Effective Date: 2019
Status: Position Statement
Written by: ANA Center for Ethics and Human Rights
Adopted by: ANA Board of Directors

Purpose

Nurses often express a desire to serve others as a volunteer. They volunteer within their communities and across borders in global settings. While nurses considering participation or serving as a volunteer express altruistic intention, their actions may result in unintended adverse consequences to the host community. The purpose of this position statement is to promote ethically responsible volunteer efforts classified as short-term (six months or less) practice experiences in local and global health care and public health (Wilson et al., 2016). This position statement includes volunteer activities by nurses and nursing students sponsored by academic institutions, religious and secular nongovernmental organizations, and for-profit businesses (Lasker et al., 2018). Additional terms encompassing global volunteering include service learning and health care missions (Dalmida et al., 2016).

This position statement excludes nurse volunteer activities at the onset of a complex humanitarian emergency, in long-term assignments through the Peace Corps or other agencies, in global health policy development, in fundraising, or in conducting research. It also excludes non-health activities such as teaching English to speakers of other languages and building houses.

Statement of ANA Position

The American Nurses Association (ANA) believes that short-term volunteer activities are an appropriate response to disparities and inequities in health care across the globe (Crigger, 2008). All nurse volunteer activities should be in accordance with the (2015) Code of Ethics for Nurses with Interpretive Statements and the International Council of Nurses (ICN) Code of Ethics for Nurses (2012).

Volunteer efforts should demonstrate social responsibility, be done with cultural humility, and involve careful planning in collaboration and partnership with the host community, so that the efforts are sustainable to the community and are mutually empowering (Foronda, Baptiste, Reinholdt, & Ousman, 2016; Tervalon & Murray-Garcia, 1998). Volunteer opportunities for nurses exist across boundaries and can include local, national, and international activities.

The Code of Ethics for Nurses with Interpretive Statements

The Code of Ethics for Nurses (The Code) (2015) provides guidance in short-term local and global health care experiences, explicitly stating that “the term practice refers to the actions of the nurse in any role or setting, whether paid or as a volunteer, including direct care provider, advanced practice registered nurse, care coordinator, educator, administrator, researcher, policy developer, or other forms of nursing practice… the values and obligations expressed in the Code apply to nurses in all roles, in all forms of practice, and in all settings” (p. viii).

There are several Interpretive Statements (IS) outlining ethical commitments that are integral to volunteer experiences:

• IS 1.1 states, “A fundamental principle that underlies all nursing practice is respect for the inherent dignity, worth, unique attributes, and human rights of all individuals…. Nurses consider the needs and respect the values of each person in every professional relationship and setting….” (p. 1).
• IS 1.4 directs that “…support of patient autonomy also includes respect for the patient’s method of decision-making and recognition that different cultures have different beliefs and understandings of health, autonomy, privacy and confidentiality, and relationships, as well as varied practices of decision-making” (p. 2).
• IS 2.1 reminds short-term volunteers that “…the nurse’s primary commitment is to the recipients of nursing and health care services—patient or client—whether individuals, families, groups, communities, or populations” (p. 5).
• IS 3.1 states, “The nurse has a duty to maintain confidentiality of all patient information, both personal and clinical in the work setting and off duty in all venues, including social media or any other means of communication…nurses must maintain vigilance regarding postings, images, recordings, or commentary that intentionally or unintentionally breaches their obligation to maintain and protect patients’ rights to privacy and confidentiality” (p. 9).
• IS 8.2 notes that “…nurses must address the context of health, including social determinants of health such as poverty, access to clean water and clean air, sanitation, human rights violations, hunger, nutritionally sound food, education, safe medications, and health care disparities. Nurses must lead collaborative partnerships…that promote and restore health, prevent illness, and alleviate suffering” (p. 31).
• IS 8.3 directs nurses to “…recognize that health care is provided to culturally diverse populations in this country and across the globe. Nurses should collaborate to create a moral milieu that is sensitive to diverse cultural values and practices” (p.32).
• IS 8.4 concludes, “…nurses must always stress human rights protection with particular attention to preserving the human rights of vulnerable groups such as the poor, the homeless, the elderly, the mentally ill, prisoners, refugees, women, children, and socially stigmatized groups” (p. 33).
• IS 9.2 addresses justice and fairness: “Nursing must continually emphasize the values of respect, fairness, and caring within the national and global nursing communities in order to promote health in all sectors of the population” (p. 36).

