About this course:
Help the nurse establish a full and complete understanding of what desirable professional behaviors they should be striving for while highlighting some of the most common unprofessional behaviors to avoid.
By completing this educational activity, the learner should be able to:
- Recognize and apply the core principles in the ANA Code of Ethics in their daily nursing role and how this helps to define professional behavior.
- Recall the importance of following the nursing process in daily care of patients.
- Employ standards of practice for self-improvement, communication, and responsibility for professional education and competence.
- Discuss how nurses affect patient safety, manage fatigue, delegate appropriately and participate in patient care on neighboring units (floating).
- Define disruptive and unprofessional behaviors in the nursing profession with common examples and associated legal risks.
- Discuss and design ways to avoid excessive tardiness, absenteeism or medical errors.
- Review how the nurse can have a positive impact on sexual harassment, violence, incivility, and bullying within healthcare.
- Discuss appropriate ways to self-terminate employment.
The purpose of this learning module is to help the nurse establish a complete understanding of desirable professional behaviors they should be striving for while highlighting some of the most common unprofessional behaviors to avoid.
As a nurse, there is almost too much information available. Learning anatomy and physiology, pathophysiology and pharmacology is important, but learning how to conduct yourself as a professional is equally, if not more important. This is not always taught in textbooks and can be much harder to communicate effectively. A great place to start is with the guiding principles, such as the American Nurses Association (ANA) Code of Ethics for Nurses (2015a). This document lists nine provisions that nurses can use to help make decisions and guide their conduct as professionals.
- The nurse practices with compassion and respect for the inherent dignity, worth, and personal attributes of every person, without prejudice. This includes an expectation of respectful interactions and conflict resolution with colleagues, as well as compassion and respect for uniqueness of patients (ANA, 2015a; Lockhart, 2017).
- The nurse’s primary commitment is to the patient, whether an individual, family, group, community, or population.
- The nurse promotes, advocates for, and protects the rights, health and safety of the patient.
- The nurse has authority, accountability, and responsibility for nursing practice, makes decisions, and takes action consistent with the obligation to promote health and to provide optimal care. This includes an expectation that nurses accept responsibility for assessing their own competence and to then seek help, guidance, and further training or education when the current level of competence is determined to be lacking.
- The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth. This includes basic needs such as ensuring adequate nutrition and sleep as well as maintaining emotional and spiritual wellbeing as defined by the nurse.
- The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and the conditions of employment that are conducive to safe, quality health care.
- The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy.
- The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities.
- The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy (ANA, 2015a).
The ANA’s accompanying interpretive statement highlights some specific examples that apply to professional conduct of the nurse. Provision 4 may apply to nurses who are starting on a new unit or in a new hospital or clinic. While the organization and leadership should design a comprehensive and relevant orientation program, the nurse is ultimately responsible for speaking up and seeking out any additional needed information that was potentially overlooked. Provision 5 also includes the expectation for continued growth and professional development throughout the nurse’s career (ANA, 2015a). The acceptance that nurses must become lifelong learners and take ownership and responsibility for their own knowledge and competence is reiterated in standard 12 of the ANA’s Scope and Standards of Practice (Zittel, Moss, O’Sullivan & Siek, 2016). Provision 6 is often interpreted as nurses’ responsibility to help create and maintain a safe and ethical work environment for themselves (Lockhart, 2017). Professional organizations, certifying bodies, as well as states and jurisdictions may also define professional behavior expected from nurses. For example, the state of Georgia specifies that nurses are expected to “function within the legal boundaries of nursing practice, accept responsibility for actions and competence, communicate, collaborate, respect the dignity and rights of all patients, maintain their privacy, and assign only those tasks which the nurse knows the other person is prepared, qualified, and licensed to perform” amongst other listed qualities and expectations (Georgia Secretary of State, 2019). A professional maintains a consistent and punctual attendance record (MasterStreet, 2018).
Ethical principles that guide the delivery of healthcare by nurses can also help instruct what should define professionalism. Once again, the ANA outlines basic ethical principles for nurses, including:
- Autonomy and the right to self-determination- this is the principle that establishes the adult patient’s right to make their own medical decisions as long as they are of sound mind. The nurse’s role is to help educate the patient in order to assist them in making the best possible decisions regarding their own health, and then respecting those decisions once they have been made.
- Beneficence and nonmaleficence- this principle guides nurses to choose the interventions that are the most beneficial and the least harmful to the patient and carrying those out with compassion.
