Tennessee Professional Assistance Program How to Report Someone with a Problem
How to Enroll
About Us
Support Groups
Duty to Report Help Us Help You When to Make a Referral
How to Make a Referral Guide for Helping Workers Employment History and Performance
Decreasing Effectiveness on Job Health History Appearance
Signs of Intoxication or Withdrawal Illness/Injury Observable Behaviors
Barriers Reporting Obligations Employer Enabling
Recognizing the Impaired Co-worker Signs and Symptoms of Impairment Signs and Symptoms Checklist


Duty to Report - CLICK HERE for Online Referral Form

Dictionary descriptionHealth care professionals often avoid dealing with drug impairment (legal and/or illegal) in their colleagues. There is a natural reluctance to approach a co-worker suspected of impairment. There is the fear that speaking out could anger the co-worker resulting in retribution or could result in a colleague losing his/her job or even their license.

Many employers end up being “enablers” of individuals whose professional competence has been impaired by physical, mental or chemical impairment. Addicted colleagues are often given lighter work schedules, and excuses are made for their poor performance. Excessive absences from the work site are often overlooked. Impaired workers are protected from the consequences of their behavior. This allows them to rationalize their behavior or continue their denial that a problem even exists.

Under the Rules of the TN Board of Nursing (Rule 1000-1-.13, Unprofessional Conduct and Negligence, Habits or Other Causes) and other health related rules of ethical conduct, anyone with knowledge of a practice that is or could be below the acceptable standard of care must immediately notify the appropriate authorities. In Tennessee there are two recognized appropriate authorities:

  1. Tennessee Department of Health, Division of Health Related Boards, Office of Investigations, or
  2. Tennessee Professional Assistance Program.

Boards who partner with TnPAP are mainly concerned in rehabilitating the practitioner, not in discipline simply for the sake of punishment. An advantage to reporting to TnPAP is early intervention. Every effort is made to retain the professional skills of the individual for the sake of the community and the profession while ensuring that public safety is not compromised. Once notified, TnPAP will:

  • Contact the individual.
  • Refer the individual to an appropriate treatment facility or practitioner for evaluation.
  • Assist the individual with any pending Board disciplinary action or procedures when appropriate.
  • Monitor and verify treatment progress and compliance.
  • Advocacy once monitoring agreement has been signed.

Individuals who are referred and refuse TnPAP services may be passed on to the Tennessee Department of Health, Office of Investigation, if it appears that a practice act violation has occurred. The TN Department of Health will determine if a practice act violation has or has not occurred and will take the appropriate action.

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Help Us Help You

If you are concerned about someone, don’t wait until a problem threatens their career, license or life, CLICK HERE to report a practitioner.

When to Make a Referral

The following examples may be useful to employers in deciding when to refer an employee to TnPAP:

  • Various Substances An individual has a positive pre-employment urine drug screen result for any illegal substance or any non-prescribed, legal substance (ask the individual to reveal all current medications prior to screening).
  • At least two people witness an individual with alcohol on his/her breath in the workplace.
  • An individual has a positive blood alcohol level and/or the individual's urine specimen tested positive for alcohol.
  • You obtain a positive urine drug screen result for an illegal substance.
  • You obtain a positive urine drug screen result for mood-altering substances and the individual cannot or does not produce a current valid prescription.
  • An individual is visibly/physically impaired while on duty regardless of whether (s)he is taking prescribed medications or not (e.g., falling asleep, slurring speech, staggering).
  • An individual displays a pattern of forgetfulness, poor practice judgment, inability to perform, medication errors (generally non-narcotic drug involvement if a mental illness only), physical deterioration, isolation, moodiness and/or mood swings.
  • A home health practitioner is a no show, no call for scheduled patients, and drugs/alcohol or mental illness is indicated (e.g., alleged to have tampered with or removed controlled substances from their patients' homes, or is charged with a DUI or possession of controlled substances while driving to work or to their patients' homes, or has displayed signs and symptoms of a mental illness or other impairment while on duty).
  • PRN patients report not receiving medications when a certain individual is on duty.
  • You notice a pattern of an employee giving drugs at inappropriate intervals or with an order.
  • You discover a paper trail of controlled substance discrepancies indicative of drug diversion and the evidence points directly to a particular employee.
  • An individual is found in the bathroom with a needle in his/her arm and a vial on the floor.
  • If in doubt, but you suspect drugs and/or a mental illness may be involved in a workplace incident or anytime you suspect that a violation of the Practice Act has occurred involving drugs and/or mental illness.