History and Previous Position Statements

To date, there are no ANA guidelines regarding volunteering; however, the ANA has a strong history of supporting nurse involvement during times of crisis, as demonstrated in the (2008) position statement Adapting Standards of Care Under Extreme Conditions: Guidance for Professionals During Disasters, Pandemics, and Other Extreme Emergencies.

Background and Supporting Material

Nurses have provided significant service through volunteer efforts since Florence Nightingale’s role during the Crimean War. A deep sense of caring and service to humanity perpetuates the desire for nurses to volunteer; the willingness to serve is often cultivated in student nurses. Travel abroad opportunities, technology, geopolitical changes, and ongoing challenges to secure health care resources expand professional boundaries on a global scale, while at the same time nurses remain committed to social justice and equity in health (Crigger, 2008; Lasker, 2016). Students across the health professions are encouraged to volunteer in both their local community and globally through study abroad and service learning opportunities.

Although the number of nurses seeking and providing volunteer service is not known, it is estimated that over one million individuals volunteered around the globe from 2004 to 2014 (Lough, 2015). Academic institutions and hospitals in high-income countries have increasingly sought collaborative relationships with providers in low-income and middle-income countries to accommodate the demand for volunteer opportunities. Businesses known as “volunteer placement organizations” now market their services to those willing to pay a fee to volunteer in low-income and middle-income countries, thus marketing the concept of volunteering as a “way to give back” or “make a difference” (Sullivan, 2018).

Ethical Guidelines for Volunteers

Professional organizations and special interest groups have created position statements, guidelines, or codes to provide ethical guidance for those who are volunteering (see Resources). For example:

• The Working Group on Ethics Guidelines for Global Health Training (WEIGHT). (2010).
• The Forum on Education Abroad. (2011). Code of ethics for education abroad.
• Projects Abroad (n.d.). Ethics and code of conduct for medical volunteering and internships.
• International Committee of the Red Cross. (2018). Code of conduct.

A review of the literature by Lasker et al. (2018) identified five common themes within 27 guidelines used to structure short-term volunteer experiences. These themes are:

1. Appropriate recruitment, preparation, and supervision of volunteers
2. A host partner that defines the program and the role of the host community in directing and teaching the volunteers
3. Sustainability and continuity of programs
4. Respect for governance and legal and ethical standards
5. Regular evaluation of program impact on the host community (p. 6)

One limitation of these published guidelines is that none are authored by individuals from low-income and middle-income host countries. Some countries have guidelines for volunteers available for review when health-related activities are planned. Examples of country guidelines are described in the International Committee of the Red Cross and Red Crescent Societies’ (2011) Legal issues related to volunteering.

Benefits to Volunteers

Professional nurses and students alike benefit from local and global volunteer experiences. Volunteers and volunteer placement organizations often claim the act of volunteering is a transformative event in one’s life. Even if transformation is not the goal or outcome of a volunteer experience, there may be a sense of personal satisfaction and an increased awareness of health care challenges and the impact of culture on health and health disparities. Trossman (2017) interviewed many nurse volunteers who identified mental health benefits, decreased stress, gratitude, and a greater sense of balance following their experiences.

Other benefits may include the opportunity to view professional practice from a different perspective; increasing competencies in global health, including future advocacy efforts; improving career choices; and developing a foundation for future networking (Lasker, 2016; White & Evert, 2014).

Crump et al. (2010) describe some possible outcomes when students work and study abroad. As a result of their experiences, students claim:

• Increased commitment to caring for poor and ethnic minorities
• Increased commitment to providing primary care
• Improved skills
• Increased interest in volunteerism
• Increased interest in public health

To maintain perspective on the experience, volunteers should reflect on their reasons for volunteering and what they will learn when traveling to low-income countries. Recognizing the need to act with moral courage and develop moral resilience is essential for a successful volunteer experience. These attributes will remain well after the individual returns home.

Benefits to Host Communities

Individuals and communities hosting volunteers appreciate the resources that volunteers bring, the added capacity to serve the community, and the potential for empowering the local community (Kraeker & Chandler, 2013; Loiseau et al., 2016). Host communities may receive financial and other material benefits as volunteers engage in shopping or local tourist activities, while individuals needing health care from specialists may see life-changing improvements in their health. Volunteers may also provide education to their hosts and community members. Reciprocal learning and respect among all involved in the volunteer experience is facilitated by mutuality, the reciprocity and valuing that volunteers and hosts demonstrate for each other. (Lasker, 2016). Mutuality encourages professional and personal growth among volunteers and hosts, honoring the strengths that everyone brings to the volunteer experience.

