CDC	Centers for Disease Control and Prevention
HIPAA	Health Insurance Portability and Accountability Act of 1996
IPV	Intimate partner violence
OBRA	Omnibus Budget Reconciliation Act of 1987

Nurse practice acts, your training and job description, and safe delegation serve to protect patients and residents from harm (Chapters 3 and 4). Protecting them from harm also involves a complex set of rules and standards of conduct. They form the ethical and legal aspects of care.

Ethical Aspects

Ethics is knowledge of what is right conduct and wrong conduct. Morals are involved. Morals involve right and wrong and good and bad behavior. Ethics also deals with choices or judgments about what should or should not be done. An ethical person behaves and acts in the right way. He or she does not cause a person harm.

Ethical behavior also involves not being prejudiced or biased. To be prejudiced or biased means making judgments and having views before knowing the facts. Your judgments and views usually are based on your values and standards. They are based on your culture, religion, education, and experiences. The person’s situation and yours may be very different. For example:

• Children think their mother needs nursing home care. In your culture, children care for older parents at home.

• A person has tattoos and body piercings. You do not like tattoos or body piercings.

• An older man does not want life-saving measures. You believe that everything must be done to save a life.

Do not judge the person by your values and standards. Do not avoid persons whose standards and values differ from your own.

Ethical problems involve making choices. What is the right thing to do? For example:

• A co-worker is in an empty room drinking from a cup. You smell alcohol on her breath. She asks you not to tell anyone.

• A resident has bruises all over her body. She told the nurse that she fell. She tells you that her son is very mean to her. She asks you not to tell the nurse.

Codes of Ethics

Professional groups have codes of ethics. A code of ethics has rules, or standards of conduct, for group members to follow. The American Nurses Association (ANA) has a code of ethics for registered nurses (RNs). The National Federation of Licensed Practical Nurses has 1 for licensed practical nurses/licensed vocational nurses (LPNs/LVNs). The rules of conduct in Box 5-1 can guide your thinking and behavior. See Chapter 6 for student and work ethics.

Box 5-1

Code of Conduct for Nursing Assistants

• Respect each person as an individual.

• Know the limits of your role and knowledge.

• Perform only those tasks within the legal limits of your role.

• Perform only those tasks that you have been trained to do.

• Perform no act that will harm the person.

• Take drugs only if prescribed and supervised by your doctor.

• Follow the directions and instructions of the nurse to your best possible ability.

• Follow agency policies and procedures.

• Complete each task safely.

• Be loyal to your employer and co-workers.

• Act as a responsible citizen at all times.

• Keep the person’s information confidential.

• Protect the person’s privacy.

• Protect the person’s property.

• Consider the person’s needs to be more important than your own.

• Report errors and incidents honestly and at once.

• Be accountable for your actions.

Professional Boundaries

A boundary limits or separates something. For example, a fence forms a boundary. You stay inside or outside of the fenced area. As a nursing assistant, you enter into a helping relationship with patients, residents, and families. The helping relationship has professional boundaries.

Professional boundaries separate helpful behaviors from behaviors that are not helpful (Fig. 5-1). The boundaries create a helpful zone. Your behavior must help the person. If you are under-involved, the following can occur.

• Disinterest—you lack interest in the person.

• Avoidance—you avoid the person.

• Neglect—you do not properly care for the person (p. 46).

FIGURE 5-1 Professional boundaries guide your behavior. Your focus is on helping the person. Being under-involved or over-involved is not helpful. (Modified from National Council of State Boards of Nursing, Inc.: A nurse’s guide to professional boundaries, Chicago, 2014, Author.)

If you are over-involved, the following can occur.

• Boundary crossing is a brief act or behavior of being over-involved with the person. The intent of the act or behavior is to meet the person’s needs. The act or behavior may be thoughtless or something you did not mean to do. Or it could have purpose if it meets the person’s needs. For example, you give a crying patient a hug. The hug meets the person’s needs at the time. If the hug meets your needs, the act is wrong. Also, it is wrong to hug the person every time you see him or her.

