Challenges for the Nursing Profession in Malaysia: Evolving Legal and Ethical Standards
Acceptance of the premise that nursing legal and ethical standards are emerging and evolving in the global community, forms the basis for this exploration of Malaysian nursing law and ethics. Recent changes in the provision of health care in Malaysia have contributed to the growing importance of nursing law and ethics. The role of Malaysian nurses has been affected by litigation related to negligence, informed consent, confidentiality, and euthanasia. Malaysian nursing legislation does not address many legal and ethical issues that require a comprehensive set of laws that recognize the considerable convergence between legal and ethical judgments. Technological advances in health care have also created challenges for the Malaysian nursing profession. Nurses must conquer these challenges by becoming more knowledgeable about legal and ethical decision making. The education of Malaysian nurses about the demands of law and ethical standards would promote greater accountability, knowledge, and personal commitment in providing health care to individuals throughout their life span.
Nurses provide a comforting human interface between patients and the hospital, and between communities and the health care system thus forming the "heart" of medical and health care service provision in Malaysia. The rapidly changing Malaysian health environment has required nurses to provide care through extended roles in order to complement the services rendered by other health professionals. These extended roles have forced Malaysian nurses to become more involved in practices that may have profound individual legal consequences. Consequently, Malaysian nurses have become increasingly aware of legal and ethical issues that have impacted on their practices and have also recognized the importance of a solid foundation in legal and ethical principles thus promoting competency in independent complex decision making.
In Malaysia, nurses represent the largest workforce in the health care sector. 1 They are the main providers of health care, particularly in rural and remote areas. The nursing workforce has now increased to around 60,000, or approximately 2.25 nurses per 1,000 population. 2 There are 18 nursing colleges under the Malaysian Ministry of Health, 6 university programs, and 32 private sector diploma programs. Graduates of Nursing and Midwifery programs, assistant nurses, and rural nurses must succeed in the respective registration examinations set by the Nursing Board and the Midwifery Board of Malaysia to qualify for registration and practice. 3 The requirements are stipulated under the Nurses Act 1950 [Act 14] and the Midwives Act 1966 [Act 436]. 4 However, these Acts do not have specific provisions regarding the liability of nurses arising in medical malpractice. Legal rules and principles regarding issues of malpractice affecting Malaysian nurses are found in the English Common Law. Section 3 of the Malaysian Civil Law Act 1956 [Act 67] provides that unless there is any written law in force in Malaysia, the courts in Malaysia shall apply the Common Law of England and the Rules of Equity as administered in England on April 7, 1956. However, the said Common Law and the Rules of Equity shall only be applied insofar as the circumstances of the States of Malaysia and their respective inhabitants permit, and subject to such qualifications as local circumstances render necessary.5
Traditionally, the doctor-nurse relationship in Malaysia is akin to that of a master and servant. Nurses have been characterized as being incapable of independent or cooperative decision making in medical treatment. Nurses had never been entrusted with formal responsibilities that may have had major legal consequences and have taken a rather passive role in such decision making. However, the recent changes in the provision of health care in Malaysia have united doctors and nurses as partners. Modern health care settings have placed greater emphasis on the nurses' role in planning, implementing, and evaluating nursing care. The role of nurses has thus been affected by litigation related to negligence, informed consent, confidentiality, and euthanasia. Hence, it would only seem just that nurses' extended roles make them legally responsible for the consequences of their actions accountable to their peers, employers, patients, and ultimately, the courts.
ADHERING TO PROFESSIONAL ETHICAL STANDARDS IN MALAYSIA
In fulfilling their responsibilities, nurses are often challenged with clinical situations that have ethical conflicts. These unresolved conflicts may cause feelings of frustration and powerlessness that can lead to compromises in patient care, job dissatisfaction, or disagreements among those on the health care team. 6 Nurses need skills and guidance to help resolve ethical conflicts. 7 Through Malaysian nursing education, nurses are taught to adhere to the values of the nursing profession. 8 Ethical codes of professional practice outline principles that demonstrate the responsibility of the profession's members to Malaysian society. The Code of Professional Conduct for Nurses (CPCN) developed by the Nursing Board of Malaysia 9 outlines the values and duties to which nurses are expected to adhere, in order to make sound ethical decisions and provide high-quality nursing care. The CPCN delineates what registered nurses 10 must know about their ethical responsibilities, informs other health care professionals and members of the public about the ethical commitments of nurses, and upholds the responsibilities of being a self-regulating profession. 11 It consists of six provisions divided into three major content areas that address the fundamental values and commitments of nurses, the boundaries of duty and loyalty, and the duties toward patients.
