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
2.1 Primacy of the patient’s interests
The nurse’s primary commitment is to the recipient of nursing and healthcare
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.
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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, healthcare 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 healthcare 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 healthcare 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 healthcare 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.
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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 healthcare 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 healthcare 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 nonclinical
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 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.
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.
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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 in 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.
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