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Code of Ethics for Nurses With Interpretive Statements

2001 Approved Provisions

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Table of Contents Preface

Provision 1. The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems.

1.1 Respect for human dignity 1.2 Relationships to patients 1.3 The nature of health problems 1.4 The right to self-determination 1.5 Relationships with colleagues and others

Provision 2. The nurse's primary commitment is to the patient, whether an individual, family, group, or community.

2.1 Primacy of the patient's interests 2.2 Conflict of interest for nurses 2.3 Collaboration 2.4 Professional boundaries

Provision 3. The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.

3.1 Privacy 3.2 Confidentiality 3.3 Protection of participants in research 3.4 Standards and review mechanisms 3.5 Acting on questionable practice 3.6 Addressing impaired practice

Provision 4. The nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurse's obligation to provide optimum patient care.

4.1 Acceptance of accountability and responsibility 4.2 Accountability for nursing judgment and action 4.3 Responsibility for nursing judgment and action 4.4 Delegation of nursing activities

Provision 5. The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth.

5.1 Moral self-respect

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5.2 Professional growth and maintenance of competence 5.3 Wholeness of character 5.4 Preservation of integrity

Provision 6. The nurse participates in establishing, maintaining, and improving health care environments and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession through individual and collective action.

6.1 Influence of the environment on moral virtues and values 6.2 Influence of the environment on ethical obligations 6.3 Responsibility for the health care environment

Provision 7. The nurse participates in the advancement of the profession through contributions to practice, education, administration, and knowledge development.

7.1 Advancing the profession through active involvement in nursing and in health care policy 7.2 Advancing the profession by developing, maintaining, and implementing professional standards in clinical, administrative, and educational practice 7.3 Advancing the profession through knowledge development, dissemination, and application to practice

Provision 8. The nurse collaborates with other health professionals and the public in promoting community, national, and international efforts to meet health needs.

8.1 Health needs and concerns 8.2 Responsibilities to the public

Provision 9. The profession of nursing, as represented by associations and their members, is responsible for articulating nursing values, for maintaining the integrity of the profession and its practice, and for shaping social policy.

9.1 Assertion of values 9.2 The profession carries out its collective responsibility through professional associations 9.3 Intraprofessional integrity 9.4 Social reform

Preface

Ethics is an integral part of the foundation of nursing. Nursing has a distinguished history of concern for the welfare of the sick, injured, and vulnerable and for social justice. This concern is embodied in the provision of nursing care to individuals and the community. Nursing encompasses the prevention of illness, the alleviation of suffering, and the protection, promotion, and restoration of health in the care of individuals, families, groups, and communities. Nurses act to change those aspects of social structures that detract from health and well-being. Individuals who become nurses are expected not only to adhere to the ideals and moral norms of the profession but also to embrace them as a part of what it means to be a nurse. The ethical tradition of nursing is self-reflective, enduring, and distinctive. A code of ethics makes explicit the primary goals, values, and obligations of the profession.

The Code of Ethics for Nurses serves the following purposes:

● It is a succinct statement of the ethical obligations and duties of every individual who enters the nursing profession.

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● It is the profession's nonnegotiable ethical standard.

● It is an expression of nursing's own understanding of its commitment to society.

There are numerous approaches for addressing ethics; these include adopting or subscribing to ethical theories, including humanist,feminist, and social ethics, adhering to ethical principles, and cultivating virtues. The Code of Ethics for Nurses reflects all of these approaches. The words "ethical" and "moral" are used throughout the Code of Ethics. "Ethical" is used to refer to reasons for decisions about how one ought to act, using the above mentioned approaches. In general, the word "moral" overlaps with "ethical" but is more aligned with personal belief and cultural values. Statements that describe activities and attributes of nurses in this Code of Ethics are to be understood as normative or prescriptive statements expressing expectations of ethical behavior.

The Code of Ethics for Nurses uses the term patient to refer to recipients of nursing care. The derivation of this word refers to "one who suffers," reflecting a universal aspect of human existence. Nonetheless, it is recognized that nurses also provide services to those seeking health as well as those responding to illness, to students and to staff, in health care facilities as well as in communities. Similarly, the termpracticerefers to the actions of the nurse in whatever role the nurse fulfills, including direct patient care provider, educator, administrator, researcher, policy developer, or other. Thus, the values and obligations expressed in this Code of Ethics apply to nurses in all roles and settings.

The Code of Ethics for Nurses is a dynamic document. As nursing and its social context change, changes to the Code of Ethics are also necessary. The Code of Ethics consists of two components: the provisions and the accompanying interpretive statements. There are nine provisions. The first three describe the most fundamental values and commitments of the nurse; the next three address boundaries of duty and loyalty, and the last three address aspects of duties beyond individual patient encounters. For each provision, there are interpretive statements that provide greater specificity for practice and are responsive to the contemporary context of nursing. Consequently, the interpretive statements are subject to more frequent revision than are the provisions. Additional ethical guidance and detail can be found in ANA or constituent member association position statements that address clinical, research, administrative, educational, or public policy issues.

The Code of Ethics for Nurses with Interpretive Statements provides a framework for nurses to use in ethical analysis and decision-making. The Code of Ethics establishes the ethical standard for the profession. It is not negotiable in any setting nor is it subject to revision or amendment except by formal process of the House of Delegates of the ANA. The Code of Ethics for Nurses is a reflection of the proud ethical heritage of nursing, a guide for nurses now and in the future.

Provision 1.

The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems.

1.1 Respect for human dignity - A fundamental principle that underlies all nursing practice is respect for the inherent worth, dignity, and human rights of every individual. Nurses take into account the needs and values of all persons in all professional relationships.

1.2 Relationships to patients - The need for health care is universal, transcending all individual differences. The nurse establishes relationships and delivers nursing services with respect for human needs and values, and without prejudice. An individual's lifestyle, value system and religious beliefs should be considered in planning health care with and for each patient. Such consideration does not suggest that the nurse necessarily agrees with or condones certain individual choices, but that the nurse respects the patient as a person.

1.3 The nature of health problems -The nurse respects the worth, dignity and rights of all human beings irrespective of the nature of the health problem. The worth of the person is not affected by disease, disability, functional status, or proximity to death. This respect extends to all who require the services of the nurse for the

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promotion of health, the prevention of illness, the restoration of health, the alleviation of suffering, and the provision of supportive care to those who are dying.

The measures nurses take to care for the patient enable the patient to live with as much physical, emotional, social, and spiritual well-being as possible. Nursing care aims to maximize the values that the patient has treasured in life and extends supportive care to the family and significant others. Nursing care is directed toward meeting the comprehensive needs of patients and their families across the continuum of care. This is particularly vital in the care of patients and their families at the end of life to prevent and relieve the cascade of symptoms and suffering that are commonly associated with dying.

Nurses are leaders and vigilant advocates for the delivery of dignified and humane care. Nurses actively participate in assessing and assuring the responsible and appropriate use of interventions in order to minimize unwarranted or unwanted treatment and patient suffering. The acceptability and importance of carefully considered decisions regarding resuscitation status, withholding and withdrawing life-sustaining therapies, forgoing medically provided nutrition and hydration, aggressive pain and symptom management and advance directives are increasingly evident. The nurse should provide interventions to relieve pain and other symptoms in the dying patient even when those interventions entail risks of hastening death. However, nurses may not act with the sole intent of ending a patient's life even though such action may be motivated by compassion, respect for patient autonomy and quality of life considerations. Nurses have invaluable experience, knowledge, and insight into care at the end of life and should be actively involved in related research, education, practice, and policy development.