Globally, the ethical principles and rules that commonly guide nursing practice and patient care include nonmaleficence, beneficence, autonomy, fidelity, veracity, and justice. 12 In Malaysia, the principles of nonmaleficence and beneficence are often discussed together and as with beneficence, the obligation is toward positive action in preventing and promoting good. With nonmaleficence, the obligation is stated as negative terms. For instance, there is a duty to do no harm, thus it is an obligation not to inflict harm intentionally. 13 In Malaysia, autonomy means a special form of personal liberty, wherein individuals are free to choose and implement their own decisions according to their own individual values and beliefs, free from deceit, duress, constraint, and coercion. 14 In Malaysian law, respect for patients includes treating patients regardless of ethnic origin, nature of health problems, religious beliefs, and social status. 15 Respect also extends to nurses' colleagues. Provision 1.5 of the CPCN provides that "the nurse should work collaboratively and co-operatively with other members of the health care team and should not hesitate to consult appropriate professional colleagues when needed." Fidelity refers to faithfulness, particularly the duty to honor commitments made to others, particularly in avoiding conduct that is considered derogatory to the nursing profession. 16 Veracity involves actions and beliefs that are based on the values of truth, accuracy, and honesty. 17 Finally, according to the principle of justice as specified in Malaysian law, all people should be treated fairly and available resources should be used equitably.
Conflicts may occur between two or more ethical principles, which may lead to ethical dilemmas in deciding what is the right or best course of action. Conflicts, particularly in respect to Malaysian culture, may occur regarding informed consent. For instance, the nurse may over rely on patient autonomy when, in reality, the information may only cause the patient to make an inappropriately unbalanced judgment due to bias and prejudice on the part of the patient. 19 Other such conflicts may include issues relating to disagreements over patients' resuscitation status, futility of treatment, and rationing of scarce resources. 20 In another example, a nurse who highly values nonmaleficence, or seeks to minimize harm, may feel uncomfortable when giving chemotherapy to an older adult patient when she feels that the risks to the patient outweigh the potential benefits. In contrast, a nurse who is guided by the principles of respect and autonomy may not be troubled, feeling that the most important duty is to fulfill the patient's request, despite the ratio of benefit to risk. 21 Nurses may also become involved in disagreements between patients and patients' families about the best courses of treatment and the needs of the patients. Nurses must therefore be encouraged to raise awareness among peers and actively discuss the legal and ethical issues in their practice settings. This will help Malaysian nurses begin to decrease feelings of uncertainty and find the best solutions to resolve these ethical
THE DEMANDS BY MALAYSIAN LAW
Undeniably, the law, being an instrument of social regulation, has established rights and responsibilities of the parties involved in the nurse-patient relationship. The law is expected to structure decisions that will reduce the conflicts and dilemmas occurring in the nursing profession, 22 but the legal outcome may not necessarily correspond to the ethical perspectives of the profession as occur and may evolve in any one particular culture.
AVOIDING CLAIMS ARISING IN MEDICAL (NURSING) NEGLIGENCE IN MALAYSIA
Nurses are expected to adhere to a certain standard as demanded by the profession. 23 The standard of care demanded by Malaysian law for nurses is the standard of care observed by a reasonably competent member of the profession. 24 A nurse will not be considered negligent if he or she has acted according to a practice accepted as proper by a body of those who possess similar skills to the nurse in question. 25 Although, many cases that go to civil court involve the issue of negligence, it is not often that nurses are sued individually. This is due to the operation of the doctrine of vicarious liability that shifts employee liability to the employers. 26 This doctrine is essentially a rule of convenience 27 but is limited in its application. It renders the employer liable only for its employees 28 and is confined to acts committed in the course of employment. The employee is held to be acting in the course of employment if he or she commits an act that is authorized by the employer. 29 Thus, as long as the nurses follow orders given to them by doctors or other superiors, they will not be held individually responsible, unless they are entrusted with certain tasks to decide for themselves. In Dr. Ks Sivananthan v The Government of Malaysia & Anor, 30 the doctor was held negligent for delaying in giving the proper treatment to the patient. The delay was mainly caused by the failure of the nurse in recording adequate and timely observations in the patient's chart. These ordered observations were to monitor the blood circulation of the leg, and if the circulation was found to be blocked as evidenced by the color of the toes, immediate medical attention would be required. Further, in Foong Yeen Keng v Assunta Hospital (M) Sdn Bhd & Anor, 31 although the medical notes recorded by the nurses were incomplete, the court held that there was ample evidence supporting the hospital's contention that the antibiotic prescribed had been dispensed sufficiently. Therefore, the hospital and doctor were not held liable. Even though Malaysian nurses are rarely sued individually, they do have to adhere to the standard of care demanded by the law in order not to be sued collectively. Being sued collectively does not absolve nurses from liability, as the employer has the right to claim for indemnity against the nurse(s) if found guilty. 32 Further, if the nurse is found guilty, the Nursing Board of Malaysia 33 has disciplinary jurisdiction under section 31 of the Nurses Act 1950 [Act 14] to suspend or remove the registered nurse from the Register, or to reprimand or suspend the registered nurse as they deem fit for a period not exceeding 2 years.34
