Doing the right thing

1 November 2012

How should nurses behave? The Nursing Council recently released its 21st century guide to what patients should and shouldn’t expect from their nurse. FIONA CASSIE looks at what’s new in a new Code of Conduct underpinned by traditional values

One nurse sends inappropriate texts. Another accesses electronic health records of patients not in their care. Yet another injects Botox without a prescription.

Welcome to professional misconduct, 21st century style. All the above are recent examples of nurses who have been successfully prosecuted for professional misconduct at Health Practitioners Disciplinary Tribunal (HPDT) hearings The Nursing Council last year decided to review and update its Code of Conduct to reflect the significant changes to “legislation, society, and the practice environment” since developing the first code in 1994.

But the new code also for the first time explicitly states the four values underpinning nurses’ professional conduct – the traditional values of respect, trust, and integrity and the more contemporary nursing value of working in partnership with health consumers.

The code as always has the dual role of providing guidance to nurses on their professional behaviour but also setting standards which, if breached, can lead to disciplinary action.

Pam Doole, the Council’s strategic policy director, doesn’t believe the new code has shifted the threshold for professional misconduct but instead made the standards clearer and more transparent – particularly professional boundaries, which now have their own guidelines booklet.

“We’re hoping that there will be fewer transgressions as people understand [the standards] more fully,” says Doole, who was responsible for consulting and developing the new code.

For example, nurses can start off innocently doing something like texting an appointment reminder to a patient.

“We’ve told them that there are warning signs once they get off the professional content to the personal.”

Nurses are now being advised to draw a line at that point – and not go over it.

Texting, Facebook, and the millennial generation

Inappropriate texting of patients came up in three successful HPDT prosecutions for breach of professional boundaries last year. Texting is just one of myriad technologies that have changed the way that nurses and their clients can now access and share information through electronic communication and social media.

Doole says these changes in technology, as well as changes in society and consumer expectations, are some of the motivations for developing the new code and related guidelines on professional boundaries and social media.

But while society and technology may have changed, the Council found that the generation most comfortable with social media – the so-called ‘millennial’ generation who have grown up with it – held the same ‘old-fashioned’ values about nurses’ behaviour, including retaining professional boundaries.

The Council, in partnership with the Children’s Commissioner’s office, consulted with a variety of young people’s groups about a variety of nursing practices, including use of social media. They found that young people were okay with organisations using Facebook to provide updates or information, but saw individual nurses using Facebook to communicate with them in person as blurring the line between professional and personal relationships.

“Stay off”, “too public, no privacy”, “they shouldn’t”, “inappropriate’, “nurses not Facebook friends”, and simply “no” were some of the comments made.

The Code guidelines endorse this by advising nurses to keep their personal and professional life separate as far as possible on social media.

Julia Anderson, a professional nursing advisor for the New Zealand Nurses Organisation (NZNO), who has been updating members about the code at recent professional forums, says social media is still relatively new to nursing.

She believes the profession has been able to put guidelines in place quite early so nurses can understand the complexity of using social media sites and the impact it can have.

Texting is a different story and can be appropriate as a means of communicating – particularly reminding people of appointments which, Anderson says, is the way it is most commonly used by nurses in practice.

This was echoed by the young people’s focus groups that said getting text reminders were okay, but they did not see texting as an appropriate or respectful way to transfer personal information like test results.

The legitimate use of texting for appointment reminders was highlighted by a number of submissions during consultation, leading the Council to revise its draft advice to say texting was an appropriate form of professional communication but professional boundaries must be retained.

Relationships: Stepping over the boundaries

Is it always inappropriate to have a sexual relationship with a former patient? When does a nurse step over the line in becoming too involved with a patient and their whānau? What do you do as a rural nurse when a friend bumps into you in the dairy and asks about their neighbour’s ill health?

Submissions on the draft code made it clear that sometimes professional boundaries are unclear and the profession wanted more clarity in the grey areas – including gifts and potential conflicts of interest – but also relationships with former patients and working in small rural communities.

The Council’s response is to be more explicit in its advice that sexual relationships with former patients may be inappropriate, however long ago the patient-nurse relationship was, because of a previous imbalance of power.

Doole says often that relationship is formed when a patient is vulnerable. Poole says clear-cut examples are when a patient has a mental health condition or an intellectual disability. But other situations include when the nurse has been providing a lot of emotional support or had a long-term close therapeutic relationship.

“Then it may be never be appropriate for a relationship to develop and the reason for that is because there is a power differential between nurse and patient … the nurse knows a lot more about the patient than the patient knows about the nurse.”

The new guidelines highlight issues for the nurse to consider when deciding if a sexual relationship could ever be appropriate.

Anderson says NZNO’s general advice is that it is inappropriate to have a sexual relationship with somebody with whom you have had a therapeutic relationship. But context is important, and when she has queries from nurses, she asks them to consider the context of the former relationship, along with the family’s likely response and the public perception.

