Suspecting a colleague of impairment is one of the most difficult situations in nursing practice. The personal stakes are high – you may be accusing someone you work alongside daily. But the professional and ethical stakes are higher. An impaired nurse is a direct patient safety risk, and failing to act when you had reason to act can expose you to board action and personal liability.
Fast answer: If you have reasonable, objective grounds to believe a colleague is impaired – based on observed behavior, not rumor – you have an ethical obligation under the ANA Code of Ethics and, in many states, a legal reporting obligation to your employer, your state Board of Nursing, or an approved peer assistance program. Document what you observed, when, and who was present. Report to your charge nurse or manager first. Most states have peer assistance programs that allow nurses to seek treatment while keeping their license. Acting protects your patient, your colleague, and yourself.
What impairment looks like: observable signs
Not every behavioral change indicates impairment. People have bad days, chronic illness, personal crises, and neurological conditions that are not substance-related. The signs that justify concern – and warrant documentation – are patterns of observable, patient-care-relevant behavior:
| Category | Observable signs |
|---|---|
| Substance impairment (alcohol) | Smell of alcohol, slurred speech, unsteady gait, poor coordination, inappropriate euphoria or aggression |
| Substance impairment (opioids/sedatives) | Excessive sedation, slurred speech, pinpoint pupils, poor reaction time, falling asleep at the nurses’ station |
| Stimulant impairment | Agitation, rapid speech, paranoia, excessive sweating, dilated pupils |
| Diversion without visible intoxication | Discrepancies in narcotic counts, frequent volunteering to waste medications, medication administered but not effective in patient, altered documentation of controlled substances |
| Cognitive decline / mental health | Repeated errors with no pattern of substance use, disorientation, inability to follow multi-step instructions, paranoid ideation affecting clinical decisions |
Diversion – taking controlled substances intended for patients – is a distinct concern. The nurse may not appear visibly impaired at work if they’re diverting but not using at the facility. Narcotic discrepancies, unusual waste patterns, or patients reporting pain despite documented analgesia are the key indicators.
Your legal and ethical obligations
Ethical obligation
The American Nurses Association Code of Ethics (2025 edition), Provision 3.5 (“Protection of Patient Health and Safety by Acting on Impaired Practice”), addresses this situation directly. It states that “nurses who report those whose job performance creates risk are acting in an ethically appropriate manner and should be protected from retaliation.” The same provision asks nurses to “extend compassion and caring” to a colleague whose performance may be affected by substance misuse, fatigue, or other circumstances, and to “support remediation, recovery, and restoration to nursing practice, when possible.” Acting on impaired practice and supporting the colleague’s recovery are both part of the same ethical duty.
Legal obligation
The specific reporting requirement varies by state, and it lives in each state’s nurse practice act and board rules:
- Many states make it a nurse’s legal duty to report a colleague who is, or is reasonably suspected to be, impaired or practicing unsafely. Texas is a clear example: Occupations Code §301.402(b) requires a nurse with reasonable cause to suspect another nurse of conduct subject to reporting – which includes impairment by chemical dependency or drug or alcohol abuse – to report to the Texas Board of Nursing
- Some states set separate reporting duties for employers, supervisors, and facilities, including a duty to report when a nurse is terminated or resigns during an investigation for impairment or diversion
- Peer assistance program reporting can satisfy the duty in some states, with limits. In Texas, Occupations Code §301.410 lets a person required to report an impaired nurse report to an approved peer assistance program instead of the board, but the report must go to the board if the reporter believes the impaired nurse committed a practice violation
Check your state Board of Nursing website and nurse practice act for the specific statute. Summaries on third-party sites, including this one, are a starting point only.
Liability for not reporting
Nurses who are aware of a colleague’s impairment and do not report it can face:
- BON discipline for failure to report (grounds for license suspension or revocation in some states)
- Civil liability if an impaired colleague causes patient harm that you witnessed and did not report
- Institutional discipline under employer policies that require mandatory reporting
BON cases involving failure to report peer impairment do appear in state discipline records.
