, professional, and emotional

harm as well as places liability on the employer. Patients’ health is also placed in jeopardy.

Strobe and Crowley (2017) concluded: patients, the public, as well as the nurses are at risk if

these nurses are addicted to alcohol or other drug substances.

Thesis Statement

The paper will address a moral and ethical concern of impaired nursing. It will also

discuss the background and significance of impaired nursing as well as the importance of the

nurse manager's role in dealing with this issue. Furthermore, it touches on the rationale for using

a utilitarian ethical decision making model and also evaluates the significance of the four major

ethical principles in addressing the issue of impaired nursing.

Ethical Dilemma Overview

A major ethical issue in approaching and addressing impaired nursing practice is

balancing the impaired nurse’s right to confidentiality associated with having a substance abuse

disorder and the rights of the public to receive safe and competent nursing care. According to the

literature, only until recent years has the practice and importance of protecting the confidentiality

of the impaired nurse been emphasized. There are many other moral, ethical, legal, and policy
THE IMPAIRED NURSE: AN ETHICAL DILEMMA 3

issues to consider in analyzing and approaching impaired nursing. This paper focuses on

maintaining confidentiality.

Literature Review

A search for literature related to the subject of substance abuse and impaired nursing

began with a review of the literature in CINHAL, ERIC and included other electronic databases.

The literature supports the ideas and concepts of a utilitarian ethical model. Utilitarianism

provides an opportunity to focus problem-solving on concrete results and actions. Though the

model has many variations, the core philosophy of the utilitarian ethical model is to unravel the

consequences related to a particular action. This is especially true when considering the best

approach to maintaining the confidentiality of the impaired nurse and the potential benefits for

the nurse even beyond maintaining confidentiality.

Exploring all the ethical issues and situations related to this ethical dilemma is beyond the

scope of this paper. A well-informed nurse manager or administrator views substance abuse as

an illness and even a disability. Therefore, the impaired nurse has a legitimate expectation and

actual right to confidentiality related to the nurse’s substance abuse. HIPPA and similar laws

apply to the nurse. In research conducted by Kunyk (2013) and Kunyk, (2015) which included

nurse peer surveys, the researcher concluded that nurse-peers considered the condition of

impaired nurses treatable hence the employers should assist with the medical treatment as well as

preserve confientiality. Furthermore, Ross, Berry, Snye, and Goldner (2017) review suggested a

long-needed shift away from a mere disciplinary approach model to interventions and to even a

more constructive and supportive model of the nurse while ensuring mutual safety for patient,

staff, and all stakeholders. A research study completed by Ayyagari (2014) concluded: poor

management and employee relations are at the foundation of dangerous practices in the
THE IMPAIRED NURSE: AN ETHICAL DILEMMA 4

workplace. Therefore, the role of the nurse manager and nurse administration to provide

appropriate and professional leadership is essential.

All patients have the right to be cared for by a competent and sober nurse. As mentioned

earlier, impaired nurses jeopardize the safety of patients since these nurses might be involved in

impaired practices including intoxication. The utilitarian ethical model addresses these issues;

how patients and others can be negatively impacted. The research of Pavlovich-Danis (2013)

revealed: impaired nurses are found in many different care areas and therefore, nurse leaders and

administrators must be vigilant and competent to recognize the occurrences of substance abuse

impaired nursing in these diverse specialty areas. Furthermore, researchers Thomas and Siela

(2011) concluded: substance abuse impaired nurses are not likely to seek treatment until they are

confronted by others. This conclusion alone places unique importance on the approach and

competency of the nurse manager and nurse administrator. A utilitarian ethical model approach

helps ensure the best mutual outcomes for all stakeholders. The nurse manager preserves the

confidentiality of the impaired nurse while securing the safety and well-being of the patients.

Ethical Situation as Applied to the Role Option

Nurse administrators and managers must carefully consider and develop interventions to

identify and intervene when impaired nursing is evident so as to protect the rights of both the

impaired nurse and the public (Ervin, 2015). Clinical nurse leaders, administrators, and nurse

managers are trained and skilled to analyze, implement, and assess the needs of impaired nurses

and patients. Nurse managers should consult administration or the organization’s ethics

committee for suggestions on how to proceed regarding the maintenance of confidentiality,

safety, patient care or any other issue of ultimate concern requiring guidance (Kangasniemi, et
THE IMPAIRED NURSE: AN ETHICAL DILEMMA 5

al., 2010). Nurse leadership should not be conducted in a vaccum. Nurse management needs to

be a collaborative effort with the purpose of providing safety and confidentiality.

Why is Impaired Nursing a Problem?

It should be noted: dangerous, incompetent, or impaired nursing can be related to issues

other than substance abuse. Mental health issues, other health issues, lack of training or

competency are a few other contributing factors to impaired nursing practice (Darbro and

Malliarakis, 2015). The focus of this paper, however, is to address impaired nursing related to

substance and alcohol abuse. The issue of impaired nursing is important to address, understand,

and resolve because impaired nurses place human lives in danger. It is an ethical nursing practice

issue and can therefore have legal consequences for the organization and other stakeholders if

left ignored or inappropriately addressed (Moses, 2017). For example, if a nurse manager ignores

the fact a nurse is working impaired and a patient is neglected or harmed then the nurse manager

could face disciplinary action from the employer or the board of nursing. Legal liabilities could

also be realized against the nurse manager and the healthcare organization (Ithal 2017)

Background and Significance of Impaired Nursing

Ervin (2015) noted the case of Nurse Jane Gibson, a contemporary and associate of

Florence Nightingale. Jane Gibson is perhaps the first documented case of an impaired nurse due

to alcohol abuse. She was fired from a London hospital after reporting to work intoxicated.