1.4 The right to self-determination - Respect for human dignity requires the recognition of specific patient rights, particularly, the right of self-determination. Self-determination, also known as autonomy, is the philosophical basis for informed consent in health care. Patients have the moral and legal right to determine what will be done with their own person; to be given accurate, complete, and understandable information in a manner that facilitates an informed judgment; to be assisted with weighing the benefits, burdens, and available options in their treatment, including the choice of no treatment; to accept, refuse, or terminate treatment without deceit, undue influence, duress, coercion, or penalty; and to be given necessary support throughout the decision-making and treatment process. Such support would include the opportunity to make decisions with family and significant others and the provision of advice and support from knowledgeable nurses and other health professionals. Patients should be involved in planning their own health care to the extent they are able and choose to participate.

Each nurse has an obligation to be knowledgeable about the moral and legal rights of all patients to self- determination. The nurse preserves, protects, and supports those interests by assessing the patient's comprehension of both the information presented and the implications of decisions. In situations in which the patient lacks the capacity to make a decision, a designated surrogate decision-maker should be consulted. The role of the surrogate is to make decisions as the patient would, based upon the patient's previously expressed wishes and known values. In the absence of a designated surrogate decision-maker, decisions should be made in the best interests of the patient, considering the patient's personal values to the extent that they are known. The nurse supports patient self-determination by participating in discussions with surrogates, providing guidance and referral to other resources as necessary, and identifying and addressing problems in the decision-making process. Support of autonomy in the broadest sense also includes recognition that people of some cultures place less weight on individualism and choose to defer to family or community values in decision-making. Respect not just for the specific decision but also for the patient's method of decision-making is consistent with the principle of autonomy.

Individuals are interdependent members of the community. The nurse recognizes that there are situations in which the right to individual self-determination may be outweighed or limited by the rights, health and welfare of others, particularly in relation to public health considerations. Nonetheless, limitation of individual rights must always be considered a serious deviation from the standard of care, justified only when there are no less restrictive means available to preserve the rights of others and the demands of justice.

1.5 Relationships with colleagues and others - The principle of respect for persons extends to all individuals with whom the nurse interacts. The nurse maintains compassionate and caring relationships with

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colleagues and others with a commitment to the fair treatment of individuals, to integrity-preserving compromise, and to resolving conflict. Nurses function in many roles, including direct care provider, administrator, educator, researcher, and consultant. In each of these roles, the nurse treats colleagues, employees, assistants, and students with respect and compassion. This standard of conduct precludes any and all prejudicial actions, any form of harassment or threatening behavior, or disregard for the effect of one's actions on others. The nurse values the distinctive contribution of individuals or groups, and collaborates to meet the shared goal of providing quality health services.

Provision 2 The nurse's primary commitment is to the patient, whether an individual, family, group, or community.

2.1 Primacy of the patient's interests - The nurse's primary commitment is to the recipient of nursing and health care services --the patient--whether the recipient is an individual, a family, a group, or a community. Nursing holds a fundamental commitment to the uniqueness of the individual patient; therefore, any plan of care must reflect that uniqueness. The nurse strives to provide patients with opportunities to participate in planning care, assures that patients find the plans acceptable and supports the implementation of the plan. Addressing patient interests requires recognition of the patient's place in the family or other networks of relationship. When the patient's wishes are in conflict with others, the nurse seeks to help resolve the conflict. Where conflict persists, the nurse's commitment remains to the identified patient.

2.2 Conflict of interest for nurses - Nurses are frequently put in situations of conflict arising from competing loyalties in the workplace, including situations of conflicting expectations from patients, families, physicians, colleagues, and in many cases, health care organizations and health plans. Nurses must examine the conflicts arising between their own personal and professional values, the values and interests of others who are also responsible for patient care and health care decisions, as well as those of patients. Nurses strive to resolve such conflicts in ways that ensure patient safety, guard the patient's best interests and preserve the professional integrity of the nurse.

Situations created by changes in health care financing and delivery systems, such as incentive systems to decrease spending, pose new possibilities of conflict between economic self-interest and professional integrity. The use of bonuses, sanctions, and incentives tied to financial targets are examples of features of health care systems that may present such conflict. Conflicts of interest may arise in any domain of nursing activity including clinical practice, administration, education, or research. Advanced practice nurses who bill directly for services and nursing executives with budgetary responsibilities must be especially cognizant of the potential for conflicts of interest. Nurses should disclose to all relevant parties (e.g., patients, employers, colleagues) any perceived or actual conflict of interest and in some situations should withdraw from further participation. Nurses in all roles must seek to ensure that employment arrangements are just and fair and do not create an unreasonable conflict between patient care and direct personal gain.

2.3 Collaboration - Collaboration is not just cooperation, but it is the concerted effort of individuals and groups to attain a shared goal. In health care, that goal is to address the health needs of the patient and the public. The complexity of health care delivery systems requires a multi-disciplinary approach to the delivery of services that has the strong support and active participation of all the health professions. Within this context, nursing's unique contribution, scope of practice, and relationship with other health professions needs to be clearly articulated, represented and preserved. By its very nature, collaboration requires mutual trust, recognition, and respect among the health care team, shared decision-making about patient care, and open dialogue among all parties who have an interest in and a concern for health outcomes. Nurses should work to assure that the relevant parties are involved and have a voice in decision-making about patient care issues. Nurses should see that the questions that need to be addressed are asked and that the information needed for informed decision-making is available and provided. Nurses should actively promote the collaborative multi-disciplinary planning required to ensure the availability and accessibility of quality health services to all persons who have needs for health care.

Intra-professional collaboration within nursing is fundamental to effectively addressing the health needs of patients and the public. Nurses engaged in non-clinical roles, such as administration or research, while not providing direct care, nonetheless are collaborating in the provision of care through their influence and direction of

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those who do. Effective nursing care is accomplished through the interdependence of nurses in differing roles-- those who teach the needed skills, set standards, manage the environment of care, or expand the boundaries of knowledge used by the profession. In this sense, nurses in all roles share a responsibility for the outcomes of nursing care.

2.4 Professional boundaries - When acting within one's role as a professional, the nurse recognizes and maintains boundaries that establish appropriate limits to relationships. While the nature of nursing work has an inherently personal component, nurse-patient relationships and nurse-colleague relationships have, as their foundation, the purpose of preventing illness, alleviating suffering, and protecting, promoting, and restoring the health of patients. In this way, nurse-patient and nurse-colleague relationships differ from those that are purely personal and unstructured, such as friendship. The intimate nature of nursing care, the involvement of nurses is important and sometimes highly stressful life events, and the mutual dependence of colleagues working in close concert all present the potential for blurring of limits to professional relationships. Maintaining authenticity and expressing oneself as an individual, while remaining within the bounds established by the purpose of the relationship can be especially difficult in prolonged or long-term relationships. In all encounters, nurses are responsible for retaining their professional boundaries. When those professional boundaries are jeopardized, the nurse should seek assistance from peers or supervisors or take appropriate steps to remove her/himself from the situation.

Provision 3 The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.

