E8. NUR09722 Exploring the Theory and Application of Ethical Reasoning in Nursing Practice

by admin | Jan 21, 2023 | Nursing

CODE FOR
NURSES AND MIDWIVES
SINGAPORE NURSING BOARD

CO NTE N TS

IN TR O DU CTIO N 2

Nurses/Midwives a n d People 4
P rin ci ple 1: Respect People s values, needs and rig h ts
P rin ci ple 2: Respect and pro mote Peoples autonomy
P rin ci ple 3: Respect Peoples rig h t to confiden tiality a nd p riva cy
P rin ci ple 4: A dvo ca te i n the best i n te re st o f Peo ple

N urs es /Midwive s and their pra ctice 8
P rin ci ple 5: P ra ctis e in a resp onsible and a cc oun table m anne r
Prin ci ple 6: M aint a in com pe ten cy in t he c are o f Pe op le
P rin ci ple 7: M ain ta in cl ea r and acc ura te r eco rd s

N urs es /Midwive s and their profess ion 11
P rin ci ple 8: P ro m ote p ro fe ssi ona lis m and upho ld pub lic trust
P rin ci ple 9: P ra ctis e sel f-re gula tio n

N urs es /Midwive s and c o-wor ker s 13
P rin ci ple 10: W ork colla b ora tiv ely w ith all m em be rs o f th e hea lt h ca re team

Refe rence s 14

Glossary of Terms 15

A ppendix 1: P ro fessi onal B oundari es : Gu id e lines for N urses &
Midwi ve s
1 7

A ppendix 2: 2 0

Use of So
cial Media : Gu idelines fo r Nurses & Midw iv es

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Upo n reg istrat ion a nd /o r enrolm en t w ith th e S ing apore Nursing Board ,
nurses and m idw ives co mmit t o u phol ding th e p ro fe ssio nal re qu ire m ents set out
in Th e Code .

E m ploy ing o rg anisat ions should support their sta ff in uph oldin g T he Cod e
to ensu re t hat a h ig h le ve l o f tru st th at th e publ ic and reg ulat ors ha ve in t h e q uali ty
and sa fety o f nursi ng/m idw ife ry p ract ice is m aint ain ed.

E duca tors can u se Th e Cod e to help nursing/m idw ife ry stu dents a nd
tra ine es understa nd the significa nce of T he Cod e and its
im pact on their
p ro fe ssion al ro les.

T he Cod e s upple ment s th e req uire m ents of the Nurse s and Midw ive s Act
(C ap 209) (20 12 Re vised editi on). It int egrate s all aspec ts of expecte d
p ro fe ssion al co nduct a nd pract ice sta ndards in to one d o cu men t a nd rep lace s th e
S ing apore Nursing B oa rds Code o f Eth ics and P ro fe ssio nal Con duct (19 99),
Cod e o f P ract ice fo r M idw iv e s (20 01) and Standa rds of P ract ice fo r Nurse s and
M idwiv e s (2 011).

R EG IS TR AR
S IN G APO RE N URSING B O AR D
2 A pril 2 018
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N URSES / M ID W IV ES A N D PEO PLE

Princ iple 1 : R es p ec t P eople s v a lu es, n eed s a nd ri ght s

N urs e s/m id wiv es p rovide ca re t hat is dete rm ined b y P eopl es va lues , n e eds and
ri g h ts , w it h o ut a ny unf air o r p re ju d ic ia l d is c rim in a tio n , whe ther o n th e b a sis of
gen de r, e th nic it y, r e lig io n, a g e, so cial o r e cono mic statu s, o r o th er p ro file , a ttri bute
o r pre fe re n ce . Of upm ost prior ity is the sa fe ty and well-bein g o f e ve ryon e wh o
req uire s n u rsi ng o r midw ifery se rv
ice s.

P ra c tic e S tateme nts

To ach ie ve t h is, nurse s/m id w iv e s m ust:
tre at P eop le w ith resp ect, co mpassi on and kindness
conside r cu ltu ral sensitiv ities when respondi ng to P eoples pe rson al and h ea lth
nee ds
conside r P eop les ne ed s, v a lu e s, w ish es a n d fe elin gs w hen d ete rm in in g a p la n o f
ca re /se rvice
re nd er a p pro pria te c a re to su ppo rt a d ig nif ie d a n d p e a ce fu l d ea th a t th e e nd o f
li fe

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P
rinc iple 2 : R es p ec t and pro mote People s au to n om y and right to self –
de te rm ination

N urse s/m id w ive s re sp e ct th a t P eop le h a ve th e r ig ht to s e lf – d ete rm in atio n . P eop le ha ve
th e ri gh t to d e te rm ine w ha t w ill be d on e w ith a n d to th em se lves ; to b e g iven a ccu rate
inf orm atio n in a m an ne r th at fa cil ita te s an inf orm ed d e cisi on. Th ey ha ve th e ri g h t to
vo lun ta rily a cce pt, re fu se or te rmina te tre a tm en t.

P ra c tic e S tatement s

To a ch ie ve t h is, n ur
se s/m id w iv e s must , to t he b est of t he ir a vailab le kn owl ed ge a nd
a b ilit y:

in fo rm P eop le unde r th e ir c a re o f th e ca re o ptio ns th at a re a va il a b le
assis t P eop le to o bta in th e re le va nt in fo rm atio n fr o m reli ab le a nd /o r off ici al
so urce s
co nside r w he th er it is like ly fo r a p e rson w ithou t de cisi on -m aking capa city to
reg ain capa city a t so me tim e in th e fu ture to m ake th e d e cisi on in qu e stio n a nd
w hen it is li kely to h app e n
pe rm it and e n co urag e a p e rs
on to p a rti cipa te , o r to im prov e h e r or his ab ility to
p a rti cipa te , as fu lly a s po ssible in an y a ct don e fo r th e p e rson o r an y d e cisi on
a ff ecti ng h er o r him
se ek, whe re app lica ble or ap p ro pria te , th e co nse nt of a leg ally a u th orise d
rep rese nta tiv e w hen a p e rson is inca pa b le of d e cisi on -m aking
en su re that th e ri gh ts an d b e st int erest s (b oth cli nical and n on -cli nical) of th ose
w ho lack men ta l ca pacity o r are oth erw ise vulne rab le to h a rm o r exp loita tion
a re a lways a t th e c en
tr e o f th e d ecisi on -m aki ng

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P rinc iple 3 : Saf egua rd P eop le s r ight t o p riv acy a nd co nfid en tia lit y

P riva cy is t he ri ght to c o n tr ol a cc ess t o one se lf, in clud in g th e c ir cu m sta nce s, tim in g a nd
e xte nt to whi ch in fo rm atio n is to be discl ose d . Con fiden tia lity per ta in s to the
n o nd iscl osu re o f pe rs on al a nd cli nica l in fo rma tio n. N urses/ midw ives ha ve a d uty to
sa feguard p riva cy and m aint ain c o nfid e ntia lit y o f a ll in fo rm ation pe rta in ing to P eopl e
unde r thei r c a re . H ow eve r, onl y re
le vant in fo rm ation may be shar ed wit h o ther s
d ir e ctly in vo lv ed in , an d nec essa ry f or, t he pro vis ion of ca re .

