Codependency, Self Care, Nursing Code of Ethics and Professional Boundaries

BY MARIANNE R. WYNN, BA
Director of Recovery Nurse Program, Mississippi State Board of Nursing

I spend a lot of my time meeting and talking with nurses who are in crisis mode.  The issues that bring nurses into my office often arise from lack of self care resulting in stress, anxiety, untreated depression and addiction.  The stories have similar themes: relationships with alcoholics or abusive individuals, stress in job situations, caretaking of co-workers and family, the pressure of being the sole provider and sleep deprivation.  Today’s nurses find themselves juggling children, marriage, higher education and employee shortages in their work environments. The result of all this over achievement is lack of sense of self, personal interests, self care and an indefinable inner life. 

Sometimes I want to jump up and say, “Hey, Florence Nightingale, when was the last time you read a book, went to the beach, said no to a co-worker, had a physical, turned down an extra shift or went on vacation?”
The common threads of these stories wind back to a tangled skein of boundaries, codependency, perfectionism and low self esteem.  The outcome often involves violations of the nurse’s code of ethics and ensuing impairment.

Codependency, what is it?

  • A tendency to place the needs and wants of others first and to the exclusion of acknowledging or addressing ones own;
  • Difficulty adjusting to changes at work or at home (electronic MARs, administrative changes,  staffing shortage);
  • Difficulty in asking for help or for what you need (orientation, training, personal time);
  • Workaholism (working back to back shifts);
  • Taking on more than you can handle professionally and personally; and
  • A pattern of relationships with needy or unstable people.

How does this relate to the International Code of Ethics for Nurses?
“The International Counsel of Nurses’ Code of Ethics was first adopted in 1953; the revision that is cited here is from 2006.  It is a guide for action based on social values and needs.  It will have meaning only as a living document if applied to the realities of nursing and health care in a changing society.
To achieve its purpose, the code must be understood, internalized and used by nurses in all aspects of their work.  It must be available to students and nurses throughout their study and work lives.  The four elements of the International Counsel of Nurses’ Code of Ethics for Nurses:  nurses and people, nurses and practice, nurses and the profession, nurses and co-workers give a framework for the standards of conduct.”  In order to translate the code into action, it is recommended to “reflect on what each standard means to you.  Think about how you can apply ethics in your nursing domain.  Discuss the code with co-workers and others; use specific examples from experience to identify ethical dilemmas and standards of conduct as outlined by the Code.  Identify how you would resolve the dilemmas.”  (http://www.icn.ch/icncode.pdf).

The Code of Ethics and Common Violations Influenced by Codependent Behaviors
The first element of the code is nurses and people.  The code reads:  “In providing care, the nurse promotes an environment in which the human rights, values, customs and spiritual beliefs of the individual and community are respected.”

Nurses and People           
Problems of sleep deprivation, stress and over commitment threaten a nurse’s ability to promote a safe environment for his/her patients. Sleep deprivation and ensuing mental impairment can occur when a nurse is working multiple shifts to compensate for staff shortages. This often manifests in administration of medication errors such as administering wrong amounts, pulling more medication than needed to save time and failure to waste medications according to procedure. Caretaking, an element of codependency, comes into play when the nurse seeks to meet the increasing demands of the administration, co-workers and patients.

Nurses and Practice
Sometimes nurses will act outside of the scope of their practice in initiating care prior to communication with the physician, wanting to meet what is identified as the pressing and immediate needs of the patient. This is the point where motivations for control and care overstep the boundaries of assigned duties.
Perfectionism often stems from a compelling need to maintain what is perceived as control of a chaotic work situation.  Stresses arise from interactions with co-workers, the demands of families and patients’ needs. 

Nurses and Co-workers
Perfectionism caretaking and poor communication manifest in relationships with co-workers in ways that ultimately can create unethical situations.  Need for control can override a cooperative relationship with co-workers.  Perfectionism can result in criticism of co-workers and an atmosphere of enabling and control that ultimately cripples co-workers ability to learn from experience and error.  The semblance of the heroine of the unit becomes a manifestation of martyrdom.
Coupled with the nursing shortage and increased numbers of patients, a culture of nurses who give to the point of depletion is becoming a threat to safety in practice and violations of ethical and professional boundaries. 

Suggested Solutions:

  • Attend a codependents anonymous meeting.  The meetings are free and can be found by state on the CODA Web site.  The meetings are based on a 12 step program of recovery which offers written guidelines on changing codependent thoughts and behaviors.
  • Start journaling about your life and all of your responsibilities.  Make a pie chart that divides up how you spend your time.  Make a list of new goals for the areas of your life that are revealed as too little or too much.  Compare it to where you are now. 
  • Take at least one night a week to care for yourself.  Enjoy a bath, a movie, watching the game with friends or whatever makes you happy.
  • Enroll in online continuing education courses on ethical and professional boundaries.
  • Honestly evaluate your diet, exercise and sleep patterns to see if they are adequate and healthy.  Take time for your own health care; get a wellness exam; go to the dentist; sit down and talk with your physician or nurse practitioner about your health needs.
  • Seek counseling from human resources or get a referral to a counselor for new coping skills, greater communication and self discovery.
  • Pick up a book by one of the pioneers in the field of codependency.  Facing Codependence: What It Is, Where It Comes from, How It Sabotages Our Lives by Pia Mellody, Andrea Wells Miller, and J. Keith Miller; Breaking Free: A Recovery Workbook for Facing Codependence by Pia Mellody and Andrea Wells Miller; The Language of Letting Go (Hazelden Meditation Series) by Melody Beattie; Codependent No More: How to Stop Controlling Others and Start Caring for Yourself by Melody Beattie.

Benefits of Change
When nurses pick up the tools of transformation their stories shift and change; the formerly exhausted and overwhelmed begin to live stories of self care translated into healthier environments in their work, discovery of self, and relationships with families, friends and co-workers. Twelve step meetings are revealed as communities of honesty, commonality and positive solutions.  Counseling experiences define the self separated from an outer sense of identification.  Outdated survival skills are dropped and new skills implemented.  The nurse as a human being opposed to a human doing is revealed.  Florence Nightingale steps free of the cocoon and takes flight. •

Reprinted with permission from the Mississippi Board of Nursing.