3.1 Privacy - The nurse safeguards the patient's right to privacy. The need for health care does not justify unwanted intrusion into the patient's life. The nurse advocates for an environment that provides for sufficient physical privacy, including auditory privacy for discussions of a personal nature and policies and practices that protect the confidentiality of information.

3.2 Confidentiality - Associated with the right to privacy, the nurse has a duty to maintain confidentiality of all patient information. The patient's well-being could be jeopardized and the fundamental trust between patient and nurse destroyed by unnecessary access to data or by the inappropriate disclosure of identifiable patient information. The rights, well-being, and safety of the individual patient should be the primary factors in arriving at any professional judgment concerning the disposition of confidential information received from or about the patient, whether oral, written or electronic. The standard of nursing practice and the nurse's responsibility to provide quality care require that relevant data be shared with those members of the health care team who have a need to know. Only information pertinent to a patient's treatment and welfare is disclosed, and only to those directly involved with the patient's care. Duties of confidentiality, however, are not absolute and may need to be modified in order to protect the patient, other innocent parties and in circumstances of mandatory disclosure for public health reasons.

Information used for purposes of peer review, third-party payments, and other quality improvement or risk management mechanisms may be disclosed only under defined policies, mandates, or protocols. These written guidelines must assure that the rights, well-being, and safety of the patient are protected. In general, only that information directly relevant to a task or specific responsibility should be disclosed. When using electronic communications, special effort should be made to maintain data security.

3.3 Protection of participants in research - Stemming from the right to self-determination, each individual has the right to choose whether or not to participate in research. It is imperative that the patient or legally authorized surrogate receive sufficient information that is material to an informed decision, to comprehend that information, and to know how to discontinue participation in research without penalty. Necessary information to achieve an adequately informed consent includes the nature of participation, potential harms and benefits, and available alternatives to taking part in the research. Additionally, the patient should be informed of how the data will be protected. The patient has the right to refuse to participate in research or to withdraw at any time without fear of adverse consequences or reprisal.

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Research should be conducted and directed only by qualified persons. Prior to implementation, all research should be approved by a qualified review board to ensure patient protection and the ethical integrity of the research. Nurses should be cognizant of the special concerns raised by research involving vulnerable groups, including children, prisoners, students, the elderly, and the poor. The nurse who participates in research in any capacity should be fully informed about both the subject's and the nurse's rights and obligations in the particular research study and in research in general. Nurses have the duty to question and, if necessary, to report and to refuse to participate in research they deem morally objectionable.

3.4 Standards and review mechanisms - Nursing is responsible and accountable for assuring that only those individuals who have demonstrated the knowledge, skill, practice experiences, commitment, and integrity essential to professional practice are allowed to enter into and continue to practice within the profession. Nurse educators have a responsibility to ensure that basic competencies are achieved and to promote a commitment to professional practice prior to entry of an individual into practice. Nurse administrators are responsible for assuring that the knowledge and skills of each nurse in the workplace are assessed prior to the assignment of responsibilities requiring preparation beyond basic academic programs.

The nurse has a responsibility to implement and maintain standards of professional nursing practice. The nurse should participate in planning, establishing, implementing, and evaluating review mechanisms designed to safeguard patients and nurses, such as peer review processes or committees, credentialing processes, quality improvement initiatives, and ethics committees. Nurse administrators must ensure that nurses have access to and inclusion on institutional ethics committees. Nurses must bring forward difficult issues related to patient care and/ or institutional constraints upon ethical practice for discussion and review. The nurse acts to promote inclusion of appropriate others in all deliberations related to patient care.

Nurses should also be active participants in the development of policies and review mechanisms designed to promote patient safety, reduce the likelihood of errors, and address both environmental system factors and human factors that present increased risk to patients. In addition, when errors do occur, nurses are expected to follow institutional guidelines in reporting errors committed or observed to the appropriate supervisory personnel and for assuring responsible disclosure of errors to patients. Under no circumstances should the nurse participate in, or condone through silence, either an attempt to hide an error or a punitive response that serves only to fix blame rather than correct the conditions that led to the error.

3.5 Acting on questionable practice - The nurse's primary commitment is to the health, well-being, and safety of the patient across the life span and in all settings in which health care needs are addressed. As an advocate for the patient, the nurse must be alert to and take appropriate action regarding any instances of incompetent, unethical, illegal, or impaired practice by any member of the health care team or the health care system or any action on the part of others that places the rights or best interests of the patient in jeopardy. To function effectively in this role, nurses must be knowledgeable about the Code of Ethics, standards of practice of the profession, relevant federal, state and local laws and regulations, and the employing organization's policies and procedures.

When the nurse is aware of inappropriate or questionable practice in the provision or denial of health care, concern should be expressed to the person carrying out the questionable practice. Attention should be called to the possible detrimental affect upon the patient's well-being or best interests as well as the integrity of nursing practice. When factors in the health care delivery system or health care organization threaten the welfare of the patient, similar action should be directed to the responsible administrator. If indicated, the problem should be reported to an appropriate higher authority within the institution or agency, or to an appropriate external authority.

There should be established processes for reporting and handling incompetent, unethical, illegal, or impaired practice within the employment setting so that such reporting can go through official channels, thereby reducing the risk of reprisal against the reporting nurse. All nurses have a responsibility to assist those who identify potentially questionable practice. State nurses associations should be prepared to provide assistance and support in the development and evaluation of such processes and reporting procedures.When incompetent, unethical, illegal, or impaired practice is not corrected within the employment setting and continues to jeopardize patient well- being and safety, the problem should be reported to other appropriate authorities such as practice committees of

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the pertinent professional organizations, the legally constituted bodies concerned with licensing of specific categories of health workers and professional practitioners, or the regulatory agencies concerned with evaluating standards or practice. Some situations may warrant the concern and involvement of all such groups. Accurate reporting and factual documentation, and not merely opinion, undergird all such responsible actions. When a nurse chooses to engage in the act of responsible reporting about situations that are perceived as unethical, incompetent, illegal, or impaired, the professional organization has a responsibility to provide the nurse with support and assistance and to protect the practice of those nurses who choose to voice their concerns. Reporting unethical, illegal, incompetent, or impaired practices, even when done appropriately, may present substantial risks to the nurse; nevertheless, such risks do not eliminate the obligation to address serious threats to patient safety.

3.6 Addressing impaired practice - Nurses must be vigilant to protect the patient, the public and the profession from potential harm when a colleague's practice, in any setting, appears to be impaired. The nurse extends compassion and caring to colleagues who are in recovery from illness or when illness interferes with job performance. In a situation where a nurse suspects another's practice may be impaired, the nurse's duty is to take action designed both to protect patients and to assure that the impaired individual receives assistance in regaining optimal function. Such action should usually begin with consulting supervisory personnel and may also include confronting the individual in a supportive manner and with the assistance of others or helping the individual to access appropriate resources. Nurses are encouraged to follow guidelines outlined by the profession and policies of the employing organization to assist colleagues whose job performance may be adversely affected by mental or physical illness or by personal circumstances. Nurses in all roles should advocate for colleagues whose job performance may be impaired to ensure that they receive appropriate assistance, treatment and access to fair institutional and legal processes. This includes supporting the return to practice of the individual who has sought assistance and is ready to resume professional duties.