PROCURING INFORMED CONSENT PRIOR TO UNDERTAKING MEDICAL TREATMENT IN MALAYSIA
The general legal and ethical principle for adult patients of sound mind is that legally valid consent must be obtained before treatment to a patient is undertaken. In order for the patient's consent to be legally valid, the consent must be informed in nature. This requires the patient to be given sufficient information about the treatment. The patient must know to what he or she is consenting. The nature, purpose, and inherent risks of the proposed treatment must be understood by the patient. 35 The current trend among the courts in many jurisdictions, relevant to Malaysian law, has been to attach greater weight to the patient's right of self-determination. It is the right of every human being to make decisions that affect his or her own life and welfare and to decide what risks he or she is willing to undertake. 36 The Federal Court of Malaysia 37 has recently ruled in the case of Foo Fio Na v Dr Soo Fook Mun & Anor 38 that cases of informed consent will be judged according to the "reasonable prudent patient test" set forth by the Australian case of Rogers v Whitaker . 39 The reasonable prudent patient test demands that for the consent given by the patient to be legally valid, sufficient information must be given to the patient so that the patient is able to make an informed decision before any medical treatment is undertaken. 40 The assessment of sufficient information requires the medical professional to inform the patient of all material risks in the medical treatment. However, the determination of what constitutes material risks is no longer the sole jurisdiction of medical practitioners, but considers several other factors that affect the circumstances of the patient, such as the likelihood and gravity of risks, 41 the desire of the patient for information, 42 and the nature of the procedure, whether routine or complex. 43 Hence, the Malaysian courts of law will play a crucial role in determining the standard of care required relevant to the duty to disclose risks before any medical treatment is undertaken by the medical professional. Thus, it is imperative that Malaysian nurses respect and promote the autonomy of their patients and help their patients to express health needs and values so that patients can make informed decisions about matters affecting life and treatment.
PATIENT'S CAPACITY TO CONSENT AND THE RIGHT OF A COMPETENT PATIENT'S REFUSAL OF MEDICAL TREATMENT
Legally valid consent depends not only on sufficient information given the patient, but also on whether the patient has the capacity to give a valid consent. 44 To have the necessary capacity to give consent, the patient must be able to have sufficient understanding of the nature, purpose, and effect of the proposed treatment 45 and the consent must be voluntarily given. 46 If the person has acquired the necessary capacity to give a legally valid consent, he or she is deemed to be legally competent to consent or refuse to consent to medical treatment.
The position of the English common law has been instrumentally determinative in assessing whether the Malaysian patient has reached sufficient understanding of the proposed treatment. 47 This is because the Malaysian Mental Disorder Ordinance 1952 48 does not have any provisions relevant to issues on capacity. 49 The common law through cases such as Re C (Adult: Refusal of Treatment ) 50 and Re MB (An Adult: Medical Treatment), 51 decided that the issue of whether the patient has the capacity to consent hinges on whether patients are able to appreciate what will be done to them if they accept treatment, the likely consequences of leaving their condition untreated, and an understanding of the risks and side effects of undertaking the treatment. 52 However, the common law position is very much similar to the upcoming Malaysian Mental Health Act 2001 [Act 615] 53 that will have a specific provision on the issue of consent to treatment, 54 addressing the issue of assessment of capacity. In order to assess whether a patient is capable of giving the required consent, section 77(5) of the 2001 Act sets out the factors that need to be considered such as whether the patient understands the condition for which the treatment is proposed, the nature and purpose of the treatment, the risks involved in undergoing or not undergoing the treatment, and whether or not his or her ability to consent is affected by his or her condition. If after considering these factors, it is shown that the patient is incapable of giving consent, only then can consent be procured from the guardian, if the patient is a minor, or a relative of the patient, if the patient is an adult. 55 If the guardian or relative is nowhere to be found, only then can consent be obtained from two psychiatrists who have examined the patient.56
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However, once the patient has been determined to have the required capacity to consent to medical treatment and deemed competent, the patient will also have the right to refuse it or to choose a different treatment. As stated by the court in Re MB (An Adult: Medical Treatment) 57 that "a competent [person], who has the capacity to decide, may, for religious reasons, other reasons, for rational or irrational reasons or for no reason at all, choose not to have medical intervention, even though the consequence may be the death." 58 Although there has yet to be any Malaysian cases directly held on the issue of refusal of consent by patients, decisions in cases such as Tan Ah Kau v Government of Malaysia, 59 Hong Chuan Lay v Dr Eddie Soo Fook Mun 60 and Foo Fio Na v Hospital Assunta & Anor 61 have constantly reiterated that the adult patient of sound mind has a right to decide whether they want to choose or refuse medical treatment.
