Defining Professional Nurse’s Accountability: Analysis Of Nurse-Patient Relationship

Discussion of Nurse’s Action with Relevant Policy Documents

Discuss About The Defining Professional Nurses Accountability?

The nurse-client relationship is an important element of nursing practice and a therapeutic relationship is maintained on the ground of trust, respect and maintaining the boundaries of professional intimacy. Often the nurses are required to closely interact with patients to identify their issues and support them during illness. However, as part of ethical code of conduct relevant to different countries, it is necessary that nurses understand the boundaries that separate therapeutic and non-professional behavior. Nurse-patient boundary violation is a serious issue, which harms nurse-client relationship and in this may be seen by behaviors like physical contact, socialization, intimacy and favoritism with patients (Campbell, Yonge, & Austin, 2016). This report analyses a scenario of nurse-patient boundary violation in which the Nurse Jackie forms close attachment with an elderly patient, Mrs. Isobel James and inappropriate judgment of nurse results in the Mrs. James being found unconscious the next days. The report justifies how nurses actions is not ethically appropriates and uses  different nursing policies and ethical conduct standards for nurse to explain how following the documents might have protected Jackie from professional misconduct allegations.

The case scenario is about Nurse Jackie, a student nurse on her first clinical placement who develops a close attachment with Mrs. Isobel, a 97year old patient with several comorbidities. The nurse took a photo of Mrs. James, posted it on her Facebook page, and discussed about her condition on Facebook. The next day, Mrs. James presented the nurse with a perfume and she took it without informing about it to the nurse unit manager. A serious violation of nursing responsibilities is also witnessed next week when Mrs. James asked the nurse bring her a bottle of whisky and she ready did that without thinking about its effect on the health of Mrs. James. The eventual outcome of such misconduct and violation of nurse-client boundary was that following morning, Mrs. James was found unconscious. In this case, several misconducts were seen. Firstly, the Nurse Jackie did not used her professional judgment to control the boundaries of therapeutic relationship with Mrs. James. Secondly, several forms of behavior like entering into friendship with patients, socializing with them and discussing them on Facebook and giving more priority to personal needs of patients than health needs is strictly not allowed in nursing practice (Zamanzadeh et al., 2014). However, Jackie was involved in all such cased of ethical misconduct.

Code of Ethics for Nurses in Australia 2008

Jackie could have safeguarded herself from misconduct allegation had she followed the guidelines mentioned in the Code of Ethics for Nurses in Australia 2008. This document is specific for nurses working in Australia and outlines the nurse commitment to uphold the fundamental rights people receiving care. The value statement 1 of this document defines that the nurse should values quality nursing care for all people. This means that they should be accountable for all decision regarding the care of patients and accept moral and ethical responsibility of promoting safety of patient (Code of Ethics for Nurses in Australia 2008, 2017). Hence, by adhering to this statement the nurse could have defended Mrs. James wish to have whisky on grounds of poor health. She could have explained to her about the adverse effect of whisky on her health and forbidden her to have it now. This could have saved the patients from harm that had occurred to her and nurse would not be subjected to any ethical actions too. Krautscheid, (2014) also defines that accountability is fundamental to professional practice and the nurse should possess behaviors that is in congruence with nursing actions promoting quality and safety in patients care.

Nurse Jackie could also have fulfilled her professional responsibilities in care by following the value statement 7, which is related to nurse commitment to value ethical management of information. This means all patient’s related information should not be altered in any way and the information should be managed by not sharing the information without the consent of the individual or the lawful authorization (Code of Ethics for Nurses in Australia 2008, 2017). Hence, in accordance with this statement, the nurse Jackie’s action of sharing client’s photo on Facebook and discussing her on Facebook page was not ethically correct. Jackie should be careful regarding her actions on duty by recalling the value statements of the Code of Conduct for nurses in Australia. Ethical issues related to social media usage has been studied a lot and one research argued that patient’s well being and nurse-patient relationship is jeopardized when nurses engage in inappropriate disclosure of patient information on social media sites (Denecke et al., 2015). Hence, Jackie’s action of discussing the patient on Facebook was breach of privacy against patients. In such situation, it is necessary for nurse to follow the social media policy.