Recent statistics report the percentage of substance abuse nurses as high as ten percent. This

same percent is found in the general public as has been tagged to impaired nursing related to

substance abuse. This has been an issue facing healthcare workers for decades (Ithal, 2017). The

impaired nurse condition is a liability to the organization. It also places in jeopardy his/her own

health, nursing license, and the impaired nurse faces disciplinary action. Pavlovich-Danis (2013)
THE IMPAIRED NURSE: AN ETHICAL DILEMMA 6

explains how nurses who are chemically impaired are rampant in all areas of nursing practice. In

addition, these nurses are present even in critical care: including the ICU, operating rooms

among other care areas (Pavlovich-Danis, 2013).

The significance of the Nurse Manager’s Role in Addressing Impaired Nursing

Nurse administrators and managers can effectively and ethically assist in addressing the

impaired nurse issue because these roles are vital in the leadership of the organization (Angres et

al., 2010). This paper suggests these leaders adopt a utilitarian ethical model which emphasizes

implementing actions that provide the greatest good for the largest amount of people and results

in the least amount of harm. Furthermore, nurse managers and administrative active leadership is

vital. Two researchers noted: nurses who are affected by substance abuse are reluctant to seek

help unless they are encouraged or comforted to do so by another person (Thomas and Siela,

2011).

Relation of the Four Major Ethical Principles to Impaired Nursing

Autonomy involves allowing self-governance and freedom to make informed decisions

without coercion (Beauchamp & Childress, 2013). Maintaining the confidentiality of the

impaired nurse affords choices without discrimination by others. Protecting patient rights and

safety allows the patient to make clear decisions and assures them of receiving the care they

deserve and are consenting to receive. The care is provided by a professional and sober nurse.

Beneficence includes acting in the best interest of the patient with care and compassion

(Beauchamp & Childress, 2013). The literature review section shows a past treatment of

impaired nurses without compassion. Recent studies take a different approach. The utilitarian

application of beneficence values the impaired nurse and recognizes the nurse as a person with a
THE IMPAIRED NURSE: AN ETHICAL DILEMMA 7

disease who deserves the assurance of confidentiality. The patients deserve to be cared for and

treated by a caring professional. Their health and safety must always be protected.

Non-malfeasance includes doing no harm to the patient. The patients within the

healthcare organization must be protected so as not to be harmed by the impaired nurse

(Beauchamp & Childress, 2013). An impaired nurse with an alcohol or substance abuse disorder

is also seen as a patient and therefore deserves non-malfeasance (Baldisseri, 2007). Assuring

confidentiality for the all is a primary goal.

Justice includes equal treatment and the fair distribution of resources. Justice does not

include discrimination or prejudice (Beauchamp & Childress, 2013). The impaired nurse with an

alcohol or substance abuse disorder is viewed and approached as a patient. Therefore, the nurse

and patient are entitled to justice. Maintaining the confidentiality of the impaired nurse is as

equally as important as maintaining the confidentiality of the healthcare organization’s patients

(Musto, et al. 2017)

Impaired Nursing Ethical Dilemma the Future

The key to the success of addressing this issue is the involvement of well qualified

nurse managers and administrators. The nurse manager has a special investment and role as a

leader and supervisor in assisting another nurse. Remember to respect confidentiality when

approaching the impaired nurse especially when providing professional interventions and

standards. Patient safety and rights to care must be ensured (Burman and Dunphy, 2010). Patient

safety and rights do not have to be mutually exclusive to the maintenance of the confidentiality

of the impaired nurse (Moses, 2017). Recovery and return of the substance abuse impaired nurse

to a productive career in nursing can eventually occur. However, the caring, healing, and

professionalism of the nursing administration and the entire healthcare team is pivotal to achieve
THE IMPAIRED NURSE: AN ETHICAL DILEMMA 8

at this end (Darbro, 2011). The application of utlitarian ethics is very helpful in assisting the

impaired nurse and to protect the safey and rights of all stakeholders. The best interest of all

parties, including the health care facility, can be honored with the use of the utilitarian ethical

model approach and standards. The utlitiarian ethical model can assist all srakeholders to realize

a win-win outcome

Conclusion

In conclusion, substance abuse impaired nursing is a real and concerning problem

(Bettinardi-Angres and Stephanie, 2011). Nurses and their supervisors must remain respectful of

the suspected impaired nurse’s right to confidentiality (Moses, 2017). One must not approach the

situation in an accusatory fashion and must make sure the evidence is clear that substance abuse

impaired nursing is present. It is vital to consider other possible causes of the behavior (Moses,

2017). Moreover, patients’ safety should always be prioritized. The utilitarian ethical model

which emphasizes the greatest benefit for the greatest number is an appropriate approach. The

impaired nurse’s confidentiality, safety, and protection must be respected. The positive outcome

for all stakeholders can be realized via the application of the utilitarian ethical model.
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