THE RIGHTS AND NEEDS OF TERMINALLY ILL PATIENTS IN MALAYSIA
The ethical principle of the sanctity of life postulates that life is sacred and should be respected. However, there are many occasions in which a nurse may face dilemmas, particularly in caring for terminally ill patients. 63 In such instances, patients may demand that their lives be terminated to reduce their suffering or family members may request for their loved ones to be allowed to die with decency and dignity. 64 In addressing such instances, the Malaysian ethical codes and law have yet to be developed to the fullest extent. At present, it is clear that a nurse who deliberately takes active steps to cause death or hasten death of his or her terminally ill patient would be committing murder under section 300 of the Penal Code (Amendment) Act 1989 [Act 727] 65 if the death causing or hastening act had been performed against the wishes of his patient. Even if the patient consents, the nurse may be committing the offense of culpable homicide under section 299 of the Penal Code (Amendment) Act 1989 [Act 727] as it is a direct violation of the principle of sanctity of life. 66 Active measures to cut short the life of a terminally ill patient are forbidden. As long as there is an intention to kill, it is sufficient to make it an unlawful act. The reason behind the intention makes no difference and the request by the patient would be irrelevant.67
However, withdrawal or withholding treatment including withdrawal of nutrition and hydration may be held lawful in certain circumstances particularly where recovery is unlikely, or continuance of treatment would be futile and not in the patient's best interests. Such requirements are discussed at length in the case of Airedale NHS Trust v Bland 68 and the decision offers good precedent by allowing the withholding and withdrawing of treatment when the patient's condition is futile. In determining futility, the courts will consider factors such as whether there was any realistic prospect of the patient recovering, whether there are new avenues of treatment that might lead to the patient regaining consciousness, whether there is any clinical benefit to the patient for the continuation of treatment, and whether it is in the patient's best interests to allow him or her to die naturally. 69 The current practice by Malaysian doctors is similar to the decision of Airedale in which the withholding and withdrawal of treatment is considered lawful where continued treatment is not in the best interest of the patient. The difference between Airedale and the current practice in Malaysia is that after nutrition and hydration are withdrawn from the patient in the hospital, the patient would be brought home and nutrition and hydration would continue to be provided by the patient's relatives until the patient died.70
TERMINATION OF PREGNANCY AND RIGHTS OF THE PREGNANT WOMAN IN MALAYSIA
Termination of pregnancy or abortion remains a controversial and extensively debated subject in Malaysia. Central to the ethical debate concerning abortion are considerations of autonomy (of the woman) and rights (of the woman and the unborn child). It is important for all medical professionals, including nurses, to comprehend the basis of the abortion debate from the perspective of their professions, society as a whole and the individual women who may have had or are considering abortions, or others who have been affected by the subject in some way. 71 The nature of abortion and its associated decision-making process involve sensitive issues for all involved. Thus, it is essential that nurses are able to support and inform their patients when required. The law and professional guidelines must also be clear and comprehensive to direct nurses' actions. Under provision 3.3 of the CPCN 72 for registered nurses in Malaysia, "induced non-therapeutic abortion" is considered to be amongst the actions that may amount to an abuse of professional privileges and skills.
Further, under the Malaysian law, sections 312 to 316 of the Penal Code (Revised 1997) Act (Act 574) deal with the issue of abortion (although the term abortion is not used, but replaced with "causing miscarriage"). According to section 312 of the Penal Code, "whoever voluntarily causes a woman with child to miscarry shall be punished with imprisonment for a term which may extend to three years, or with fine, or with both; and if the woman is quick with child, shall be punished with imprisonment for a term which may extend to seven years, and shall also be liable to fine." This section makes abortion a criminal offense. The term "a woman with child" means that the act of causing miscarriage must be done on a woman who is, in fact, pregnant. If the woman is not pregnant, then the act even if fatal, does not fall within the ambit of this section. 73 The gravity of the punishment of section 312 would depend on the stage of pregnancy. The word "quick with child" is not defined in the provision but according to Ratanlal 74 that particular phrase is derived from the term "quickening," which refers to the peculiar sensations experienced by a woman in the 4th or 5th month of the pregnancy. The term can also be ascribed to the first perception of the movements of the fetus. Thus, the punishment will be more severe if the woman is in the later stages of her pregnancy.
Prior to the revision of the Penal Code in 1989, 75 abortion can only be conducted if there is a threat to the mother's life. The revision in 1989 made several amendments, for example, by inserting an exception in section 312. The exception provides that "this section  does not extend to a medical practitioner registered under the Medical Act 1971 [Act 50] who terminates the pregnancy of a woman if such medical practitioner is of the opinion, formed in good faith, that the continuance of the pregnancy would involve risk to the life of the pregnant woman, or injury to the mental or physical health or the pregnant woman, greater than if the pregnancy were terminated." 76 Therefore, abortion will not be an offense under Malaysian law if the above exception is satisfied.