P ra c tic e S tateme nts

To ach ie ve t h is, nurse s/m id w iv e s must:

respect Peop les r ig h t to priv a cy a nd d ig n it y i n a ll a spects of t hei r care
sa fe gu a rd and m aint ain co nfid en tia lity unles s there is so und ju sti fica tions fo r
d iscl osu re to b e m ade w ithout the person s co nsent ; su ch ju sti ficat ions in clude
d iscl osu re that is m andate d b y law o r nece ssa ry in orde r to prote ct
th e p erso n
o r o thers fro m a serio us ri sk o f har m
r e spec t that a per so ns r ig h t to p riv a cy and conf id entia lit y c o ntinue s a fte r
dea th

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P rinc iple 4 : A dvo ca te fo r a nd in t h e b es t int ere s t o f P eopl e

N urse s/m id w ive s adv oca te fo r P eop le b y sp ea ki ng up in f a vo u r o r supp ort o f t h e ir ri g h ts,
va lu e s, i n te re sts and wi shes.

P ra c tic e S tateme nts

To ach ie ve t h is, nu rs es/m id w ives m ust :
sa fe gu a rd P eople fr o m undu e in flu ence to acce pt or ch ang e a pa rtic u la r
co urse o f a ctio n, if th e y d o n ot c h oo se to d o s o v o lu n ta ril y
b e a le rt to a n d ta ke a p pro p ria te a ction whe
n th e rig h ts , w ell- b e in g o r s a fe ty o f
P eop le a re in je opar dy
rep ort un sa fe cli nical p ract ices that co uld po te ntia lly co mpro mise P eopl es
sa fe ty
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NUR SES / M IDW IV ES AN D THEI R PR ACT IC E

P rinc iple 5 : P ra cti se in a re spo nsible a n d ac co u nta b le m ann er

N urs e s/m id w ive s are re sp on si ble a nd a cco un ta ble fo r their ju dg m ents, deci sion s and
a ctions. Th ey e n su re th a t P eople re ce iv e sa fe , e ff e ct ive a nd e th ica lly a pp rop ria te ca re .

P ra c tic e S tateme nts

To ach ie ve t h is, nu rs es/m id w ives m ust:

recogn ise a nd work with in th e li m its of their co mpe te nce , sco pe of pract ice
and ta ke in to a cco unt their own s
a fe ty
e sca late c once rns when asked to p ra cti ce b eyo nd their scope, experi ence
and t raining
ensu re th at p ra ctice is ca rried out in a cc ord a nce w ith e th ical p rin cip les,
i n stit u tio na l p o lici es and req uire m ents
ide ntify a nd re duce ri sk to p ro mote w ork p lace sa fety a nd healt h fo r co –
w orkers and those re ce iv ing ca re
a le rt th e a p p ro p ria te a uth o rit y o f a n y si tu a tio ns w hich m ay e nd an ge r the
hea lt h o r s a fe ty o f P eop le
p ro vi de a cc u ra te , re le va nt a nd e vid
e nce -bas ed in fo rm atio n w hen sp ea kin g
o n n u rsi ng/m idw ife ry o r hea lt h -re la te d m atte rs
u se jud gm ent re ga rd in g a nur se/m idwi fe s co mpete nci es whe n a ccept ing
and d ele gatin g r espon sibilitie s.
e n su re th at r e se a rch is c ond ucte d in a cco rd a nce w it h e th ic a l p rin cip le s a nd
i n stit u tio na l g u id elin e s and, w her e app ro pria te , a p prov ed by th e app ropr iate
i n stit u tio na l r eview b oa rd a nd /o r r egula to ry aut ho rity

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P rinc iple 6 : M aint ain c o m pete n cy in t h e c a re of Peop le

N urse s/m id w ive s co nsta ntly eva lu ate th eir kn ow le dge an d skil ls as well as th e
e ffe ct iv e n ess of ca re th e y p ro vi de. T hey m ain ta in th e ir co mpete ncy th ro u gh co ntin u in g
e du ca tio n , q u a lity improve men t a ctivities a nd li fe lon g le a rnin g. T he y p ra ct ise e vi de n ce –
b a se d n u rs in g/m id wi fe ry .

P ra c tic e S tatement s

To a ch ie ve t h is, n u rs es/m id w ives m ust :

ensu re th at th eir p ra ct i
ce is ba se d o n p rev ailing clinica l pract ice gu id e lin e s
ke ep a b re ast w it h p ro fe ssio na l a d va n ce s a nd d e ve lop men ts by p a rtici pa tin g
i n co ntin uin g e du ca tio n a ct iv it ie s
co mple te n e ce ssary tra inin g a n d a ch iev em en t of c o m pete ncy p rio r to ca rrying
o u t a n ew ro le/assig nm ent
prov ide h o ne st an d co nstru ctive fe edb a ck to co lle a gu e s in ord e r to h e lp th em
im prov e t he ir p ract ice and p e rfo rm an ce
ob ta in a nd re fle ct on fe ed ba ck t o im prov e p ra ctice and p erfo rm an ce

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P rinc iple 7 : M ain ta in c le ar a n d acc ura te r e co rd s

N urse s/m id w ive s en su re t ha t a ll re cords a re c om plet e, accu rate a n d tim ely .

P ra c tic e S tatement s

To a ch ie ve t h is, n u rs es/m id w ives m ust :

co mple te a ll d ocu m en ta tio n/re co rds at th e t im e o r a s s oon a s po ssibl e a fte r
a n e ve n t
en su re their e ntri es m ad e a re clea r, da te d , tim ed a nd sig ned /in itialled
exclud e t he u se of u nau th orize d a bb rev iation s, jarg on s or sp ecu lat io n s
en su re that all re cord s are k
e pt se cu rely
ab ide by le gisl ativ e a nd in stitu tiona l guid elin es

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NUR SES / M IDW IV ES AN D THEI R PR OF ESS ION

Princ iple 8 : P ro m ote prof ession alis m a n d up hol d p ub lic t r u st

N urse s/mid w ive s have a duty to upho ld the rep uta tion of t he p rofession a t a ll t im es.
Th ey should persistently s tr ive to p re se rve pub lic tr u st a n d c o nfid e nce .

P ra c tic e S ta teme nts

To ach ie ve t h is, nu rs e s/m id w ives m ust :
uph old and abid e b y t he st andards and v alue s se t ou t in th is Co de
be conscio us at all ti m es how th eir b ehav iour an d co nduc t ca n a ff ect
an d
inf luenc e o thers and the p ro fession
maint ain object ivity w ith clea r pro fe ssio nal bound arie s (ref er to A ppe ndix 1 ) a t a ll
tim es with P eople
be res pect ful, r e sp on sible and a cco untable at a ll t im es w hen u sing a ll f orm s o f
spoke n, writt en, and dig ita l co mm unic atio n, incl uding so cial medi a and
netw orki ng site s (r efe r to App endix 2)
nev er m isuse th e p ro fession al sta tu s o r prac tice in a w ay th at co uld b rin g th e
p ro fe ssio n t o d isr epu te o r se riously unde rm ine p ub lic t rust o r co nfid ence
ensu re that a n y publi cations o r p ub lished /subm itte d m ate ria ls pro duce d a re
a ccu ra te , resp on si ble, e th ical an d re flec t th eir rele vant skills, experi ence and
q uali ficat ions.
adh ere to inst itu tio nal policies and g u ide lines w here ava ilable, wi th reg ard to
th e a cc ept anc e o f g if ts, m on ies, h o sp ita lity o r induc em ents fr o m cli ents and/or
co mpanies , or to o th e rw ise a vo id beco ming beho lden to a n y person a n d
o rg anisat ion and /or a lle ga tions o f pro fessio na l m isco nduc t

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P rinc iple 9 : P ra ctis e s elf – r e g u la tio n

N urs e s/M id w iv e s a re re sp onsib le a nd a cc oun ta ble to s e lf , P eop le , a n d th e p ro fe ss io n fo r
m ain ta in in g co m pete n ce and co ntinued pers ona l and pro fe ssio na l gro w th , fit n ess to
p ra ctis e and a v a lid li c e nse to p ra ctis e . T hey a re re spon sib le fo r th eir o w n hea lt h , s a fe ty
and w ell- b e in g.

