Legal / Ethics

Beyond a box of chocolates

thank you gift patient giving

Often, patients and families express their gratitude for a special nurse’s outstanding care with spoken thanks or heartfelt commendations written to a nursing supervisor. Some even offer a small gift, perhaps a box of chocolates or a fruit basket. Most nurses are skilled at accepting these tokens of appreciation with gracious responses like,It’s why I love my job, or It’s a pleasure to take care of patients like you.

But how should you respond if a patient’s expression of gratitude takes the form of expensive jewelry, cash, or another lavish gift?

Defining the problem

You already know it’s unethical to accept expensive gifts from patients. It could damage your career, too. Colleagues, supervisors, and subordinates may assume that a nurse who accepts costly gifts also allocates care on the basis of patients financial status; coworkers might even view that nurse as an untrustworthy team member. In fact, many healthcare facilities require employees to sign annual conflict-of-interest agreements that reaffirm compliance with the facility’s ban on accepting such gifts.

A pricey gold watch is out of the question. That’s clear. The stickier issue is how to be sensitive in sidestepping your patient’s opulent expression of gratitude without a residual sense that by declining the gift you’re rejecting the giver, or even renouncing the human bond that developed between the two of you. Reciting details of the conflict-of-interest standards might even leave an impression that the patient crossed a moral line by offering the gift.

Many facilities set an upper limit (typically about $25) on gifts that individual employees may accept. Such cutoff points, useful as they are, don’t offer nurses much support in finding benign ways to protect their patient’s dignity and generosity while adhering to guidelines. At the same time, they may squander an opportunity to find ethical and creative ways in which larger gifts might be accepted and put to good use in a manner that gratifies all the stakeholders.

Designing a solution

Wearing three of my professional hats; nurse, educator, and fundraiser, I’ve sought a solution to the gift dilemma through discussions with nurses and other leaders. I’ve arrived at what I believe is a solution that protects and respects all parties, while avoiding awkwardness and hard feelings and enhancing the image of the nursing profession itself: Assist the patient or family to redirect the gift to a specific nursing organization or initiative, so that the gift will benefit the nursing profession or nurses in general.


While large gifts to an individual nurse are unethical, such gifts to honor an individual nurse by name donated to charitable organizations are on solid ethical ground. To ensure that gift redirection meets ethical standards and applicable laws and tax regulations, facilities must establish policies and standards that address the process.

The impetus to establish policies and standards might come from nurses, nursing supervisors, development officers, or other facility decision makers. The project calls for input from all those job categories, along with legal and administration decision makers. Their collaboration would center on creating protocols by which gifts could be accepted to commemorate the care provided by an outstanding nurse while they’re used to benefit nurses and nursing.

For instance, the facility might want to offer donors an assortment of gift-giving program options, along with all relevant legalities; (for example, tax deductibility) and details of how nurses and nursing will benefit from such gifts. Probably the facility would open a separate Nurses Account specifically to accept such donations. Gifts could be earmarked for such expenditures as nursing scholarships, advanced-training nursing programs, even nursing-journal subscriptions.

If a donor wishes to honor a specific nurse, the policies could offer individual nurses the opportunity to designate personal preference of organizations to benefit. Beneficiaries may include the facility’s nursing staff, the honored nurse’s nursing-school alma mater, or a nursing organization or foundation the nurse respects.

Once details are accepted by all decision makers, the policy should be distributed to and affirmed by all employees. Included in the policy packet as well might be guidelines for nurses in such redirection conversations. Here’s an example: It means a lot to me that what we nurses do has been so meaningful to you. I’m not able to accept a personal gift, but you would honor me deeply if you were to make a donation to support the profession I love, nursing.

Armed with such organizational support, many nurses would feel more confident in suggesting a gift redirection. If some nurses still feel ill at ease when discussing donations, they might suggest that the patient or family speak with a nursing leader, the facility’s development officer, or another staff member who’s skilled in such discussions. A nurse might say, If you would like, I can introduce you to someone who knows more than I do about our nursing gifts program. Particularly when the gift is large or has multiple components, the facility’s development officer should assume leadership, building a relationship with the donor.

Be aware, though, that the idea of the gift must originate with the patient or family. To suggest gift-giving to a prosperous patient would be unethical just as it would be unethical to suggest that a facility’s development officer pursue a wealthy patient.

Building a bronze wall for nurses

Nearly every healthcare facility and health-related university building boasts a bronze wall covered with plaques each one representing a gift from a grateful patient to honor a special physician at the facility.

Why not build a bronze wall for nurses? By redirecting patients gifts from individual nurses to nursing organizations or the nursing profession, we begin to build bronze walls of our own. This would be a win-win-win situation: Grateful patients would have the satisfaction of knowing they’ve expressed admiration for their special nurse in a meaningful, tangible way. The nurse in whose name the gift is made not only would see her name on the wall she’d know that other nurses and nursing itself benefit from the tribute she has earned. And the nursing profession would gain increased visibility and credibility in a way that testifies to the value of our service.

Selected references

American Nurses Association. Code of ethics for nurses with interpretative statements. Washington, DC: American Nurses Association; 2001. Available at: http://nursingworld.org/mainmenucategories/ethicsstandards/codeofethicsfornurses/code-of-ethics-for-nurses.html_
nwcoe813.htm. Accessed January 31, 2007.

Husted G, Husted J. Ethical Decision Making in Nursing. 2nd ed. St. Louis, Mo: Mosby; 2001.

Anne R. Bavier, PhD, RN, FAAN, is Dean and Professor at the School of Nursing, University of Connecticut in Storrs.

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