RESPECTING PRIVACY AND JUSTIFICATIONS FOR BREACHING CONFIDENTIALITY IN MALAYSIA
In facilitating patient care, nurses may face dilemmas between the requirement of patient confidentiality and the need to disclose information. Provision 3.5 of the CPCN specifically provides that "the nurse must not disclose information which she obtained in confidence from or about a patient unless it is to other professionals concerned directly with the patient's care." The duty of confidentiality is not only an ethical duty but a legal duty as well. Nevertheless, this duty is by no means absolute as the law recognizes several justifications in breaching confidentiality. 77 In particular, if the patient has given informed consent to the disclosure 78 and provided that the information is only shared amongst those who are relevant in maintaining the patient's welfare. 79 Disclosing without patient's consent but with the aim of protecting public interest is another legal justification for breaching confidentiality. This was clearly mentioned in the case of W v Egdell, 80 in which W, who pleaded guilty to manslaughter on the grounds of diminished responsibility, was diagnosed as suffering from paranoid schizophrenia. On W's application to a mental health tribunal to review his condition in view of procuring an early discharge, Dr Egdell, a consultant psychiatrist, was asked by W's solicitors to prepare a psychiatric report on W. After examining W, Dr Egdell's opined that W is still highly dangerous and showed persistent interest in explosives. Upon receiving the report, W's solicitors withdrew his application to the mental health review tribunal. However, Dr Egdell believed that the contents of his report should be made available both to the medical director of the hospital that was caring for W and the Home Office, in order to warn those who were involved in caring for W at the hospital and to ensure that the public was in no way endangered by W's early release. W applied to the court for an injunction preventing the disclosure of the report by Dr Egdell. The Court of Appeal refused to prevent disclosure of the report and held that public interest justified disclosure to the medical director and the Home Office. The report described the dangerousness of W that was not known to many. To suppress it would have prevented material relevant to public safety from reaching the authorities responsible for protecting the public. It was in the public interest to ensure that they based decisions on the need for such protection on the best available information. However, before disclosure can be made lawful, there must be an overwhelming public interest in disclosure. A real and serious risk of danger to the public must be shown before the public interest exception is appropriate. The public interest exception can only justify disclosure so long as the threat persists. 81 Thus, although nurses must respect a patient's privacy and protect the confidentiality of all information gained in the context of the professional relationship, they must also be acquainted with the relevant laws governing privacy and confidentiality of personal health information versus public protection. This will help nurses analyze what information should be disclosed, to whom, and for what reasons.
In Malaysia and globally, the nursing profession has developed through various phases in its role as a profession of primary caregivers in health care settings. The evolution of the nurses' roles in upholding legal and ethical standards clearly reflects society's changing perceptions about what is considered acceptable behavior in a caregiving profession. Changes in the legal and ethical frameworks have undoubtedly impacted the nursing profession as nurses are encouraged to take on more responsibility for decision making in the patient care process. It is simply imperative that nurses prepare themselves with the required knowledge so necessary to address the complex legal and ethical issues that have challenged today's professional nurses in Malaysia. Education of nurses about the demands of law and ethics is crucial to nursing practice in order to foster greater accountability, disseminate knowledge, and promote personal commitment in providing health care to individuals across their lifespan. Required course offerings in both university and private sector nursing curricula that specifically focus on the appreciation of evolving legal and ethical standards are essential for the maturation and sophistication of nursing as a profession in Malaysia.
Nursing's Future: Challenges and Opportunities
Nursing possesses a rich history characterized by compassion, dedication and service. As society's culture continues to experience change, the profession of nursing is undergoing continuous evolution. The future of nursing holds a myriad of challenges. These challenges include both external forces as well as influences from within the profession as the role of the nurse is further defined. Although often uncomfortable, change is inevitable and should be embraced. It is the responsibility of nurses to shape the future rather than merely react to the shifts in the tide. Nurses will be positioned to appropriately respond if they adopt an attitude of expectancy, recognize challenges as opportunities, and are adequately prepared to take an active role in shaping future practice. This article will reflect changes we anticipate will impact nursing at the close of the first decade of the 21st century. In addition, we will describe driving forces and key elements in strategies necessary to navigate the waves of change.
Factors contributing to globalization include advances in information technology and communications, international travel and commerce, the growth of multinational corporations, the fall of communism in Eastern Europe and the Soviet Union, and major political changes in Africa and Asia (Heller, Oros, & Durney-Crowley, 2000). Although this death of distance has contributed to the spread of disease, it has also fostered an environment with unprecedented potential. The opportunity for sharing of information regarding advances in medicine and "best practices" among cultures and health care systems will require the nursing profession to broaden its perspective. The concept of community may require redefining in order to consider the impact of international issues in healthcare. Future nurses will especially need to be efficient managers of information. Necessary skills include the ability to access, retrieve, interpret, assimilate, analyze and apply information. Nurses will be looked to for guidance and leadership in coordinating care as diverse populations move across health care settings. Not only is a broadened perspective necessary regarding the view of society, but also for a focus on the individual. Future nurses will face the challenge of maintaining a holistic approach to client care in an environment of growing specialization. Focus on health promotion, maintenance, and revitalization will continue to grow.