Peer assistance programs
Most states operate a Peer Assistance Program (PAP) – also called an Alternative to Discipline (ATD) program, nurse assistance program, or similar – specifically designed for nurses experiencing substance use or mental health challenges. These programs are a critical part of this conversation.
What they offer:
- Evaluation by an addiction medicine or mental health professional
- Treatment without immediate license revocation
- Monitoring and return-to-work protocols
- Confidentiality protections in many states
The key distinction: A nurse who self-reports to the PAP before discipline is initiated is in a fundamentally different position than a nurse who is reported by colleagues and then enters treatment under compulsion. In states with robust ATD programs, voluntary entry can allow a nurse to continue working (sometimes with restrictions) while in treatment, and to avoid a formal BON discipline record.
If you are reporting a colleague, knowing whether they’ve already engaged with the peer assistance program may affect how you frame the conversation with your manager.
Finding your state’s program: The National Council of State Boards of Nursing (NCSBN) lists each state’s alternative-to-discipline program for substance use on its Alternative to Discipline Programs page at ncsbn.org, with a state-by-state drop-down. NCSBN’s Nursys system is also where you can verify a colleague’s license status and any existing restrictions.
How to report: step by step
Step 1: Document before you act
Write down – contemporaneously, not from memory later – what you observed, when, where, who else was present, and what patient care was or could have been affected. Be factual. “At 0230 on [date], [colleague name] was observed [specific behavior]. I smelled alcohol. Three other staff members were present: [names].” Do not interpret; describe.
Your documentation should:
- Use exact times and dates
- Describe observable behaviors, not conclusions (“walked with unsteady gait and held the wall for support” rather than “was drunk”)
- Note any patient safety incidents that occurred or were narrowly avoided
- Be kept in a personal record, not just in the facility system – you may need it later
Step 2: Report to your charge nurse or immediate supervisor
Your first report is internal. Go to your charge nurse or manager during the shift if there is active patient safety concern. Do not wait if a patient is at risk.
If the concern is about pattern behavior rather than an acute event, a private meeting with your manager or house supervisor is appropriate. Either way, put your report in writing after the verbal report: “Per our conversation on [date], I reported the following concerns regarding [name]…”
Step 3: If your manager doesn’t act – escalate
If you report to a manager and nothing happens within a reasonable time frame, escalate:
- To the Director of Nursing or CNO
- To HR, particularly if the failure to act appears related to protecting a preferred employee
- To the facility’s compliance or ethics hotline if one exists
- To the state Board of Nursing directly, if institutional reporting has failed
You do not need your employer’s permission to report to the BON. Reporting to the BON is an independent right – and in many states, an independent obligation.
Step 4: Report to the state Board of Nursing (if required or institutional channels have failed)
BON complaints are typically submitted via the board’s online complaint portal. You’ll need:
- The nurse’s full name and license number (verifiable via Nursys)
- Your contact information
- A written description of what you observed, with dates and supporting documentation
- Names of other witnesses, if applicable
The BON will investigate and may or may not take action. Not every complaint results in discipline – the board assesses whether there’s sufficient evidence of a violation.
Fear of retaliation
For most nurses reporting an impaired colleague, the main legal protection against retaliation comes from state law:
- Nurse practice act protections. Some nurse practice acts bar retaliation against anyone who reports in good faith. Texas Occupations Code §301.402(f) and §301.413, for example, prohibit suspending, terminating, disciplining, or otherwise retaliating against a person who reports a nurse in good faith
- Health care whistleblower statutes. Several states protect health care workers who report patient-safety or quality-of-care concerns. California Health and Safety Code §1278.5 bars a health facility from retaliating against an employee who presents a grievance, complaint, or report to the facility or a government agency about the quality of care
- Federal law is narrower than many nurses assume. Section 11(c) of the Occupational Safety and Health Act protects employees who raise occupational safety or health concerns (hazards to workers) and has a 30-day filing deadline. Most patient-safety reports fall outside it, so don’t count on it as your main protection
The ANA Code of Ethics also states that nurses who report risky practice “should be protected from retaliation,” although the Code itself is not law. Retaliation still happens, and legal protection doesn’t make it costless. Before reporting:
- Know your state’s whistleblower statute
- Report in writing so there’s a record of the date and content
- Retain copies of your own reports and any management responses
- Consult your union rep if you’re covered by a CBA
- If retaliation occurs, document it immediately and consult an employment attorney
See nursing whistleblower protection for a full breakdown of your state and federal rights.