P ra c tic e S tatement s

T o a ch iev e th is, n urse s/m idwives m ust :
maint ain a v alid P ract is ing Ce rtificat e
co m
ply w ith all re gu lat ory p olicies and guid elin e s
pract ise with in th eir o wn level o f co mpe te nce and scop e o f pract ice
ensu re c o n tin u ing co mpe te ncy in th e re lev an t a rea s of p ra ctice
maint ain th e ir o w n p h ysical, psy ch olog ical a nd e m otio na l fit n e ss
up ho ld p e rson al i nte grity

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NUR SES / M IDW IV ES AN D CO -W ORK ERS

Princ iple 10 : W ork c o lla bor ativ e ly w it h a ll m em bers o f t h e h eal th car e t eam

Nurse s/midwives w ork collaborativ ely and res pectf ully with c o -worke rs in nursi ng and in
o th er rel ate d fie lds , a s the conte xt o r situ atio n r equir es. T hey c ont ribut e t o a co llabor ative
and s upporti ve e n vi ro n m en t t hat p rio ritise s th e b est int erest s of P eop le .

P ra c tic e S tateme nts

To ach ie ve t h is, nurse s/m id w iv e s must:

promot e re spect ful int eract ions and mutu al p ee r su ppo rt

m aint ain cle ar, co ncise and t im ely co mmunica tion w ith co -w orkers
resp ect the skill s and experti se of co -w orkers, and when a pp rop ria te , r efe r
m atte rs to the m fo r a dvice
adv oca te e th ical hea lth ca re d eliv e ry a nd sa fe p ract ices a s a te am
share kn ow led ge a nd experi ence to re solve e th ical issu es

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REFERENCES

International Council of Nurses (ICN) (2012) . The ICN Code of Ethics for Nurses .
Geneva: ICN.

National Council of State Boards of Nursing (NCSBN) (2014 ). A Nurses Guide to
Professional Boundaries . USA: NCSBN.

Nurses and Midwives Act, Cap 209 ( 2012 Revised edition) . Singapore .

Singapore Nursing Board (SNB) (1999 .) Code of Ethics and Professional Conduct .
Singapore: SNB .

Singapore Nursing Board (2001) . Code of Practice for Midwives . Singapore: SNB .

Singapore Nursing Board (2011) . Standards of Practice for Nurses and Midwives .
Singapore: SNB .

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GLOSSARY OF TERMS

Accountability Being answerable and responsible for the outcome of ones
p ro fe ssi onal a ct io ns (in cl udes a n y judg ment, de cisi on or a ct io n
t a ke n or om itted in nursin g pra ctic e ). Nurs es/m idw iv es are
a cc o u ntabl e to people, their em plo yer and t h e S ingapo re N ursi ng
Boa rd .

Advocacy Speaking up in favour or support of peoples rights, values,
in te re sts an d w is hes .

Autonomy The right of adults to determine their actions and destinies
based on their values, interests and wishes.

Client(s) An individual or group who seeks or receives professional care,
health services o r a d vic e f r o m a n u rs e /m idw if e .

Competence The ability of a nurse to demonstrate the knowledge, skills,
judgment and attitude required to perform activities within the
defined scope of practice at an acceptable level of proficiency .

Confidentiality The obligation not to disclose certain types of information
without appropriate consent or justifications.

Consent Permission given by people for a procedure or action to be
carried out upon them by their attending n u rse /m idw if e .

Dignity Treating people with respect and consideration for their rights.

Evidence-based
nur sing
The process of reviewing current research findings (evidence)
pu blis hed in s ci ent if ic jour nals or o th er d ata s o u rc es. Eva luat in g
the re le vance of th is evid en ce to cu rr e nt nu rsi ng pra ct ic e .
M od if y ing e xis tin g p ra ctic e w her e in dic at ed and eva luat in g th e
i m pa ct o f the m odif ied pra ctic e.

Healthcare
team
Co-workers in nursing, healthcare and other related fields; may
extend to volunteers and others who play a role in providing
health services.

Integrity An internal quality (a cluster of attributes) within oneself.
Manifested externally as honesty and moral consistency:
consistency with ones values, convictions, beliefs, knowled ge,
commitments and obligati ons.

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GLOSSARY OF TERMS

Midwife A person who has completed a course in midwifery and is
li c e nsed by the Sin ga po re Nursi ng Boar d to pra ct ise as a
R egis te red Mid w ife .

Nurse A person who has completed a pre-registration or pre-enrolment
nur sing c o u rs e a n d is li c en sed by th e Sin gapo re N ursi ng B oard
(SNB) to p ra ct ise as a Regist ere d Nurs e o r E nro lled Nurs e .

People Individuals (clients, patients), family members, significant others
and the community who receive care and health -related services
from nurses and midwives .

Professional
Misconduct
Defined as any act or omission that:

constitutes a deviation from the C ode
abuses the professional relationship with the client
brings the nursing profession into disrepute

Responsibility Obligation to properly carry out duties which are expected of a
nurse/midwife and for which they can be held accountable .

Relevant
authority
A person or entity having legal, regulatory or administrative power
and control pursuant to legislation or regulation, including
regulatory guidelines or policies.

Acknowledgement

The Singapore Nursing Board gratefully acknowledges the contributions of its Ethics
Committee members (2015 to 2017) , nursing representatives from various settings,
nursing students, nursing leaders and ethics expert Dr Megan-Jane Johnstone.

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Appendix 1
Professional Boundaries : G uidelines for Nurses & Midwives
(Adapted from National Council of State Boards of Nursing (2014) A Nurses Guide to
Professional Boundaries )

Professional boundaries are the spaces between t he nurses/midwives power and the
client s vulnerability. The power of the nurse /midwife comes from the professional
position and access to sensitive personal information. The differ ence in personal
information the nurse/midwife knows about the client versus personal information the
clien t knows about the nurse /midwife creates an imbalance i n the nurse-client
relationship. Nurses /midwives should make every effort to respect the pow er imbalance
and ensure a client-centred relationship.

Boundary crossings are brief excursions across professional lines of behavio ur that
may be inadvertent, thoughtless or even purposeful, while attempting to meet a specia l
therapeutic need of the client. Boundary crossings can result in a return to established
boundaries, but should be evaluated by the nu rse/midwife for potential adverse client
consequences and implications. Repeated boundary crossings should be avoided.

Boundary violations can result when there is confusion between the needs of t he
nurse /midwife and those of the client. Such violations are characteri sed by excessive
personal disclosure by the nurse, secrecy or even a rever sal of roles. Boundary violations
can cause distress for the clien t, which may not be recognised or felt by the client until
harmful consequences occur.