- Fidelity- this principle encourages nurses to be caring, loyal, honest, and altruistic in their care delivery.
- Justice- this principle compels nurses to provide equal care to all patients in a fair manner regardless of financial or social standing.
- Paternalism- this principle is the power to intentionally reveal or conceal information to a patient or family regarding a diagnosis, treatment, or prognosis. The decision to either share or not share information with a patient and/or family is a careful balance of the potential benefits and risks of both options (Davis, 2018).
Additional related ethical principles that should help shape a nurse’s practice include the principle of disclosure (an ethical obligation to disclose all necessary information to a patient to optimize informed decision making) and veracity (providing accurate, complete, and unbiased information when asked) (Sorrell, 2017). Industry standards expect that nurses should care for patients regardless of their socioeconomic status, personal attributes or the nature of their health problems. However, in practice the decision to act or not is often complicated and difficult to assess. The ANA offers the following checklist a nurse may use to assess their own personal risk in caring for a patient. If the nurse can answer yes to the following, they have a moral obligation to
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- If there is significant risk to the patient if the nurse does not act.
- If the nurse’s action is directly relevant to and will likely reduce the risk of harm.
- If the potential risk to the nurse by acting is not more than is acceptable and will be outweighed by the benefit gained by the patient (ANA, 2015c).
The nursing process can also help nurses determine what behavior is considered professional. The process stipulates in step 3 that a care plan is to be developed, and in step 4 that care should be “implemented according to the care plan, so continuity of care for the patient during hospitalization and in preparation for discharge needs to be assured”. The importance of establishing a care plan and following through are crucial for quality patient care. Once the appropriate care has been delivered, the nursing process also reminds the nurse to document the care was given (ANA, n.d.b). Failure to follow standards of care and established protocols as well as failure to document that care has been provided have been cited as leading causes for fault in nursing malpractice cases (Perry, 2019).
The ANA (2015a) Code of Ethics plainly states that the patient is the nurse’s primary commitment, so many of these professional behaviors are directly related to patient safety. As healthcare becomes more aware of how culture affects patient safety, behaviors that positively or negatively impact that culture become clear. Communication that is clear, open, and direct is of the utmost importance for patient safety. Ethicists suggest using handoff tools to help with clear and prompt nursing communication. When performing important tasks such as medication administration, distractions should be minimized. Simplify tasks, standardize procedures and organize (both your supplies and your thoughts) to become more efficient. Nurses are human at their core, and humans require help. Nurses should utilize checklists, reminders, double checks, computers and technology when helpful to promote efficiency, improve accuracy, and reduce the risk of human error. When nurses are involved in shared governance and are brave enough to share their stories and experience, their colleagues benefit from other’s previous mistakes and everyone learns. Being honest, especially when mistakes are made, can be scary in this modern litigious age of medicine, but studies have shown that there is no link between a nurse’s willingness to disclose and litigation. Nurses can affect culture even if they are not in leadership positions, simply through leading by example (Davis, 2017; Sorrell, 2017).
As previously mentioned in Provision 5 of the ANA (2015a) Code of Ethics, self-care is an expectation of all nurses, and this may be the hardest for some to follow. However, in light of the challenging 12-hour shifts and requirement for most inpatient units to be staffed around the clock, combined with the dangerous effects of fatigue and high stakes at hand, the requirement that nurses exercise self-care is absolutely necessary. Studies have shown that nurse fatigue leads to less than optimal patient care, increased risk of medical errors or clinical decision regret, decreased functional or short-term memory ability, decreased learning ability, poor critical thinking skills, increased risk-taking behaviors, poor mood, decreased communication skills and numerous physical health consequences. The ANA recommends that health care providers, including nurses, limit their working hours to no more than 12 hours in a 24-hour period, and no more than 40 hours in a 7-day period. Over 40 hours in a week has been shown to affect patient safety as well as nurse health. The ANA also includes several other suggestions for minimization of nurse fatigue and optimization of nurse performance, such as:
- Arrive for work alert and well-rested.
- Sleep is important, at least seven to nine hours is recommended in a 24-hour period.
- Rest before the beginning of a shift.
- Avoid medications that may cause drowsiness while working.
- Communicate with your coworkers ahead of time to plan that everyone gets the opportunity to take the suggested meal and rest breaks during the shift without compromising patient safety.
- Maintain good general health by managing stress, maintaining good nutrition and exercising regularly.
- Ask your manager or supervisor for a copy of your institutions nap policy as many hospitals have a specific policy to address this issue (ANA, 2014).