• Boundary violation is an act or behavior that meets your needs, not the person’s. The act or behavior is not ethical. It violates the code of conduct in Box 5-1. The person can be harmed. Boundary violations include:

• Abuse (p. 44).

• Giving a lot of information about yourself. You tell the person about your personal relationships or problems.

• Keeping secrets with the person.

• Professional sexual misconduct is an act, behavior, or comment that is sexual in nature. It is sexual misconduct even if the person consents or makes the first move.

Some boundary violations and some types of professional sexual misconduct also are crimes. To maintain professional boundaries, follow the rules in Box 5-2. Be alert to boundary signs. Boundary signs are acts, behaviors, or thoughts that warn of a boundary crossing or boundary violation (Box 5-3).

Box 5-2

Maintaining Professional Boundaries

• Follow the code of conduct listed in Box 5-1.

• Talk to the nurse if you sense a boundary sign, crossing, or violation.

• Avoid caring for family, friends, and people with whom you do business. This may be hard to do in a small community. Always tell the nurse if you know the person. The nurse may change your assignment.

• Do not make sexual comments or jokes.

• Do not use offensive language.

• Use touch correctly (Chapter 9). Touch or handle sexual and genital areas only to give needed care. Such areas include the breasts, nipples, perineum, buttocks, and anus.

• Do not visit or spend extra time with a patient or resident who is not part of your assignment.

• The following apply to patients, residents, and family members.

• Do not date, flirt with, kiss, or have a sexual relationship with them.

• Do not discuss your sexual relationships with them.

• Do not say or write things that could suggest a romantic or sexual relationship with them.

• Do not accept gifts, loans, money, credit cards, or other valuables from them.

• Do not give gifts, loans, money, credit cards, or other valuables to them.

• Do not borrow from them. This includes money, personal items, and transportation.

• Maintain a professional relationship at all times. Do not develop a personal relationship or friendship with them.

• Do not share personal or financial information with them.

• Do not help with their finances.

• Do not take a person home with you. This includes for holidays or other events.

• Ask yourself these questions before you date or marry a person whom you cared for. Be aware of the risk for professional sexual misconduct.

• How long ago were you involved with the person’s care?

• Was the person’s care short-term or long-term?

• What kind and how much information do you have about the person? How will that information affect your relationship with the person?

• Will the person need more care in the future?

• Does dating or marrying the person place the person at risk for harm?

Box 5-3

Boundary Signs

• You think about the person when not at work.

• You organize your work and provide other care around the person’s needs.

• You spend time with the person. You visit with the person during breaks, meal times, when off duty, and so on.

• You trade assignments so you provide the person’s care.

• You give more care or attention to the person at the expense of others.

• You believe that you are the only person who understands the person and his or her needs.

• The person gives you gifts or money.

• You give the person gifts or money.

• You share information about yourself with the person.

• You talk about your work situation with the person.

• You flirt with the person.

• You make comments with a sexual message.

• You tell the person “off-color” jokes.

• You notice more touch between you and the person.

• You use foul, vulgar, or offensive language when talking to the person.

• You and the person have secrets.

• You choose the person’s side when he or she disagrees with other staff or the family.

• You select what you report and record. You do not give complete information.

• You do not like questions about your care or your relationship with the person.

• You change how you dress or your appearance when you will work with the person.

• You receive gifts from the person after he or she leaves the agency.

• You have contact with the person after he or she leaves the agency.

See Focus on Communication: Professional Boundaries.

Focus on Communication

Professional Boundaries

Some patients, residents, and families want to thank the staff. Some send thank-you cards and letters. Some offer gifts—candy, cookies, money, gift certificates, flowers, and so on. Accepting gifts is a boundary violation. When offered a gift, you can say:

• “Thank you so much for thinking of me. It’s very kind of you. However, it is against center policy to accept gifts of any kind. I do appreciate your offer.”