A nurse /midwifes use of social media is another way that nurses can unintentionally
blur the lines between their professional and personal lives. Making a comment via
social media, even if done on a nurse /midwifes own time and in their own home,
regarding an incident or person in the scope of their emplo yment, may be a breach of
clien t confidentiality or privacy, as well as a boundary violation.

Professional sexual misconduct is an extreme form of boundary violation and
includes any behavio ur that is seductive, sexually demeaning, harassing or reasonably
interpreted as sexual by the client. Professional sexual misconduct is an extremely
serious, and criminal violation.
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Boundaries and the Continuum of Professional Nursing/Midwifery Behaviour
Every nurse
-patient relationship can be plotted on the continuum of professional
behaviour illustrated above.
The nurses/midwifes responsibility is to delineate and maintain boundaries.
The nurse/midwife should work within the therapeutic relationship ;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/midwife are
boundary violations.
The nurse/midwife should avoid situations where he or she has a personal, professional
or business relationship with the client.
Post-termination relationships are complex because the client may need additional
services. It may be difficult to determine when the nurse -client relationship is completely
terminated.
Be careful about personal relationships with clients who might continue to need
nursing/midwifery services (such as those with mental health issues or oncology
clien ts).18

A CONTINUUM OF PROFESSIONAL BEHAVIOUR

UNDER-INVOLVEMENT THERAPEUTIC RELATIONSHIP OVER-INVOLVEMENT

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Appendix 2
Use of Social Media: Guidelines for Nurses & Midwives

Introduction

Social media is a beneficial tool when used wisely. It fosters professional connections,
promotes timely communication, and educates people and healthcare professionals. The
use of social media, however, can pose a risk as the ease of posting allows little time for
reflective thought , verification or authentication , could be misinterpreted or
misappropriated and that information once posted, has the potential of rapid circulation.
Moreover, deleted contents are often still accessible and recoverable. Hence, nurses
need to pay attention to the following guidelines in order to reduce risks to members of
the public and the healthcare profession.

The purpose of this guide is to provide advice to nurses on using social media.

Definition

Social media describes the online and mobile tools that people use to share opinions,
information and experiences, images and video or audio clips, and includes websites
and applications used for social networking. Common sources of social media include,
but are not limited to: social networking sites such as Facebook and LinkedIn; personal,
professional and anonymous blogs; WOMO, True Local and micro blo gs such as Twitter;
content -sharing websites such as YouTube and Instagram, and discussion forums and
message boards.

Common expectations for nurses include:

1. Benefits and Risks

Know the benefits and risks of social media. Build your competence. Know the
technology and have the skills and judgment to use it appropriately and ethically. Be
aware of social medias evolving culture and changing technology. Reflect on the intent
and possible consequences of your online behaviour – before you blog, post or tweet.

2. Professional Image

Use the same level of professionalism in your online interactions as you do face -to -face.
Keep your personal and professional lives separate. Use different accounts for personal
and professional activities.

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3. Confidentiality

Do not share any client information on social media sites. Leaving out details when you
post information or images does not protect client confidentiality. Report confidentiality
breaches to the right person, immediately.

EXAMPLE
Jane has been working in the cancer ward for the last six years. She is friends on
Facebook with her patient Mary. One day, Mary posted about her depression. As her
nurse, Jane wanted to provide support, so she posted, I know the past month has been
difficult and trying. Hopefully the new anti -depressant will help. The morphine dose has
been increased and should make you more comfortable. I will see you next Friday. On
Janes Facebook profile page, she has listed herself as an Oncology trained nurse
wor king in an Oncology Ward.

Jane had Marys best intentions at heart when she offered her words of support.
However, she inadvertently disclosed Marys condition on a social media site. Everyone
who read that post now knows Marys medication, increase in m orphine and possibly
even her cancer diagnosis, violating her right to privacy and confidentiality.

4. Privacy

Set and maintain your privacy settings to limit access to your personal information. Be
aware of your privacy settings and know that even if you use the highest privacy settings,
others can copy and share your information without your knowledge or permission.

EXAMPLE
Julia, a newly graduated nurse, took a photo of William, an elderly patient seated in a
chair beside his bed. Julia had asked W illiam if she could take his photo and he
immediately consented to it. Julia took his photo with her personal hand phone and
posted in on Facebook with the following caption: My favourite cute patient, the one who
is always so thankful despite suffering f rom his liver failure. I pray he will be better soon!
In the photo, Williams face was turned sideways. However, the bed number on one of
the bedside board showed 3A, and a uniformed nursing colleague was in the
background.

One of Julias friends saw the photo that night and advised her that she had breached
patients confidentiality. Julia told her that her post is private and accessible only by
intended reci pients. Nevertheless, Julia immediately removed her posting. However, it
was too late as her photo had been reposted by others on public websites. From Julias
post, people were able to identify William as a Liver Failure patient and the hospital he
was receiving treatment from. Julias innocent yet inappropriate action of posting a
patients pho to had breached patients confidentiality.

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5. Boundaries

Maintain professional boundaries. Just as with face -to -face relationships, you must set
and communicate these boundaries with clients online. End your professional
relationships appropriately and do n ot accept or initiate client friend requests on your
personal social media accounts. If you use social media with clients, use a professional
account separate from your personal one.

EXAMPLE
Jean, a nurse, receives a friend request from someone she vaguely knows. He later
revealed to her that he is her patient and asks her out. By friending a current patient,
she may have inadvertently encouraged him to believe they could also have a personal
relationship. It is Jeans responsibility to maintai n the professional boundaries of the
relationship.

6. Expectations

Use caution if you identify yourself as a nurse online. If you do so, others may ask for
advice, which could lead to a professional relationship.
Using a name that hides your identity does not release you from this expectation. Know
this and practise accordingly.

7. Integrity

Protect yours and the professions integrity. Use proper communication channels to
discuss, report and resolve workplace issues – not social media.
Refer to colleagues or clients online with the same level of respect as you would in the
workplace. Before you blog, tweet or share information about your practice, reflect on
your intentions and the possible consequences. Understand that liking someone s
disrespectful comments is not much different than making them yourself.

8. Employer Policies

Know and follow employer policies on using social media, photography, computers and
mobile devices, including personal, at work. If you communicate with clients via social
media, work with your employer to develop policies.

9. Accountability

Make sure you can answer for your actions. Reflect on why, how and when you use
social media and help others do the same. Know that personal use of social media while
working could be viewed as client abandonment. If you are unable to discuss your online
b ehaviour with others, consider this a red flag. Use professional judgment to keep your
obligations to clients, colleagues and employers front and centre.
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6
Ps of Social Media Use
P rofessional Act professionally at all times
P ositive Keep posts positive
P atient/Person-free Keep posts patient or person free
P rotect yourself Protect your professionalism, your reputation and yourself
P rivacy Keep your personal and professional life separate; respect privacy of others
P ause before you post Consider implications; avoid posting in haste or anger 23
Copyright 2018 by Singapore Nursing Board.
All rights reserved.
This publication may be downloaded for study or training purposes and fo
r personal use, with proper citation.
This publication may not be reprinted and redistributed, in whole or part without the prior written
permission of Singapore Nursing Board.