If impaired practice poses a threat or danger to self or others, regardless of whether the individual has sought help, the nurse must take action to report the individual to persons authorized to address the problem. Nurses who advocate for others whose job performance creates a risk for harm should be protected from negative consequences. Advocacy may be a difficult process and the nurse is advised to follow workplace policies. If workplace policies do not exist or are inappropriate--that is, they deny the nurse in question access to due legal process or demand resignation--the reporting nurse may obtain guidance from the professional association, state peer assistance programs, employee assistance program or a similar resource.

Provision 4 The nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurse's obligation to provide optimum patient care.

4.1 Acceptance of accountability and responsibility - Individual registered nurses bear primary responsibility for the nursing care that their patients receive and are individually accountable for their own practice. Nursing practice includes direct care activities, acts of delegation, and other responsibilities such as teaching, research, and administration. In each instance, the nurse retains accountability and responsibility for the quality of practice and for conformity with standards of care.

Nurses are faced with decisions in the context of the increased complexity and changing patterns in the delivery of health care. As the scope of nursing practice changes, the nurse must exercise judgment in accepting responsibilities, seeking consultation, and assigning activities to others who carry out nursing care. For example, some advanced practice nurses have the authority to issue prescription and treatment orders to be carried out by other nurses. These acts are not acts of delegation. Both the advanced practice nurse issuing the order and the nurse accepting the order are responsible for the judgments made and accountable for the actions taken.

4.2 Accountability for nursing judgment and action - Accountability means to be answerable to oneself and others for one's own actions. In order to be accountable, nurses act under a code of ethical conduct that is grounded in the moral principles of fidelity and respect for the dignity, worth, and self-determination of patients. Nurses are accountable for judgments made and actions taken in the course of nursing practice, irrespective of health care organizations' policies or providers' directives.

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4.3 Responsibility for nursing judgment and action - Responsibility refers to the specific accountability or liability associated with the performance of duties of a particular role. Nurses accept or reject specific role demands based upon their education, knowledge, competence, and extent of experience. Nurses in administration, education, and research also have obligations to the recipients of nursing care. Although nurses in administration, education, and research have relationships with patients that are less direct, in assuming the responsibilities of a particular role, they share responsibility for the care provided by those whom they supervise and instruct. The nurse must not engage in practices prohibited by law or delegate activities to others that are prohibited by the practice acts of other health care providers.

Individual nurses are responsible for assessing their own competence. When the needs of the patient are beyond the qualifications and competencies of the nurse, consultation and collaboration must be sought from qualified nurses, other health professionals, or other appropriate sources. Educational resources should be sought by nurses and provided by institutions to maintain and advance the competence of nurses. Nurse educators act in collaboration with their students to assess the learning needs of the student, the effectiveness of the teaching program, the identification and utilization of appropriate resources, and the support needed for the learning process.

4.4 Delegation of nursing activities - Since the nurse is accountable for the quality of nursing care given to patients, nurses are accountable for the assignment of nursing responsibilities to other nurses and the delegation of nursing care activities to other health care workers. While delegation and assignment are used here in a generic moral sense, it is understood that individual states may have a particular legal definition of these terms.

The nurse must make reasonable efforts to assess individual competence when assigning selected components of nursing care to other health care workers. This assessment involves evaluating the knowledge, skills, and experience of the individual to whom the care is assigned, the complexity of the assigned tasks, and the health status of the patient. The nurse is also responsible for monitoring the activities of these individuals and evaluating the quality of the care provided. Nurses may not delegate responsibilities such as assessment and evaluation; they may delegate tasks. The nurse must not knowingly assign or delegate to any member of the nursing team a task for which that person is not prepared or qualified. Employer policies or directives do not relieve the nurse of responsibility for making judgments about the delegation and assignment of nursing care tasks.

Nurses functioning in management or administrative roles have a particular responsibility to provide an environment that supports and facilitates appropriate assignment and delegation. This includes providing appropriate orientation to staff, assisting less experienced nurses in developing necessary skills and competencies, and establishing policies and procedures that protect both the patient and nurse from the inappropriate assignment or delegation of nursing responsibilities, activities, or tasks.

Nurses functioning in educator or preceptor roles may have less direct relationships with patients. However, through assignment of nursing care activities to learners they share responsibility and accountability for the care provided. It is imperative that the knowledge and skills of the learner be sufficient to provide the assigned nursing care and that appropriate supervision be provided to protect both the patient and the learner.

Provision 5 The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth.

5.1 Moral self-respect - Moral respect accords moral worth and dignity to all human beings irrespective of their personal attributes or life situation. Such respect extends to oneself as well; the same duties that we owe to others we owe to ourselves. Self-regarding duties refer to a realm of duties that primarily concern oneself and include professional growth and maintenance of competence, preservation of wholeness of character, and personal integrity.

5.2 Professional growth and maintenance of competence - Though it has consequences for others, maintenance of competence and ongoing professional growth involves the control of one's own conduct in a way

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that is primarily self-regarding. Competence affects one's self-respect, self-esteem, professional status, and the meaningfulness of work. In all nursing roles, evaluation of one's own performance, coupled with peer review, is a means by which nursing practice can be held to the highest standards. Each nurse is responsible for participating in the development of criteria for evaluation of practice and for using those criteria in peer and self-assessment.

Continual professional growth, particularly in knowledge and skill, requires a commitment to lifelong learning. Such learning includes, but is not limited to, continuing education, networking with professional colleagues, self- study, professional reading, certification, and seeking advanced degrees. Nurses are required to have knowledge relevant to the current scope and standards of nursing practice, changing issues, concerns, controversies, and ethics. Where the care required is outside the competencies of the individual nurse, consultation should be sought or the patient should be referred to others for appropriate care.

5.3 Wholeness of character - Nurses have both personal and professional identities that are neither entirely separate, nor entirely merged, but are integrated. In the process of becoming a professional, the nurse embraces the values of the profession, integrating them with personal values. Duties to self involve an authentic expression of one's own moral point-of-view in practice. Sound ethical decision-making requires the respectful and open exchange of views between and among all individuals with relevant interests. In a community of moral discourse, no one person's view should automatically take precedence over that of another. Thus the nurse has a responsibility to express moral perspectives, even when they differ from those of others, and even when they might not prevail.

This wholeness of character encompasses relationships with patients. In situations where the patient requests a personal opinion from the nurse, the nurse is generally free to express an informed personal opinion as long as this preserves the voluntariness of the patient and maintains appropriate professional and moral boundaries. It is essential to be aware of the potential for undue influence attached to the nurse's professional role. Assisting patients to clarify their own values in reaching informed decisions may be helpful in avoiding unintended persuasion. In situations where nurses' responsibilities include care for those whose personal attributes, condition, lifestyle or situation is stigmatized by the community and are personally unacceptable, the nurse still renders respectful and skilled care.

5.4 Preservation of integrity - Integrity is an aspect of wholeness of character and is primarily a self- concern of the individual nurse. An economically constrained health care environment presents the nurse with particularly troubling threats to integrity. Threats to integrity may include a request to deceive a patient,to withhold information, or to falsify records, as well as verbal abuse from patients or coworkers. Threats to integrity also may include an expectation that the nurse will act in a way that is inconsistent with the values or ethics of the profession, or more specifically a request that is in direct violation of the Code of Ethics. Nurses have a duty to remain consistent with both their personal and professional values and to accept compromise only to the degree that it remains an integrity-preserving compromise. An integrity-preserving compromise does not jeopardize the dignity or well-being of the nurse or others. Integrity-preserving compromise can be difficult to achieve, but is more likely to be accomplished in situations where there is an open forum for moral discourse and an atmosphere of mutual respect and regard.