Rising Costs of Health Care
The cost of health care has been a major concern for decades. The Center for Medicare and Medicaid projects that healthcare spending will continue to escalate. Despite the fact that the majority of healthcare is publicly funded and out of pocket expenses account for only approximately 14%, heightened consumerism exists along the spectrum of healthcare. As a result, increasing demands for quality, accountability, and cost-effectiveness are shifting the focus of evaluation from process to outcome measures. Along with this, emergence of patient satisfaction and functional status are being recognized as indicators of quality health care (American Association of Colleges of Nursing, 2002). This shift in attention provides nursing with an immense opportunity to herald the positive impact of nursing care on patient outcomes. Current studies are revealing distinct correlation between positive patient outcomes and number and skill mix of nurses (Department of Health and Human Services, 2001). Although additional research is needed, nurses should communicate this relationship between nursing care and positive patient outcomes in order to accentuate the value of nursing.
The realization that 40 million Americans are currently without healthcare insurance seems overwhelming and presents cultural and ethical considerations. Proponents of healthcare rationing as a solution to controlling mushrooming costs exist among all levels of care providers. The nursing profession will need to be prepared to accept the familiar role of patient advocate as the tapestry of decision-making becomes ever so complex. Additionally, the orchestrated shift from acute care to population-focused outcomes by third party payers will over the next 5-10 years result in communities becoming the arena for managing recurring illnesses. This will result in an expanded need for more nurses with population-level assessment, management, and evaluation skills (Stanhope & Lancaster, 2000). The burden of cost control is no longer limited to those in the accounting office but should be shouldered as a collaborative effort of all involved disciplines with nursing playing an integral role.
Health Care Complexity
The comprehensive health care needs of individuals and communities will require a plethora of knowledge and skills provided in an effective and efficient manner (Heller, Oros, & Durney-Crowley, 2000). This will require greater degrees of team based collaboration among health care professionals. Nursing education programs must therefore incorporate interdisciplinary education and collaborative practice to prepare tomorrow's nurses.
The mounting complexity of patient care and resultant changes in health care delivery systems has also afforded nurses a wider range of functionality. Although independence and the entrepreneurial spirit have been cultivated through expanded roles, reimbursement for nursing services shows slow progress. Trends towards downsizing and the current nursing shortage have increased the use of non-licensed personnel in many healthcare arenas. This will continue to force the nursing profession to identify, clarify, and communicate its scope of practice.
Additionally, recruitment and retention efforts must include an awareness of the changes in student demographics. Comprehensive recruitment strategies aimed toward minority populations will help increase enrollment of minority groups. An influx of minorities such as men, Hispanics, African-Americans, and American Indian into the profession will cultivate a diversity of trained professionals to answer the call of an increasingly diverse population.
Nursing's dissatisfaction with the workplace environment is another issue that must be faced when considering the profession's future. A Georgia Nurses Association survey demonstrated that 82% of the nurses surveyed were dissatisfied with their work (Hatmaker, 2001). This dissatisfaction was multifaceted and included issues such as workplace violence, inability to attend continuing education programs due to heavy workloads, exhaustion, and inability to provide safe patient care (Hatmaker, 2001). The survey also revealed that 73% would actively discourage their child from choosing nursing as a career. What measures will take place to overcome or help alleviate these serious issues? Programs such as Georgia's Commission on Workplace Advocacy are developing to help staff nurses, nurse managers, and employers with these challenges (Hatmaker, 2001). Issues such as workplace violence, mandatory overtime, and nurse/patient ratios are being discussed in legislatures across the country. Mee and Robinson (2003) state that "nurses need work environments with strong professional practice models that value their work and recognize their impact on patient outcomes" (p. 4). The future of nursing must include resolution of these issues or the sting of the nursing shortage will be more painful.
Nurses of the future must be able to educate the public and policy makers of nursing's scope of practice and skills (American Association of Colleges of Nursing, 2002). As one takes into account the allocation of limited resources of nurses and money, it becomes clear; the nursing profession cannot afford to sit idly by and simply react to changes dictated by policy makers, but rather, should be proactive in its approach to anticipating needed change and develop strategies to shape the future of healthcare. Florence Nightingale set the stage for political activism and we must therefore honor her actions and not become politically apathetic. At 2.7 million, nurses rank as the nations largest healthcare profession (Nursing's Agenda for the Future, 2002). However, only one out of ten nurses are members of the American Nurses Association (ANA). Reasons why the ANA has not captured the majority of their constituency must be examined. We all know that power exists in numbers. Unification and organization is the key for success in rallying this vast army and mobilizing for action.
With advances in technology, communication of concerns and priorities to the masses regarding issues directly affecting nursing practice will be facilitated. Nurses should be intent in developing communication skills, both written and verbal, that may be employed in one-on-one interactions, small groups, and public arenas. At all levels of education, preparing the nurse to negotiate the political system should be a priority (American Association of Colleges of Nursing, 2002). By increasing nurses' representation and participation in health policy agencies, committees, and consumer boards, the voice of nursing will be heard.