“Sometimes I say ‘you have phoned me for a reason, what is that reason?’ and it’s often that they have a level of discomfort, and therefore, that’s a flag for them.”

Doole says most of its professional boundary complaints are not about sexual relationships but about nurses becoming over-involved with their patients.

“They may see a need and want to help and they may not realise that their involvement, or over-involvement, may not be ultimately helpful for that person.” The new guidelines set out signs of when that boundary is at risk of being crossed.

Anderson says likewise nurses can over-identify with a situation – particularly when caring for children and their families – and have to remember that caring for people puts them in a very privileged position, not only about a patient’s health information but also their wider living and family situation.

In the case of rural communities, Doole says feedback to the Council was that it’s often totally unrealistic for rural nurses not to care for patients who are also neighbours or friends. So the aim has been to provide meaningful advice in its guidelines to help keep nurses safe and retain the trust of the community.

Anderson says she generally finds that nurses working in smaller communities have heightened awareness of their boundaries because they are familiar with caring for neighbours and seeing them in the shops.

Patients’ rights foremost

The new code also places more emphasis on a health consumer rights-centred approach to health care.

The wording is more closely aligned than ever before with the Code of Health Consumer Rights (1996) that sets out ten consumer rights, including the right to complain to the Health & Disability Commissioner’s (HDC) office if those rights are breeched and they do not receive quality care.

Theo Baker, an HDC deputy commissioner, is congratulating the Council on pulling together the need for both consumer-centred care and professionalism in a code of conduct that both “complements and overlaps” the HDC’s code of rights, and also acknowledges that nurses hold a unique and privileged position.

“You become a nurse to treat and look after patients,” says Baker. “That’s the reason you exist because patients exist and it [nursing] is about providing care that’s in accordance with their needs, and when appropriate, their wishes.”

“If people feel they have not been treated with respect, they will complain, and they will complain whether there is a code of conduct saying that a nurse should treat a patient with respect or not – it’s how they feel about that [behaviour].”

Baker says a code of conduct is foremost about maintaining professional standards and the reason health providers need to maintain professional standards is to deliver an appropriate service to the public. “And that’s really well reflected in this code of conduct because of the emphasis on partnership in care.”

Consumer complaints about a nurse’s behaviour or quality of care may surface at either the HDC or Council, with the nature and impact of the alleged misconduct leading to a decision about which body under which code (sometimes both) investigates the complaint.

The good news is that very few complaints about nurses’ conduct or behaviour are received by either body. The Council last year investigated 29 conduct complaints, a similar number to the 30 the year before, and there were 16 successful HPDT prosecutions.

Likewise, Baker said very few of the complaints made to the HDC are specifically made against nurses, with most being made against health providers like public hospitals.

The annual report shows that 66 complaints were laid about nurses – about seven per cent of the 969 complaints made against individual health professionals – many fewer than the 300 complaints against GPs, but a similar number to that received about physicians, midwives, and dentists.

Baker says the complaints about nurses are often about communication – either the manner of communication or the failure to provide information. Occasionally, complaints surface for assault, and some investigations find nurses providing inadequate assessments, documentation, or post-operative care.

“Then in any given year, there will be two or three medication-administration errors.”

Most of the other complaints are likely to involve rest homes where nurses are commonly the clinical leader of care.

Teamwork needed

A new trend in complaints received by the Council has prompted a whole new principle in the latest code – nurses working respectfully with their colleagues.

“Interestingly, in the old code, this isn’t even mentioned,” says Doole.

Increasingly, the Council noted complaints mentioning unprofessional behaviour either between nurses or between nurses and other health professionals.

“So the council thought it needed to offer some specific advice on working with others.”

Again, communication was a key issue – people not documenting clearly or communicating clearly with other members of their own team or not communicating clearly with an outside team they are referring a patient.

“So, there is to which potential for things to fall through the cracks.”

But there were also complaints about disrespectful behaviour in the workplace, like bullying, or verbal abuse, or not sharing information.

Privacy and confidentiality complaints can also arise from nurses inappropriately accessing or sharing patient information that can now be just a few quick mouse clicks away.

“With the advent of electronic records, nurses need to understand that they have to have a clinical reason for accessing records … it’s going to become more of an issue,” says Doole.

In the end, it all comes back to honouring the four values – previously unwritten but now clearly stated in the opening of the new code – of respect, trust, partnership, and integrity that underpin the full 81 standards of the code.

Anderson says those values seem obvious once down in black and white, but having them stated in the code means they can be discussed and explored during professional forums on how the values and code relate to nurses’ own practice.

She sees the code as a benchmark to guide nurses’ behaviour, and the new code gives greater clarity “so no-one can be confused about the importance of nursing behaviour and conduct in the delivery of nursing care”.

Doole is very much aware that the Council’s primary purpose is to protect the public.