Singapore Nursing Board81 Kim Keat Road
#08-00 Singapore 328836
Website: http://www.snb.gov.sg
CODE FOR
NURSES AND MIDWIVES
SINGAPORE NURSING BOARD

CO NTE N TS

IN TR O DU CTIO N 2

Nurses/Midwives a n d People 4
P rin ci ple 1: Respect People s values, needs and rig h ts
P rin ci ple 2: Respect and pro mote Peoples autonomy
P rin ci ple 3: Respect Peoples rig h t to confiden tiality a nd p riva cy
P rin ci ple 4: A dvo ca te i n the best i n te re st o f Peo ple

N urs es /Midwive s and their pra ctice 8
P rin ci ple 5: P ra ctis e in a resp onsible and a cc oun table m anne r
Prin ci ple 6: M aint a in com pe ten cy in t he c are o f Pe op le
P rin ci ple 7: M ain ta in cl ea r and acc ura te r eco rd s

N urs es /Midwive s and their profess ion 11
P rin ci ple 8: P ro m ote p ro fe ssi ona lis m and upho ld pub lic trust
P rin ci ple 9: P ra ctis e sel f-re gula tio n

N urs es /Midwive s and c o-wor ker s 13
P rin ci ple 10: W ork colla b ora tiv ely w ith all m em be rs o f th e hea lt h ca re team

Refe rence s 14

Glossary of Terms 15

A ppendix 1: P ro fessi onal B oundari es : Gu id e lines for N urses &
Midwi ve s
1 7

A ppendix 2: 2 0

Use of So
cial Media : Gu idelines fo r Nurses & Midw iv es

2

3
Upo n reg istrat ion a nd /o r enrolm en t w ith th e S ing apore Nursing Board ,
nurses and m idw ives co mmit t o u phol ding th e p ro fe ssio nal re qu ire m ents set out
in Th e Code .

E m ploy ing o rg anisat ions should support their sta ff in uph oldin g T he Cod e
to ensu re t hat a h ig h le ve l o f tru st th at th e publ ic and reg ulat ors ha ve in t h e q uali ty
and sa fety o f nursi ng/m idw ife ry p ract ice is m aint ain ed.

E duca tors can u se Th e Cod e to help nursing/m idw ife ry stu dents a nd
tra ine es understa nd the significa nce of T he Cod e and its
im pact on their
p ro fe ssion al ro les.

T he Cod e s upple ment s th e req uire m ents of the Nurse s and Midw ive s Act
(C ap 209) (20 12 Re vised editi on). It int egrate s all aspec ts of expecte d
p ro fe ssion al co nduct a nd pract ice sta ndards in to one d o cu men t a nd rep lace s th e
S ing apore Nursing B oa rds Code o f Eth ics and P ro fe ssio nal Con duct (19 99),
Cod e o f P ract ice fo r M idw iv e s (20 01) and Standa rds of P ract ice fo r Nurse s and
M idwiv e s (2 011).

R EG IS TR AR
S IN G APO RE N URSING B O AR D
2 A pril 2 018
3

4
N URSES / M ID W IV ES A N D PEO PLE

Princ iple 1 : R es p ec t P eople s v a lu es, n eed s a nd ri ght s

N urs e s/m id wiv es p rovide ca re t hat is dete rm ined b y P eopl es va lues , n e eds and
ri g h ts , w it h o ut a ny unf air o r p re ju d ic ia l d is c rim in a tio n , whe ther o n th e b a sis of
gen de r, e th nic it y, r e lig io n, a g e, so cial o r e cono mic statu s, o r o th er p ro file , a ttri bute
o r pre fe re n ce . Of upm ost prior ity is the sa fe ty and well-bein g o f e ve ryon e wh o
req uire s n u rsi ng o r midw ifery se rv
ice s.

P ra c tic e S tateme nts

To ach ie ve t h is, nurse s/m id w iv e s m ust:
tre at P eop le w ith resp ect, co mpassi on and kindness
conside r cu ltu ral sensitiv ities when respondi ng to P eoples pe rson al and h ea lth
nee ds
conside r P eop les ne ed s, v a lu e s, w ish es a n d fe elin gs w hen d ete rm in in g a p la n o f
ca re /se rvice
re nd er a p pro pria te c a re to su ppo rt a d ig nif ie d a n d p e a ce fu l d ea th a t th e e nd o f
li fe

4

5
P
rinc iple 2 : R es p ec t and pro mote People s au to n om y and right to self –
de te rm ination

N urse s/m id w ive s re sp e ct th a t P eop le h a ve th e r ig ht to s e lf – d ete rm in atio n . P eop le ha ve
th e ri gh t to d e te rm ine w ha t w ill be d on e w ith a n d to th em se lves ; to b e g iven a ccu rate
inf orm atio n in a m an ne r th at fa cil ita te s an inf orm ed d e cisi on. Th ey ha ve th e ri g h t to
vo lun ta rily a cce pt, re fu se or te rmina te tre a tm en t.

P ra c tic e S tatement s

To a ch ie ve t h is, n ur
se s/m id w iv e s must , to t he b est of t he ir a vailab le kn owl ed ge a nd
a b ilit y:

in fo rm P eop le unde r th e ir c a re o f th e ca re o ptio ns th at a re a va il a b le
assis t P eop le to o bta in th e re le va nt in fo rm atio n fr o m reli ab le a nd /o r off ici al
so urce s
co nside r w he th er it is like ly fo r a p e rson w ithou t de cisi on -m aking capa city to
reg ain capa city a t so me tim e in th e fu ture to m ake th e d e cisi on in qu e stio n a nd
w hen it is li kely to h app e n
pe rm it and e n co urag e a p e rs
on to p a rti cipa te , o r to im prov e h e r or his ab ility to
p a rti cipa te , as fu lly a s po ssible in an y a ct don e fo r th e p e rson o r an y d e cisi on
a ff ecti ng h er o r him
se ek, whe re app lica ble or ap p ro pria te , th e co nse nt of a leg ally a u th orise d
rep rese nta tiv e w hen a p e rson is inca pa b le of d e cisi on -m aking
en su re that th e ri gh ts an d b e st int erest s (b oth cli nical and n on -cli nical) of th ose
w ho lack men ta l ca pacity o r are oth erw ise vulne rab le to h a rm o r exp loita tion
a re a lways a t th e c en
tr e o f th e d ecisi on -m aki ng

5

6
P rinc iple 3 : Saf egua rd P eop le s r ight t o p riv acy a nd co nfid en tia lit y

P riva cy is t he ri ght to c o n tr ol a cc ess t o one se lf, in clud in g th e c ir cu m sta nce s, tim in g a nd
e xte nt to whi ch in fo rm atio n is to be discl ose d . Con fiden tia lity per ta in s to the
n o nd iscl osu re o f pe rs on al a nd cli nica l in fo rma tio n. N urses/ midw ives ha ve a d uty to
sa feguard p riva cy and m aint ain c o nfid e ntia lit y o f a ll in fo rm ation pe rta in ing to P eopl e
unde r thei r c a re . H ow eve r, onl y re
le vant in fo rm ation may be shar ed wit h o ther s
d ir e ctly in vo lv ed in , an d nec essa ry f or, t he pro vis ion of ca re .