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How to Make a Referral - CLICK HERE for employer online referral form

We encourage you to file the report online which allows you to provide extensive details regarding the "who", "what", "when”, where" and "how". Specifically,

  • You will need to provide demographic information about the person.
  • You will need to provide a detailed summary of each allegation, including dates of each alleged incident and the medical record number or name of the patient involved (first name last initial will work).
  • Be very specific in describing the event including the date and location of incident. If reporting “suspected impairment or reasonable cause” describe what was observed, e.g., alcohol on breath, sleepiness, stumbling, staggering/balance, motor skills, slurred speech, eye movement, etc.
  • If diversion is suspected, provide what drug(s) is/are involved, quantity and frequency.
  • Be sure to include your contact information.


  • During business hours (8 a.m. – 4:30 p.m., central time) TnPAP will accept a referral verbally. However, this may result in an abbreviated report since someone is interrupting what is being said and could unintentionally miss an important detail in the translation.


  • TnPAP does not accept anonymous referrals.

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Guide for Helping Workers Who Demonstrate Impairment in the Workplace


LonelinessThis guide is to assist employers in helping workers whose practice may be threatened because of chemical impairment (prescribed/illegal drugs or alcohol). The guide focuses on what you in the workplace can do to assist an employee/co-worker.

Chemical impairment is a problem that has major impact on today’s society and the health professions are not immune. When the problem exists it impacts not only the individual practitioner’s well being and ability to practice but also co-workers and possibly the safety of patients. Our goal is to provide some clear-cut steps to assist a colleague, rather than enable a problem to continue.

Recognizing the Problem in the Workplace

The first step in assisting an employee is recognition: The signs, symptoms and behaviors that are often displayed as a result of problems can impact a professional’s ability to practice. It is important to know these so that when red flags are observed in a co-worker they can be documented clearly and concisely. Often, supervisors feel uncomfortable when there is a chemical dependency or similar type problem with an employee. Barriers which often prohibit one from helping an employee may include: fear, lack of knowledge and negative attitudes regarding chemical impairment in the health profession. This guide is not intended to diagnose a problem, but rather to identify signs of a problem, document the concerns and communicate them effectively.

Some behaviors associated with emotional problems and/or substance abuse are specific to alcohol and drug abuse, while others are common to alcohol and drug abuse and may also be signs of other psychological or psychiatric conditions. Each situation is individual and symptoms vary.

Employment History and Performance

Alcohol and Other Drugs

  • Exhibits frequent moves, job changes (attempts at geographical cure of starting over). Explains these by family needs, problems, transfers, etc.
  • Periods of unaccounted time lapses between jobs, school, birth of children, etc.
  • Eagerness to begin work before references or out-of-state licensure is checked.


  • Alcohol.
  • Above average rate of absenteeism, especially following days off.
  • Apt to call at last minute to extend time off.
  • Use of sick time at beginning of work day (unable to get up and get to work on time, due to hangover).
  • Calls in sick after work day has already begun.
  • Arrives late (hangover) or leaves early (for a drink).

Often arrives early, stays late, skips lunch and breaks (e.g., volunteers to work extra, shortens vacations to obtain supply of drugs).

Decreasing Effectiveness on Job

Alcohol and Other Drugs

  • Frequent, longer breaks; trips to bathroom, lounge, etc., alone.
  • Declines offer for meals or breaks with peers, (eats in unit, skips meals or goes alone to use drugs or alcohol).
  • Inconsistent or erratic performance.
  • Has difficulty conceptualizing.
  • Ability to make quick judgments affected more than ability to accomplish routine tasks.
  • Failure to meet deadlines or schedules.

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Health History

Alcohol and Other Drugs

  • Excessive use of insurance coverage.
  • Reluctance to submit to initial physical examination without advance warning.

Physical Signs and Symptoms

  • Although the physiological effects of drugs are specific for each chemical used and signs are more easily identified in a full physical exam, there are a number of common clues which may become apparent through observation and conversation.