In an effort to draw more people into nursing, nursing educational programs will become more flexible, affordable, and accessible. According to Wieck (2004), "nursing education is probably the most inflexible 'onesize fits all' environment that exists today" (p. 6). This will have to change if nursing is to have any hope of luring the twenty something generation into professional nursing careers. As the American society becomes more diverse, so too will the nursing workforce. More campaigns such as Johnson and Johnson's Campaign for Nursing's Future and the Oregon Center for Nursing's campaign, Are You Man Enough to be a Nurse, will need to be launched to bring more men and minorities into the profession. Other recruitment trends will be lower educational costs, greater access to federal loans and grants, and new educational methods including shortening the time required to become a registered nurse (Buerhaus, Staiger, & Auerbach, 2001).
Imaginative research and development strategies will help secure greater numbers of graduate students choosing nursing educator careers and more federally funded scholarships and grants will enable them to affordably complete their education. The programs of study may also reflect innovative changes already pursued in other programs. According to Matthews (2003), "educator preparation should be a core competency for nursing graduate students regardless of specialty" (p. 4). Greater access to masters and doctoral programs and the elevation of faculty salaries and benefits will enhance recruitment into nurse educator programs of study (Matthews, 2003). Unless these challenges facing the shortage of nurse educators are addressed, the pattern of more graduate students choosing more lucrative career options such as certified registered nurse anesthetist, nurse midwife, nurse practitioner, and clinical nurse specialist will continue.
Nursing leadership will become increasingly important in the next five years. Effective, well-prepared, transformational nurse leaders are needed to tackle the challenges facing the profession. These leaders will help to unify nursing, which is known for 'eating its young". The profession must change old harmful patterns of behavior and learn to respect and care for one another. Nurses must believe and demonstrate the worth of nursing so that society will recognize its value. As the number one ranked profession in honesty and ethics in three out of the last four years, we hypothesize that perhaps the image problem is confined within the profession and not among society as a whole. The profession must capitalize on the public's trust.
Clearly, nursing's future does indeed include manifold opportunities and challenges. The profession must not be complacent but it must become proactive in shaping its future, otherwise someone else will do it for us. Consider this statement; "time is short, resources are scarce, and issues are critical" (Nursing's Agenda for the Future, 2002, p.7). Nursing must act now in a unified voice with a resolved spirit to determine its own destiny.
A nurse's guide to the importance of appropriate professional boundaries
As a health care professional who provides nursing serves to clients, the nurse strives to inspire the confidence of their. clients. The nurse needs to treat all clients, as well as other health care providers, professionally. Clients can expect the nurse to act in their best interests and respect their dignity. This means that the nurse should abstain from obtaining personal gain at the client's expense and refrain from inappropriate involvement in the clients personal relationships. The nurse should promote the client's independence.
To do these things, the nurse must understand and apply the following concepts of professional boundaries.
Professional boundaries are the spaces between the nurse's power and the client's vulnerability. The power of the nurse comes from the professional position and the access to private knowledge about the client. Establishing boundaries allows the nurse to control this power differential and allows a safe connection to meet the clients needs.
Boundary crossings are brief excursions across boundaries that may be inadvertent, thoughtless or even purposeful if done to meet a special therapeutic need. Boundary crossings result in a return to established boundaries but should be evaluated by the nurse for potential client consequences and implications. Repeated boundary crossings should be avoided!
Boundary violations can result when there is a confusion between the needs of the nurse and those of the client. Such violations are characterized by excessive personal disclosure by the nurse, secrecy or even a reversal of roles. Boundary violations can cause delayed distress for the client, which may not be recognized or felt by the client until harmful consequences occur.
Professional sexual misconduct is an extreme form of boundary violation and includes any behavior that is seductive, sexually demeaning, harassing or reasonably interpreted as sexual by the client. Professional sexual misconduct is an extremely serious violation of the nurse's professional responsibility to the client. It is a breach of trust!
A Continuum of Professional Behavior
Every nurse-client relationship can be plotted on the continuum of professional behavior illustrated below.
A zone of helpfulness is in the center of this professional behavior continuum. This zone is where the majority of client interactions should occur for effectiveness and client safety. Overinvolvement with a client, which includes boundary crossings, boundary violations and professional sexual misconduct, is on the right side of the continuum. Under-involvement, which include distancing, disinterest and neglect and can also be detrimental to the client and nurse, lies on the left side. There are no definite lines separating the zone of helpfulness from the ends of the continuum; instead, it is a gradual transition or melding.
This continuum provides a frame of reference to assist nurses in evaluating their own and their colleagues' professional-client interactions. For a given situation, the facts should be reviewed to determine whether or not the nurse was aware that a boundary crossing occurred and for what reason. The nurse should be asked: What was the intent of the boundary crossing? Was it for a therapeutic purpose? Was it in the clients best interest? Did it optimize or detract from the nursing care? Did the nurse consult with a supervisor or colleague? Was the incident appropriately documented?
