values (loyalty to the patient) and what was (loyalty to the physician) jeopardized patient care (ANA, 2008). After the 1950s, treatment of illness and the roles of nurses became more complex. The 1950s heralded the use of mechanical ventilation while the 1960s brought a flood of technologies including cardiopulmonary resuscitation, hemodialysis, cardiac monitoring and cardioversion, all offering life-sustaining possibilities. Nurses’ roles changed in response to this explosion in technology and greater emphasis on treatments offered in the acute care setting. It was during this time of transition that a two-part article series, Role Confusion and Conflict in Nursing: What is Real Nursing and Role Confusion and Conflict in Nursing: The Role of the Professional Nurse (Benne & Bennis, 1959a; 1959), appeared in a leading professional publication, the American Journal of Nursing. Since that time, unionization, collective bargaining, third party payer systems, complex healthcare organizations, increasing costs of healthcare, and continued development of technology all have been identified as adding to competition for the loyalties of nurses. But, are these truly competing loyalties or are they incongruent internal and external role 11 expectations or duties? Although included in the Nightingale Pledge, loyalty remains a vaguely defined and under-researched concept that should be further explored (ANA, 2015). According to provision two of the Guide to the Code of Ethics for Nurses with Interpretive Statements (ANA, 2015) a nurse’s primary commitment, or loyalty, is clear; the nurse’s primary duty is to the patient, which may be an individual, family, group, community or population. Section 2.1 of the ANA Code of Ethics (2015), identifies a nurse’s commitment to the patient as carrying “the greatest weight and priority and consequently it trumps all other loyalties”. A classic example includes the conflict between a nurse’s obligation to patients and the obligation to ones’ own family, including children, in times of threat, disaster or emergency. While leaving one’s patients without nursing care would be abandonment in most other circumstances, in the setting of a disaster where one’s familial obligations also need to be attended to acutely, a nurse would be unlikely to be held professionally accountable for abandoning his/her patients. Role conflict includes both intra-role and inter-role conflicts. Intra-role conflicts stem from internal expectations or competing ideals (e.g., forensic nurse as both a nurse and the collector of items holding potential evidentiary value). Inter-role conflicts arise from external or environmental factors (e.g., conflict between the emergency department nurse who becomes a forensic nurse and emergency department nurses) (Hazel, 1985). Role confusion results from the nurse’s lack of clarity, or uncertainty, about expectations of others regarding one’s role (e.g., the forensic nurse with an employer, law enforcement, or patients) (Benne & Bennis, 1959). This confusion may be related to practice level (e.g., scope of practice), inconsistent role definitions or descriptions, or specific roles within a given setting (e.g., specialty role within an emergency department versus community setting). Role confusion is also referred to in the literature as role 12 ambiguity, focusing on specialty roles or settings, or role clarity, focusing on practice level or inconsistent role definitions and descriptions. Considering the medico-legal nature of forensic nursing, multidisciplinary collaboration is essential, yet conflicting professional values among multidisciplinary professionals will inevitably surface. Coupled with expectations from patients, forensic nursing colleagues, health care providers, agents of law enforcement, victim advocates, criminal justice professionals and the public, it is arguably understandable that competing loyalties and dual roles have been identified as factors contributing to role conflict or confusion among forensic nurses (Downing & Macking, 2012; DuMont & Parnis, 2003; Mason, 2002). This still begs the question of the actual existence of a dual loyalty or role. It is possible that there are role specific duties or functions that are in conflict, or perhaps incongruent expectations, rather than a true dual loyalty or role. Conflicts of Interest and Conflicting Interests Section 2.2 of the 2008 ANA Code of Ethics, although titled Conflict of Interest, speaks to potentially conflicting interests that may arise for nurses in the context of professional duty, personal obligations or societal needs usually due to conflicting expectations: “Nurses are frequently put in situations of conflict arising from competing loyalties in the work place, including situations of conflicting expectations from patients, families, physicians, colleagues, and in many cases, healthcare organizations and health plans. Nurses must examine the conflicts arising between their own personal and professional values, the values and interests of others who are also responsible for patient care and healthcare decisions, as well as those of patients. Nurses strive to resolve such conflicts in ways that ensure patient safety, 13 guard the patient’s best interests and preserve the professional integrity of the nurse.” The 2015 ANA Code of ethics more clearly focuses on defining and identifying conflicts of interest rather than conflicting interests. In this revision of the Code, there is a focus