  • Odor of alcohol lingers on breath, through skin to clothing. (May use mouthwash or strong perfume to cover smell).
  • Bloodshot eyes: red, bleary.
  • Spider veins, especially around the nose.
  • Face wrinkled, flushed, puffy.
  • Thin, fat in front with liver enlargement (appearance of weight slightly higher on frame than obesity, which is in lower abdomen, hips and thighs).


  • Always wears clothing with pockets, long sleeves or sweaters.
  • Band-Aids on hands, arms.
  • Pupils may be constricted (narcotics) or dilated (stimulants). This is not always reliable during poly drug abuse.
  • Runny eyes; or runny nose, with clear mucous drainage.

Alcohol and Other Drugs

  • Unkempt, hair lacks luster.
  • Avoids eye contact.
  • Premature aging.
  • Fatigue.
  • Thin, rarely athletic or physically fit.
  • Malnourished, anorectic, signs of fluid and electrolyte imbalance (edema, dehydration).
  • May carry large purse or satchel which is kept in view or locked.

Signs of Intoxication or Withdrawal


  • Tremulous hands.
  • Poor coordination, gait.
  • Headaches (hangover) especially in a.m. or at the beginning of shift.


  • Tremulous hands (tremors increase in impending withdrawal).
  • Abdominal and muscle cramps.
  • Diarrhea.
  • Irritable, restless manner.

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  • Frequent minor illnesses—vague somatic complaints (flu, virus, backache, toothache).
  • Accident-proneness.
  • GI problems (gastritis, bleeding ulcers, etc.).
  • Cirrhosis, liver malfunction.


  • Frequent minor illnesses, vague somatic complaints.
  • Frequent injuries which require medications.
  • Demonstrates low pain tolerance and high tolerance to drugs. (Average dosage produces little or no effect.)
  • Infection, abscesses, or scar tissue from IVs.
  • Hepatitis.

Observable Behaviors


  • Socializes only with persons who drink, which becomes the focus of all activities; may finally become isolated.
  • Demonstrates tolerance to alcohol (can gulp or have several drinks quickly without much effect).
  • Blackouts (appears normal but later cannot recall periods from a few minutes up to several hours).
  • All prodromal clues to alcoholism (drinks early in the day, before parties where drinks are served, drinks alone, sneaks drinks, sensitive to comments referring to drinking).
  • Financial problems (attempts to borrow money).
  • Excessive use of coffee and cigarettes.
  • Prone to auto accidents.
  • No longer drives to work (may have had license taken away due to DUI’s).
  • Carries large purse, satchel or thermos kept in view.


  • Social isolation, restricted interests, Spends time alone sleeping.
  • Preoccupied with obtaining and using drugs.

Alcohol and Other Drugs

  • Altered states of consciousness.
  • Wide mood swings in short time periods (anxious or depressed, too calm or euphoric).
  • Difficulty in all types of relationships (marital/sexual/family).
  • Irritable with staff and patients/clients.
  • Defensive and suspicious.
  • Projects blame on others.
  • Lies, tell inconsistent stories, rationalize, and create elaborate excuses for behavior. Cannot recall what was said before and changes story.

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The major factor in determining whether an employee with a problem is offered assistance and help is determined by the attitudes, the knowledge and the courage of those around him/her. In order to help someone who may have a problem it is important that we be knowledgeable of the signs and symptoms of problems and the resources available to intervene and assist.

There are many barriers which block intervening with a co-worker. The most common barrier is the lack of knowledge:

  • Of chemical dependency as a primary disease with signs and symptoms and a specific course that can be identified, documented and treated.
  • That chemical dependency does exist in health professions.
  • Of the signs and symptoms of a problem in the workplace.
  • About how and what steps to take to intervene in the workplace and what resources are available.
  • Of exactly what our obligation is as professionals under the Board’s statute, rules and regulations and code of ethics for the profession.
  • Fear.
  • What may happen if you do intervene?
  • That somehow you may be sued for intervening.
  • That you may be the one to cause a professional to lose a job or place his/her license in jeopardy.

Then there are attitudes and beliefs that prohibit intervention:

  • The belief that chemical dependent people are only skid row street people. Most are functioning, working people. Chemical impairment is an equal opportunity disease that can indeed affect all people.
  • That you as an employer can take care of problems yourself. You can counsel; you can help an employer who may have a problem and there is no need to refer or to contact other sources of help.