Where nurses are placed in situations of compromise that exceed acceptable moral limits or involve violations of the moral standards of the profession, whether in direct patient care or in any other forms of nursing practice, they may express their conscientious objection to participation. Where a particular treatment, intervention, activity, or practice is morally objectionable to the nurse, whether intrinsically so or because it is inappropriate for the specific patient, or where it may jeopardize both patients and nursing practice, the nurse is justified in refusing to participate on moral grounds. Such grounds exclude personal preference, prejudice, convenience, or arbitrariness. Conscientious objection may not insulate the nurse against formal or informal penalty. The nurse who decides not to take part on the grounds of conscientious objection must communicate this decision in appropriate ways. Whenever possible, such a refusal should be made known in advance and in time for alternate arrangements to be made for patient care. The nurse is obliged to provide for the patient's safety, to avoid patient abandonment, and to withdraw only when assured that alternative sources of nursing care are available to the patient.

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Where patterns of institutional behavior or professional practice compromise the integrity of all its nurses, nurses should express their concern or conscientious objection collectively to the appropriate body or committee. In addition, they should express their concern, resist, and seek to bring about a change in those persistent activities or expectations in the practice setting that are morally objectionable to nurses and jeopardize either patient or nurse well-being.

Provision 6

The nurse participates in establishing, maintaining, and improving health care environments and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession through individual and collective action.

6.1 Influence of the environment on moral virtues and values - Virtues are habits of character that predispose persons to meet their moral obligations; that is, to do what is right. Excellences are habits of character that predispose a person to do a particular job or task well. Virtues such as wisdom, honesty, and courage are habits or attributes of the morally good person. Excellences such as compassion, patience, and skill are habits of character of the morally good nurse. For the nurse, virtues and excellences are those habits that affirm and promote the values of human dignity, well-being, respect, health, independence, and other values central to nursing. Both virtues and excellences, as aspects of moral character, can be either nurtured by the environment in which the nurse practices or they can be diminished or thwarted. All nurses have a responsibility to create, maintain, and contribute to environments that support the growth of virtues and excellences and enable nurses to fulfill their ethical obligations.

6.2 Influence of the environment on ethical obligations - All nurses, regardless of role, have a responsibility to create, maintain, and contribute to environments of practice that support nurses in fulfilling their ethical obligations. Environments of practice include observable features, such as working conditions, and written policies and procedures setting out expectations for nurses, as well as less tangible characteristics such as informal peer norms. Organizational structures, role descriptions, health and safety initiatives, grievance mechanisms, ethics committees, compensation systems, and disciplinary procedures all contribute to environments that can either present barriers or foster ethical practice and professional fulfillment. Environments in which employees are provided fair hearing of grievances, are supported in practicing according to standards of care, and are justly treatedallow for the realization of the values of the profession and are consistent with sound nursing practice.

6.3 Responsibility for the health care environment - The nurse is responsible for contributing to a moral environment that encourages respectful interactions with colleagues, support of peers, and identification of issues that need to be addressed. Nurse administrators have a particular responsibility to assure that employees are treated fairly and that nurses are involved in decisions related to their practice and working conditions. Acquiescing and accepting unsafe or inappropriate practices, even if the individual does not participate in the specific practice, is equivalent to condoning unsafe practice. Nurses should not remain employed in facilities that routinely violate patient rights or require nurses to severely and repeatedly compromise standards of practice or personal morality.

As with concerns about patient care, nurses should address concerns about the health care environment through appropriate channels. Organizational changes are difficult to accomplish and may require persistent efforts over time. Toward this end, nurses may participate in collective action such as collective bargaining or workplace advocacy, preferably through a professional association such as the state nurses association, in order to address the terms and conditions of employment. Agreements reached through such action must be consistent with the profession's standards of practice, the state law regulating practice and the Code of Ethics for Nursing. Conditions of employment must contribute to the moral environment, the provision of quality patient care and professional satisfaction for nurses.

The professional association also serves as an advocate for the nurse by seeking to secure just compensation and humane working conditions for nurses. To accomplish this, the professional association may engage in

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collective bargaining on behalf of nurses. While seeking to assure just economic and general welfare for nurses, collective bargaining, nonetheless, seeks to keep the interests of both nurses and patients in balance.

Provision 7 The nurse participates in the advancement of the profession through contributions to practice, education, administration, and knowledge development.

7.1 Advancing the profession through active involvement in nursing and in health care policy - Nurses should advance their profession by contributing in some way to the leadership, activities, and the viability of their professional organizations. Nurses can also advance the profession by serving in leadership or mentorship roles or on committees within their places of employment. Nurses who are self-employed can advance the profession by serving as role models for professional integrity. Nurses can also advance the profession through participation in civic activities related to health care or through local, state, national, or international initiatives. Nurse educators have a specific responsibility to enhance students' commitment to professional and civic values. Nurse administrators have a responsibility to foster an employment environment that facilitates nurses' ethical integrity and professionalism, and nurse researchers are responsible for active contribution to the body of knowledge supporting and advancing nursing practice.

7.2 Advancing the profession by developing, maintaining, and implementing professional standards in clinical, administrative, and educational practice - Standards and guidelines reflect the practice of nursing grounded in ethical commitments and a body of knowledge. Professional standards and guidelines for nurses must be developed by nurses and reflect nursing's responsibility to society. It is the responsibility of nurses to identify their own scope of practice as permitted by professional practice standards and guidelines, by state and federal laws, by relevant societal values, and by the Code of Ethics.

The nurse as administrator or manager must establish, maintain, and promote conditions of employment that enable nurses within that organization or community setting to practice in accord with accepted standards of nursing practice and provide a nursing and health care work environment that meets the standards and guidelines of nursing practice. Professional autonomy and self regulation in the control of conditions of practice are necessary for implementing nursing standards and guidelines and assuring quality care for those whom nursing serves.

The nurse educator is responsible for promoting and maintaining optimum standards of both nursing education and of nursing practice in any settings where planned learning activities occur. Nurse educators must also ensure that only those students who possess the knowledge, skills, and competencies that are essential to nursing graduate from their nursing programs.

7.3 Advancing the profession through knowledge development, dissemination, and application to practice - The nursing profession should engage in scholarly inquiry to identify, evaluate, refine, and expand the body of knowledge that forms the foundation of its discipline and practice. In addition, nursing knowledge is derived from the sciences and from the humanities. Ongoing scholarly activities are essential to fulfilling a profession's obligations to society. All nurses working alone or in collaboration with others can participate in the advancement of the profession through the development, evaluation, dissemination, and application of knowledge in practice. However, an organizational climate and infrastructure conducive to scholarly inquiry must be valued and implemented for this to occur.

Provision 8 The nurse collaborates with other health professionals and the public in promoting community, national, and international efforts to meet health needs.

8.1 Health needs and concerns - The nursing profession is committed to promoting the health, welfare, and safety of all people. The nurse has a responsibility to be aware not only of specific health needs of individual patients but also of broader health concerns such as world hunger, environmental pollution, lack of access to health care, violation of human rights, and inequitable distribution of nursing and health care resources. The availability and accessibility of high quality health services to all people require both interdisciplinary planning and collaborative partnerships among health professionals and others at the community, national, and international

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levels.