A generally acceptable goal for a nurse is to take three 15-minute breaks and one meal break (typically 30 minutes) in a 12-hour shift. This is ideal, and is not always possible, but is more likely to occur with advanced planning and good communication amongst the nursing team. A recent survey of nurses in Seattle, Washington found that over a two-week period every nurse that was surveyed missed at least ten breaks and two meals over that period of time. While this goal may seem difficult, adequate breaks are an integral factor in nurse job satisfaction and retention (Patricelli, 2016).
Regarding delegation, this skill is honed over the course of a career but basic guidelines like those published in 2019 by the National Council of State Boards of Nursing (NCSBN) and the ANA help even graduate nurses start to develop this skill. The expectations of many nurses far exceed what a single person could hope to accomplish in a 12-hour shift, making delegation necessary for success and quality patient care. The guidelines stipulate that delegating involves requesting a delegatee (whether registered nurse [RN], licensed practical nurse [LPN] or assistive personnel) to perform a specific nursing activity that is outside their traditional role but within their capabilities. The delegatee must have validated competence for the activity, and the delegator (an advanced practice RN [APRN], RN, or LPN) maintains responsibility for ensuring the activity has been done completely and correctly. Activities that are outside of the delegator’s scope of practice or that involve nursing judgement, assessment or critical thinking should not be delegated (NCSBN & ANA, 2019).
Floating consists of nurses who typically provide patient care on a specific unit who are assigned to help provide care on a neighboring unit due to staff shortages. While floating can be stressful, anxiety provoking and frustrating for some nurses, it is a basic form of resource sharing that is employed by institutions commonly. It can be viewed positively as a refreshing change of pace that allows a nurse the opportunity to gain knowledge and build new skills. While a nurse has the right to reject or object in writing to any assignment that endangers the patient, floating can be done safely and become a positive learning experience if certain steps are taken to ensure success. The Joint Commission (as cited in O’Connor & Dugan, 2017) expects that nurses who are floating should be placed on a unit of patients with comparable clinical diagnoses and acuities. The RN Safe Staffing Act of 2015 (as cited in O’Connor & Dugan, 2017) also states that hospitals are not to assign nurses to units for which they lack adequate experience, education, and training such as specialty units. When floating to another unit, nurses should expect or request the following:
- A brief orientation to the new unit, including any shift routines and the location of a break room, bathrooms, important equipment (think: crash cart), medications, and patient care supplies.
- An introduction to an experienced nurse on the unit who may serve as a resource or partner throughout the shift.
- A written copy of contact information for unit resources, unit-specific documentation, and any written policies, procedures, or unit-specific clinical practices.
Finally, as a floating nurse there should be support and encouragement for honest and open feedback at the end of the shift regarding what went well and what could have been made easier with specific and constructive suggestions without fear of retribution or judgement (O’Connor & Dugan, 2017).
The attainment of professionalism is often more clearly understood when examples of unprofessional behavior can be used as an explanation of what not to do. Common unprofessional behaviors that should be avoided in any professional environment, healthcare not excluded, include:
- Missing a deadline (an example for nurses would be consistently administering patient medications behind schedule).
- Not being forthright with or withholding information (for example, not reporting an error to a manager as soon as possible).
- Not respecting privacy or need-to-know (sharing patient information with others inappropriately).
- Failing to accept responsibility or passing blame to others.
- Exaggerating qualifications or past experience.
- Frequently changing jobs.
- A sloppy or unkempt appearance (Purdy, n.d.).