P ra c tic e S tateme nts

To ach ie ve t h is, nurse s/m id w iv e s must:

respect Peop les r ig h t to priv a cy a nd d ig n it y i n a ll a spects of t hei r care
sa fe gu a rd and m aint ain co nfid en tia lity unles s there is so und ju sti fica tions fo r
d iscl osu re to b e m ade w ithout the person s co nsent ; su ch ju sti ficat ions in clude
d iscl osu re that is m andate d b y law o r nece ssa ry in orde r to prote ct
th e p erso n
o r o thers fro m a serio us ri sk o f har m
r e spec t that a per so ns r ig h t to p riv a cy and conf id entia lit y c o ntinue s a fte r
dea th

6

7
P rinc iple 4 : A dvo ca te fo r a nd in t h e b es t int ere s t o f P eopl e

N urse s/m id w ive s adv oca te fo r P eop le b y sp ea ki ng up in f a vo u r o r supp ort o f t h e ir ri g h ts,
va lu e s, i n te re sts and wi shes.

P ra c tic e S tateme nts

To ach ie ve t h is, nu rs es/m id w ives m ust :
sa fe gu a rd P eople fr o m undu e in flu ence to acce pt or ch ang e a pa rtic u la r
co urse o f a ctio n, if th e y d o n ot c h oo se to d o s o v o lu n ta ril y
b e a le rt to a n d ta ke a p pro p ria te a ction whe
n th e rig h ts , w ell- b e in g o r s a fe ty o f
P eop le a re in je opar dy
rep ort un sa fe cli nical p ract ices that co uld po te ntia lly co mpro mise P eopl es
sa fe ty
7

8
NUR SES / M IDW IV ES AN D THEI R PR ACT IC E

P rinc iple 5 : P ra cti se in a re spo nsible a n d ac co u nta b le m ann er

N urs e s/m id w ive s are re sp on si ble a nd a cco un ta ble fo r their ju dg m ents, deci sion s and
a ctions. Th ey e n su re th a t P eople re ce iv e sa fe , e ff e ct ive a nd e th ica lly a pp rop ria te ca re .

P ra c tic e S tateme nts

To ach ie ve t h is, nu rs es/m id w ives m ust:

recogn ise a nd work with in th e li m its of their co mpe te nce , sco pe of pract ice
and ta ke in to a cco unt their own s
a fe ty
e sca late c once rns when asked to p ra cti ce b eyo nd their scope, experi ence
and t raining
ensu re th at p ra ctice is ca rried out in a cc ord a nce w ith e th ical p rin cip les,
i n stit u tio na l p o lici es and req uire m ents
ide ntify a nd re duce ri sk to p ro mote w ork p lace sa fety a nd healt h fo r co –
w orkers and those re ce iv ing ca re
a le rt th e a p p ro p ria te a uth o rit y o f a n y si tu a tio ns w hich m ay e nd an ge r the
hea lt h o r s a fe ty o f P eop le
p ro vi de a cc u ra te , re le va nt a nd e vid
e nce -bas ed in fo rm atio n w hen sp ea kin g
o n n u rsi ng/m idw ife ry o r hea lt h -re la te d m atte rs
u se jud gm ent re ga rd in g a nur se/m idwi fe s co mpete nci es whe n a ccept ing
and d ele gatin g r espon sibilitie s.
e n su re th at r e se a rch is c ond ucte d in a cco rd a nce w it h e th ic a l p rin cip le s a nd
i n stit u tio na l g u id elin e s and, w her e app ro pria te , a p prov ed by th e app ropr iate
i n stit u tio na l r eview b oa rd a nd /o r r egula to ry aut ho rity

8

9
P rinc iple 6 : M aint ain c o m pete n cy in t h e c a re of Peop le

N urse s/m id w ive s co nsta ntly eva lu ate th eir kn ow le dge an d skil ls as well as th e
e ffe ct iv e n ess of ca re th e y p ro vi de. T hey m ain ta in th e ir co mpete ncy th ro u gh co ntin u in g
e du ca tio n , q u a lity improve men t a ctivities a nd li fe lon g le a rnin g. T he y p ra ct ise e vi de n ce –
b a se d n u rs in g/m id wi fe ry .

P ra c tic e S tatement s

To a ch ie ve t h is, n u rs es/m id w ives m ust :

ensu re th at th eir p ra ct i
ce is ba se d o n p rev ailing clinica l pract ice gu id e lin e s
ke ep a b re ast w it h p ro fe ssio na l a d va n ce s a nd d e ve lop men ts by p a rtici pa tin g
i n co ntin uin g e du ca tio n a ct iv it ie s
co mple te n e ce ssary tra inin g a n d a ch iev em en t of c o m pete ncy p rio r to ca rrying
o u t a n ew ro le/assig nm ent
prov ide h o ne st an d co nstru ctive fe edb a ck to co lle a gu e s in ord e r to h e lp th em
im prov e t he ir p ract ice and p e rfo rm an ce
ob ta in a nd re fle ct on fe ed ba ck t o im prov e p ra ctice and p erfo rm an ce

9

10
P rinc iple 7 : M ain ta in c le ar a n d acc ura te r e co rd s

N urse s/m id w ive s en su re t ha t a ll re cords a re c om plet e, accu rate a n d tim ely .

P ra c tic e S tatement s

To a ch ie ve t h is, n u rs es/m id w ives m ust :

co mple te a ll d ocu m en ta tio n/re co rds at th e t im e o r a s s oon a s po ssibl e a fte r
a n e ve n t
en su re their e ntri es m ad e a re clea r, da te d , tim ed a nd sig ned /in itialled
exclud e t he u se of u nau th orize d a bb rev iation s, jarg on s or sp ecu lat io n s
en su re that all re cord s are k
e pt se cu rely
ab ide by le gisl ativ e a nd in stitu tiona l guid elin es

10

11
NUR SES / M IDW IV ES AN D THEI R PR OF ESS ION

Princ iple 8 : P ro m ote prof ession alis m a n d up hol d p ub lic t r u st

N urse s/mid w ive s have a duty to upho ld the rep uta tion of t he p rofession a t a ll t im es.
Th ey should persistently s tr ive to p re se rve pub lic tr u st a n d c o nfid e nce .

P ra c tic e S ta teme nts

To ach ie ve t h is, nu rs e s/m id w ives m ust :
uph old and abid e b y t he st andards and v alue s se t ou t in th is Co de
be conscio us at all ti m es how th eir b ehav iour an d co nduc t ca n a ff ect
an d
inf luenc e o thers and the p ro fession
maint ain object ivity w ith clea r pro fe ssio nal bound arie s (ref er to A ppe ndix 1 ) a t a ll
tim es with P eople
be res pect ful, r e sp on sible and a cco untable at a ll t im es w hen u sing a ll f orm s o f
spoke n, writt en, and dig ita l co mm unic atio n, incl uding so cial medi a and
netw orki ng site s (r efe r to App endix 2)
nev er m isuse th e p ro fession al sta tu s o r prac tice in a w ay th at co uld b rin g th e
p ro fe ssio n t o d isr epu te o r se riously unde rm ine p ub lic t rust o r co nfid ence
ensu re that a n y publi cations o r p ub lished /subm itte d m ate ria ls pro duce d a re
a ccu ra te , resp on si ble, e th ical an d re flec t th eir rele vant skills, experi ence and
q uali ficat ions.
adh ere to inst itu tio nal policies and g u ide lines w here ava ilable, wi th reg ard to
th e a cc ept anc e o f g if ts, m on ies, h o sp ita lity o r induc em ents fr o m cli ents and/or
co mpanies , or to o th e rw ise a vo id beco ming beho lden to a n y person a n d
o rg anisat ion and /or a lle ga tions o f pro fessio na l m isco nduc t

11

12
P rinc iple 9 : P ra ctis e s elf – r e g u la tio n

N urs e s/M id w iv e s a re re sp onsib le a nd a cc oun ta ble to s e lf , P eop le , a n d th e p ro fe ss io n fo r
m ain ta in in g co m pete n ce and co ntinued pers ona l and pro fe ssio na l gro w th , fit n ess to
p ra ctis e and a v a lid li c e nse to p ra ctis e . T hey a re re spon sib le fo r th eir o w n hea lt h , s a fe ty
and w ell- b e in g.