• “Thank you for wanting me to have the flowers from your friend. They are lovely. However, it is against hospital policy to receive gifts. Let me help you find a way to take them home.”

Legal Aspects

Ethics is about what you should or should not do. Laws tell you what you can and cannot do. A law is a rule of conduct made by a government body. The U.S. Congress and state legislatures make laws. Enforced by the government, laws protect the public welfare.

Criminal laws are concerned with offenses against the public and society in general. An act that violates a criminal law is called a crime. A person found guilty of a crime is fined or sent to prison. Murder, robbery, stealing, rape, kidnapping, and abuse (p. 44) are crimes.

Civil laws are concerned with relationships between people. Examples of civil laws are those that involve contracts and nursing practice. A person found guilty of breaking a civil law usually has to pay a sum of money to the injured person.

Torts

Tort comes from the French word meaning wrong. Torts are part of civil law. A tort is a wrong committed against a person or the person’s property. Some torts are unintentional. Harm was not intended. Some torts are intentional. The act was done on purpose and harm was intended.

Negligence and Malpractice.

Negligence is an unintentional wrong. The negligent person did not act in a reasonable and careful manner. As a result, a person or the person’s property was harmed. The person causing the harm did not intend or mean to cause harm. The person failed to do what a reasonable and careful person would have done. Or he or she did what a reasonable and careful person would not have done. The negligent person may have to pay damages (a sum of money) to the one injured.

Malpractice is negligence by a professional person. A person has professional status because of his or her education and the service provided. Nurses, doctors, dentists, and pharmacists are examples.

What you do or do not do can lead to a lawsuit if you harm a person or the property of another. Standard of care refers to the skills, care, and judgments required by a health team member under similar conditions. Standards of care come from:

• Laws, including nurse practice acts and those relating to nursing assistants.

• Textbooks.

• Agency policy books and procedure manuals (Fig. 5-2, p. 42). Policy books are guides for staff conduct. Procedure manuals explain how to perform certain procedures.

FIGURE 5-2 A nurse and a nursing assistant review an electronic policy manual.

• Manufacturer’s instructions for equipment and supplies.

• Job descriptions.

• Approval and accrediting agency standards.

• Standards and guidelines from government agencies.

The following actions could lead to charges of negligence.

• You fail to test the water temperature for a shower. The water is too hot. The person is burned.

• Mrs. Parks needs help to the bathroom. You do not answer her call light promptly. She gets up without help. She falls and breaks an arm.

• You do not follow the manufacturer’s instructions for using a mechanical lift. Mr. Brown slips out of the lift and falls to the floor. He fractures a hip.

• Mrs. Clark complains of chest pain. You do not tell the nurse. Mrs. Clark has a heart attack and dies.

• Two residents have the same last name. You do not identify the person before a procedure. You perform the procedure on the wrong person. Both residents are harmed. One had a procedure that was not ordered. The other did not have a needed procedure.

You are legally responsible (liable) for your own actions. The nurse is liable as your supervisor. However, you have personal liability. Remember, sometimes refusing to follow the nurse’s directions is your right and duty (Chapter 4).

Defamation.

Defamation is injuring a person’s name and reputation by making false statements to a third person.

• Libel is making false statements in print, in writing (including e-mail and text messages), through pictures or drawings, through broadcast (radio, TV, or video), posted on-line on websites, or through video sites and social media sites. See “Wrongful Use of Electronic Communications.”

• Slander is making false statements through the spoken word, sounds, sign language, or gestures.

Examples of defamation include:

• Implying or suggesting that a person uses drugs

• Saying that a person is insane or mentally ill

• Posting on-line that a co-worker was fired for hitting a resident

• Implying or suggesting that a person steals money from the staff

To protect yourself from defamation, never make false statements about a patient, resident, family member, visitor, co-worker, or any other person. This includes:

• Through e-mails or text messages

• On websites, video sites, or social media sites

• In newspapers, magazines, or other print sources

• Through broadcasts ( TV, radio, or film)

• With words, sounds, signs, gestures, or any form of communication

False Imprisonment.