Absenteeism and tardiness in nursing is especially destructive as these behaviors are not only unprofessional, but also have a direct impact on patient care, patient safety, and the happiness and respect of colleagues and coworkers. If a nurse calls at the last minute to inform the manager that they are unable to work, another nurse may have to work overtime or multiple nurses on the unit may have to care for more patients that shift. If a nurse arrives late, the nurses that have been caring for their patients may not be able to leave work on time, and may even receive reprimands from management for accruing too much overtime while they were waiting for the late nurse to arrive and receive report on the patients. USLegal (n.d.) defines absenteeism as an unscheduled absence from work due to illness, a family or household emergency, or a family death. They define excessive absenteeism as three or more episodes of absenteeism in any 90-day period (USLegal, n.d.). In general, absenteeism leads to decreased performance and increased costs within an organization (Ticharwa, Cope & Murray, 2018). Absenteeism affects staffing ratios, lowers staff morale, increases workloads, decreases productivity, disrupts workflow, creates job dissatisfaction, and directly and indirectly decreases the quality of patient care (MasterStreet, 2018). The irony in this situation is that the increased workload and decreased job satisfaction then increases the risk for absences, creating a vicious cycle (Ticharwa, Cope & Murray, 2018). Illness/injury is the most common reason for absenteeism, and in nursing this is often a valid and reasonable occurrence. Arriving to work sick not only risks spreading the illness to patients and coworkers, but functioning at suboptimal levels due to illness may also endanger patients further (MasterStreet, 2018). However, risk for illness and injury can be mitigated by good self-care and safe lifting practices (Ticharwa, Cope & Murray, 2018). Other reasons commonly cited for absence include transportation issues, child care issues, and a death in the family. While a short leave of absence to attend a family member’s funeral is reasonable and expected, especially for immediate family members, unexpected absences for transportation issues and child care issues can often be avoided by ensuring reliable forms of both as well as contingency or back-up plans that are considered in advance (MasterStreet, 2018). Avoiding double shifts and other forms of overtime have also been shown to decrease absenteeism (Ticharwa, Cope & Murray, 2018).
Within healthcare, unprofessional behavior may have additional specific inclusions. For example, the state of Georgia provides a good balance to their aforementioned definition of professional behavior for nurses by providing the following items considered unprofessional behavior:
- Inappropriate or unsafe judgement,
- Abandoning or neglecting patients,
- Providing false or misleading information,
- Accepting a patient assignment that is unsafe,
- Accepting a responsibility that is outside of the nurse’s scope of practice,
- Failing to maintain accurate documentation,
- Drug diversion,
- Arriving to work or working while under the influence or otherwise impaired,
- Failing to maintain professional boundaries with a patient or patient’s family member,
- Threatening or violent behavior (Georgia Secretary of State, 2019).
While errors are a normal part of the human existence, for a nurse there are some errors that can be deadly for the patient. There are over 250,000 deaths annually due to medical errors, most of which are preventable. According to researchers at Johns Hopkins in 2016, medical errors surpassed respiratory illness as the third leading cause of death (Sorrell, 2017). A key element in patient safety involves fostering a blame-free environment of interdisciplinary teamwork (AHRQ, 2019). The most common and most dangerous nursing errors and how to avoid them include:
- Medication errors- avoid distractions during medication administration, always use the “8 rights” (right patient, right time, right drug, right dose, right route, right reason, right documentation, and right response), do not hesitate to ask questions or double check something especially if it looks different or incorrect to you. In the United States alone there is estimated to be one patient death per day due to medication errors.
- Falls- falls can cause patients not just physiological harm but also psychological distress, increasing their anxiety and thus increasing their risk for future falls as well. Nurses can limit risk by educating patients about calling for help and the reasons behind this request, performing hourly rounding to check on patients frequently, and implementing safety features such as non-slip socks, bed alarms and posted signs alerting staff and family members when a patient is at increased risk.
- Infection- hand hygiene is the most effective way that nurses can limit the risk and spread of hospital acquired infections, in combination with sterilizing equipment and good aseptic technique.
- Documentation- the old adage in healthcare continues to ring true today: if you did not document it, it did not happen. Be sure all interventions are documented along with the time they were completed. The same principle holds true for interventions that were not completed. Be sure to document why a particular intervention was not carried out as ordered (i.e. the patient refused the medication).
- Body mechanics- nurses should be aware of the correct way to transfer, lift, turn, and move a patient safely. Many hands make light work, so asking for help from colleagues and coworkers decreases the risk of injury, as well as appropriately using assistive equipment such as a mobility-promoting support aid or a patient lift/transfer device when available.
- Equipment- be sure to familiarize yourself with all available equipment in your daily environment, ask for training or in-services if additional instruction is needed, and always use the equipment as suggested.
- Failure to prioritize- nurses are often reluctant to ask for help, but no one is an island. Delegate, ask your fellow nurses for help and offer to help them in return. Work as a team and if you are unsure about something, ask your charge nurse, manager or supervisor for guidance (Francisco, 2014).
In addition to having grave consequences for the patient, errors can also lead to malpractice and other legal issues for the nurse. Malpractice can be defined as negligence, misconduct, or breach of duty. The most common reasons that nurses are found at fault include failure to assess or monitor a patient, follow standards of care or protocol, use equipment in a responsible manner, communicate effectively, document completely, act as a patient advocate, follow the chain of command, or respect privacy (Perry, 2019).
Disruptive behavior is unfortunately common in healthcare, despite the Nurse’s Bill of Rights clearly stating that all nurses have a right to a safe, supportive, and ethical work environment (ANA, n.d.a). The Agency for Healthcare Research and Quality (AHRQ) defines unprofessional or disruptive behavior as “any behavior that shows disrespect for others, or any interpersonal interaction that impedes the delivery of patient care”. This may include behavior that is demeaning or harassing. Although the common stereotype of disruptive behavior involves a physician as the instigator, a recent survey showed that 65% of respondents had witnessed disruptive behavior by nurses. This behavior has been shown to increase the risk for medical errors, adverse events and even deaths (AHRQ, 2019). The ANA cites disruptive behavior as a known cause for decreased job satisfaction, worsened personal health, additional healthcare costs, and overall decreased patient safety (ANA, 2015b). JCAHO’s code of conduct instructs adoption of a zero-tolerance policy for disruptive behavior. Nurses can actively discourage disruptive behavior by modeling healthy communication as described above and by addressing and/or reporting disruptive behavior immediately if witnessed (AHRQ, 2019). The ANA (2015b) defines incivility as including rudeness, gossip, or refusing to help another nurse in their recently published position statement on incivility, bullying and workplace violence. The ANA places the responsibility on nurses to treat colleagues, coworkers, employees, employers, students, and others with both respect and dignity at all times. All nurses should take the time to review the ANA’s full list of recommendations for nurses in the full position statement (ANA, 2015b)
An especially troubling aspect of disruptive behavior is violence, either physical or non-physical (which includes incivility and verbal abuse), and sexual harassment. A recent quantitative review of nurse exposure to violence found that in cases of physical violence against nurses, another nurse was the aggressor in 3.2% of cases and another staff member in 6.3% of cases. In non-physical violence cases against nurses, another nurse was the aggressor in 21.8% of cases (Spector, Zhou & Che, 2014). This type of violence between nurses is called horizontal or lateral violence, and in a recent survey as many as 37% of nurses admitted to instigating incivility at work. Bullying, harassment, intimidation, manipulation, threats, or physical violence are all morally unacceptable in the profession of nursing and should be treated with immediate and appropriate intervention to ensure a pattern of complacency and acceptance of this behavior does not develop. Even less obvious but nonetheless toxic unprofessional behaviors such as eye rolling, sarcasm, aggression, withholding information, rudeness, condescension, and disrespect should not be tolerated amongst healthcare professionals. When any of the aforementioned behaviors is witnessed, the matter should be dealt with directly in a private, personal, and calm manner so as to avoid escalation of emotions (MacLean, Coombs, & Beda, 2016). Sexual harassment is defined by the U.S.Equal Employment Opportunity Commission (n.d.) as harassment that is directed at an individual because of their sex, and it may include unwelcome advances, requests for sexual favors, verbal harassment, physical harassment, or offensive remarks about a person’s sex. By definition, it must be severe or frequent enough to create a hostile work environment or result in an adverse employment decision such as a demotion, termination, or lack of promotion. It can be directed at or committed by a coworker/colleague, boss, employee, or patient (U.S.Equal Employment Opportunity Commission, n.d.).
So, what exactly is a nurse to do if they find themselves in a position that is unacceptable despite their best efforts, or it is simply time to move on to the next great adventure? Giving notice of self-termination can also be done professionally. Giving ample notice is a sign of respect to your manager, coworkers and patients, and while two weeks is the legal minimum in most cases, many employers may specify more time in order to advertise, interview, and train a replacement for your current role. Leaving without sufficient notice not only eliminates the ability to utilize the current employer as a positive professional reference in the future, but it also puts other nurses and patients at risk. Ideally nurses should give as much notice as possible, such as four weeks. The decision to self-terminate should be communicated face-to-face in a direct, honest and concise manner, often with a formal written letter in email or paper form if needed for Human Resources. If there is criticism, be sure to be truthful but deliver the message in a constructive and respectful manner. Express gratitude for the experience and opportunity. Fulfill all your existing commitments prior to your last day, and exit interviews are often conducted by Human Resources in an anonymous manner to allow an additional opportunity for constructive and respectful feedback (Hamstra, 2018).
A Gallup poll conducted in late 2017 found that the American public rated nurses as the most honest and ethical profession (Brenan, 2017). However, as Spider-Man taught us, with great power comes great responsibility. Let's make sure that as nurses we are practicing to maintain and honor that trust every day.
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