Reporting Obligations - CLICK HERE for employer online referral form

Any person who has knowledge of conduct by a licensed healthcare practitioner that may violate his/her practice act or related state or federal law must report the alleged violation to the state board of nursing where the situation occurred or to TnPAP.

Conduct that demonstrates poor judgment or skill resulting in violations of the Practice Act that are reportable include, but may not be limited to, suspected drug diversion, failing to account for wastage of control drugs/falsification of documents, impairment, positive workplace drug screen without a valid prescription, misappropriation/theft, exploitation of a vulnerable patient, physical/verbal abuse, patient neglect, sexual abuse/boundary violations, falsification of documents, single serious medication errors or repeated medication errors or charting errors, giving medications without an authorized order, criminal charges/convictions, failing to assess or intervene in behalf of a patient.

You are encouraged to review your board's Practice Act and rules and regulations frequently.

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Employer Enabling

Accepting sloppy work, excessive sick time and unexplained absence from work site.

Avoidance of confrontation.

Assuming or reassigning the practitioner's responsibilities; lightening the load

Demotions and other arrangements to force the practitioner to quit.

Waiting and hoping.

Recognizing the Impaired Co-worker

If an individual consistently displays the below signs and symptoms it’s time to express concern. You may endanger a person’s future if you cover up or don’t report your concern. Many healthcare providers lose their families, careers, and futures to a chemical impairment. Sadly, some healthcare providers have even lost their lives to the illness perhaps because the people who saw the signs and symptoms refused to get involved.

By becoming involved your action could ensure the safety and welfare of your co-workers and the public who may come in contact with the practitioner.

Mood swings
  • Interpersonal relations with colleagues, staff and patients suffer.
  • Behavioral changes including anxiety, depression, lack of impulse control, suicidal thoughts or gestures.
  • Patients and co-workers complain about provider’s attitude/behavior changing.
Inappropriate behavior at work
  • Unreliability in keeping appointments and meeting deadlines.
  • Frequent disappearances from the work site, having long unexpected absences, making improbable excuses and taking frequent or long trips to the bathroom or to the area where drugs are kept.
  • Absenteeism without notification and an excessive number of sick days used.
  • Deteriorating appearance.
  • Wearing long sleeves when inappropriate.
Deteriorating work performance
  • Sloppy recordkeeping, suspect entries and drug shortages.
  • Uncharacteristic deterioration of handwriting and charting.
  • Heavy “wastage” of narcotics.
  • Inappropriate prescription for large narcotic doses.
  • Insistence on personal administration of injected narcotics to patients.
  • Increased errors.
  • Confusion, memory loss and difficulty concentrating or recalling details and instructions.
  • Ordinary tasks require greater effort and consume more time.
  • Poor judgment and concentration.

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Signs and Symptoms of Impairment

Behavior Changes

Alcohol Drug
Irritable with patients and co-workers Extreme and rapid mood swings
Withdrawn Always wears long sleeves
Mood swings Suspicious behavior concerning controlled substances
Lunch alone Consistently signs out more controlled drugs than anyone else
Inappropriate responses Frequent breaks or spills drugs
Elaborate excuses for behavior Waits until alone to open narcotics cabinet
Unkempt appearance Constantly volunteers to be medication nurse
Blackouts, loss of memory of events, conversations,
phone calls, euphoric recall of events
Defensive when questioned about medication errors

Job Performance

Alcohol Drug
Job shrinkage Too many medication errors
Difficulty meeting deadlines Too many controlled drugs spilled or broken or vials appear altered
Illogical or sloppy charting Illogical or sloppy charting
Frequent errors Incorrect narcotic count or count inconsistent with pharmacy orders
  Patients complain that pain medications dispensed by nurse are ineffective


Alcohol Drug
Increased absenteeism Unexplained absence from unit or takes frequent bathroom breaks
Long lunch hours Comes to work early and stays late for no reason
Absent from floor without explanation Hangs around
Call in to request time at the beginning of shift or after scheduled days off Uses sick leave lavishly
Euphoric recall of events Volunteers for extra shifts

Signs and Symptoms Checklist

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TnPAP is a program of the Tennessee Nurses Foundation. This program is funded under an agreement with the Tennessee Department of Health.

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Tennessee Professional Assistance Program
545 Mainstream Drive, Suite 414
Nashville, TN  37228-1219
FAX 615-726-4003

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