8.2 Responsibilities to the public - Nurses, individually and collectively, have a responsibility to be knowledgeable about the health status of the community and existing threats to health and safety. Through support of and participation in community organizations and groups, the nurse assists in efforts to educate the public, facilitates informed choice, identifies conditions and circumstances that contribute to illness, injury and disease, fosters healthy life styles, and participatesin institutional and legislative efforts to promote health and meet national health objectives. In addition, the nurse supports initiatives to address barriers to health, such as poverty, homelessness, unsafe living conditions, abuse and violence, and lack of access to health services.

The nurse also recognizes that health care is provided to culturally diverse populations in this country and in all parts of the world. In providing care, the nurse should avoid imposition of the nurse's own cultural values upon others. The nurse should affirm human dignity and show respect for the values and practices associated with different cultures and use approaches to care that reflect awareness and sensitivity.

Provision 9 The profession of nursing, as represented by associations and their members, is responsible for articulating nursing values, for maintaining the integrity of the profession and its practice, and for shaping social policy.

9.1 Assertion of values - It is the responsibility of a professional association to communicate and affirm the values of the profession to its members. It is essential that the professional organization encourages discourse that supports critical self-reflection and evaluation within the profession. The organization also communicates to the public the values that nursing considers central to social change that will enhance health.

9.2 The profession carries out its collective responsibility through professional associations - The nursing profession continues to develop ways to clarify nursing's accountability to society. The contract between the profession and society is made explicit through such mechanisms as

(a) The Code of Ethics for Nurses (b) the standards of nursing practice (c) the ongoing development of nursing knowledge derived from nursing theory, scholarship, and research in order to guide nursing actions (d) educational requirements for practice (e) certification, and (f) mechanisms for evaluating the effectiveness of professional nursing actions.

9.3 Intraprofessional integrity A professional association is responsible for expressing the values and ethics of the profession and also for encouraging the professional organization and its members to function in accord with those values and ethics. Thus, one of its fundamental responsibilities is to promote awareness of and adherence to the Code of Ethics and to critique the activities and ends of the professional association itself. Values and ethics influence the power structures of the association in guiding, correcting, and directing its activities. Legitimate concerns for the self-interest of the association and the profession are balanced by a commitment to the social goods that are sought. Through critical self-reflection and self-evaluation, associations must foster change within themselves, seeking to move the professional community toward its stated ideals.

9.4 Social reform - Nurses can work individually as citizens or collectively through political action to bring about social change. It is the responsibility of a professional nursing association to speak for nurses collectively in shaping and reshaping health care within our nation, specifically in areas of health care policy and legislation that affect accessibility, quality, and the cost of health care. Here, the professional association maintains vigilance and takes action to influence legislators, reimbursement agencies, nursing organizations, and other health professions. In these activities, health is understood as being broader than delivery and reimbursement systems, but extending to health-related sociocultural issues such as violation of human rights, homelessness, hunger, violence, and the stigma of illness.

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© 2001 The American Nurses Association, Inc. All Rights Reserved

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A Nurse’s Guide to Professional Boundaries

A nurse must understand

and apply the

following concepts of

professional boundaries.

Y

ear after year, nursing tops national

polls of the most widely respected and

trusted professions. The results of these polls

reflect the special relationship and bond

between nurses and those under their care.

Patients can expect a nurse to act in their best

interests and to respect their dignity. This

means that a nurse abstains from attaining

personal gain at the patient’s expense and

refrains from jeopardizing the therapeutic

nurse–patient relationship. In order to maintain

that trust and practice in a manner consistent

with professional standards, nurses should

be knowledgeable regarding professional

boundaries and work to establish and maintain

those boundaries.

A Nurse’s Guide to Professional Boundaries

A therapeutic relationship is one that allows nurses to apply their professional knowledge, skills, abilities and experiences towards meeting the health needs of the patient. This relationship is dynamic, goal-oriented and patient-centered because it is designed to meet the needs of the patient. Regardless of the context or length of interaction, the therapeutic nurse–patient relationship protects the patient’s dignity, autonomy and privacy and allows for the development of trust and respect.

Professional boundaries are the spaces between the nurse’s power and the patient’s vulnerability. The power of the nurse comes from the nurse’s professional position and access to sensitive personal information. The differ- ence in personal information the nurse knows about the patient versus personal information the patient knows about the nurse creates an imbalance in the nurse–patient relationship. Nurses should make every effort to respect the power imbalance and ensure a patient-centered relationship.

Boundary crossings are brief excursions across professional lines of behavior that may be inadvertent, thoughtless or even purposeful, while attempting to meet a special therapeutic need of the patient. Boundary crossings can result in a return to established boundaries, but should be evaluated by the nurse for potential adverse patient consequences and implications. Repeated boundary crossings should be avoided.

Boundary violations can result when there is confusion between the needs of the nurse and those of the patient. Such violations are characterized by excessive personal disclosure by the nurse, secrecy or even a rever- sal of roles. Boundary violations can cause distress for the patient, which may not be recognized or felt by the patient until harmful consequences occur.

A nurse’s use of social media is another way that nurses can uninten tionally blur the lines between their professional and personal lives. Making a comment via social media, even if done on a nurse’s own time and in their own home, regarding an incident or person in the scope of their employment, may be a breach of patient confidentiality or privacy, as well as a boundary violation.

Every nurse–patient relationship can be conceptualized on the continuum of professional behavior. Nurses can use this graphic as a frame of reference to evaluate their behavior and consider if they are acting within the confines of the therapeutic relationship or if they are under- or overinvolved in their patients’ care. Overinvolvement includes boundary crossings, boundary violations and professional sexual misconduct. Under involvement includes distancing, disinterest and neglect, and can be detrimental to the patient and the nurse. There are no definite lines separating the therapeutic relationship from under involvement or over- involvement; instead, it is a gradual transition.

This continuum provides a frame of reference to assist nurses in evaluating their own and their colleagues’ professional–patient interactions. For a given situation, the facts should be reviewed to determine whether or not the nurse was aware that a boundary crossing occurred and for what reason. The nurse should be asked: What was the intent of the boundary crossing? Was it for a therapeutic purpose? Was it in the patient’s best interest? Did it optimize or detract from the nursing care? Did the nurse consult with a supervisor or colleague? Was the incident appropriately documented?

Professional sexual misconduct is an extreme form of boundary violation and includes any behavior that is seductive, sexually demeaning, harassing or reasonably interpreted as sexual by the patient. Professional sexual misconduct is an extremely serious, and criminal, violation.

A CONTINUUM OF PROFESSIONAL BEHAVIOR

UNDER- INVOLVEMENT

OVER- INVOLVEMENT

THERAPEUTIC RELATIONSHIP

Every nurse–patient relationship can be plotted on the continuum of professional behavior illustrated above.

 The nurse’s responsibility is to delineate and maintain boundaries.

 The nurse should work within the therapeutic relationship.

 The nurse should examine any boundary crossing, be aware of its potential implications and avoid repeated crossings.

 Variables such as the care setting, community influences, patient needs and the nature of therapy affect the delineation of boundaries.

 Actions that overstep established boundaries to meet the needs of the nurse are boundary violations.

 The nurse should avoid situations where he or she has a personal, professional or business relationship with the patient.

 Post-termination relationships are complex because the patient may need additional services. It may be difficult to determine when the nurse–patient relationship is completely terminated.