Some guiding principles to determining professional boundaries and the continuum of professional behavior include the following:
The nurse is responsible to delineate and maintain boundaries.
The nurse should work within the zone of helpfulness.
The nurse should examine any boundary crossing, be aware of its potential implications and avoid repeated crossings.
Variables such as the care setting, community influences, client needs and the nature of therapy affect the delineation of boundaries.
Actions that overstep established boundaries to meet the needs of the nurse are boundary violations.
The nurse should avoid dual relationships where the nurse has a personal or business relationship, as well as the professional one.
Post-termination relationships are complex because the client may need additional services, and it may be difficult to determine when the nurse-client relationships is truly terminated.
Questions and Answers Regarding Professional Boundaries and Sexual Misconduct
What if a nurse lives in a small community? Does this mean that he or she cannot interact with neighbors and friends?
Variables such as the care setting, community influences. client needs. nature of the therapy provided, age of the client and degree of involvement affect the delineation of behavioral limits. All of these factors must be considered when establishing boundaries, and all contribute to the complexity of professional boundaries.
The difference between a caring relationship and an over-involved relationship is narrow. A professional living and working in a remote community will, out a necessity, have business and social relationships with clients. Setting appropriate standards is very difficult. If they do not relate to real life, these standards may be ignored by the nurse or simply not work. However, the absence of consideration of professional boundaries places the client and nurse at risk.
What if a nurse wants to date or even marry a former patient? Is that considered sexual misconduct?
The key word here is former, and the important factors to be considered when making this determination are: What is the length of time between the nurse-client relationshin and the dating? What kind of therapy did the client receive? (Assisting a client with a short-term problem, such as a broken limb, is different than providing long-term care for a chronic condition.) What is the nature of the knowledge the nurse has had access to, and how will that affect the future relationship? Will the client need therapy in the future? Is there risk to the client?
Do boundary violations always precede professional sexual misconduct?
Boundary violations are extremely complex. Most are ambiguous and difficult to evaluate. Boundary violations may lead to sexual misconduct, or they may not. In some cases, extreme sexual misconduct, such as assault or rape, may be habitual behavior, while at other times, it is a crime of opportunity. Regardless of the motive, extreme sexual misconduct is not only a boundary violation, it is criminal behavior.
Does client consent make a sexual relationship acceptable?
If the client consents, even if the client initiates the sexual contact, a sexual relationship is still considered sexual misconduct for the health care professional. It is an abuse of the nurse-client relationship that puts the nurse's needs first. It is always the responsibility of the health care professional to establish appropriate boundaries with present and former clients.
How can a nurse identify a potential boundary violation in the making?
Some behavioral indicators can alert nurses to potential boundary issues, for which there may be reasonable explanations. However, nurses who display one or more of the following behaviors should examine their client relationships for possible boundary crossings or violations.
The nurse discusses personal problems or aspects of his or her intimate life with the client, or discusses feelings of sexual attraction.
The nurse keeps secrets with the client and/or becomes guarded or defensive when someone questions their interaction.
"Super Nurse" behavior
The nurse believes that he or she is immune from fostering a nontherapeutic relationship and that only he or she understands and can meet the client's needs.
Singled out client treatment or client attention to the nurse
The nurse spends inappropriate amounts of time with a particular client, visits the client when off duty or trades assignments to be with the client. This form of treatment may also be reversed, with the client paying special attention to the nurse, e.g., giving gifts to the nurse.
The nurse. fails to explain actions and aspects of care, reports only some aspects of the client's behavior or gives "double messages. In the reverse; the client returns repeatedly to the nurse because other staff members are "too busy"
The nurse communicates in a flirtatious manner, perhaps employing sexual innuendo, off-color jokes or offensive language.
"You and me against the world" behavior
The nurse views the client in a protective manner as his or her client, tends not to accept the client as merely a client or sides with the client's position regardless of the situation.
Failure to protect client
The nurse fails to recognize feelings of sexual attraction to the client, consult with supervisor or colleague, or transfer care of the client when needed to support boundaries.
The Nurse's Challenge
* Be Aware.
* Be cognizant of feelings and behavior.
* Be observant of the behavior of other professionals.
* Always act in the best interest of the client.
What are some nursing practice implications of professional boundaries?
Nurses need to practice in a manner consistent with professional standards. Nurses should be knowledgeable regarding professional boundaries and work to establish and maintain those boundaries. Nurses should examine any boundary crossing behavior and seek assistance and counsel from their colleagues and supervisors when crossing occur.
What should a nurse do if confronted with possible boundary violations or sexual misconduct?
The nurse needs to be prepared to deal with violations by any member of the health care team. Client safety must be the first priority. If a health care provider's behavior is ambiguous, or if the nurse is unsure how to interpret a situation, the nurse should consult with a trusted supervisor or colleague. Incidents should be documented in a thorough and timely manner. Nurses should be familiar with reporting requirements, as well as the grounds for discipline, in their respective jurisdictions, and they are expected to comply with these legal and ethical mandates for reporting.