Short-term volunteer experiences can facilitate a sustainable approach to health care and community life. Sustainability refers to an ongoing process open to growth and change over time (Riner & Broome, 2014), and requires integration with community goals that allow for growth and transformation without time constraints. Short-term volunteer experiences are not typically stand-alone, isolated experiences, but may occasionally be a bridge to ongoing, sustainable volunteer programs. The nurse can be a part of creating a sustainable plan by collaborating “with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities” (ANA, 2015, p. 31). Sustainable changes from short-term volunteer activities may be difficult to document, but evaluation processes and measurable outcomes need to be considered as part of the host community and volunteer organization planning efforts.

Potential Harms to Volunteers

Preparing for a volunteer experience requires consideration of the potential physical demands, psychological fatigue, and exposure to safety issues and diseases not commonly found in the volunteer’s home country (Leffers & Plotnick, 2011). Physical demands are context dependent and relate to extreme weather conditions, sanitation infrastructure, sleeping accommodations, and access to transportation. Volunteers may need to walk long distances, lift equipment, and carry supplies during their experience. Just as physical demands depend on the volunteer site, there are also psychological demands that are draining and ethical challenges that can result in moral distress.

Threats to health and safety are important to consider when preparing for a volunteer experience. Consideration of immunization requirements, food and water safety while on-site, risks from perpetrators of unlawful acts, and animal and insect disease transmission, as well as any other potential emergencies, is important. Volunteers are vulnerable and safety issues need particular attention. Learning about the culture, the local environment, and the laws of the area where volunteering must be part of the preparation experience (Leffers & Plotnick, 2011).

Culture shock, the emotions experienced when encountering a different culture, must be anticipated. Communication difficulties may exacerbate the feelings of helplessness or of being overwhelmed by the culture and setting. Irritability with other volunteers and those at the volunteer site along with feelings of powerlessness can be expected as part of culture shock. Volunteers who are prepared for culture shock and approach the experience with humility, flexibility, tolerance, openness, and reflection can move to the adjustment and acceptance phases of the culture shock process more readily. However, the volunteer must also be prepared for reverse cultural shock once the excitement of returning home begins to fade and the volunteer realizes much has changed within himself or herself. Friends and relatives may not be able to relate to stories of experiences, or they may appear disinterested. Maintaining contact with other volunteers and hosts from the volunteer site can facilitate re-entry (Unite for Sight, 2018).

Potential Harms to Host Communities

Attention is needed to discern the impact of the volunteer experience, given the potential unintended consequences resulting from cultural differences and power differentials related to resources and lack of shared goals (Dalmida et al., 2016; White & Evert, 2014). Criticism of global volunteering includes perpetuating the idea that global poverty can be reduced through caring volunteers and ignoring the disparities caused by structural inequality within countries considered to be “developing.” Host communities may be exploited when volunteers are a burden to the community, when equipment is left that cannot be used without repairs or supplies, or when outdated medications remain after the volunteers leave. Gift-giving and discarding of unwanted items must be carefully done to avoid insult or the creation of waste management problems. Volunteers must also consider that they may be influencing or even taking away local employment through the volunteer program. These system-level harms are complex and should not be exacerbated by self-serving attitudes of the volunteer (Bauer, 2017).

Frequently, host communities voice concern regarding insensitive, uninformed behavior from volunteers. Volunteers who arrive on-site with little knowledge of local traditions and beliefs may influence host provider status and the host’s ability to continue providing service long after the volunteers leave the community. Hosts want the volunteers to learn from them and value their skills and knowledge as much as they also learn from the volunteers (Lasker et al., 2018). Volunteer programs ignoring the voice of the host risk ongoing power struggles resulting from an unequal relationship, and lack sustainability, thus violating the ethical principles of beneficence, non-maleficence, respect for persons, and justice.

Recommendations

ANA recommends that all nurses champion volunteerism, whether by volunteering or by supporting and facilitating those who choose to volunteer (both locally and globally).