 Be careful about personal relationships with patients who might continue to need nursing services (such as those with mental health issues or oncology patients). Regarding Professional Boundaries and Sexual Misconduct

Boundaries and the Continuum of Professional Nursing Behavior

Q&A Regarding Professional Boundaries and

Sexual Misconduct

What if a nurse wants to date or even marry a former patient? Is that considered sexual misconduct? The key word here is former. The following are important factors to consider when making this determination:

 What is the length of time between the nurse–patient relationship and dating?

 What kind of therapy did the patient receive? Assisting a patient with a short-term problem, such as a broken limb, is different than providing long-term care for a chronic condition.

 What is the nature of the knowledge the nurse has had access to and how will that affect the future relationship?

 Will the patient need therapy in the future?

 Is there risk to the patient?

What if a nurse lives in a small community? Does this mean that he or she cannot provide care for neighbors or friends? The difference between a caring relationship and an overinvolved relationship is sometimes difficult to discern. A nursing professional living and working in a small, rural or remote community will, out of necessity, have business and social relationships with patients. In these instances, it is extremely important for nurses to openly acknowledge their dual relationship with patients and to emphasize when they are performing in a professional capacity.

The nurse must ensure the patient’s care needs are primary. When this is not possible, nurses should remove themselves from the situation or request assistance from a supervisor or colleague.

Do boundary violations always precede sexual misconduct? Boundary violations are extremely complex. Most are ambiguous and difficult to evaluate. Boundary violations may or may not lead to sexual misconduct. In some cases, extreme sexual misconduct, such as assault or rape, may be habitual behavior, while at other times it is a crime of opportunity. Regardless of the motive, extreme sexual misconduct is not only a boundary violation, it is criminal behavior.

Does patient consent make a sexual relationship acceptable? If the patient consents, and even if the patient initiates the sexual conduct, a sexual relationship is still considered sexual misconduct for a health care professional. It is an abuse of the nurse–patient relationship that puts the nurse’s needs first. It is always the responsibility of a health care professional to establish appropriate boundaries with current and former patients.

RED FLAG BEHAVIORS Some behavioral indicators can alert nurses to potential boundary issues for which there may be reasonable explanations, however, nurses who display one or more of the following behaviors should examine their patient relationships for possible boundary crossings or violations.

Signs of inappropriate behavior can be subtle at first, but early warning signs that should raise a “red flag” can include:  Discussing intimate or personal issues with a patient

 Engaging in behaviors that could reasonably be interpreted as flirting

 Keeping secrets with a patient or for a patient

 Believing that you are the only one who truly understands or can help the patient

 Spending more time than is necessary with a particular patient

 Speaking poorly about colleagues or your employment setting with the patient and/or family

 Showing favoritism

 Meeting a patient in settings besides those used to provide direct patient care or when you are not at work

Patients can also demonstrate signs of overinvolvement by asking questions about a particular nurse, or seeking personal information. If this occurs, the nurse should request assistance from a trusted colleague or a supervisor.

What should a nurse do if confronted with possible boundary violations or sexual misconduct? The nurse needs to be prepared to deal with violations by any member of the health care team. Patient safety must be the first priority. If a health care provider’s behavior is ambiguous, or if the nurse is unsure of how to interpret a situation, the nurse should consult with a trusted supervisor or colleague. Incidents should be thoroughly documented in a timely manner. Nurses should be familiar with reporting requirements and the grounds for discipline in their respective jurisdictions; they are expected to comply with these legal and ethical mandates for reporting.

What are some of the nursing practice implications of professional boundaries? Nurses need to practice in a manner consistent with professional standards. Nurses should be knowledgeable regarding professional boundaries and work to establish and maintain those boundaries. Nurses should examine any boundary-crossing behavior and seek assistance and counsel from their colleagues and supervisors when crossings occur. Nurses also need to be cognizant of the boundary violations that occur when using social media to discuss patients, their family or their treatment. These issues are discussed in depth in NCSBN’s brochure A Nurse’s Guide to the Use of Social Media.

NCSBN Professional Boundaries Resources NCSBN offers a variety of resources pertaining to professional boundaries:

 The “Professional Boundaries in Nursing” video, at ncsbn.org/464.htm, helps explain the continuum of professional behavior and the consequences of boundary crossings, boundary violations and professional sexual misconduct. Internal and external factors that contribute to professional boundary issues, including social media, are explored.

 The “Professional Boundaries in Nursing” online course was developed as a companion to the video. The cost of the course is $30. Upon successful completion of the course, 3.0 contact hours are available. The course is approved by the Alabama Board of Nursing. Register for the course at learningext.com.

Other resources can be found at ncsbn.org/1615.htm.

111 E. Wacker Drive, Suite 2900 Chicago, IL 60601-4277

312.525.3600 ncsbn.org

THE NURSE’S CHALLENGE  Be aware.

 Be cognizant of feelings and behavior.

 Be observant of the behavior of other professionals.

 Always act in the best interests of the patient.

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312.525.3600 ncsbn.org

10/14

To find the board of nursing in your state/territory visit ncsbn.org/contactbon.htm.

To order additional copies of this brochure, contact [email protected].

Copyright ©2014 National Council of State Boards of Nursing, Inc. (NCSBN®)

All rights reserved. This document may not be used, reproduced or disseminated to any third party without written permission from NCSBN.

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Email: [email protected] Website: www.nursingboard.state.mn.us TTY: (800 627-3529 Voice: (612) 617-2270 Voice (MN, IA, ND, SD, WI): (888) 234-2690 Fax: (612) 617-2190

1

Professional Boundaries in Nursing

Boundary issues are everywhere for nurses. Issues on the continuum range from stopping to buy a few groceries for a home-bound client, to accepting a personal gift from a client, to having a friendship with a former client, to having a sexual relationship with a current client. Although there is more gray area than black and white when studying boundaries, nurses can make thoughtful decisions when provided with information about the fundamentals of boundaries. This article is intended to highlight some of the basics. Nurses are encouraged to read additional information and have discussions with colleagues to broaden their understanding of the topic. Boundaries are defined as limits that protect the space between the professional's power and the client's vulnerability. Maintaining appropriate boundaries controls this power differential and allows for a safe connection between the professional and client based on the client's needs. The need for maintaining appropriate boundaries arises from the nature of the nurse-client relationship. Like other professional relationships, the client places his or her confidence in the nurse who possesses special knowledge, expertise, and authority. In addition, the client is vulnerable in so far as he or she has a nursing care need which the nurse has the ability to meet. It is imperative that the nurse be aware of this power differential and ensure that the nurse’s actions are intended to meet the nursing care needs of the client. The maintenance of boundaries need not be seen as an impediment to the professional relationship, but rather as facilitating it. Maintaining professional boundaries protects the safe space in the relationship and thereby enhances the building of the trust which is essential to enable clients to reveal their needs. A boundary violation occurs when a nurse, consciously or unconsciously, uses the nurse-client relationship to meet personal needs rather than client needs. This violation breaches the fundamental nature of care that obligates the professional to place clients' needs first. It is helpful to view this as a process or a “slippery slope” rather than an end result or a “crossing the line.” This provides an opportunity for the nurse to heed warning signs which will allow the nurse to take steps to reevaluate the relationship with the client and to reestablish appropriate professional boundaries. It also prevents ignoring, normalizing or dismissing relatively minor or less visible boundary violations. The minor violations may be damaging to the relationship and left unexamined, the minor violations can be repeated and expanded. Four elements characteristically appear in boundary violations: role reversal, secrecy, double bind, and indulgence of professional privilege.