What to say (and not say) to the colleague
Most situations do not require you to confront your colleague directly before reporting. Investigation and intervention belong to management and the board, so your role is to report what you saw.
If you feel compelled to say something, keep it brief and non-accusatory: “I’ve noticed some things lately that concern me, and I wanted to let you know I’m going to raise them with the manager.” Do not conduct your own investigation, do not discuss with other colleagues (beyond those who directly witnessed events), and do not accept a colleague’s assurance that “everything is fine.”
If the colleague discloses impairment to you directly – “I’ve been struggling with [substance]” – that disclosure may itself create a reporting obligation under your state’s BON rules. Do not promise confidentiality you cannot keep.
BON requirements vary by state: key things to check
- Does your state have a mandatory peer reporting statute?
- Does your state BON accept anonymous reports?
- Does your state have a non-disciplinary ATD/PAP track?
- What is the timeline between a BON complaint and investigation?
- Are you protected from defamation claims for good-faith reports to the BON?
Most states provide immunity from civil liability for good-faith BON reports. Verify this in your state.
The cost of not acting
Nurses who witness impairment and do not report face real professional risk. BON discipline records include cases where nurses were sanctioned not for their own impairment but for witnessing a colleague’s impairment and taking no action. The standard applied is: what would a reasonable nurse have done with this information?
Reporting a colleague protects patients, can route a colleague who needs help into treatment, and upholds the integrity of the license you worked to earn. Peer assistance programs exist because the nursing community treats impairment as a health condition as well as a practice-safety problem, and because recovery and return to practice are possible.
For related guidance on what the BON complaint and investigation process looks like, see nursing board complaint.
References
- American Nurses Association, “Code of Ethics for Nurses with Interpretive Statements,” 2025 edition, Provision 3.5: Protection of Patient Health and Safety by Acting on Impaired Practice. https://codeofethics.ana.org/provision-3-5
- National Council of State Boards of Nursing, “Substance Use Disorder in Nursing” resource page, including “A Nurse Manager’s Guide to Substance Use Disorder in Nursing” (2014). https://www.ncsbn.org/nursing-regulation/practice/substance-use-disorder/substance-use-in-nursing.page
- National Council of State Boards of Nursing, “Alternative to Discipline Programs” (state-by-state program directory), ncsbn.org, accessed September 2026. https://www.ncsbn.org/nursing-regulation/discipline/board-proceedings/alternative-to-discipline.page
- National Council of State Boards of Nursing, “Nursys License Verification and e-Notify,” nursys.com, accessed 2026.
- U.S. Department of Labor, Occupational Safety and Health Administration, “Occupational Safety and Health Act (OSH Act), Section 11(c),” whistleblowers.gov, accessed September 2026. https://www.whistleblowers.gov/statutes/oshact
- Strobbe S, Crowley M, “Substance Use Among Nurses and Nursing Students: A Joint Position Statement of the Emergency Nurses Association and the International Nurses Society on Addictions” (endorsed by the American Nurses Association), Journal of Addictions Nursing, 2017;28(2):104–106. doi:10.1097/JAN.0000000000000150
- Texas Occupations Code §§301.401, 301.402, 301.410, and 301.413 (Nursing Practice Act: reporting requirements, reports to peer assistance programs, and retaliation protections). https://statutes.capitol.texas.gov/Docs/OC/htm/OC.301.htm
- California Health and Safety Code §1278.5 (health facility whistleblower protections for patients, employees, and medical staff). https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=HSC§ionNum=1278.5