P ra c tic e S tatement s

T o a ch iev e th is, n urse s/m idwives m ust :
maint ain a v alid P ract is ing Ce rtificat e
co m
ply w ith all re gu lat ory p olicies and guid elin e s
pract ise with in th eir o wn level o f co mpe te nce and scop e o f pract ice
ensu re c o n tin u ing co mpe te ncy in th e re lev an t a rea s of p ra ctice
maint ain th e ir o w n p h ysical, psy ch olog ical a nd e m otio na l fit n e ss
up ho ld p e rson al i nte grity

12

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NUR SES / M IDW IV ES AN D CO -W ORK ERS

Princ iple 10 : W ork c o lla bor ativ e ly w it h a ll m em bers o f t h e h eal th car e t eam

Nurse s/midwives w ork collaborativ ely and res pectf ully with c o -worke rs in nursi ng and in
o th er rel ate d fie lds , a s the conte xt o r situ atio n r equir es. T hey c ont ribut e t o a co llabor ative
and s upporti ve e n vi ro n m en t t hat p rio ritise s th e b est int erest s of P eop le .

P ra c tic e S tateme nts

To ach ie ve t h is, nurse s/m id w iv e s must:

promot e re spect ful int eract ions and mutu al p ee r su ppo rt

m aint ain cle ar, co ncise and t im ely co mmunica tion w ith co -w orkers
resp ect the skill s and experti se of co -w orkers, and when a pp rop ria te , r efe r
m atte rs to the m fo r a dvice
adv oca te e th ical hea lth ca re d eliv e ry a nd sa fe p ract ices a s a te am
share kn ow led ge a nd experi ence to re solve e th ical issu es

13

14
REFERENCES

International Council of Nurses (ICN) (2012) . The ICN Code of Ethics for Nurses .
Geneva: ICN.

National Council of State Boards of Nursing (NCSBN) (2014 ). A Nurses Guide to
Professional Boundaries . USA: NCSBN.

Nurses and Midwives Act, Cap 209 ( 2012 Revised edition) . Singapore .

Singapore Nursing Board (SNB) (1999 .) Code of Ethics and Professional Conduct .
Singapore: SNB .

Singapore Nursing Board (2001) . Code of Practice for Midwives . Singapore: SNB .

Singapore Nursing Board (2011) . Standards of Practice for Nurses and Midwives .
Singapore: SNB .

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GLOSSARY OF TERMS

Accountability Being answerable and responsible for the outcome of ones
p ro fe ssi onal a ct io ns (in cl udes a n y judg ment, de cisi on or a ct io n
t a ke n or om itted in nursin g pra ctic e ). Nurs es/m idw iv es are
a cc o u ntabl e to people, their em plo yer and t h e S ingapo re N ursi ng
Boa rd .

Advocacy Speaking up in favour or support of peoples rights, values,
in te re sts an d w is hes .

Autonomy The right of adults to determine their actions and destinies
based on their values, interests and wishes.

Client(s) An individual or group who seeks or receives professional care,
health services o r a d vic e f r o m a n u rs e /m idw if e .

Competence The ability of a nurse to demonstrate the knowledge, skills,
judgment and attitude required to perform activities within the
defined scope of practice at an acceptable level of proficiency .

Confidentiality The obligation not to disclose certain types of information
without appropriate consent or justifications.

Consent Permission given by people for a procedure or action to be
carried out upon them by their attending n u rse /m idw if e .

Dignity Treating people with respect and consideration for their rights.

Evidence-based
nur sing
The process of reviewing current research findings (evidence)
pu blis hed in s ci ent if ic jour nals or o th er d ata s o u rc es. Eva luat in g
the re le vance of th is evid en ce to cu rr e nt nu rsi ng pra ct ic e .
M od if y ing e xis tin g p ra ctic e w her e in dic at ed and eva luat in g th e
i m pa ct o f the m odif ied pra ctic e.

Healthcare
team
Co-workers in nursing, healthcare and other related fields; may
extend to volunteers and others who play a role in providing
health services.

Integrity An internal quality (a cluster of attributes) within oneself.
Manifested externally as honesty and moral consistency:
consistency with ones values, convictions, beliefs, knowled ge,
commitments and obligati ons.

15

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GLOSSARY OF TERMS

Midwife A person who has completed a course in midwifery and is
li c e nsed by the Sin ga po re Nursi ng Boar d to pra ct ise as a
R egis te red Mid w ife .

Nurse A person who has completed a pre-registration or pre-enrolment
nur sing c o u rs e a n d is li c en sed by th e Sin gapo re N ursi ng B oard
(SNB) to p ra ct ise as a Regist ere d Nurs e o r E nro lled Nurs e .

People Individuals (clients, patients), family members, significant others
and the community who receive care and health -related services
from nurses and midwives .

Professional
Misconduct
Defined as any act or omission that:

constitutes a deviation from the C ode
abuses the professional relationship with the client
brings the nursing profession into disrepute

Responsibility Obligation to properly carry out duties which are expected of a
nurse/midwife and for which they can be held accountable .

Relevant
authority
A person or entity having legal, regulatory or administrative power
and control pursuant to legislation or regulation, including
regulatory guidelines or policies.

Acknowledgement

The Singapore Nursing Board gratefully acknowledges the contributions of its Ethics
Committee members (2015 to 2017) , nursing representatives from various settings,
nursing students, nursing leaders and ethics expert Dr Megan-Jane Johnstone.

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Appendix 1
Professional Boundaries : G uidelines for Nurses & Midwives
(Adapted from National Council of State Boards of Nursing (2014) A Nurses Guide to
Professional Boundaries )

Professional boundaries are the spaces between t he nurses/midwives power and the
client s vulnerability. The power of the nurse /midwife comes from the professional
position and access to sensitive personal information. The differ ence in personal
information the nurse/midwife knows about the client versus personal information the
clien t knows about the nurse /midwife creates an imbalance i n the nurse-client
relationship. Nurses /midwives should make every effort to respect the pow er imbalance
and ensure a client-centred relationship.

Boundary crossings are brief excursions across professional lines of behavio ur that
may be inadvertent, thoughtless or even purposeful, while attempting to meet a specia l
therapeutic need of the client. Boundary crossings can result in a return to established
boundaries, but should be evaluated by the nu rse/midwife for potential adverse client
consequences and implications. Repeated boundary crossings should be avoided.

Boundary violations can result when there is confusion between the needs of t he
nurse /midwife and those of the client. Such violations are characteri sed by excessive
personal disclosure by the nurse, secrecy or even a rever sal of roles. Boundary violations
can cause distress for the clien t, which may not be recognised or felt by the client until
harmful consequences occur.