• Role Reversal Role reversal occurs when the client takes care of the nurse as the nurse looks to the client for satisfaction and gratification, rather than the nurse placing client needs first. The nurse may not be consciously aware of this role reversal or may attempt to justify it by contending his or

_________________________________________________________________________________________ Minnesota Board of Nursing, 2829 University Avenue SE #200, Minneapolis, MN 55414-3253

Email: [email protected] Website: www.nursingboard.state.mn.us TTY: (800 627-3529 Voice: (612) 617-2270 Voice (MN, IA, ND, SD, WI): (888) 234-2690 Fax: (612) 617-2190

2

her actions are for the client's benefit. Example: A client becomes a nurse's chemical dependency sponsor.

• Secrecy Secrecy involves the nurse keeping critical knowledge or behavior from the client and/or others or selectively sharing information. Example: A nurse takes a client into his or her home and tells the client the nurse's employer cannot know about this or the nurse will lose his or her job.

• Double Bind A double-bind consists of two sets of messages which contradict each other while they discourage the receiver of the messages from noticing the inconsistency. The client is left feeling caught in a conflict of interest: any attempt at resolution places the client at risk of loss. The client is torn between the desire to terminate the relationship and the realization that this will end any form of help from the professional. The double-bind contains an implied threat. A sense of guilt and fear of possible abandonment by the professional blocks the client from taking action. The double-bind constricts the client from using all available options and thus limits growth. Examples: 1) A nurse makes negative comments about other nurses caring for a client who has development of trust as a therapeutic goal. 2) A nurse tells a therapy client that they may begin a personal relationship when the client is no longer in therapy.

• Indulgence of Professional Privilege Indulgence involves using information obtained in the relationship with a client for the benefit of the professional. Because the professional has authority over the client's situation, that professional is susceptible to extending the privilege of his or her position to intrude on the client. However, access to information does not constitute a right to it. This access is a professional privilege; it is not a professional right to use the information for one's own benefit. Example: Using proximity to post-partum mothers to locate a baby for adoption by the nurse.

To avoid boundary violations, it may be helpful to be aware of “warning signs.” In isolation these do not necessarily indicate a problem, but if repeated or if several warning signs are present, the nurse should reevaluate his or her actions.

♦ Perception: The nurse should ask: Is this what other nurses would do? How would this appear to others (peers, family, superiors)? How does this appear to the client?

♦ Time: The nurse should consider the quality and quantity of time spent with the client. Does it vary from that spent with other clients? Is the nurse spending "off duty" time with the client?

♦ Meeting time and place: Is the location of the interaction appropriate to the relationship? Would you provide nursing service to other clients in this location? If there is a legitimate, therapeutic need to meet at an unusual time, has it been made known to others and documented?

♦ Gifts: Does the gift giving create a sense of obligation on the part of the recipient? Is this a routine part of your practice regardless of the age or gender of the client? Is the gift of a personal nature, given to one nurse or a general gift give to a group of caregivers? Does the facility have a policy regarding gifts?

♦ Forms of address: Has there been a change in the way the client is addressed or how this client is addressed in relation to others?

♦ Personal attire: Has the nurse's style of dress changed with more attention paid to personal appearance?

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♦ Making exceptions: In general the nurse should carefully consider the therapeutic purpose in making exceptions in helping a client or family member. Another type of exception to note would be the nurse who changes assignments to care for a particular client.

♦ Internal cues: Learning to recognize and trust internal cues is important. A nurse should seek guidance if he or she is in a situation which raises questions in the nurse’s mind. When in doubt, check it out. Nonverbal behavior, the nurse's or the client's, may provide helpful insight. Does the nurse become defensive if questioned about the interaction with the client?

♦ Meeting personal needs: In addition to recognizing that the client's needs must come first, the nurse should be aware of his or her own social and emotional needs and take affirmative steps to have those needs met away from work. Thoughts such as "I only feel appreciated at work" or "Only I can help this client" indicate the nurse may be meeting his or her needs through clients.

♦ Dual relationships: The nurse enters a nurse-client relationship in order to provide the client with nursing services. Nursing services would not include, for example, dating, baby-sitting or entering a business relationship with clients.

♦ Confidentiality: The nurse should maintain confidentiality by not using or sharing confidential information unless it is for a legitimate therapeutic purpose.

♦ Choosing sides: Is the nurse taking sides with the client against the client’s significant others? The nurse should ask: "What is the value in taking sides?" How can the nurse assist the client in looking at all sides of the issue to utilize his or her own problem solving skills?

♦ Self-disclosure: While professionals want to be perceived as caring, self-disclosure is rarely helpful or necessary. The nurse should consider the client need served by the self-disclosure and determine whether personal issues shared with the client are brief, resolved and related to what the client is experiencing.

♦ Touch: Touching is an integral part of many nursing interventions. Touch may be a component of another action, e.g. checking a blood pressure, or may be therapeutic in and of itself. Touch, however, should not be used indiscriminately. The nurse should be clear in his or her own mind why touch is called for and communicate this to the client.

♦ Communication: It is the responsibility of the nurse to establish and maintain boundaries and to communicate this to the client. In addition, the nurse should be able to communicate to others the nature of the relationship with the client. Is the nurse keeping secrets with or about the client? Does the nurse fail to document or report negative information about the client?

This is not an exhaustive list but should be instructional for all nurses. A nurse in any practice setting will encounter boundary issues. With forethought, planning, communication, and evaluation, the nurse can take steps to ensure a boundary issue does not progress to a boundary violation.

BIBLIOGRAPHY

Curtin, L.L. (1994). Of Confidentiality, Co-Workers and Adoption. Nursing Management 25(4), 22-28. Justic, M. (1995). Can We Care Too Much? Therapeautic nurse-patient relationships. Creative Nursing (March/April), 10-12. Kagle, J.D. and Giebelhausen, P.N. (1994) “Dual Relationships and Professional Boundaries,” Social Work 39(2), pp. 213-220. Linklater, D. and MacDougall, S. (1993). Boundary Issues. What do they mean for family physicians? Canadian Family Physician 39 (Dec.), 2569-2573.

_________________________________________________________________________________________ Minnesota Board of Nursing, 2829 University Avenue SE #200, Minneapolis, MN 55414-3253

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Milgrom, J.H. (1992). Boundaries in Professional Relationships. A Training Manual. Minneapolis, Minnesota: Walk-In Counseling Center at 21-25. Nielsen, L., Peterson, M. Shapiro, M. and Thompson, P. (1989). It's Never OK: A Handbook for Professionals on Sexual Exploitation by Counselors and Therapists. St. Paul, Minnesota: Department of Corrections, State of Minnesota. Pennington, S., Gafner, G., Schilit, R., and Bechtel, B.L. (1993). Addressing Ethical Boundaries Among Nurses. Nursing Management, 24(6), 36-39. Peterson, M. (1992). At Personal Risk: Boundary Violations in Professional-Client Relationships. New York, New York: W.W. Norton and Company. Simon, R.I. (1992). Treatment Boundary Violations: Clinical, Ethical and Legal Considerations. Bulletin of the American Academy of Psychiatry Law 20(3)

Published 1995; Reviewed 2000; 2010