ANA recommends that nurse volunteers do the following:

• Reflect on reasons for volunteering.
• Review the ethics statement of the sponsoring organization to ensure agreement of views prior to agreeing to volunteer.
• Look into the reputation of the sponsoring organization.
• Partner/collaborate with host communities by communicating and planning prior to the experience and while on-site.
• Evaluate the experience with the host community and the sponsoring organization.
• Perform/work within their scope of practice regardless of the location and purpose of the activity and with the consent and supervision of local professionals.
• Confirm and comply with licensing and practice regulations in the host country.
• Consider motives for taking photos and the feelings/emotions of those in the photo.
• Avoid posting photos on social media or using them in public presentations without permission.
• Understand and use the chain of command or appropriate reporting authorities.
• Recognize ethically problematic situations and anticipate associated moral distress.
• Be aware of post-volunteer reactions and attend available debriefing sessions with other volunteers.

When planning a short-term volunteer experience, ANA recommends that the individual and/or the organization do the following:

• Foster mutuality before, during, and after the volunteer experience.
• Conduct a needs assessment in collaboration with the host community.
• Plan/work within the expectation of being a part of a sustainable process by creating long-term partnerships.
• Educate volunteers regarding culture and environment.
• Acquire required immunizations and take other appropriate health precautions.
• Design activities that allow volunteers to work within their identified scope of practice (based on education and professional experience).
• Provide adequate supervision and preparation of volunteers.
• Be transparent around costs and funding, and buy supplies locally if possible.
• Consider the community’s relationship to the local and national health systems.
• Strive for long-term relationships within the local community that provide continuity of services and encourage longer length of service by volunteers.
• Stay connected to the host community when possible through technology (social media).
• Volunteer to be part of committees of volunteer organizations.

ANA recommends that nurse researchers do the following:

• Identify the ethical dimensions of volunteer work in local and global communities.
• Collaborate with international partners to investigate the impact and outcomes of global volunteering.
• Explore the impact short-term volunteer experiences have on the achievement of sustainable goals.

ANA recommends that nurse educators do the following:

• Develop ethics curricula that help students develop problem-solving skills for identifying and minimizing harms related to volunteer experiences.
• Provide opportunities for group and individual reflection/debriefing of the volunteer experience.
• Encourage students to critically appraise the use of social media.
• Explore relationships with nurse educators in host countries to generate mutual learning opportunities.

ANA recommends that nursing administrators do the following:

• Develop staffing policies that allow nurses the opportunity to participate in short-term volunteer experiences.
• Provide a forum for returning volunteers to share their experiences.

Summary

Volunteer experiences have the potential to both benefit and harm the host community as well as the volunteer. Humility, trust, and respect must characterize the volunteer’s approach to all interactions, and ethical obligations must be honored. All volunteer experiences, local and global, should be carefully planned with adequate volunteer preparation, and should lead to sustainable outcomes when possible. Pre-departure planning, on-site experience, and post-departure evaluation should be done in collaboration with the host community. Acting with moral courage and developing moral resilience are essential for successful volunteer experiences. Ongoing assessment of ethical issues and practicing according to The Code during all phases of the volunteer experience are critical to mitigating any potential harms. Volunteering can be a powerful means for nurses to meet their social responsibilities and expand their world views.

Acknowledgment: ANA acknowledges Ethics Advisory Board members Marcia Bosek, DNSc, RN and Michele Upvall, PhD, RN, CNE, FAAN; former Center for Ethics and Human Rights Assistant Director, Martha Turner, PhD, RN-BC, FAAN, Col. USAF, NC (ret); and Center for Ethics and Human Rights intern Persis Naumann, MA, who contributed to the drafting of this document on behalf of the ANA Ethics Advisory Board.

Column Editor

Liz Stokes, JD, MA, RN
Email: liz.stokes@ana.org

Liz Stokes is the Director of the American Nurses Association Center for Ethics and Human Rights and demonstrates expertise in writing public policy on ethical issues including medical marijuana, assisted death, intellectual disabilities, and women's reproductive health. She is an international speaker on the Code of Ethics for Nurses is published in the Journal of Nursing Regulation and the Journal for Nurse Practitioners. Liz also serves as an Associate Editor for the Journal of Bioethical Inquiry. Liz's sphere of influence as a nurse-attorney combined with her education in bioethics enables a unique contribution to nursing, ethics, law, and policy.