A nurse /midwifes use of social media is another way that nurses can unintentionally
blur the lines between their professional and personal lives. Making a comment via
social media, even if done on a nurse /midwifes own time and in their own home,
regarding an incident or person in the scope of their emplo yment, may be a breach of
clien t confidentiality or privacy, as well as a boundary violation.

Professional sexual misconduct is an extreme form of boundary violation and
includes any behavio ur that is seductive, sexually demeaning, harassing or reasonably
interpreted as sexual by the client. Professional sexual misconduct is an extremely
serious, and criminal violation.
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Boundaries and the Continuum of Professional Nursing/Midwifery Behaviour
Every nurse
-patient relationship can be plotted on the continuum of professional
behaviour illustrated above.
The nurses/midwifes responsibility is to delineate and maintain boundaries.
The nurse/midwife should work within the therapeutic relationship ;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/midwife are
boundary violations.
The nurse/midwife should avoid situations where he or she has a personal, professional
or business relationship with the client.
Post-termination relationships are complex because the client may need additional
services. It may be difficult to determine when the nurse -client relationship is completely
terminated.
Be careful about personal relationships with clients who might continue to need
nursing/midwifery services (such as those with mental health issues or oncology
clien ts).18

A CONTINUUM OF PROFESSIONAL BEHAVIOUR

UNDER-INVOLVEMENT THERAPEUTIC RELATIONSHIP OVER-INVOLVEMENT

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Appendix 2
Use of Social Media: Guidelines for Nurses & Midwives

Introduction

Social media is a beneficial tool when used wisely. It fosters professional connections,
promotes timely communication, and educates people and healthcare professionals. The
use of social media, however, can pose a risk as the ease of posting allows little time for
reflective thought , verification or authentication , could be misinterpreted or
misappropriated and that information once posted, has the potential of rapid circulation.
Moreover, deleted contents are often still accessible and recoverable. Hence, nurses
need to pay attention to the following guidelines in order to reduce risks to members of
the public and the healthcare profession.

The purpose of this guide is to provide advice to nurses on using social media.

Definition

Social media describes the online and mobile tools that people use to share opinions,
information and experiences, images and video or audio clips, and includes websites
and applications used for social networking. Common sources of social media include,
but are not limited to: social networking sites such as Facebook and LinkedIn; personal,
professional and anonymous blogs; WOMO, True Local and micro blo gs such as Twitter;
content -sharing websites such as YouTube and Instagram, and discussion forums and
message boards.

Common expectations for nurses include:

1. Benefits and Risks

Know the benefits and risks of social media. Build your competence. Know the
technology and have the skills and judgment to use it appropriately and ethically. Be
aware of social medias evolving culture and changing technology. Reflect on the intent
and possible consequences of your online behaviour – before you blog, post or tweet.

2. Professional Image

Use the same level of professionalism in your online interactions as you do face -to -face.
Keep your personal and professional lives separate. Use different accounts for personal
and professional activities.

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3. Confidentiality

Do not share any client information on social media sites. Leaving out details when you
post information or images does not protect client confidentiality. Report confidentiality
breaches to the right person, immediately.

EXAMPLE
Jane has been working in the cancer ward for the last six years. She is friends on
Facebook with her patient Mary. One day, Mary posted about her depression. As her
nurse, Jane wanted to provide support, so she posted, I know the past month has been
difficult and trying. Hopefully the new anti -depressant will help. The morphine dose has
been increased and should make you more comfortable. I will see you next Friday. On
Janes Facebook profile page, she has listed herself as an Oncology trained nurse
wor king in an Oncology Ward.

Jane had Marys best intentions at heart when she offered her words of support.
However, she inadvertently disclosed Marys condition on a social media site. Everyone
who read that post now knows Marys medication, increase in m orphine and possibly
even her cancer diagnosis, violating her right to privacy and confidentiality.

4. Privacy

Set and maintain your privacy settings to limit access to your personal information. Be
aware of your privacy settings and know that even if you use the highest privacy settings,
others can copy and share your information without your knowledge or permission.

EXAMPLE
Julia, a newly graduated nurse, took a photo of William, an elderly patient seated in a
chair beside his bed. Julia had asked W illiam if she could take his photo and he
immediately consented to it. Julia took his photo with her personal hand phone and
posted in on Facebook with the following caption: My favourite cute patient, the one who
is always so thankful despite suffering f rom his liver failure. I pray he will be better soon!
In the photo, Williams face was turned sideways. However, the bed number on one of
the bedside board showed 3A, and a uniformed nursing colleague was in the
background.

One of Julias friends saw the photo that night and advised her that she had breached
patients confidentiality. Julia told her that her post is private and accessible only by
intended reci pients. Nevertheless, Julia immediately removed her posting. However, it
was too late as her photo had been reposted by others on public websites. From Julias
post, people were able to identify William as a Liver Failure patient and the hospital he
was receiving treatment from. Julias innocent yet inappropriate action of posting a
patients pho to had breached patients confidentiality.

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5. Boundaries

Maintain professional boundaries. Just as with face -to -face relationships, you must set
and communicate these boundaries with clients online. End your professional
relationships appropriately and do n ot accept or initiate client friend requests on your
personal social media accounts. If you use social media with clients, use a professional
account separate from your personal one.

EXAMPLE
Jean, a nurse, receives a friend request from someone she vaguely knows. He later
revealed to her that he is her patient and asks her out. By friending a current patient,
she may have inadvertently encouraged him to believe they could also have a personal
relationship. It is Jeans responsibility to maintai n the professional boundaries of the
relationship.

6. Expectations

Use caution if you identify yourself as a nurse online. If you do so, others may ask for
advice, which could lead to a professional relationship.
Using a name that hides your identity does not release you from this expectation. Know
this and practise accordingly.

7. Integrity

Protect yours and the professions integrity. Use proper communication channels to
discuss, report and resolve workplace issues – not social media.
Refer to colleagues or clients online with the same level of respect as you would in the
workplace. Before you blog, tweet or share information about your practice, reflect on
your intentions and the possible consequences. Understand that liking someone s
disrespectful comments is not much different than making them yourself.

8. Employer Policies

Know and follow employer policies on using social media, photography, computers and
mobile devices, including personal, at work. If you communicate with clients via social
media, work with your employer to develop policies.

9. Accountability

Make sure you can answer for your actions. Reflect on why, how and when you use
social media and help others do the same. Know that personal use of social media while
working could be viewed as client abandonment. If you are unable to discuss your online
b ehaviour with others, consider this a red flag. Use professional judgment to keep your
obligations to clients, colleagues and employers front and centre.
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6
Ps of Social Media Use
P rofessional Act professionally at all times
P ositive Keep posts positive
P atient/Person-free Keep posts patient or person free
P rotect yourself Protect your professionalism, your reputation and yourself
P rivacy Keep your personal and professional life separate; respect privacy of others
P ause before you post Consider implications; avoid posting in haste or anger 23
Copyright 2018 by Singapore Nursing Board.
All rights reserved.
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r personal use, with proper citation.
This publication may not be reprinted and redistributed, in whole or part without the prior written
permission of Singapore Nursing Board.

Singapore Nursing Board81 Kim Keat Road
#08-00 Singapore 328836
Website: http://www.snb.gov.sg

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