Students nurses like Jackie must also be aware of the Code of Professional Conduct for Nurses in Australia because Nursing Australia expects the nursing profession to uphold a certain minimum national standards of conduct. There are a number of ethical conduct statement outlined in the document and the most relevant statement relevant to safeguarding the Nurse Jackie from ethical allegations includes statement 1, statement 5, statement 6, statement 9 and statement 10. For instance, statement 5 advices nurse to use personal and confidential information of patients for professional use only. Following this statement would have restricted Jackie from discussing Mrs. James condition on Facebook. Secondly, statement 6 gives the insight that nurses must provide honest information to patients regarding nursing care and treatment procedures (Code of Professional Conduct for Nurses in Australia, 2017). Hence, when Mrs. James had asked the nurse to bring her whisky, the nurse could have defended by explaining the patient about the risk of alcohol on her health. Barne et al., (2010) has explained that older adults may experience adverse health effects even when consuming moderate amount of alcohols. This is because the effect of certain dose of alcohol increases due to the age associated morbidity and alcohol use in older adults. Hence, nurse’s action to educate Mrs. James about this effect was important instead to giving her whisky and causing risk to her health.

Code of Professional Conduct for Nurses in Australia

The Registered nurse standards for practice 2016 is also an important policy document given by the Nursing and Midwifery Board of Australia (NMBA) to maintain the requirements for professional and safe nursing practice in Australia. There are seven key standards of this policy which includes critical reflection in nursing practice, getting involved in therapeutic and professional relationship, updating the skills for practice, conducting detailed assessment, developing nursing care plan, delivering safe and responsive care and evaluating outcome to inform practice (Registered nurse standards for practice 2017). In the context of the Nurse Jackie, it was important for her to comply with legislations and policies while making any decisions in accordance with standard 1. For instance, when she was engaged in a therapeutic relationship with patients, she should have understood her professional boundaries in care and tried not to go outside of it to exchanges gifts and fulfill personal wishes of patient. Maintaining professional boundary is also important because such violations lead to complaints about professional misconduct. She could have tackled the situation by taking advice from her nurse unit manager. Such form of professional mentoring or seeking advices from seniors would have prevented her from turning small boundary violations to a major boundary violations (Chiarella & Adrian, 2014). Poor management to professional ethics was the main reason for the issue in case of the Nurse  Jackie and she should be serious about applying ethical knowledge in workplace (Dehghani, Mosalanejad, & Dehghan-Nayeri, 2015).

Having knowledge about standard 2 related to engaging in therapeutic and professional relationship would also have safeguarded the nurse Jackie from ethical allegations. As part of nursing duty, the most important actions for Jackie was to maintain boundaries between professional and personal relationship (Registered nurse standards for practice 2017). Instead of changing the professional relationship into a friendly relationship, she could have given support to patient in a professional way. While interacting with Mrs. James, she needed to have non-judgmental attitude. Showing interest in patient during daily nursing care is good, but taking it to personal level by taking photos and discussing about patients with others is not congruence to professional responsibility of nurses. Other strategies that Jackie could have employed to maintain professional boundaries include establishing clear boundaries between her and others and developing self-awareness regarding her response to the needs of patients (Langendyk et al., 2015). Although people from different culture and ethnic groups will have different rules for interactions, however Jackie will have to set her own professional rules for interaction to safeguard herself from professional misconduct and allegation.

Registered Nurse Standards for Practice 2016

As the scenario of the Nurse Jackie and patient Mrs. James is clearly a case of boundary violation in nursing practice, the Nurse’s guide to professional boundaries would have been an important document for her to protect herself from misconduct allegations. It defines therapeutic relationship as a goal oriented and patient centered relationship where balance is maintained between nurse’s power and patient’s vulnerability. The nurse Jackie violated the space between her power and Mrs. James vulnerability by not protecting her from consuming whisky. As a nurse on duty for Mrs. James, Jackie had all the power to control the inappropriate demand of patients on grounds of health risk. However, instead of exercising her power to protect the patient from harm, Jackie herself was involved in causing harm to patient by building personal relationship with her. The Nurse’s guide to professional boundaries also explains that use of social media by nurses blurs the line between professional and personal lives. Even if a nurse comments about a person on social media from home, then also it is a case of boundary violation. Hence, Jackie could have conceptualized her relationship with Jackie on the continuum of professional behavior. The continuum of professional behavior framework defines over involvement by behavior of boundary crossing and professional misconduct. Secondly, under involvement is defined by disinterest and neglect of patient (A Nurse’s Guide to Professional Boundaries 2017). Therefore, Jackie could have used this frame to determine if she is over involved or under involved in patient’s care and correct her actions accordingly. O’Keeffe et al., (2015) proposes nurse to adapt a flexible boundary or risk assessment to manage the relationship with patient.

Social media is a widely used tool used extensively by people in their daily lives. By the use of social medias, nurses and other professionals remain connected with their families and friends. However, nurses need to have knowledge regarding the appropriate online behavior needed by them and its implication for professional life. The social media policy 2008 informs that nurses must be aware of organizational policies related to social media use. Secondly, while uploading or posting any comment on social media, it is very important for them to analyze whether it is offensive or not. According to the social media policy, there are two obligations for nurses. Firstly, have professional obligation in relation to confidentiality of patients when using social media. Jackie uploaded Mrs. James photo on social media and made comments about her too and according to the policy, posting unauthorized photos of patients is a breach of patient’s privacy and confidentiality. Secondly, there are legal restrictions to any form of advertising by means of social media (Nursing and Midwifery Board of Australia – Social media policy, 2017). Hence, if the Nurse Jackie was aware about this policy, she could have avoided posting Mrs. James photo and save herself from breach of professional conduct.

Conclusion:

The report analyzed the case of the Nurse Jackie who was involved in serious breach of conduct by getting involved in a close relationship with patient and causing harm to patient in the process. The review of different policy documents like code of ethics for nurses in Australia, Code of Professional Conduct for Nurses, the Registered Nurse Standards for Practice, the nurse guide to professional boundaries and the social media policy gave the idea regarding several breaches done by patients. However, with support from this policy document, it was also explained regarding how knowledge about these guideline could have saved Jackie from misconduct allegation. In the future, it is necessary that nurses understands and closely apply these policies to maintain professional standards of practice.

Reference

A Nurse’s Guide to Professional Boundaries. (2017). Retrieved 19 September 2017, from https://www.ncsbn.org/ProfessionalBoundaries_Complete.pdf

Barnes, A. J., Moore, A. A., Xu, H., Ang, A., Tallen, L., Mirkin, M., & Ettner, S. L. (2010). Prevalence and correlates of at-risk drinking among older adults: the project SHARE study. Journal of general internal medicine, 25(8), 840-846.

Campbell, R. J., Yonge, O., & Austin, W. (2016). Intimacy boundaries: Between mental healthcare nurses & psychiatric patients. Journal of psychosocial nursing and mental health services, 43(5), 32-39.

Chiarella, M., & Adrian, A. (2014). Boundary violations, gender and the nature of nursing work. Nursing ethics, 21(3), 267-277.

Code of Ethics for Nurses in Australia 2008. (2017). Retrieved 19 September 2017, from https://file:///C:/Users/admin/Downloads/5_New-Code-of-Ethics-for-Nurses-August-2008%20(1).PDF

Code of Professional Conduct for Nurses in Australia. (2017). Retrieved 19 September 2017, from https://file:///C:/Users/admin/Downloads/6_New-Code-of-Professional-Conduct-for-Nurses-August-2008-1-%20(3).PDF

Dehghani, A., Mosalanejad, L., & Dehghan-Nayeri, N. (2015). Factors affecting professional ethics in nursing practice in Iran: a qualitative study. BMC medical ethics, 16(1), 61.

Denecke, K., Bamidis, P., Bond, C., Gabarron, E., Househ, M., Lau, A. Y. S., … & Hansen, M. (2015). Ethical issues of social media usage in healthcare. Yearbook of medical informatics, 10(1), 137.

Krautscheid, L. C. (2014). Defining professional nursing accountability: a literature review. Journal of Professional Nursing, 30(1), 43-47.

Langendyk, V., Hegazi, I., Cowin, L., Johnson, M., & Wilson, I. (2015). Imagining alternative professional identities: reconfiguring professional boundaries between nursing students and medical students. Academic Medicine, 90(6), 732-737.

Nursing and Midwifery Board of Australia – Social media policy. (2017). Nursingmidwiferyboard.gov.au. Retrieved 19 September 2017, from https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Policies/Social-media-policy.aspx

O’Keeffe, V. J., Tuckey, M. R., & Naweed, A. (2015). Whose safety? Flexible risk assessment boundaries balance nurse safety with patient care. Safety Science, 76, 111-120.

Registered nurse standards for practice. (2017). Retrieved 19 September 2017, from https://file:///C:/Users/admin/Downloads/Nursing-and-Midwifery-Board—Standard—Registered-nurse-standards-for-practice—1-June-2016%20(3).PDF

Zamanzadeh, V., Valizadeh, L., Azimzadeh, R., Aminaie, N., & Yousefzadeh, S. (2014). First and fourth-year student’s perceptions about importance of nursing care behaviors: socialization toward caring. Journal of caring sciences, 3(2), 93.