The last page of the code – guidance on escalating concerns – brings home the individual nurse’s role in protecting the public by setting out their ethical obligation to raise concerns of “issues, wrongdoings, or risk” that could endanger health consumers (which also includes completing records as soon as possible after any event has occurred).

“Put the interests of health consumers first,” the code states, “and if an issue is not resolved satisfactorily, keep escalating your concerns upwards” (with a reference included so nurses can find out about potential protection under the ‘whistle-blowing’ legislation). The new code may be an attractive and concisely written publication, but it is no lightweight document.

Doole is keen for the new code and guidelines to be more than nice booklets that sit gathering dust on the shelf and are only brought down when something goes wrong or something out of the ordinary happens.

“The Council knows that it’s the nurse at the bedside that keeps the patient safe, and it’s really important nurses understand their professional role and the way they are supposed to behave, because that’s going to improve health services experiences for patients. That’s what it is ultimately about.”

CODE OF CONDUCT FOR NURSES 2012

PRINCIPLES

1 Respect the dignity and individuality of health consumers.

2 Respect the cultural needs and values of health consumers.

3 Work in partnership with health consumers to promote and protect their wellbeing.

4 Maintain health consumer trust by providing safe and competent care.

5 Respect health consumer’s privacy and confidentiality.

6 Work respectfully with colleagues to best meet health consumers’ needs.

7 Act with integrity to justify health consumers’ trust.**

8 Maintain public trust and confidence in the nursing profession.

**Each principle has eight to 14 related standards.

Further guidance is provided in an additional booklet Guidelines: Professional Boundaries.

Recent professional misconduct statistics^

• 28–33 complaints about conduct issues investigated each year by Nursing Council in past four years.

• 27–61 court convictions by nurses are referred to Council (the majority by the nurses themselves).

• These result in 8–16 successful HPDT prosecutions a year in recent years for professional misconduct, leading to orders ranging from censure and further training and supervision through to being struck off the register.

• Last year’s professional misconduct prosecutions included falsifying sick leave and time sheets, misappropriating drugs, inappropriately accessing confidential information, failure to respect patient’s rights, and a number of professional boundary breaches including inappropriately texting vulnerable patients.

What is the Code of Conduct for Nurses?

• The Code is a set of standards defined by the Nursing Council that provides guidance on the appropriate behaviour or conduct that all nurses are expected to uphold.

• It can be used by health consumers, nurses, employers, and the Nursing Council to evaluate the behaviour of nurses.

• Failure to uphold the standards can lead to a disciplinary investigation.

• The first code was developed back in 1994 at the same time the Health & Disability Commissioner’s office came into being.

What is new in the code?

• Addition of four underpinning values: respect, trust, partnership, and integrity.

• Doubling of principles from original four to eight.

• Inclusion of more specific and detailed professional boundaries advice on sexual relationships, social media, and nurses working in small communities.

• Aligning of code standards with the Code of Health Consumer Rights (1996).

• New principle on working respectfully with colleagues in response to Council noting complaints about unprofessional behaviour between health professionals.

• Inclusion of separate principle about respecting the cultural needs and values of health consumers, including revised standards focused on Māori health consumers.

• Release of the associated Guidelines: Professional Boundaries and soon to follow Guideline: Social media and electronic communication.

What do nurses need to do about the new code?

• Over the next three years, ALL nurses will be required to complete professional development on both the new code AND professional boundaries guidelines as part of their continuing competence requirements.

• The Nursing Council is holding a limited number of workshops and is also developing resources for employers and exploring offering online learning opportunities.

• Professional organisations like NZNO and College of Nurses are also providing workshops.

• The Code of Conduct for Nurses and Guidelines: Professional Boundaries can be downloaded in the publications section of the Council’s website: www.nursingcouncil.org.nz

Some young people’s feedback on Code of Conduct review

Q When you get health care from a nurse, what is it like?

ANSWERS

• “Embarrassing – awkward if they don’t like their job”

• “Professional – make you relax”

• “They will do their absolute best to help you”

• “They need to know what they are doing, don’t talk sh*&. They need to know what is wrong (diagnosis) not just pretend or make stuff up.”

• “They know what subjects to push and what to stay away from”

• “Nurses are sometimes grumpy – especially old ones”

• “But no mothering – motherly quality is nice without babying – just kindness”

• “Good connections with other professionals who can help you out”

• “Respect – treating you as if you are important”

• “Sometimes patronising”

• “Sensitive, reassuring”

• “Approachable, friendly, kind”

Q Is it ok for a nurse to have a personal relationship with a family/or support person they met through a young person?

ANSWERS

• “When treating a young person, keep privacy – have to have confidentiality”

• “Not lead a double life”

• “NO. Client should come first”

• “Weird. Could you trust them to keep your information private?”

• “If met through the professional relationship – NO (Creepy/wrong)”

From report compiled by Children’s Commissioner’s office after focus groups with young people.