False imprisonment is the unlawful restraint or restriction of a person’s freedom of movement. It involves:

• Threatening to restrain a person

• Restraining a person

• Preventing a person from leaving the agency

Invasion of Privacy.

Invasion of privacy is violating a person’s right not to have his or her name, photo, or private affairs exposed or made public without giving consent. You must treat the person with respect and ensure privacy. Only staff involved in the person’s care should see, handle, or examine his or her body. See Box 5-4 for measures to protect privacy.

Box 5-4

Protecting the Right to Privacy

• Keep all information about the person confidential.

• Cover the person when he or she is being moved in hallways and elevators.

• Ask visitors to leave the room when care is given.

• Screen the person. Close the privacy curtain as in Figure 5-3. Close the room door when giving care. Also close window coverings.

FIGURE 5-3 Pulling the privacy curtain around the bed helps protect the person’s privacy.

• Close the bathroom door when the person uses the bathroom for elimination or personal hygiene.

• Expose only the body part involved in a task.

• Do not discuss the person or the person’s treatment with anyone except the nurse supervising your work. “Shop talk” is a common cause of invasion of privacy.

• Do not open the person’s mail.

• Allow the person to visit with others in private.

• Allow the person to use the phone in private.

• Follow agency policies and procedures required to protect privacy.

Health Insurance Portability and Accountability Act of 1996.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) protects the privacy and security of a person’s health information. Protected health information refers to identifying information and information about the person’s health care that is maintained or sent in any form (paper, electronic, oral). Failure to follow HIPAA rules can result in fines, penalties, and criminal actions including jail time.

To avoid HIPAA violations:

• Always follow agency policies and procedures.

• Never take photos or videos of patients or residents or any person in the health care or home care setting. Sharing photos or videos or posting them on video sites or social media sites is a very serious violation of HIPAA.

• Never send an e-mail or text message or post anything on a website, video site, or social media site about a patient, resident, family member, or visitor. Sharing information is a very serious violation of HIPAA.

• Never write anything for a newspaper, magazine, or print source about a patient, resident, family member, or visitor.

• Never broadcast (through TV, radio, or video) anything about a patient, resident, family member, or visitor.

• Only discuss the person’s health information with staff directly involved in the person’s care.

• See “Wrongful Use of Electronic Communications.”

You may be asked questions about the person or the person’s care. Direct any questions about the person or the person’s care to the nurse. Also follow the rules for using computers and other electronic devices (Chapter 7).

Fraud.

Fraud is saying or doing something to trick, fool, or deceive a person. The act is fraud if it does or could harm a person or the person’s property. Telling a person or family that you are a nurse is fraud. So is giving wrong or incomplete information on a job application.

Assault and Battery.

Assault and battery may result in both civil and criminal charges.

• Assault is intentionally attempting or threatening to touch a person’s body without the person’s consent. The person fears bodily harm. Threatening to “tie down” a person is an example of assault.

• Battery is touching a person’s body without his or her consent. The person must consent to any procedure, treatment, or other act that involves touching the body. The person has the right to withdraw consent at any time.

Protect yourself from being accused of assault and battery. Explain to the person what you are going to do and get the person’s consent. Consent may be verbal—“yes” or “okay.” Or it can be a gesture—a nod, turning over for a back rub, or holding out an arm for you to take a pulse.

Wrongful Use of Electronic Communications

Electronic communications include e-mail, text messages, faxes, websites, video sites, and social media sites. Video and social media sites include Facebook, Twitter, LinkedIn, YouTube, Instagram, blogs and comments to blog postings, chat rooms, bulletin boards, and so on. Other forms of electronic communications are expected in the future.

Correct use of electronic communications is essential in your personal life and as a member of the health and nursing teams. Follow the rules in Box 5-5. Do so whether using a computer, wireless phone, camera, or other electronic device at home, at school, at work, or in any other setting. Wrongful use of electronic communications can result in job loss and loss of your certification (license, registration) for: