Code of Ethics for Nurses with Interpretive Statements 1

Code of Ethics for Nurses with Interpretive Statements 1
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The Code of Ethics for Nurses

with Interpretive Statements

Silver Spring, Maryland

2014

Code of Ethics for Nurses with Interpretive Statements 2
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Contents

The Code of Ethics for Nurses

Preface

Provision 1

1.1 Respect for human dignity

1.2 Relationships to patients

1.3 The nature of health

1.4 The right to self-determination

1.5 Relationships with colleagues and others

Provision 2

2.1 Primacy of the patient's interests

2.2 Conflict of interest for nurses

2.3 Collaboration

2.4 Professional boundaries

Provision 3

3.1 Protection of the rights of privacy and confidentiality

3.2 Protection of human participants in research

3.3 Performance standards and review mechanisms

3.4 Professional competence in nursing practice

3.5 Protecting patient health and safety by action on
questionable practice

3.6 Patient protection and impaired practice

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Provision 4

4.1 Authority, accountability, and responsibility

4.2 Accountability for nursing judgment, decisions, and action

4.3 Responsibility for nursing judgment, decisions, and action

4.4 Delegation of nursing activities or tasks

Provision 5

5.1 Duty to self and others

5.2 Promotion of personal health, safety, and well-being

5.3 Wholeness of character

5.4 Preservation of integrity

5.5 Maintenance of competence and professional growth

5.6 Personal growth

Provision 6

6.1 The environment and moral virtue and values

6.2 The environment and ethical obligation

6.3 Responsibility for the healthcare environment

Provision 7

7.1 Contributions through research and scholarly inquiry

7.2 Contributions through developing maintaining, and
implementing professional

practice standards

7.3 Contributions through nursing and health policy
development

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Provision 8

8.1 Health is a universal right

8.2 Collaboration for health, human rights, and health
diplomacy

8.3 Obligation to advance health and human rights

8.4 Collaboration for human rights in complex and
extraordinary practice settings

Provision 9

9.1 Articulation of values

9.2 Integrity of the profession

9.3 Integrating social justice

9.4 Social justice in nursing and health policy

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The Code of Ethics for Nurses

Provision 1

The nurse practices with compassion and respect for the

inherent dignity, worth, and

personal attributes of every person, without prejudice.

Provision 2

The nurse’s primary commitment is to the patient, whether an
individual, family, group,

community, or population.

Provision 3

The nurse promotes, advocates for, and protects the rights,
health and safety of the

patient.

Provision 4

The nurse has authority, accountability, and responsibility for
nursing practice, makes

decisions, and takes action consistent with the obligation to
provide optimal care.

Provision 5

The nurse owes the same duties to self as to others, including
the responsibility to

promote health and safety, preserve wholeness of character and
integrity, maintain

competence, and continue personal and professional growth.

Provision 6

The nurse, through individual and collective action, establishes,
maintains, and improves

the moral environment of the work setting and the conditions of
employment, conducive

to quality health care.

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Provision 7

The nurse, whether in research, practice, education, or
administration, contributes to the

advancement of the profession through research and scholarly
inquiry, professional

standards development, and generation of nursing and health
policies.

Provision 8

The nurse collaborates with other health professionals and the
public to protect and

promote human rights, health diplomacy, and health initiatives.

Provision 9

The profession of nursing, collectively through its professional
organizations, must

articulate nursing values, maintain the integrity of the
profession, and integrate principles

of social justice into nursing and health policy.

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Preface

The Code of Ethics for Nurses with Interpretive Statements
establishes the ethical

standard for the profession and provides a guide for nurses to
use in ethical analysis

and decision-making. It is non-negotiable in any setting, neither
is it subject to

revision or amendment except by formal process of revision by
the American Nurses

Association. The Code of Ethics for Nurses arises from within
the long, distinguished,

and enduring moral tradition of modern nursing in the United
States. It is

foundational to nursing theory, practice, and praxis in its
expression of the values,

virtues and obligations that shape, guide, and inform nursing as
a profession.

Nursing encompasses the prevention of illness, the alleviation
of suffering, and the

protection, promotion, and restoration of health in the care of
individuals, families,

groups, communities, and populations. This is reflected, in part,
in nursing’s persisting

commitment to the welfare of the sick, injured, and vulnerable
in society and for social

justice issues. Nurses act to change those aspects of social
structures that detract from

health and well-being. Individuals who become nurses, as well
as the professional

organizations that represent them, are expected not only to
adhere to the values, moral

norms, and ideals of the profession but also to embrace them as
a part of what it means to

be a nurse. The ethical tradition of nursing is self-reflective,
enduring, and distinctive. A

code of ethics for the nursing profession makes explicit the
primary obligations, values,

and ideals of the profession that inform every aspect of the
nurse’s life.

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The Code of Ethics for Nurses serves the following purposes:

duties, and

professional ideals of nurses individually and collectively.

commitment to

society.

Statements that describe activities and attributes of nurses in
this code of ethics

and its interpretive statements are to be understood as normative
or prescriptive

statements expressing expectations of ethical behavior. The
Code of Ethics for Nurses

also expresses the ethical ideals of the nursing profession and
is, thus, both normative

and aspirational. While this Code articulates the ethical
obligations of all nurses, it

does not predetermine how those obligations must be met. In
some instances nurses

meet those obligations individually; in other instances a nurse
will support other

nurses in their execution of these obligations; and at other times
those obligations can

and will only be met collectively. The Code of Ethics for
Nurses addresses individual

as well as collective nursing intentions and requires each nurse
to demonstrate ethical

competence in professional life.

It is recognized that nurses provide services to those seeking
health as well as those

responding to illness, to students and to staff, and to those in
healthcare facilities as well

as in communities and greater populations. The term practice
refers to the actions of the

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nurse in any role or setting, whether paid or as a volunteer,
including clinical care

provider, advanced practice nurse, educator, administrator,
researcher, policy developer,

or other forms of nursing practice. Thus, the values and
obligations expressed in this

Code of Ethics for Nurses apply to nurses in all roles, in all
forms of practice, and in all

settings.

The Code of Ethics for Nurses is a dynamic document. As
nursing and its social

context change, changes to the Code are also necessary. The
Code of Ethics for Nurses

consists of two components: the provisions and the
accompanying interpretive

statements. There are nine provisions that contain an intrinsic
relational motif: nurse to

patient, nurse to nurse, nurse to self, nurse to others, nurse to
profession, and nurse and

nursing to society. The first three provisions describe the most
fundamental values and

commitments of the nurse; the next three address boundaries of
duty and loyalty; the last

three address aspects of duties beyond individual patient
encounters. Each provision is

accompanied by interpretive statements that provide greater
specificity for practice and

are responsive to the contemporary context of nursing.
Consequently, the interpretive

statements are subject to more frequent revision than are the
provisions. Additional

ethical guidance and details can be found in the position or
policy statements of the ANA

or its constituent member associations and affiliate
organizations that address clinical,

research, administrative, educational, public policy, or global
and environmental health

issues.

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The origins of The Code of Ethics for Nurses with Interpretive
Statements reach

back to the late 1800s in the foundation of the American Nurses
Association, the

early ethics literature of modern nursing, and the first nursing
code of ethics, formally

adopted in 1950. In the 65 years since the adoption of that first
professional ethics

code, nursing has changed as its art, science, and practice have
developed, as society

itself has changed, and as awareness of the global nature of
health and the

determinants of illness has grown. While The Code of Ethics for
Nurses with

Interpretive Statements is a reflection of the proud ethical
heritage of nursing, it is

also a guide for all nurses now and into the future.

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Provision 1

The nurse practices with compassion and respect for the
inherent

dignity, worth, and personal attributes of every person, without

prejudice.

1.1 Respect for Human Dignity

A fundamental principle that underlies all nursing practice is
respect for the inherent

dignity, worth, and human rights of all individuals. The need for
and right to health care

is universal, transcending all individual differences. Nurses
consider the needs and

respect the values of each person in every professional

relationship and setting; they

lead in the development of changes in public and health policies
that support this duty.

1.2 Relationships with Patients

Nurses establish relationships of trust and provide nursing
services according to need,

setting aside any bias or prejudice. When planning patient,
family and population

centered care, factors such as lifestyle, culture, value system,
religious or spiritual

beliefs, social support system and primary language shall be
considered. Such

considerations must promote health, address problems and
respect patient decisions.

This respect for patient decisions does not require that the nurse
agree with or support

all patient choices.

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1.3 The Nature of Health

Nurses respect the dignity and rights of all human beings
regardless of the factors

contributing to the health status. The worth of a person is not
affected by disease,

disability, functional status, or proximity to death. Nurses
assess, diagnose, plan,

intervene, and evaluate patient care in accord with individual
patient needs and values.

Respect is extended to all who require and receive nursing care
whether in the

promotion of health, prevention of illness, restoration of health,
alleviation of suffering,

and provision of supportive care to those who are dying.

Optimal nursing care enables the patient to live with as much
physical, emotional,

social, and religious or spiritual well-being as possible and
reflects the patient’s own

values. Supportive care is extended to the family and significant
others and is directed

toward meeting needs comprehensively across the continuum of
care. This is

particularly important at the end of life in order to prevent and
alleviate the cascade of

symptoms and suffering that are commonly associated with
dying.

Nurses are leaders who actively participate in assuring the
responsible and

appropriate use of interventions in order to optimize the health
and well-being of those

in their care. This includes acting to minimize unwarranted or
unwanted medical

treatment and patient suffering. Such care must be avoided and
advance care planning

throughout many clinical encounters helps to make this
possible. Nurses are also

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leaders who collaborate in alleviating systemic structures that
have a negative influence

on individual and community health.

1.4 The Right to Self-Determination

Respect for human dignity requires the recognition of specific
patient rights, in

particular, the right of self-determination. Patients have the
moral and legal right to

determine what will be done with their own person; to be given

accurate, complete, and

understandable information in a manner that facilitates an
informed decision; to be

assisted with weighing the benefits, burdens, and available
options in their treatment,

including the choice of no treatment; to accept, refuse, or
terminate treatment without

deceit, undue influence, duress, coercion, or prejudice; and to
be given necessary

support throughout the decision-making and treatment process.
Such support includes

the opportunity to make decisions with family and significant
others and to obtain

advice from expert/knowledgeable nurses and other health
professionals. The

acceptability and importance of carefully considered decisions
regarding resuscitation

status, withholding and withdrawing life-sustaining therapies,
forgoing medically

provided nutrition and hydration, aggressive pain and symptom
management, and

advance directives are widely recognized. Nurses provide
patients with assistance as

necessary with these decisions. Nurses should promote

conversations around advance

care planning and must be knowledgeable about the benefits and
limits of various

advance directive documents. The nurse should provide
interventions to relieve pain

and other symptoms in the dying patient even when those
interventions entail risks of

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hastening death. However, nurses may not act with the intent to
end life even though

such action may be motivated by compassion, respect for patient

autonomy, or quality

of life considerations. Nurses have invaluable experience,
knowledge, and insight into

effective and compassionate care at the end of life and should
be actively involved in

related research, education, practice, and policy development.

Nurses have an obligation to be knowledgeable about the moral
and legal rights of

patients. Nurses preserve, protect, and support those rights by
assessing the patient’s

understanding of both the information presented and the
implications of decisions.

When the patient lacks capacity to make a decision, a formally
designated surrogate

should be consulted. The role of the surrogate is to make
decisions as the patient would,

based upon the patient’s previously expressed wishes and
known values. In the absence

of an appropriate surrogate decision maker, decisions should be
made in the best

interests of the patient, considering the patient’s personal
values to the extent that they

are known. Nurses include patients or surrogate decision-makers

in discussions,

provide referrals to other resources as indicated, identify
options, and address problems

in the decision-making process. Support of patient autonomy
also includes respect for

the patient’s method of decision-making and recognition that
different cultures have

different understandings of health, autonomy, privacy and
confidentiality, and

relationships as well as varied practices of decision-making. For
example, nurses

reaffirm the patient’s values and respect decision-making
including those that are

culturally hierarchical or communal.

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Individuals are interdependent members of the community.
Nurses recognize

situations in which the right to self-determination may be
outweighed or limited by the

rights, health, and welfare of others, particularly in public
health. The limitation of

individual rights must always be considered a serious deviation
from the standard of

care, justified only when there are no less restrictive means
available to preserve the

rights of others and the demands of the law.

1.5 Relationships with Colleagues and Others

Respect for persons extends to all individuals with whom the
nurse interacts. Nurses

maintain professional, respectful and caring relationships with
colleagues and are

committed to fair treatment, integrity-preserving compromise,
and the resolution of

conflicts. Nurses function in many roles and many settings,
including direct care

provider, care coordinator, administrator, educator, researcher,
and consultant. In every

role, the nurse creates a moral environment and culture of
civility and kindness, treating

others, colleagues, employees, co-workers, and students with
dignity and respect. This

standard of conduct includes an affirmative duty to act to
prevent harm. Disregard for

the effect of one’s actions on others, bullying, harassment,
manipulation, threats or

violence are always morally unacceptable behaviors. Nurses
value the distinctive

contribution of individuals or groups, and collaborate to meet
the shared goal of

providing efficient, effective, and compassionate health services
seeking to achieve

quality outcomes in all settings.

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Provision 2

The nurse’s primary commitment is to the patient, whether an
individual,

family, group, community, or population.

2.1 Primacy of the Patient’s Interests

The nurse’s primary commitment is to the recipients of nursing
and healthcare

services—the patient—whether individuals, families, groups,
communities, or

populations. Any plan of care must reflect the fundamental
commitment of nursing to

the uniqueness, worth and dignity of the patient. Nurses provide
patients with

opportunities to participate in planning and implementing care
and support that is

acceptable to the patient. Addressing patient interests requires
recognition of the

patient’s place within the family and other relationships. When
the patient’s wishes

are in conflict with others, nurses help to resolve the conflict.
Where conflict persists,

the nurse’s commitment remains to the identified patient.

2.2 Conflict of Interest for Nurses

Nurses may experience conflict arising from competing
loyalties in the workplace,

including conflicting expectations from patients, families,
physicians, colleagues,

healthcare organizations and health plans. Nurses must examine
the conflicts arising

between their own personal and professional values and the
values and interests of

others including those who are also responsible for patient care
and healthcare

decisions, and perhaps patients themselves. Nurses address
these conflicts in ways

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that ensure patient safety and promote the patient’s best
interests while preserving the

professional integrity of the nurse and supporting
interdisciplinary collaboration.

Conflicts of interest may arise in any domain of nursing activity
including clinical

practice, administration, education, consultation and research.
Nurses in all roles must

identify and, whenever possible, avoid conflicts of interest.
Nurses who bill directly

for services and nurse executives with budgetary
responsibilities must be especially

aware of the potential for conflicts of interest. Changes in
healthcare financing and

delivery systems may create conflict between economic self-
interest and professional

integrity. Bonuses, sanctions, and incentives tied to financial
targets may present such

conflict. Any perceived or actual conflict of interest should be
disclosed to all

relevant parties and, if indicated, nurses should withdraw from
further participation.

2.3 Collaboration

In health care the goal is to address the health of the patient and
the public. The

complexity of healthcare requires effort that has the strong
support and active

participation of all health professions. Nurses should actively
foster collaborative

planning to provide high quality, patient-specific health care.
Nurses are responsible

for articulating, representing and preserving the unique
contribution of nursing to

patient care and the nursing scope of practice. The relationship
with other health

professions also needs to be clearly articulated, represented and
preserved.

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Collaboration intrinsically requires mutual trust, recognition,
respect,

transparency, shared decision-making, and open communication
among all who share

concern and responsibility for health outcomes. Nurses assure
that all relevant

persons, as moral agents, are participatory in patient care
decisions. Patients do not

always know what questions to ask. Nurses assure informed
decision-making by

assisting patients to secure the information that they need to
make choices consistent

with their own values.

Collaboration within nursing is fundamental to address the
health of patients and

the public effectively. Nurses who are engaged in non-clinical
roles, such as educator,

administrator, consultant, or researcher, though not primarily
involved in direct

patient care, collaborate for the provision of high quality care
through the influence

and direction of those who provide direct care. In this sense,
nurses in all roles are

interdependent and share a responsibility for outcomes in
nursing care and for

maintaining nursing’s primary commitment to the patient.

2.4 Professional Boundaries

The nature of nursing work is inherently personal. Within their
professional role, nurses

recognize and maintain appropriate personal relationship
boundaries. Nurse–patient

relationships and collegial relationships have as their
foundation the protection,

promotion, and restoration of health and the alleviation of
suffering. Professional

relationships are therapeutic in nature yet at times remaining
within professional

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boundaries can be tested. The intimate nature of nursing care,
the involvement of nurses

in important and sometimes highly stressful life events, the
mutual dependence of

colleagues working in close concert, all may contribute to the
risk of boundary violations.

This is compounded by the need for nurses to maintain
authenticity in expressing

themselves as individuals. In all communications and actions
nurses are responsible for

maintaining professional boundaries and for seeking the
assistance of peers or

supervisors in managing difficult situations or taking
appropriate steps to remove

themselves from the situation.

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Provision 3

The nurse promotes, advocates for, and protects the rights,
health and

safety of the patient.

3.1 Protection of the Rights of Privacy and Confidentiality

Privacy is the right to control access to and disclosure or
nondisclosure of information

pertaining to oneself, and to control the circumstances, timing,
and extent to which

information might be disclosed. The need for health care does
not justify unwanted or

unwarranted intrusion into people’s lives. Nurses safeguard the
individual’s, family’s,

and community’s right to privacy. The nurse advocates for an
environment that provides

sufficient physical privacy, including privacy for discussions of
a personal nature. Nurses

also participate in the maintenance of and policies and practices
that protect both personal

and clinical information at institutional and societal levels.

Confidentiality pertains to the nondisclosure of personal
information that has been

communicated within the nurse–patient relationship. Central to
that relationship is an

element of trust and an expectation that personal information
will not be divulged without

consent. 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. Because of the rapidly evolving means of
communication and the

porous nature of social media, nurses must maintain vigilance
regarding commentary that

intentionally and/or unintentionally breaches their obligation to
maintain and protect

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patients' rights to privacy and confidentiality.   The patient’s
well-being could be

jeopardized and the fundamental trust between patient and nurse
damaged by

unauthorized access to data or by the inappropriate or unwanted
disclosure of identifiable

information. Patient rights are the primary factors in any
decisions concerning personal

information, whether from or about the patient. This pertains to
all information in any

manner that is communicated or transmitted. Nurses are
responsible for providing

accurate, relevant data to members of the healthcare team and
others who have a need to

know. The duty to maintain confidentiality is not absolute and
may need to be modified

in order to protect the patient, other innocent parties, and in
circumstances of required

disclosure such as mandated reporting or for safety or public
health reasons.

Information used for purposes of peer review, professional
practice evaluation, third-

party payments, and other quality improvement or risk
management mechanisms may

only be disclosed under defined policies, mandates, or
protocols. These written guidelines

must assure that the rights, well-being, and safety of the patient
remain protected. Only

that information directly relevant to a task or specific
responsibility should be disclosed.

When using electronic communications or in electronic health
records, special effort

should be made to maintain data security.

3.2 Protection of Human Participants in Research

Stemming from the right to autonomy or self-determination,
individuals have the right to

choose whether or not to participate in research as a human
subject. Participants or legal

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surrogates must receive sufficient and materially relevant
information to make informed

decisions and to understand that they have the right to decline
to participate or to

withdraw at any time without fear of adverse consequences or
reprisal. Information

needed for informed consent includes the nature of
participation, potential harms and

benefits, available alternatives to taking part in the study, and
how the data will be

protected. It must be communicated in a manner that is
comprehensible to the patient.

Prior to implementation, all research must be approved by a
formally constituted and

qualified review board to ensure participant protection and the
ethical integrity of the

research.

Nurses should be aware of the special concerns raised by
research involving

vulnerable groups, including patients, children, minority
populations, prisoners, pregnant

women, fetuses, the elderly, cognitively impaired persons, and
economically or

educationally disadvantaged persons. The nurse who directs or
engages in research

activities in any capacity should be fully informed about the
qualifications of the

principal investigator, the rights and obligations of all those
involved in the particular

research study, and the ethical conduct of research in general.
Nurses have a duty to

question and, if necessary, to report research that is ethically
questionable and to decline

to participate.

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3.3 Performance Standards and Review Mechanisms

Professional nursing is a process of education and formation
that involves the ongoing

acquisition and development of the knowledge, skills,
dispositions, practice

experiences, commitment, relational maturity, and personal
integrity essential for

professional practice. Nurse educators must ensure that basic
competence and

commitment to professional practice exist prior to entry into
practice. Nurse managers

and executives similarly ensure that nurses have the required
knowledge, skills, and

dispositions to perform clinical responsibilities requiring
preparation beyond the basic

academic programs. In this way nurses— individually,
collectively and as a

profession—are responsible and accountable for nursing
practice and professional

behavior.

3.4 Professional Competence in Nursing Practice

Nurses must lead in the development of policies and review
mechanisms to promote

patient health and safety, reduce errors, and create a culture of
excellence. When errors

occur, nurses must follow institutional guidelines in reporting
errors to the appropriate

authority and ensure responsible disclosure of errors to patients.
Nurses must establish

processes where mistakes or errors are revealed and nurses are
personally accountable,

and any system factors that led to error are rectified. Error
should be corrected or

remediated, not punished. When error occurs, whether one’s
own or an error of a

coworker, nurses may not participate in, or condone through
silence, any attempts to

hide it. Engaging the appropriate intra-institutional sequence of
reporting and authority

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is critical to maintaining a safe patient care environment.
Nurses must use the chain of

authority when a problem or issue has escalated beyond their
problem-solving ability

and/or scope of responsibility or authority. Issue reporting
escalation ensures that

appropriate individuals are aware of the concern.
Communication should start at the

level closest to the event and escalate only as the situation
warrants.

3.5 Protecting Patient Health and Safety by Action on
Questionable Practice

Nurses must be alert to and take appropriate action in instances
of incompetent,

unethical, illegal, or impaired practice or any actions that place
the rights or best

interests of the patient in jeopardy. To function effectively,
nurses must be

knowledgeable about The Code of Ethics of Ethics for Nurses,
standards of practice of

the profession, relevant federal, state and local laws and
regulations, and the employing

organization’s policies and procedures.

When nurses are aware of inappropriate or questionable
practice, the concern

should be expressed to the person involved, focusing on the
patient’s best interests as

well as the integrity of nursing practice. When practices in the
healthcare delivery

system or organization threaten the welfare of the patient,
similar action should be

directed to the responsible administrator or, if indicated, to an
appropriate higher

authority within the institution or agency, or to an appropriate
external authority. When

incompetent, unethical, illegal, or impaired practice is not
corrected and continues to

jeopardize patient well-being and safety, the problem must be
reported to appropriate

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external authorities such as practice committees of professional
organizations and

regulatory, licensing, and quality assurance agencies or boards.
Some situations are

sufficiently egregious that they may warrant the notification and
involvement of all

such groups.

Nurses should use established processes for reporting and
handling questionable

practices. All nurses have a responsibility to assist those
“whistleblowers” who identify

potentially questionable practice and to reduce the risk of
reprisal against the reporting

nurse. State nurses associations should be prepared to provide
their members with

advice and support in the development and evaluation of such
processes and reporting

procedures. Accurate reporting and factual documentation are
essential for all such

actions. When a nurse chooses to engage in the act of
responsible reporting about

situations that are perceived as unethical, incompetent, illegal,
or impaired, the

professional organization has a responsibility to protect the
practice of those nurses

who choose formally to report their concerns. Reporting
questionable practices, even

when done appropriately, may present substantial risk to the
nurse; nevertheless, such

risk does not eliminate the obligation to address threats to
patient safety.

3.6 Patient Protection and Impaired Practice

Nurses must protect the patient, the public, and the profession
from potential harm

when a colleague’s practice appears to be impaired. When
another’s practice appears to

be impaired, the nurse’s duty is to take action to protect patients
and to ensure that the

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impaired individual receives assistance. This process begins
with consulting

supervisory personnel and includes approaching the individual
in a clear and supportive

manner and helping the individual to access appropriate
resources. The nurse extends

compassion and caring to colleagues throughout processes of
identification,

remediation, and recovery.

Nurses must follow policies of the employing organization,
guidelines outlined by

the profession, and relevant laws to assist colleagues whose job
performance may be

adversely affected by mental or physical illness or by personal
circumstances. Nurses in

all professional relationships must advocate in instances of
impairment for appropriate

assistance, treatment, and access to fair institutional and legal
processes. This includes

supporting the return to practice of individuals who have sought
assistance and, after

recovery, are ready to resume professional duties. If impaired
practice poses a threat or

danger to self or others, regardless of whether the individual has
sought help, the nurse

must report the individual to persons authorized to address the
problem. Nurses who

report those whose job performance creates risk should be
protected from retaliation or

other negative consequences. If workplace policies do not exist
or are inappropriate—

that is, they deny the nurse in question access to due legal
process or demand

resignation—nurses may obtain guidance from professional
associations, state peer

assistance programs, employee assistance programs, or similar
resources.

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Provision 4

The nurse has authority, accountability, and responsibility for

nursing

practice, makes decisions, and takes action consistent with the
obligation

to provide optimal care.

4.1 Authority, Accountability, and Responsibility

Nurses bear primary responsibility for the nursing care that
their patients and clients

receive and are accountable for their own practice. Nursing
practice includes

independent direct nursing care activities, care as ordered by an
authorized healthcare

provider, delegation of nursing interventions, evaluation of
interventions, and other

responsibilities such as teaching, research, and administration.
In each instance,

nurses have the authority and retain accountability and
responsibility for the quality

of practice and for compliance with state nurse practice acts,
and standards of care,

including The Code of Ethics for Nurses.

In the context of the increased complexity and changing
patterns in healthcare

delivery, the scope of nursing practice evolves. Nurses must
exercise judgment in

accepting responsibilities, seeking consultation, and assigning
activities to others who

provide nursing care. Where advanced practice nurses have the
authority to issue

medication and treatment orders to nurses, these are not acts of
delegation. Both the

advanced practice nurse issuing the order and the nurse
accepting the order are

responsible for the judgments made and accountable for the
actions taken.

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4.2 Accountability for Nursing Judgments, Decisions, and
Actions

In order to be accountable, nurses act under a code of ethical
conduct that includes

adherence to the scope and standards of nursing practice and
such moral principles as

fidelity, gratitude, and respect for the dignity, worth, and self-
determination of

patients. Nurses are accountable for judgments made and
actions taken in the course

of nursing practice, irrespective of other providers’ directives
or institutional policies.

Systems and technologies that assist in clinical practice are
adjunct to, not

replacements for, the nurse’s knowledge and skill. The nurse
retains accountability

and responsibility for nursing practice even in instances of
system or technological

failure.

4.3 Responsibility for Nursing Judgments, Decisions and

Actions

Nurses are accountable for their judgments, decisions, and
actions; but, in

compromising circumstances, responsibility may be borne by
both the nurse and the

institution. Nurses accept or reject specific role demands and
assignments based on

their education, knowledge, competence, experience, and
assessment of patient

safety. Nurses in administration, education, and research also
have obligations to the

recipients of nursing care. Although their relationships with
patients are less direct, in

assuming the responsibilities of a particular role, they share
responsibility for the care

provided by those whom they supervise and teach. Nurses must
not engage in

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practices prohibited by law or delegate activities to others that
are prohibited by their

state nursing practice acts or those of other healthcare
providers.

Nurses have a responsibility to define, implement, and maintain
standards of

professional practice. Nurses must plan, establish, implement,
and evaluate review

mechanisms to safeguard patients and nurses. These include
peer review processes,

credentialing processes, and quality improvement initiatives.
Nurses must bring

forward difficult issues related to patient care, and/or
institutional constraints upon

ethical practice for discussion and review. The nurse acts to
promote inclusion of

appropriate others in all ethical deliberations. Nurse executives
are responsible for

ensuring that nurses have access to and inclusion on
organizational committees that

affect the quality and the safety of the care of the patients they
serve. Nurses are

obligated to attend, actively engage, and contribute to the
dialogue and decisions

made by such committees.

Nurses are responsible for assessing their own competence.
When the needs of the

patient are beyond the qualifications or competencies of the
nurse, consultation and

collaboration must be sought from qualified nurses, other health
professionals, or

other appropriate resources. Educational resources should be
used by nurses and

provided by agencies or organizations to maintain and advance
nurse competence.

Nurse educators in any setting collaborate with their students to
assess learning needs,

evaluate teaching effectiveness, and provide appropriate
learning resources.

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4.4 Delegation of Nursing Activities or Tasks

Nurses are accountable and responsible for the assignment or
delegation of nursing

activities. Such assignment or delegation must be consistent
with state practice acts,

institutional policy, and nursing standards of practice.

Nurses must make reasonable effort to assess individual
competence when

delegating selected nursing activities. This assessment includes
the evaluation of the

knowledge, skill, and experience of the individual to whom the
care is assigned; the

complexity of the assigned tasks; and the nursing care needs of
the patient. Nurses are

responsible for monitoring the activities and evaluating the
quality and outcomes of

the care provided by other healthcare workers to whom they
have delegated tasks.

Nurses may not delegate responsibilities such as assessment and
evaluation; they may

delegate interventions. Nurses must not knowingly assign or
delegate to any member

of the nursing team a task for which that person is not prepared
or qualified.

Employer policies or directives do not relieve the nurse of
responsibility for making

delegation or assignment decisions.

Nurses in management or administration have a particular
responsibility to

provide an environment that supports and facilitates appropriate
assignment and

delegation. This includes orientation, skill development;
licensure, certification, and

competency verification; and policies that protect both the
patient and nurse from

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inappropriate assignment or delegation of nursing
responsibilities, activities, or tasks.

Nurses in management or administration should facilitate open
communication with

staff allowing them, without fear of reprisal, to express
concerns or even to refuse an

assignment for which they do not possess the requisite skills.

Nurses functioning in educator or preceptor roles share
responsibility and

accountability for the care provided by students when they make
clinical assignments.

It is imperative that the knowledge and skill of the nurse or
nursing student be

sufficient to provide the assigned nursing care under
appropriate supervision.

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Provision 5

The nurse owes the same duties to self as to others, including
the

responsibility to promote health and safety, preserve wholeness
of

character and integrity, maintain competence, and continue
personal and

professional growth.

5.1 Duty to Self and Others

Moral respect accords moral worth and dignity to all human
beings regardless of their

personal attributes or life situation. Such respect extends to
oneself as well: the same

duties that we owe to others we owe to ourselves. Self-
regarding duties primarily concern

oneself and include promotion of health and safety, preservation
of wholeness of

character and integrity, maintenance of competence, and
continuation of personal and

professional growth.

5.2 Promotion of Personal Health, Safety, and Well-Being

As professionals who assess, intervene, evaluate, protect,
promote, educate, and conduct

research for the health and safety of others and society, nurses
have a duty to take the

same care for their own health and safety. Nurses should model
the same health

maintenance and health promotion measures that they teach and
research, seek health

care when needed, and avoid taking unnecessary risks to health
or safety in the course of

their customary professional and personal activities. A healthy
diet and exercise,

maintenance of family and personal relationships, adequate
leisure and recreation,

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attention to spiritual or religious needs, and satisfying work
must be held in balance to

promote and maintain the health and well-being of the nurse.

5.3 Wholeness of Character

Nurses have both personal and professional identities that are
integrated and embrace the

values of the profession, merging them with personal values.
Authentic expression of

one’s own moral point-of-view is a duty to self. Sound ethical
decision-making requires

the respectful and open exchange of views among all those with
relevant interests: nurses

must work to foster a community of moral discourse. As moral
agents, nurses are an

important part of that community and have a responsibility to
express moral perspectives,

especially when integral to the situation, whether or not those
perspectives are shared by

others and whether or not they might prevail.

Wholeness of character pertains to all professional relationships
with patients or

clients. When nurses are asked for a personal opinion, they are
generally free to express

an informed personal opinion as long as this maintains
appropriate professional and

moral boundaries and preserves the voluntariness of the patient.
It is essential to be aware

of the potential for undue influence attached to the nurse’s
professional role. Nurses assist

others to clarify values in reaching informed decisions, always
avoiding coercion,

manipulation, and unintended influence. When nurses care for
those whose personal,

condition, attributes, lifestyle, or situations are stigmatized, or
encounter a conflict with

their own personal beliefs, nurses still render respectful and
competent care.

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5.4 Preservation of Integrity

Personal integrity is an aspect of wholeness of character; its
maintenance is a self-

regarding duty. Nurses may face threats to their integrity in any
healthcare environment.

Threats to integrity may include requests to deceive a patient, to
withhold information, to

falsify records, to misrepresent research aims, as well as
enduring verbal abuse by

patients or coworkers. Expectations that nurses will make
decisions or take action in

ways that are inconsistent with the ideals, values, or ethics of
nursing, or that are in direct

violation of this Code of Ethics for Nurses, may also occur.
Nurses have a right and a

duty to act according to their personal and professional values
and to accept compromise

only if reaching a compromise preserves the nurse’s moral
integrity and does not

jeopardize the dignity or well-being of the nurse or others.
Integrity-preserving

compromises can be difficult to achieve, but are more likely to
be accomplished where

there is an open forum for moral discourse and a safe
environment of mutual respect.

When nurses are placed in circumstances that exceed moral
limits or violate

professional moral standards, in any nursing practice setting,
they must express their

conscientious objection to participating in these situations.
When a particular decision or

action is morally objectionable to the nurse, whether
intrinsically so or because it may

jeopardize a specific patient, family, community or population,
or when it may jeopardize

nursing practice, the nurse is justified in refusing to participate

on moral grounds.

Conscience-based refusals to participate exclude personal
preference, prejudice, bias,

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convenience, or arbitrariness. Acts of conscientious objection
are acts of moral courage

and may not insulate nurses from formal or informal
consequences. Nurses who decide

not to participate on the grounds of conscientious objection
must communicate this

decision in timely and appropriate ways. Such refusal should be

made known as soon as

possible, in advance, and in time for alternate arrangements to
be made for patient care.

Nurses are obliged to provide for patient safety, to avoid patient
abandonment, and to

withdraw only when assured that nursing care is available to the
patient.

When the moral integrity of nurses is compromised by patterns
of institutional

behavior or professional practice, nurses must express their
concern or conscientious

objection collectively to the appropriate authority or committee
and seek to change

enduring activities or expectations in the practice setting that
are morally objectionable.

5.5 Maintenance of Competence and Professional Growth

Maintenance of competence and professional growth involve the
control of one’s own

conduct in a way that is primarily self-regarding. Competence
affects one’s self-respect,

self-esteem, and the meaningfulness of work. Nurses must
maintain competence and

strive for excellence in their nursing practice, whatever the role
or setting. Nurses are

responsible for developing criteria for evaluation of practice
and for using those criteria

in both peer and self-assessment. To achieve the highest
standards, nurses must evaluate

their own performance and participate in substantive peer
review.

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Continual professional growth, particularly in knowledge and

skill, requires a

commitment to lifelong learning. Such learning includes
continuing education,

networking with professional colleagues, self-study,
professional reading, specialty

certification, and seeking advanced degrees. Nurses must
continue to learn about new

concepts, evolving issues, concerns, controversies, and
healthcare ethics relevant to the

current and evolving scope and standards of nursing practice.
When care that is required

is outside the competencies of the individual nurse, specialized
consultation should be

sought or the patient should be referred to others for appropriate
specialized care.

5.6 Personal Growth

Nursing care addresses the whole person as an integrated being;
nurses should also apply

this principle to themselves. As such, professional and personal
growth reciprocate and

interact. Activities that broaden nurses’ understanding of the
world and of themselves

affect their understanding of patients; those that increase and

broaden nurses’

understanding of nursing’s science and art, values, ethics, and
policies also affect the

nurse’s self-understanding. Thus, in continuity with nursing
ethics’ historic and enduring

emphasis, nurses are encouraged to read broadly, continue life-
long learning, engage in

personal study, seek financial security, participate in a wide
range of social advocacy and

civic activities, and to pursue leisure and recreational activities
that are enriching.

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Provision 6

The nurse, through individual and collective action, establishes,

maintains, and improves the moral environment of the work
setting and the

conditions of employment, conducive to quality health care.

6.1 The environment and moral virtue and value

Virtues are universal, learned, and habituated attributes of
moral character that

predispose persons to meet their moral obligations; that is, to do
what is right. There is

a presumption and expectation that we will commonly see
virtues such as integrity,

respect, temperance, and industry in all those whom we
encounter. Virtues are what we

are to be and make for a morally “good person”. There are more
particular attributes of

moral character, not expected of everyone, that are expected of
nurses. These include

knowledge, skill, wisdom, patience, compassion, honesty, and
courage. These attributes

describe what the nurse is to be as a morally “good nurse”.
Furthermore, virtues are

necessary for the affirmation and promotion of the values of
human dignity, well-being,

respect, health, independence, and other ends that nursing
seeks.

For virtues to develop and be operative they must be supported
by a moral milieu

that causes them to flourish. Nurses must create, maintain, and
contribute to morally

good environments that enable nurses to be virtuous. Such a
moral milieu fosters

mutual respect, communication, transparency, moral equality,
kindness, prudence,

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generosity, dignity, and caring. This applies to all whether
nurse, colleague, patient, or

others.

6.2 The Environment and Ethical Obligation

Virtues focus on what is good and bad in whom we are to be as
moral persons;

obligations focus on right and wrong or what we are to do as
moral agents. Obligations

are often specified in terms of principles such as beneficence or
doing good;

nonmaleficence or doing no harm; justice or treating people
fairly; reparations, or

making amends for harm; fidelity, and respect for persons.
Nurses, in all roles, must

create, maintain, and contribute to practice environments that
support nurses and others

in the fulfillment of their ethical obligations. Environmental
factors include all that

contribute to working conditions. These include but are not
limited to: clear policies

and procedures that set out professional ethical expectations for
nurses; uniform

knowledge of The Code of Ethics for Nurses with Interpretive
Statements; and

associated ethical position statements. Peer pressure can also
shape moral expectations

within a work group. Organizational processes and structures,
position descriptions,

performance standards, health and safety initiatives, grievance
mechanisms that prevent

reprisal, ethics committees, compensation systems, disciplinary
procedures, and more,

all contribute to a practice environment that can either present
barriers or foster ethical

practice and professional fulfillment. Environments constructed
for equitable, fair, and

just treatment of all reflect the values of the profession and
nurture excellent nursing

practice.

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6.3 Responsibility for the Healthcare Environment

Nurses are responsible for contributing to a moral environment
that demands respectful

interactions among colleagues, mutual peer support, and open
identification of difficult

issues that includes on-going formation of staff in ethical
problem solving. Nurse

executives have a particular responsibility to assure that
employees are treated fairly

and justly, and that nurses are involved in decisions related to
their practice and

working conditions. Unsafe or inappropriate activities or
practices must not be

condoned or be allowed to persist. Nurses should address
concerns about the healthcare

environment through appropriate channels. After repeated
efforts to make change,

nurses have a duty to resign from healthcare facilities, agencies,
or institutions that

demonstrate sustained patterns of violation of patient’s rights,
or where nurses are

required to compromise standards of practice or personal
integrity, and where the

administration is unresponsive to nurses’ expressions of
concern. Following

resignation, efforts to address violations should continue. The
needs of patients may

never be used to hold nurses hostage in persistently morally
unacceptable work

environments. Remaining in such an environment, even if from
financial necessity,

nurses risk becoming complicit in ethically unacceptable
practices and may have both

untoward personal and professional, and potentially legal,
consequences.

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Organizational changes are difficult to achieve and require
persistent, sometimes

collective efforts over time. Participation in collective action
and interdisciplinary effort

for workplace advocacy to address conditions of employment is
appropriate.

Agreements reached through such actions must be consistent
with the nursing

profession’s standards of practice, state law regulating practice,

and The Code of Ethics

for Nurses. The workplace must be a morally good environment
to ensure ongoing

quality patient care and professional satisfaction for nurses and
to minimize and address

moral distress, strain, and dissonance. These organizations
advocate for nurses by

supporting legislation; publishing position statements;
maintaining standards of

practice; and by monitoring social, professional and healthcare
changes. Through

professional associations, nurses can help to secure the just
economic and general

welfare of nurses, safe practice environments, and a balance of
patient–nurse interests.

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Provision 7

The nurse, whether in research, practice, education, or
administration,

contributes to the advancement of the profession through
research and

scholarly inquiry, professional standards development, and
generation of

nursing and health policies.

7.1 Contributions through Research and Scholarly Inquiry

All nurses must participate in the advancement of the profession
through knowledge

development, evaluation, dissemination, and application to
practice. Knowledge

development relies chiefly, though not exclusively, upon
research and scholarly

inquiry. Nurses engage in scholarly inquiry in order to expand

the body of knowledge

that forms and advances the theory and practice of the
discipline in all its spheres.

Nursing knowledge draws from and contributes to
corresponding sciences and

humanities. Nurse researchers test existing and generate new
nursing knowledge. They

may involve human participants in their research, as
individuals, groups, or

communities. In such cases, nursing research conforms to
national and international

ethical standards for the conduct of research employing human
participants.

Where research is conducted with the use of animals, all
appropriate ethical

standards are observed. In every situation care is taken that
research is soundly

constructed, significant, and worthwhile. Dissemination of
research findings, whether

positive or negative, is an essential part of respect for the
participants. Knowledge

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development also occurs through the process of scholarly
inquiry, clinical and

educational innovation, and interdisciplinary collaboration.
Dissemination of findings is

fundamental to ongoing disciplinary discourse and knowledge
development.

Nurses remain committed to patients/participants throughout the
continuum of care

and during their participation in research. Whether the nurse is
data collector,

investigator, or care provider, patients’ rights and autonomy
must be honored and

respected. Patients’/participants’ welfare may never be
sacrificed for research ends.

Nurse executives and administrators must develop the structure
and foster the

processes that create an organizational climate and
infrastructure conducive to scholarly

inquiry. In addition to teaching research methods, nurse
educators also teach the moral

standards that guide the profession in the conduct of its
research. Research utilization is

an expected part of nursing practice in all settings.

7.2 Contributions through Developing Maintaining, and
Implementing

Professional Practice Standards

Practice standards must be developed by nurses and grounded in
nursing’s ethical

commitments and body of knowledge. These standards must also
reflect nursing’s

responsibility to society. Nursing identifies its own scope of
practice as informed,

specified, or directed by state and federal law, by relevant
societal values, and by The

Code of Ethics with Interpretive Statements, and Nursing:
Scope and Standards of

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Practice. Nurse executives establish, maintain, and promote
conditions of employment

that enable nurses to practice according to accepted standards.
Professional autonomy

and self-regulation are necessary for implementing nursing
standards and guidelines

and for assuring quality care.

Nurse educators promote and maintain optimal standards of
education and practice

in every setting where learning activities occur. They must also
ensure that only

students possessing the knowledge, skills, and moral
dispositions that are essential to

nursing graduate from their nursing programs.

7.3 Contributions through Nursing and Health Policy
Development

Nurses must lead, serve, and mentor on institutional or agency
policy committees

within the practice setting. Nurses ought to participate in civic
activities related to

healthcare through local, regional, state, national, or global
initiatives. Nurse educators

have a particular responsibility to foster and develop students’
commitment to

professional and civic values and to informed perspectives on
nursing and healthcare

policy. Nurse executives and administrators must foster
institutional or agency policies

that support and reinforce a work environment committed to
nurses’ ethical integrity

and professionalism. Nurse researchers must contribute to the
body of knowledge by

translating science, supporting evidence-based nursing practice,
and advancing

effective, ethical healthcare policies, environments, and a
balance of patient–nurse

interests.

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Provision 8

The nurse collaborates with other health professionals and the

public to

protect and promote human rights, health diplomacy, and health
initiatives.

8.1 Health is a Universal Right

The nursing profession holds that health is a universal human
right and that the need

for nursing is universal. The right to health is a fundamental
right to a universal

minimum standard of health to which all individuals are
entitled. Such a right has

economic, political, social, and cultural dimensions. It includes
public education

concerning health maintenance and promotion; education
concerning the prevention,

treatment, and control of prevailing health problems; food
security; potable water;

basic sanitation; reproductive health care; immunization;
prevention and control of

locally endemic diseases and vectors; and access to health,
emergency, and trauma

care. This affirmation of health as a fundamental, universal
human right is held in

common with the United Nations and the International Council

of Nurses and many

human rights treaties.

8.2 Collaboration for Health, Human Rights, and Health
Diplomacy

The nursing profession commits to advancing the health,
welfare, and safety of all.

This nursing commitment reflects the intent to achieve and
sustain health as a means

to the common good so that individuals and communities here
and abroad can

develop to their fullest potential and live with dignity. Ethics,
human rights, and

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nursing converge as a formidable instrument for social justice
and health diplomacy

that can be amplified by collaboration with other health
professionals. Nurses

understand that the lived experience of poverty, inequality, and
social marginalization

contribute to the deterioration of health globally. Nurses must
address the context of

health, including social determinants of health such as poverty,
hunger, access to

clean water and sanitation, human rights violations, and
healthcare disparities. Nurses

must lead collaborative partnerships to develop effective public
health policies,

legislation, projects, and programs that promote health, prevent
illness, restore health,

and alleviate suffering.

Participation includes collaboration to raise health diplomacy to
parity with other

international concerns such as treaties, commerce, and warfare.

Human rights must be

diligently protected and promoted, interfered with only when
necessary and in ways

that are proportionate and in accord with international
standards. Advances in

technology and genetics require robust responses from nurses
working together with

other health professionals for creative solutions and innovative
approaches that are

ethical, respectful of human rights, and equitable in reducing
health disparities.

8.3 Obligation to Advance Health and Human Rights

Nurses collaborate with others to change unjust structures and
processes that affect

persons or communities. Structural social inequalities and
disparities, inadequate

social policies, or institutional policies or practices exacerbate
the incidence and

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burden of illness, trauma, suffering, and premature death.
Through community

organizations and groups, nurses educate the public; facilitate
informed choice;

identify conditions and circumstances that contribute to illness,
injury and disease;

foster healthy life styles; and participate in institutional and
legislative efforts to

protect and promote health. Nurses collaborate to address
barriers to health, such as

poverty, homelessness, unsafe living conditions, abuse and
violence, and lack of

access by engaging in open discussion, education, public debate
and legislative

action. Nurses must recognize that health care is provided to

culturally diverse

populations in this country and across the globe. Nurses
collaborate to create a moral

milieu that is culturally sensitive to diverse cultural values and
practices.

8.4 Collaboration for Human Rights in Complex and
Extraordinary

Practice Settings

Nurses must be mindful of competing moral claims (that is,
conflicting values or

obligations) and bring attention to human rights violations in all
settings and contexts.

Human trafficking; the global feminization of poverty, rape, and
abuse as an

instrument of war; the oppression or exploitation of migrant
workers; and all such

human rights violations are of grave concern to nurses. The
nursing profession must

intervene when these violations are encountered. Human rights
may be jeopardized in

extraordinary contexts related to fields of battle, pandemics,
political turmoil,

regional conflicts, or environmental catastrophes where nurses

must necessarily

practice under altered standards of care. Nurses must always
stress human rights

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protection under all conditions, with particular attention to
preserving the human

rights of vulnerable groups such as women, children, the
elderly, prisoners, refugees,

and socially stigmatized groups. All actions and omissions risk
unintended

consequences with implications for human rights. Thus, nurses

must engage in

discernment, carefully assessing their intentions, reflectively
weighing all possible

options and rationales, and formulating a clear moral
justification for their actions.

Only under extreme and exceptional conditions, while
conforming to international

standards and engaging in an appropriate and transparent
process of authorization,

may nurses subordinate human rights concerns to other
considerations.

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Provision 9

The profession of nursing, collectively through its professional

organizations, must articulate nursing values, maintain the
integrity of the

profession, and integrate principles of social justice into
nursing and health

policy.

9.1 Articulation of Values

Individual nurses are represented by their professional
associations and organizations.

These groups give united voice to the profession. It is the
responsibility of a profession

collectively to communicate, affirm, and promote shared values
both within the

profession and to the public. It is essential that the profession
engage in discourse that

supports ongoing critical self-analysis and evaluation. The
language that is chosen

evokes the shared meaning of nursing, its values and ideals, as
it interprets and explains

the place and role of nursing in society. The profession’s
organizations communicate to

the public the values that nursing considers central to the
promotion or restoration of

health, prevention of illness, and alleviation of suffering.
Through professional

organizations the nursing profession must reaffirm and
strengthen nursing values and

ideals so that when those values are challenged, adherence is
steadfast and unwavering.

Acting in solidarity, the ability of the profession to influence
social justice and global

health is formidable.

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9.2 Integrity of the Profession

The profession’s integrity is strongest when its values and
ethics are evident in all

professional and organizational relationships. Nursing must
continually emphasize the

values of justice, fairness, and caring within the national and
global nursing

communities, in order to promote health in all sectors of the
population. A fundamental

responsibility is to promote awareness of and adherence to the
codes of ethics for nurses

(the American Nurses Association and the International Council
of Nurses). Balanced

policies and practices regarding access to nursing education,
workforce sustainability,

nurse migration, and utilization are requisite to achieving these
ends. Together, nurses

must bring about the improvement of all facets of nursing,
fostering and assisting in the

education of professional nurses in developing regions across
the globe. The values and

ethics of the profession must be evident in all professional
relationships whether inter-

organizational, or international.

The nursing profession engages in an ongoing formal and
informal dialog with

society. The covenant between the profession and society is
made explicit through The

Code of Ethics for Nurses, Nursing’s Social Policy Statement,
Nursing: Scope and

Standards of Practice, and other published standards of
specialized nursing practice;

continued development and dissemination of nursing
scholarship; rigorous educational

requirements for entry and continued practice including
certification and licensure; and

commitment to evidence-based practice.

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9.3 Integrating Social Justice

It is the shared responsibility of professional nursing
organizations to speak for nurses

collectively in shaping health care and to promulgate change to
improve health care

nationally and internationally. Nurses must be vigilant and take
action to influence

legislators, governmental agencies, non-governmental
organizations, and international

bodies in all related health affairs for addressing the social
determinants of health. All

nurses, through organizations and accrediting bodies involved
in nurse formation and

development, must firmly anchor students in nursing's
professional responsibility to

address unjust systems and structures, modeling the profession's
commitment to social

justice and health through content, clinical and field
experiences, and critical thought.

9.4 Social Justice in Nursing and Health Policy

The nursing profession must actively participate in solidarity
with the global nursing

community and health organizations to represent the collective
voice of U.S. nurses

around the globe. Professional nursing organizations must
actively engage in the political

process, particularly addressing those legislative concerns that
most impact the public's

health and the profession of nursing. Nurses must promote open
and honest

communication that enables nurses to work in concert, share in
scholarship, and advance

a nursing agenda for health. Global health, as well as the
common good, are ideals that

can be realized when all nurses unite their efforts and energies.

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Social justice extends beyond human health and well-being to
the health and well-

being of the natural world. Human life and health are
profoundly affected by the natural

world that surrounds us; thus, consistent with Nightingale's
historic concerns for

environmental influences on health and the meta-paradigm
concepts of nursing,

nursing's advocacy for social justice extends to eco-justice.

Environmental degradation,

water depletion, earth resources exploitation, ecosystem
destruction, excessive carbon

production, waste, and other environmental assaults
disproportionately affect the health

of the poor and ultimately affect the health of all humanity.
Nursing must also advocate

for policies, programs, and practices within the healthcare
environment that maintain,

sustain, and repair the natural world. As nursing seeks to
promote and restore health,

prevent illness, and alleviate suffering, it does so within the
holistic context of healing

the world.

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The Strengths Perspective in Social Work Practice: Extensions
and Cautions
Author(s): Dennis Saleebey
Source: Social Work, Vol. 41, No. 3 (May 1996), pp. 296-305

Published by: Oxford University Press
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The Strengths Perspective in Social Work

Practice: Extensions and Cautions

Dennis Saleebey

The strengths perspective in social work practice continues to
develop

conceptually. The strengths-based approach to case management
with people with severe mental illness is well established. More

recently, there have been developments in strengths-based
practice
with other client groups and the emergence of strengths
orientations

in work with communities. To augment these developments,

converging lines of thinking, research, and practice in areas
such as

developmental resilience, healing and wellness, and
constructionist

narrative and story have provided interesting supports and

challenges to the strengths perspective. This article reviews
some

current thinking and research about using a strengths orientation

and assesses conceptual endorsements and criticisms of the

strengths perspective.

Key words: empowerment; health; resilience;
social work practice; wellness

Over

the past few years, a strengths-based ap
proach to case management with people
with severe mental illness has emerged

(Saleebey, 1992; Sullivan & Rapp, 1994; Weick,

Rapp, Sullivan, & Kisthardt, 1989). More recently,
the profession has developed strengths-based

practice with other client groups—elderly people,

youths in trouble, people with addictions, even

communities and schools (Chamberlain & Rapp,

1991; Kretzmann & McKnight, 1993; Miller &

Berg, 1995; Parsons & Cox, 1994). In addition,

ongoing research, thinking, and practice in areas

such as developmental resilience, healing and

wellness, and constructionist narrative and story
have provided some interesting supports and

challenges to the strengths perspective. This ar

ticle briefly outlines some of the principles and

lexicon of the strengths orientation and addresses

CCC Code: 0037-8046/96 $3.00 © 1996
National Association of Social Workers, Inc.

some emergent and supportive ideas in other dis

ciplines and professions to re-examine some ele

ments of social work theory and practice.

In part the impetus for the evolution of a more

strengths-based view of social work practice
comes from the awareness that U.S. culture and

helping professions are saturated with psychoso
cial approaches based on individual, family, and

community pathology, deficits, problems, abnor

mality, victimization, and disorder. A conglom
eration of businesses, professions, institutions,

and individuals—from medicine to the pharma
ceutical industry, from the insurance industry to

the media—assure the nation that everyone has a

storehouse of vulnerabilities born of toxic experi
ences (usually occurring earlier in life) that put
him or her at risk of everything from sex addic

tion to borderline personality disorder (Kaminer,

296

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1993; Peele, 1989; Peele & Brodsky, 1991; Rieff,
1991).

The DSM-IV (American Psychiatric Association,
1994), although only seven years removed from

its predecessor, has twice the volume of text on

disorders. Victimhood has become big business as

many adults, prodded by a variety of therapists,

gurus, and ministers, go on the hunt for wounded

inner children and the poisonous ecology of their

family background. These phenomena are not

unlike a social movement or evangelism.

Practicing from a strengths perspective does

not require social workers to ignore the real

troubles that dog individuals and groups. Schizo

phrenia is real. Child sexual abuse is real. Pancre

atic cancer is real. Violence is real. But in the lexi

con of strengths, it is as wrong to deny the

possible as it is to deny the problem. The

strengths perspective does not deny the grip and

thrall of addictions and how they can morally and

physically sink the spirit and possibility of any

individual. But it does deny the overweening reign

of psychopathology as civic, moral, and medical

categorical imperative. It does deny that most

people are victims of abuse or of their own ram

pant appetites. It denies that all people who face

trauma and pain in their lives inevitably are

wounded or incapacitated or become less than

they might. It decries the fact that the so-called

recovery movement, now so far beyond its origi

nal intended boundaries, has

pumped out a host of illnesses and addictions

that were by earlier standards, mere habits, some

good, some bad. Everywhere in public we find

people talking freely, if not excitedly, even

proudly, about their compulsions—whether it

be gambling, sex, shopping, exercise, or the hor

rible desire to please other people. We are awash

in a sea of codependency, wounded inner chil

dren, and intimacy crises. (Wolin & Wolin,

1993, p.7)

To exemplify, in a homely way, this cultural

obsession with pathology, a few notes and num

bers culled from the media and professional

sources follow;

■ Eighty million Americans are codependent

(Kaminer, 1993).
■ Twenty million Americans are gambling

addicts (Peele, 1989).
■ Ninety-six percent of all families are dys

functional (Rieff, 1991).

■ Since 1990, there has been a 300 percent
increase in claims filed with the Prudential
Insurance Company for multiple personal

ity disorder (Harper's Index, 1993).
■ There is a 3 in 5 chance that if you go to a

physician you will be put on a regimen of
medication (Harper's Index, 1992).

The appreciations and understandings of the

strengths perspective are an attempt to correct

this overwrought and, in some instances, destruc

tive emphasis on what is wrong, what is missing,
and what is abnormal.

Elements of the Strengths Perspective

The strengths perspective demands a different way

of looking at individuals, families, and communi
ties. All must be seen in the light of their capaci

ties, talents, competencies, possibilities, visions,

values, and hopes, however dashed and distorted

these may have become through circumstance,

oppression, and trauma. The strengths approach

requires an accounting of what people know and

what they can do, however inchoate that may

sometimes seem. It requires composing a roster of

resources existing within and around the indi

vidual, family, or community.
It takes courage and diligence on the part of

social workers to regard professional work

through this different lens. Such a "re-vision" de

mands that they suspend initial disbelief in clients.

Too often practitioners are unprepared to hear

and believe what clients tell them, what their par

ticular stories might be (Lee, 1994), especially if

they have engaged in abusive, destructive, addic

tive, or immoral behavior.

It is also important in rediscovering the whole

ness of clients to recognize that the system—the

bureaucracies and organizations of helping—is

often diametrically opposed to a strengths orien

tation. In both formal and informal venues and

structures, policies, and programs, the preferred

language replaces the clients' own lexicon with the

vocabulary of problem and disease (Goldstein,

1990; Saleebey, 1992). Finally, the professional

language and the metaphorical devices social

workers use to understand and help sometimes

subvert the possibility of understanding clients in

the light of their capácities. Pursuing a practice

based on the ideas of resilience, rebound, possi

bility, and transformation is difficult because,

oddly enough, it is not natural to the world of

helping and service. Table 1 contrasts the

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Comparison of Pathology and Strengths

Pathology Strengths

Person is defined as a "case"; symptoms add up to a Person is
defined as unique; traits, talents, resources

diagnosis. add up to strengths.

Therapy is problem focused. Therapy is possibility focused.

Personal accounts aid in the evocation of a diagnosis Personal
accounts are the essential route to knowing

through reinterpretation by an expert. and appreciating the
person.

Practitioner is skeptical of personal stories, rational-
Practitioner knows the person from the inside out.

izations.

Childhood trauma is the precursor or predictor of Childhood
trauma is not predictive; it may weaken

adult pathology. or strengthen the individual.

Centerpiece of therapeutic work is the treatment Centerpiece of
work is the aspirations of family, in

plan devised by practitioner. dividual, or community.

Practitioner is the expert on clients' lives. Individuals, family,
or community are the experts.

Possibilities for choice, control, commitment, and Possibilities
for choice, control, commitment, and

personal development are limited by pathology. personal
development are open.

Resources for work are the knowledge and skills of Resources
for work are the strengths, capacities, and

the professional. adaptive skills of the individual, family, or
com

munity.

Help is centered on reducing the effects of symp- Help is
centered on getting on with one's life, af

toms and the negative personal and social conse- firming and
developing values and commitments,

quences of actions, emotions, thoughts, or rela- and making and
finding membership in or as a

tionships. community.

strengths approach with conventional pathology
based approaches.

Language

"We can act," wrote William James (1902) in re

flecting on Immanuel Kant's notions about con

ceptions, "as if there were a God; feel as if we were

free; consider nature as if she were full of special

designs; lay plans as if we were to be immortal; and

we find then that these words do make a genuine
difference in our moral life" [italics added] (p.
55). But, as Joseph Conrad (1900) knew, words
can harbor danger as well: "There is a weird

power in a spoken word.... And a word carries

far—very far—deals destruction through time as

the bullets go flying through space" (p. 185).
Language is like a pseudopodia with which we

reach out to the world, grasping its shape and in

corporating, for our own, the sustenance there.

Words do have the power to elevate or destroy.
The profession's discourse on clients can be noble

or base depending on the words used. Words can

lift and inspire or frighten and constrain. Words

are the aliment that feeds the sense of self. Thus,

social workers are obligated to examine their dic

tionary of helping.
Certain words are key to the strengths perspec

tive. Empowerment, rapidly becoming a hackneyed
idea and term, means assisting individuals, fami

lies, and communities in discovering and using
the resources and tools within and around them

(Kaplan 8t Girard, 1994). The empowerment im

perative also requires that social workers help

people become aware of the tensions and conflicts

that oppress and limit them and help them free

themselves from these restraints (Pinderhughes,

1994).
Resilience means the skills, abilities, knowledge,

and insight that accumulate over time as people

struggle to surmount adversity and meet chal

lenges. It is an ongoing and developing fund of

energy and skill that can be used in current

struggles (Garmezy, 1994).

Membership means that people need to be citi

zens—responsible and valued members in a viable

group or community. To be without membership

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is to be alienated, and to be at risk of marginal
ization and oppression, the enemies of civic and

moral strength (Walzer, 1983). As people begin to

realize and use their assets and abilities, collec

tively and individually, as they begin to discover

the pride in having survived and overcome their

difficulties, more and more of their capacities
come into the work and play of daily life. These
build on each other exponentially, reflecting a

kind of synergy. The same synergistic phenom
enon seems true of communities and groups as

well. In both instances, one might suggest that

there are no known limits to individual and col

lective capacities.

Strengths

also provide the diction, symbols, metaphors, and

tools for rebound (Lifton, 1993). Finally, people
who have overcome abuse and trauma often have

"survivor's pride" (Benard, 1994; Wolin & Wolin,

1993). Such pride is often buried under shame,

guilt, and alienation, but it is often there waiting
to be tapped into.

Resilience

Resilience should not be understood as the blithe

denial of difficult life experiences, pains, and
scars; it is, rather, the ability to go on in spite of
these (Rutter, 1985; Wolin & Wolin, 1993). Dam

age, to be sure, has been done. Despite the

wounds inflicted, for many the trauma also has

been instructive and chastening. Resilience is not

Personal qualities and strengths a trait or static dimension. It

are sometimes forged in the fires is the continuing articulation

of trauma, sickness, abuse, and of capacities and knowledge

oppression. A sense of humor, A sense of humor, loyalty,
derived through the interplay
loyalty independence,insight,

independence, insight, and ofri,i®aundProtectionsinthe and
other virtues might very ,
~~

world. The environment con

well become the source of en- Other Virtues might very tinually
presents demands,
ergy for successful work with well become the SOUrce of
stresses, challenges, and op
clients even though their seeds energy for successful work
portunities.

These become
were sown in trouble and pain fateful, given a complexity of

(Vaillant, 1993; Wolin&Wolin,
With Clients. other factors—genetic, neuro

1993). What people learn about biological, familial, commu
themselves and others as they nal—for the development of

struggle to surmount difficulty strength, of resilience, or of

can become knowledge useful in getting on with

one's life. People learn from their trials and tribu

lations, even those that they inflict on themselves

(Anthony 8c Cohler, 1987; Wolin 8c Wolin, 1993).

People learn from the world around them,

through formal education or through the distill

ing of their day-to-day experience. Clients can

often surprise practitioners (and themselves) with

the talents they have (or once had but let fall into

disuse or out of memory). Such talents, whether

juggling, cooking, baking bread, or tending to the
needs of the ill, may become tools for helping to
build a better life.

Extremely important sources of strength are

cultural and personal stories, narratives, and lore.

Cultural approaches to healing may provide a

source for the revival and renewal of energies and

possibilities. Cultural accounts of origins, devel

opment, migrations, and survival may provide

inspiration and meaning. Personal and familial

stories of falls from grace and redemption, failure

and resurrection, and struggle and resilience may

diminution in capacity.
Research on developmental resilience has in

troduced ideas that challenge three dominant

concepts about development: ( 1 ) there are fixed,

inevitable, critical, and universal stages of devel

opment; (2) childhood trauma inevitably leads to

adult psychopathology (Benard, 1994; Garmezy,

1994); and (3) there are social conditions, inter

personal relationships, and institutional arrange
ments that are so toxic they inevitably lead to dec

rements or problems in the everyday functioning

of children and adults, families, and communities

(Rutter, 1994).

Perhaps the most celebrated study of develop

mental resilience in children as they gro\v into

adulthood is the longitudinal research in Kauai,
Hawaii, begun in 1955 by Werner and Smith

(1992). In their earlier report, Werner and Smith

(1982) reported that one of every three children

who was evaluated by several measures to be at

significant risk for adolescent problems actually

developed into competent and confident young

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adults at age 18. In their follow-up study, Werner

and Smith (1992) revealed that two of three of the

remaining two-thirds had turned into caring and

efficacious adults by age 32. One of their central

conceptualizations was that individuals have self

righting tendencies. From that, they concluded

that some of the factors that ensure the emergence

of self-correction of the life course can be identi

fied. They also concluded that a significant pro
tective factor for many children is a steadfast, car

ing relationship with at least one adult. This adult

(in a few cases it was a peer) does not have to be a

family member or physically present all of the
time. These relationships provide a protective belt

for the child, and they also invigorate the self

righting capacities of the child. Finally, and most

important, Werner and Smith argued that it is

never too late to change a life trajectory from dis

solution to aspiration and accomplishment.

Critical Factors

Many factors, highly variable, interactive, and dy

namic, affect how an individual or group will re

spond to a series of traumatic, even catastrophic

situations (Benard, 1994; Chess, 1989; Garmezy,

1994). The critical factors have been termed "risk

factors" (they enhance the likelihood of adaptive

struggles and poorer developmental outcomes)

and "protective factors" (they increase the likeli
hood of rebound from trauma and stress). I

would add "generative factors"—remarkable and

revelatory experiences that, taken together, dra

matically increase learning, resource acquisition,
and development, accentuating resilience and har

diness. As examples of some of the ingredients of

resilience and adaptation, Masten (1994) listed

the following: competence or functioning over

time, the nature of adversities faced, individual
and social assets and environmental protections

and challenges, the context in which stresses are

experienced, and individual perceptions and defi
nitions of stressful situations. She cautioned that

these factors must always be understood as dy

namic, interactive, and synergistic and as occur

ring over time.

Community

Over the past few years, another complex of fac

tors has emerged as important in the transactions

among risk, protective, and generative circum

stances: the community. In communities that am

plify individual resilience, there is awareness, rec

ognition, and use of the assets of most members

of the community. Informal networks of indi

viduals, families, and groups; social networks of

peers; and intergenerational mentoring relation

ships provide succor, instruction, support, and

encouragement (Benard, 1994; Kretzmann &

McKnight, 1993). These communities can be un

derstood as "enabling niches" (Taylor, 1993),

places where individuals become known for what

they do, are supported in becoming more adept

and knowledgeable, and can establish solid rela

tionships within and outside the community. In

"entrapping niches" (Taylor, 1993), individuals
are stigmatized and isolated. Membership in the

community is based on collective stigma and

alienation.

In communities that provide protection and

minimize risk, there are many opportunities to

participate, to make significant contributions to

the moral and civic life of the community, and to

take on the role of full-fledged citizen (Benard,

1994; McLaughlin, Irby, & Langman, 1994). In
these communities, high expectations of members

are the rule. Youths, elders, and all members are

expected to do well, are given opportunities to do

so, and are instructed in the use of the tools

needed for meeting such expectations. These ex

pectations are related to the life and needs of the

community as well as to the developing compe
tencies of the individual (Montuori 8c Conti, 1993).

Health and Wellness

The ample literature exploring the relationship
between body, mind, and environment and health

and wellness suggests that this interaction is com

plex, recursive, and reticulate and always impli

cated in keeping people well, assisting individuals

in regenerating after trauma, and helping indi

viduals and communities survive the impact and

aftermath of calamity and ordeal. In a sense, the

strengths perspective itself begins with appreciat

ing the body and its tremendous restorative pow

ers as well as its powers to resist disease (Ornstein

&Sobel, 1987; Saleebey, 1985).
A budding conception of the human brain also

indicates the inherent wisdom of the body and

mind. Over evolutionary time, the human brain

has grown into a lattice work of neuronal modules

that lie beneath many inchoate or heretofore un

expressed capacities. Whether these capacities ap

pear depends mightily on the environment. In a

sense, we already "know" what we need to know

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to survive. This knowledge may not be manifest in

behavior and cognition or in language and learn

ing unless the environment requires and elicits it.

The environment, in this way, "selects" from this

enormous neurobiological endowment, and, if all

goes well, individually and collectively, human

kind adapts and thrives (Gazzaniga, 1992). To be
lieve in the naturally selected hardiness and wis

dom of the body is to believe in the possibility of

any individual or group surmounting difficulty
(Dossey, 1989).

Beliefs and Emotions

Positive beliefs about one's self and condition play
a significant role in health maintenance and re

generation (Cousins, 1989). Supported by positive
beliefs and a supportive environment, the brain

acts as a "health maintenance organization"

(Ornstein 8c Sobel, 1987). Emotions, too, have a

profound effect on wellness and health. They may

act as signals for the body's immune and recu

perative responses. It does seem the case that

emotions experienced as positive can activate "the

pharmacy within" as well as embolden the appli
cation of reason in day-to-day life (Damasio,
1994; Ornstein 8c Sobel, 1987). When people be

lieve that they can recover, when they have an ar

ray of positive emotions about that prospect in

the context of their daily lives, their bodies often

respond optimally. Under certain conditions,
the

body's regenerative powers can be augmented.

These factors may operate at the community level

as well.

Health Realization and Community
Empowerment

The health realization-community empowerment

model developed by Mills (1995) is based on edu

cating people and helping them recognize their

innate resilience and knowledge that can be used

in achieving individual aspirations and improving

community vitality. Mills's idea is that resilience,

health, wisdom, intelligence, and positive motiva

tion are within each person and are accessible

through education, support, and encouragement.

The goals of health realization and community

empowerment are to "reconnect people to
the

health in themselves and then direct them in ways

to bring forth the health of others in their com

munity. The result is a change in people
and com

munities which builds up from within rather than

[being] imposed from without" (cited in Benard,

1994, p. 22). Supportive and instructive relation

ships, predictable and enduring sources of comfort

and guidance, the creation of an ethos of health

and accomplishment, and the soothing hand of

others may inspire health and promote a better

quality of life for individuals and communities.

The resilience and the health and wellness lit

eratures run parallel in many regards. Both imply

that individuals and communities have intrinsic

capacities for restoration and rebound. Both sug

gest that individuals are best served, from a health

and competence standpoint, by creating belief and

thinking around possibility and values, around

accomplishment and renewal, rather than center

ing exclusively on risk factors and disease pro

cesses. Both indicate that health and resilience are,

in the end, community projects, an effect of social

connection, the aggregation of collective vision,

the provision of mentoring, and the reality of be

longing to an organic whole.

Constructionism: Stories and Narratives

The constructionist view, in its many guises, em

phasizes the importance of meaning making in

human affairs (Becker, 1968). Human beings can
build themselves into the world only by creating

meaning, fashioning out of symbols, icons, and

words a sense of what the world is all about

(Bruner, 1990). The building blocks of meaning
making are, for the most part, found in the edifice

of culture. Culture provides the means by which

people receive, organize, rationalize, and under

stand their experiences in the world. Central ele

ments of the patterns woven by culture are story

and narrative. Individuals impart, receive, or af

firm meanings largely through telling and retell

ing stories and recounting narratives, the plots

often laid out by culture. There is always, as

Rosaldo (1989) argued, a tension between struc

ture (culture) and agency (selfhood), so that indi

viduals, families, and subcultures (or "minority"

cultures) may develop their own stories or shape

those laid out by the culture. Groups who suffer

the domination of broader social institutions or

suppression of their own cultural devices
under

the dominant culture frequently do not have their

stories told or heard, not only in the wider world

but also, regrettably, in their own world (Gergen,

1991; Laird, 1989; Rosaldo, 1989). Certainly one

of the characteristics of being oppressed is having
one's stories buried under the forces of ignorance

and stereotype.

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Lifting oppression and emancipating the moral

imagination, the visions and hopes, and the life

chances of people who are dispossessed involve

recapturing and reconstructing the "generative
themes" (Freire, 1973) of the culture, community,

neighborhood, or family. It is a part of the work

toward liberation to collaborate in the projection
of peoples' stories, narratives, and myths outward

to the institutions that have ignored or marginal
ized them (Saleebey, 1994).

Criticisms of the Strengths Perspective

Many individuals who present the strengths ap

proach in workshops and training for professional
social workers, in consultation with agencies, and

in the classroom report some common reservations

and objections about the strengths perspective
from practitioners and students: that the strengths

perspective is just positive thinking in another

guise, simply reframes deficits and misery, is "Polly

annaish," or ignores or downplays real problems.

Positive Thinking in Disguise
America has a long tradition of the idea of the

power of positive thinking from Mary Baker Eddy
to Norman Vincent Peale to Anthony Robbins.

Though its current face is presented in slicker

technological garb, positive thinking has not

drifted very far from Emile Coué, who, at the turn

of the century, advised repeating "Every day, in

every way, I get better and better."

The strengths perspective, however, is not

predicated on the repetition of uplifting mantras

or the idea that transformation is a matter of a few

minutes and a timely miracle. Rather, the idea is

that to build something of lasting significance
with clients, social workers must use their exper
tise in the service of capitalizing on client re

sources, talents, knowledge, and motivation, as

well as environmental collateral. There is little else

with which to construct possibility and to reach

out for promise. This is hard work. People, espe

cially people in trouble or dire straits, are not

given to thinking of themselves or others in terms

of strengths or as having emerged from scarring
events with something useful and redemptive (de

Shazer, 1991; Lee, 1994). In addition, if they have

been clients of the welfare, social services, or men

tal health systems, they likely have been inculcated

in the doctrine of themselves as deficient and

needy. They are not easily dissuaded from this

identity (Holmes & Saleebey, 1993).

More important, the strengths perspective re

quires formation of appreciative, collaborative

relationships with clients, which social workers

are taught are essential to effective, principled
work. To establish such relationships social work

ers must devise strict and accurate accountings of

client assets.

Reframing Misery

The criticism that the strengths perspective simply
reframes deficit and misery suggests that clients

are not really expected to do the work of transfor

mation and risk action. Rather, they are required

merely to reconceptualize their difficulties so that

they are sanitized and less threatening to self and

others. In this way, schizophrenia, for example,
becomes an exquisite sensitivity to the motives and

meanings of others. The strengths approach hon

ors the reality of schizophrenia and the damage
this neurobiological, psychosocial disorder can do.

The strengths perspective does not deny reality;
it demands some reframing, however, to develop
an attitude and language about the nature of pos

sibility and opportunity and the nature of the in

dividual beneath the diagnostic label. The work

involves creating access to communal resources so

that they become the ticket to expanded choices

and routes to change.

Pollyannaism

Another criticism is that the strengths approach is

Pollyannaish, that it ignores how manipulative
and dangerous or destructive certain clients and

client groups can be. The argument is, apparently,
that some people are simply beyond redemption.

Clearly, there are individuals who commit acts

that are beyond our capacity to understand, let

alone accept.

But the strengths perspective demands that

practitioners ask what useful qualities and skills or

even motivation and aspirations these clients

have, how they can be tapped in the service of

change, and in what more salubrious ways these

individuals can meet their needs and resolve their

conflicts. Social workers cannot automatically dis

count people. There may be genuinely evil people,

beyond grace or hope, but it is best not to make

that assumption first.

Ignoring Reality
A very serious criticism is that the strengths per

spective ignores or downplays real problems. The

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strengths approach does not discount the prob
lems of clients. Often, these problems are where

clients begin, what they are compelled to talk

about, what are most urgent. The individual or

group may need the opportunity for catharsis, for

grieving and mourning, for the expression of rage
or anxiety, for the recounting of barriers to satis

faction and esteem (Wolin & Wolin, 1993).
All helpers should assess and evaluate the

sources and remnants of client troubles, difficul

ties, pains, and disorders. As Cousins (1989) sug
gested, one should not deny the verdict (diagnosis

or assessment) but should defy the sentence. Hav

ing assessed the damage, social workers need to

ensure that the diagnosis does not become a cor

nerstone of identity. To avoid that possibility,
they calculate how clients have managed to sur

vive thus far and what they have drawn on in the

face of misfortune. What part of their struggle has

been useful to them, and what positive or con

structive learning has it yielded? People are not

often thought to think of the afflictions of circum

stance, context, or character in this way, but with

encouragement, they can. Whatever else symp

toms are, they may also be a sign of the soul's

struggle to be alive, responsible, and involved

(Moore, 1992). For helpers, the goal may be not

the heroic cure but rather the constancy of caring

and connection and collaborative work toward

improving the quality of day-to-day living.

Yes, but...

Many social workers and agencies argue that they

already abide by the strictures of a strengths ori

entation. A review of actual practices reveals that

they often fall short of full endorsement and ap

plication of a strengths-based practice. For ex

ample, in many mental health agencies around the

country, individual service plans (ISPs) are de

vised to "incorporate" the strengths of client and

family in assessment and planning. But many ISPs

the author and other colleagues have examined

are rife with diagnostic assessments and elabora

tions, narratives about decompensation, and ex

plorations of continuing symptomatic struggles

and manifestations. Axes I and II of the DSM are

usually prominently featured. Often, the strengths

assessment is consigned to a few lines at the end

of the evaluation and planning form. The ac

countings rendered on these forms are, for the

most part, in the language of the worker and use

the mental health system lexicon.

Conclusion

The strengths perspective honors two things: the

power of the self to heal and right itself with the

help of the environment, and the need for an alli

ance with the hope that life might really be other

wise. Helpers must hear the individual, family, or

community stories, but people can write the story
of their near and far futures only if they know ev

erything they need to know about their condition

and circumstances. The job is to help individuals

and groups develop the language, summon the

resources, devise the plot, and manage the subjec

tivity of life in their world.
In a strengths approach, how social workers

encounter their fellow human beings is critical.

They must engage individuals as equals. They

must be willing to meet them eye to eye and to

engage in dialogue and a mutual sharing of

knowledge, tools, concerns, aspirations, and re

spect. The process of coming to know is a mutual

and collaborative one. The individuals and groups
the profession assist, also must be able to "name"

their circumstances, their struggles, their experi

ences, themselves. Many alienated people have

been named by others—labeled and diagnosed—

in a kind of total discourse. The power to name

oneself and one's situation and condition is the

beginning of real empowerment.
The American philosopher Susanne Langer

(1963) wrote, "The limits of thought in any age
are set not so much from the outside by the full

ness or poverty of experience ... as from within

by the power of conception and the wealth of for

mative notions with which the mind meets expe

rience" (p. 8). The strengths perspective is a

standpoint. Supporters believe that it offers a new

way of thinking and acting professionally. Clearly,

it is not a theory. But its emerging body of prin

ciple and method does create opportunities for

professional knowing and doing that go beyond

the boundaries of the "technical-rational" ap

proach (Schôn, 1983) so common today.

Some social work practitioners may find little

in this article that is "new" and may regard these

ideas as simply good social work practice. How

ever, it is the experience of those who have

worked to develop it that a strengths-based prac

tice does provide a richness of thought and an ar

ray of actions that go far toward serving well

those who seek help from the profession (Cham

berlain & Rapp, 1991; Sullivan & Rapp, 1994;

Saleebey / The Strengths Perspective in Social Work Practice:
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Weick et al., 1989). Kaplan and Girard (1994) put
it this way:

People are more motivated to change when their

strengths are supported. Instead of asking family

members what their problems are, a worker can

ask what strengths they bring to the family and

what they think are the strengths of other family
members.... The worker creates a language of

strength, hope, and movement, (p. 53)

In the end, it is that kind of rhetoric that preserves
the possibility and promise of our clients. ■

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Dennis Saleebey, DSW, LMSW, is chair, PhD pro
gram in social welfare, and professor, School of So
cial Welfare, University of Kansas, Twente Hall,

Lawrence, KS 66045.

Accepted August 18, 1995

MSW's

Join the dynamic team at Saint Margaret

Mercy Healthcare Centers and become

a part of Northwest Indiana's premier
medical facility. Rapid growth and

expansion in our Home Care

Department has created exceptional

opportunities for MSW's interested

in fee-for-service positions.

Please call or send your resume to:

Sonja Ogrizovich, Professional Recruiter,

219/933-2180 or 708/891-9305, ext.

32180, Saint Margaret Mercy Healthcare

Centers, North Campus, 5454 Hohman Ave,

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Saleebey / The Strengths Perspective in Social Work Practice:
Extensions and Cautions

305

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Contentsp. 296p. 297p. 298p. 299p. 300p. 301p. 302p. 303p.
304p. 305Issue Table of ContentsSocial Work, Vol. 41, No. 3
(May 1996) pp. 241-336Front MatterEditorial: Affordable
Housing: A Basic Need and a Social Issue [pp. 245-249]Female
Gang Members: A Profile of Aggression and Victimization [pp.
251-257]Empowering Battered Women Transnationally: The
Case for Postmodern Interventions [pp. 261-268]When Social
Workers and Physicians Collaborate: Positive and Negative
Interdisciplinary Experiences [pp. 270-281]Afrocentricity: An
Emerging Paradigm in Social Work Practice [pp. 284-294]The
Strengths Perspective in Social Work Practice: Extensions and

Cautions [pp. 296-305]Radicalizing Recovery: Addiction,
Spirituality, and Politics [pp. 306-312]Correction: Pathways of
Older Adolescents out of Foster Care: Implications for
Independent Living Services [pp. 312-312]Practice
UpdateTraining and Supporting the Telephone Intake Worker
for an AIDS Prevention Counseling Study [pp. 314-
319]CommentaryThe Personal Is Ecological: Environmentalism
of Social Work [pp. 320-323]Points &ViewpointsHIV/AIDS and
Suicide: Be Open [pp. 324-324]HIV/AIDS and Suicide: Further
Precautions [pp. 325-326]BooksReview: untitled [pp. 328-
328]Review: untitled [pp. 328-329]Review: untitled [pp. 329-
330]Review: untitled [pp. 330-331]Review: untitled [pp. 331-
331]Review: untitled [pp. 331-332]Selected Books Received
[pp. 332-334]LettersClassism in the Curriculum [pp. 336-336]

Guide to the

Code of Ethics
for Nurses

Interpretation
and

Application

editor: Martha D. M. Fowler, PhD, MDiv, MS, RN, FAAN

2010 RE-IssuE

American Nurses Association
Silver Spring, Maryland

2010

Guide to the
Code of Ethics
for Nurses

Interpretation
and

Application

editor: Martha D. M. Fowler, PhD, MDiv, MS, RN, FAAN

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

2010 REIssuE

http://www.nursesbooks.org

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Library of Congress Cataloging-in-Publication data
Guide to the code of ethics for nurses : interpretation and
application / Marsha D.M. Fowler, editor.
p. ; cm.

Includes bibliographical references and index.
ISBN-13: 978-1-55810-287-3 (e-publication, single user)
ISBN-10: 1-55810-287-6 (e-publication, single user)
ISBN-13: 978-1-55810-295-8 (e-publication, multiple
users)
ISBN-10: 1-55810-295-7 (e-publication, multiple users)
1. Nursing ethics. I. Fowler, Marsha Diane Mary. II.
American Nurses Association.
[DNLM: 1. Ethics, Nursing--Guideline. 2. Codes of
Ethics--Guideline. 3. Societies, Nursing--
Guideline. WY 85 G946 2008]
RT85.G85 2008
174.2--dc22 2008004469

The American Nurses Association (ANA) is a national
professional association. This ANA publica-
tion—Guide to the Code of Nursing: Interpretation and
Application—reflects the thinking of the nursing
profession on various issues and should be reviewed in
conjunction with state board of nursing policies
and practices. State law, rules, and regulations govern the
practice of nursing; Guide to the Code of
Nursing: Interpretation and Application guides nurses in the
application of their professional skills and
responsibilities. The opinions in this book reflect those of the
authors and do not necessarily reflect
positions or policies of the American Nurses Association.
Furthermore, the information in this book
should not be construed as legal or professional advice.

Published by Nursesbooks.org
The Publishing Program of ANA
www.Nursesbooks.org

American Nurses Association
8515 Georgia Avenue, Suite 400

Silver Spring, MD 20910-3492
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www.Nursingworld.org

development editor: Rosanne O’Connor Roe (ANA staff)
production editor: Eric Wurzbacher (ANA staff)
copyediting and indexing: Grammarians, Inc., Alexandria, VA
design & composition 2010: David Fox, AURAS Design, Silver
Spring, MD
printing: McArdle Printing, Upper Marlboro, MD

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or
utilized in any form or any means, electronic or mechanical,
including photocopying and recording, or by
any information storage and retrieval system, without
permission in writing from the publisher.

ISBN-13: 978-1-55810-287-3

First eBook publication August 2010. (First paper publication
July 2010.*)

The American Nurses Association (ANA) is the only full-
service professional organization representing the inter-
ests of the nation’s 3.1 million registered nurses through
its constituent member nurses associations, its organi-
zational affiliates, and the Center for American Nurses.
The ANA advances the nursing profession by fostering
high standards of nursing practice, promoting the rights of
nurses in the workplace, projecting a positive and real-
istic view of nursing, and by lobbying the Congress and
regulatory agencies on health care issues affecting nurses
and the public.

*This book was re-issued with a new cover in July 2010. All

content other than the annotations on this
page and on page 137 is identical to that which was first
published in February 2008 and subsequent
reprints. (See page 137 for guidelines on citing the content of
Appendix A.)

http://www.nursesbooks.org
http://www.nursingworld.org

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

iii

Contents

Acknowledgments v

About the Authors vii

Preface xi
Anne J. Davis, PhD, DS, MS, RN, FAAN

Introduction xiii
Marsha D.M. Fowler, PhD, MDiv, MS, RN, FAAN

Provision 1 1
Carol R. Taylor, PhD, MSN, RN

Provision 2 11
Anne J. Davis, PhD, DS, MS, RN, FAAN

Provision 3 23
John G. Twomey, PhD, PNP

Provision 4 41
Laurie A. Badzek, JD, LLM, MS, RN, NAP

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

iv

Provision 5 55
Marsha D.M. Fowler, PhD, MDiv, MS, RN, FAAN

Provision 6 71
Linda L. Olson, PhD, RN, CNAA

Provision 7 89
Theresa S. Drought, PhD, RN, and Elizabeth G.
Epstein, PhD, RN

Provision 8 103
Mary C. Silva, PhD, RN, FAAN

Provision 9 121
Marsha D.M. Fowler, PhD, MDiv, MS, RN, FAAN

Appendix A 137
Code of Ethics for Nurses with Interpretive
Statements
(American Nurses Association, 2001)

Index 171

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© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

v

The American Nurses Association would like to thank the
following people for their
help in reviewing the content of this book:

Laurie A. Badzek, JD, LLM, MS, RN, NAP
Janet M. Dahm, PsyD, RNC
Barbara J. Daly, PhD, RN, FAAN
Anne J. Davis, PhD, DS, MS, RN, FAAN
Candia B. Laughlin, MS, RN-BC
Kathleen M. Poi, MS, RN, CNAA
Molly Sullivan, MAOL, RN
Carol R. Taylor, PhD, MSN, RN
Linda S. Warino, BSN, RN, CPAN

Permissions
The American Nurses Association gratefully acknowledges the
publishers’ permis-
sion to reproduce passages from the following publications.

Chapter 5

Burgess, Mary Ayers. 1928. The hospital and the nursing
supply. Transaction of
the American Hospital Association, pp. 440–414. Chicago:
AHA.

Jameton, Andrew. Duties to Self: Professional Nursing in the
Critical Care
Unit, in Fowler, Marsha and Levine-Ariff, June (eds.). Ethics at
the Bedside.
Philadelphia: JB Lippincott, 1985, pp. 115–135.

Acknowledgments

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vi Guide to the Code of Ethics for Nurses

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

AcknowlEDgMEnts

Chapter 8

Cooper, R. W., G L Frank, C A Gouty, and M M Hansen. 2003.

Ethical helps
and challenges faced by nurse leaders in the healthcare industry.
Journal of
Nursing Administration 33(1): 17–23.

DeVries, R., and J. Subedi, eds. 1998. Bioethics and Society:
Constructing the
Ethical Enterprise. Upper Saddle River, NJ: Prentice Hall, p
xiii.

Lee, M. B., and I. Saeed. 2001. Oppression and horizontal
violence: The case of
nurses in Pakistan. Nursing Forum 36(1): 15–24.

Oberle, K., and S. Tenove. 2000. Ethical issues in public health
nursing. Nursing
Ethics 7:425–38.

Page–Sikma, S. K., and H. M. Young, 2003. Nurse delegation in
Washington
state: A case study of concurrent policy implementation and
evaluation.
Policy, Politics, & Nursing Practice 4(1): 53-61.

Shapiro, H. T. 1999. Reflections on the interface of bioethics,
public policy, and
science. Kennedy Institute of Ethics Journal 9(3): 209–24.

Weston, A. 2002. A Practical Companion to Ethics, 2nd ed.
New York: Oxford
University Press., p 12.

Chapter 9

Perlman, C. H., Olbrechts-Tyteca, L. The New Rhetoric: A
Treatise on

Argumentation. Notre Dame: Notre Dame University; 1969. p.
51.

Winter, Gibson. Elements for a Social Ethics. NY: Macmillan;
1966, p. 215.

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part of this book may be reproduced or utilized in any form or

any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

vii

Provision 1
Carol R. Taylor, PhD, MSN, RN, is a faculty member of the
Georgetown University
School of Nursing and Health Studies and Director of the
Georgetown University
Center for Clinical Bioethics. She is a graduate of Holy Family
University (BSN),
the Catholic University of America (MSN), and Georgetown
University (PhD in
philosophy with a concentration in bioethics). Bioethics has
been a focus of her
teaching and research since 1980 linked to her passion to “make
health care work”
for those who need it. Special interests include healthcare
decision making and
professional ethics.

Provision 2
Anne J. Davis, PhD, DS, MS, RN, FAAN, and Professor
Emerita, taught at
the University of California for 34 years. Beginning in 1962,
Dr. Davis’s career
focused on international work with appointments in Israel,
India, Nigeria, Ghana,
Kenya, Japan, Korea, China, and Taiwan. These rich
experiences led to the devel-
opment of her overriding interest in cultural diversity and
nursing ethics. She is
a graduate of Emory University in Atlanta (BS, Nursing),

Boston University
(MS, Psychiatry), and University of California, Berkeley (PhD,
Higher Education).
Dr. Davis has been the recipient of numerous awards, including
an honorary
Doctor of Science from Emory University and election as a
Fellow in the American
Academy of Nursing.

Provision 3
John G. Twomey, PhD, PNP, is an Associate Professor at the
Graduate Program
in Nursing at the MGH Institute of Health Professions in
Boston, Massachusetts.
Dr. Twomey’s doctoral work was in bioethics. He teaches
bioethics and research

About the Authors

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viii Guide to the Code of Ethics for Nurses

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

About thE AuthoRs

and serves on several human subjects research protection
committees. He has
completed two National Institute of Nursing Research-supported
post-doctoral
fellowships in genetics. A member of the International Society
of Nurses in
Genetics, he does research in the area of the ethics of genetic
testing of children.
He is the editor of the Ethics Column in the Society’s quarterly
newsletter.

Provision 4
Laurie A. Badzek, JD, LLM, MS, RN, NAP, is currently
Director of the American

Nurses Association Center of Ethics and Human Rights, a role
in which she
previously served from 1998–99. During that time, Badzek was
instrumental in
developing a plan that ultimately resulted in the approval of a
new Code of Ethics
for Nurses by the 2001 House of Delegates. Currently a tenured,
full professor
at the West Virginia University School of Nursing, Badzek, a
nurse attorney, teaches
nursing, ethics, law, and health policy. Having practiced in a
variety of nursing and
law positions, she is an active researcher, investigating ethical
and legal healthcare
issues. Her current research interests include patient and family
decision making,
nutraceutical use, mature minors, genomics, and professional
healthcare ethics.
Her research has been published in nursing, medical, and
communication studies
journals, including Journal of Nursing Law, Nephrology
Nursing Journal, Annals
of Internal Medicine, Journal of Palliative Care, and Health
Communication.

Provision 5
Marsha D.M. Fowler, PhD, MDiv, MS, RN, FAAN, is Senior
Fellow and Professor
of Ethics, Spirituality, and Faith Integration at Azusa Pacific
University. She is a
graduate of Kaiser Foundation School of Nursing (diploma),
University of California
at San Francisco (BS, MS), Fuller Theological Seminary
(MDiv), and the University
of Southern California (PhD). She has engaged in teaching and
research in bioethics

and spirituality since 1974. Her research interests are in the
history and development
of nursing ethics and the Code of Ethics for Nurses, social
ethics and professions,
suffering, the intersections of spirituality and ethics, and
religious ethics in nursing.
Dr. Fowler is also a Fellow in the American Academy of
Nursing.

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Guide to the Code of Ethics for Nurses ix

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

About thE AuthoRs

Provision 6
Linda L. Olson, PhD, RN, CNAA, is currently Professor and
Dean of the School of
Nursing at North Park University in Chicago, Illinois.
Previously, she taught courses
in healthcare policy and economics, leadership, and nursing
service administration
at the graduate and undergraduate levels as an Associate
Professor at St. Xavier
University in Chicago. She has prior experience in nursing
service administration,
practice, and consultation. Dr. Olson received her PhD and
MBA from the University
of Illinois at Chicago, and her baccalaureate and master’s
degrees in nursing from
Northern Illinois University. Her area of research interest is the
work environment,
particularly focusing on organizational culture and ethics. As
part of her dissertation
work, she developed the research instrument, the Hospital
Ethical Climate Survey,
which has also been used by several researchers, nurses, and
others in the United
States and internationally. She was a member of the ANA Task

Force to Revise the
Code of Ethics, as well as the Congress on Nursing Practice and
Economics, and has
held numerous leadership positions at local, state, and national
levels. In addition,
she serves as an appraiser for the Magnet Recognition Program.

Provision 7
Theresa S. Drought, PhD, RN, is currently an Assistant
Professor at the
University of Virginia School of Nursing. She has long been
interested in the
ethical issues related to professionalism in health care, serving
as a nurse consul-
tant to the California Medical Association’s Council on Ethical
Affairs, chair of
the ANA\C Ethics Committee (ANA/California), and as a
member of the
American Nurses Association Task Force that produced the
2001 Code of Ethics
for Nurses. Her publications and research address issues of
professionalism and
ethics in nursing and end-of-life decision making. Her current
research focuses
on decisions made by stranger surrogates. She received her PhD
in nursing from
the University of California at San Francisco in 2000.

Elizabeth G. Epstein, PhD, RN, received her PhD in Nursing
from the University
of Virginia in 2007. In August 2007, she took a position as
Assistant Professor
at the University of Virginia School of Nursing. Her doctoral
dissertation and
continuing interests are in ethics and end-of-life issues in the
pediatric setting.

In particular, she is interested in studying moral distress and
moral obligations

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x Guide to the Code of Ethics for Nurses

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,

including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

About thE AuthoRs

among healthcare providers, as well as determining how care-
based ethics is
evident in pediatric end-of-life care. She is a member of the
American Society
for Bioethics and Humanities. She serves as a facilitator for
Conversations in
Clinical Ethics, a multidisciplinary group at the University of
Virginia that meets
to discuss ethical issues that arise in the hospital setting.

Provision 8
Mary C. Silva, PhD, RN, FAAN, received her BSN and MS
from the Ohio State
University and her PhD from the University of Maryland. In
addition, she under-
took postdoctoral studies at Georgetown University. She has
taught healthcare
ethics at the master’s and doctoral levels and published
extensively in the area
of ethics, beginning in the 1970s. She is currently Professor
Emerita at George
Mason University in Fairfax, Virginia. Dr. Silva is also a
Fellow in the American
Academy of Nursing.

Provision 9
Marsha D.M. Fowler, PhD, MDiv, MS, RN, FAAN, is Senior
Fellow and
Professor of Ethics, Spirituality, and Faith Integration at Azusa
Pacific University.

She is a graduate of Kaiser Foundation School of Nursing
(diploma), University
of California at San Francisco (BS, MS), Fuller Theological
Seminary (MDiv),
and the University of Southern California (PhD). She has
engaged in teaching
and research in bioethics and spirituality since 1974. Her
research interests are
in the history and development of nursing ethics and the Code
of Ethics for
Nurses, social ethics and professions, suffering, the
intersections of spirituality
and ethics, and religious ethics in nursing. Dr. Fowler is also a
Fellow in the
American Academy of Nursing.

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© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

xi

A code of ethics stands as a central and necessary mark of a
profession. It functions
as a general guide for the profession’s members and as a social
contract with the
public that it serves. The group that would eventually become
the American Nurses
Association first discussed a code of ethics in 1896. When the
ANA code of ethics
was first developed, it was used as a model by nursing
organizations elsewhere in
the world, so it had considerable influence both in this country
and internationally.
As American nursing education and practice advanced over the
years since then,
and we developed a deeper understanding and appreciation of
ourselves as profes-
sionals, the code has been updated on several occasions to
reflect these changes.
However, the core value of service to others has remained

consistent throughout.
One major change that can be found is the re-conceptualization
of the patient.
Formerly limited to an individual person usually in the hospital,
now the concept of
the patient includes individuals, their families, and the
communities in which they
reside. Another change of great significance, detailed in the
fifth provision of the
code, reminds us that nurses owe the same duties to self as to
others. Such duties
include professional growth, maintenance of competence,
preservation of whole-
ness of character, and personal integrity. Just as the health
system and professional
organizations need to attend to the rights of patients, they also
must support nurses
and help them to take the actions necessary to fulfill these
duties.

You will need to read this Code carefully and repeatedly to
reflect on these nine
provisions for what they mean in your daily life as a nurse.
Ethics and ethical codes
are not just nice ideas that some distant committee dreamed up.
Rather, they are
what give voice to who we as professional nurses are at our
very core. This Code
reflects our fundamental values and ideals as individual nurses
and as a member
of a professional group.

When the ANA House of Delegates first unanimously accepted
the Code for
Professional Nurses in 1950, years of consideration had been
given to the develop-

ment of this code, consideration that continues to this day. The
ANA modified the
Code in 1956, 1960, 1968, 1976, 1985, and 2001 so that it could
continue to guide
nurses in increasingly more complex roles and functions. These
revisions reflect not

Preface

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

PREFAcE

only the changing roles and functions of nurses and their
relationships with col-
leagues, but also and, more important, the commitment of
professional nursing to
maintaining one of its most important and vital document that
continues to inform
nurses, other health professionals, and the general public of
nursing’s central values.
These values underpin this Code of Ethics. Read it often and
use it wisely.

And finally, join me in thanking the latest ANA task force for
their excellent
work in revising our Code.

Anne J. Davis, PhD, DS, MS, RN, FAAN
Professor Emerita, University of California, San Francisco
Professor, Nagano College of Nursing, Japan
Former Chair, ANA Ethics Committee

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

xiii

The Code Of Ethics For Nurses:
Something Old And Something New
The American Nurses Association’s (ANA) Code of Ethics for

Nurses with Interpretive
Statements (ANA, 2001) was never intended to be carved in
stone for all eternity.
Rather, it was meant to be a document that has naturally
evolved and developed
in accord with the changing social context of nursing, and with
the progress and
aspirations of the profession. However, despite the changes over
time in the Code’s
expression, interpretation, and application, the central ethical
values, duties and
commitments of nursing have remained stable. The Code of
Ethics for Nurses is
the profession’s public expression of those values, duties, and
commitments. An
understanding of the conventional history of this document and
its various revisions
over time is prerequisite to understanding the current Code of
Ethics for Nurses.

The first generally accepted code of ethics for nursing in the
United States was
written in 1893 by Lystra Gretter, principal of the Farrand
Training School for
Nurses, in Detroit, in the form of a pledge patterned after
medicine’s Hippocratic
Oath. Gretter felt that Florence Nightingale embodied the
highest ideals of nursing
and, consequently, named the first version of the Code the
“Florence Nightingale
Pledge.” The Nightingale Pledge was generally accepted in this
country in its original
version, and was usually administered at school of nursing
graduation exercises,
even after ANA adopted its first official code of ethics in 1950.
The Nightingale

Pledge reads as follows:

I solemnly pledge myself before God and in the presence of this
assembly: To
pass my life in purity and to practice my profession faithfully. I
will abstain
from whatever is deleterious and mischievous, and will not take
or know-
ingly administer any harmful drug. I will do all in my power to
elevate the
standard of my profession, and will hold in confidence all
personal matters
committed to my keeping, and all family affairs coming to my
knowledge in
the practice of my profession. With loyalty will I endeavor to
aid the physi-
cian in his work and devote myself to the welfare of those
committed to my
care (Gretter, 1910).

Introduction

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any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

IntRoDuctIon

The original Nightingale Pledge has served as the basis for
numerous Hollywood
portrayals of nurses, and it continues to be administered at
nursing school gradu-
ations to this day. In 1896, three years after the appearance of
the Nightingale
Pledge, the delegates and representatives of the Nurses’
Associated Alumnae of the
United States and Canada (renamed the American Nurses
Association in the early
1900s) met at the Manhattan Beach Hotel in New York to

establish their constitu-
tion and articles of incorporation. The first purpose of the group
was “to establish
and maintain a code of ethics” (Minutes, 1896). However,
despite the recognized
significance of a code of ethics for the profession, 54 years
were to lapse before a
Code was officially adopted.

In 1926, A Suggested Code was provisionally adopted by ANA
and published
in the American Journal of Nursing (AJN) [ANA, Committee on
Ethics, 1926].
Critical comments were sought from the AJN readership. The
first proposed Code
was written in the flowery narrative style characteristic of the
late 1800s and early
1900s. Although somewhat idealized, it was a solid document,
admirably unwaver-
ing and professionally astute in its statement of the values of
the profession at the
time. However, despite its rhetorical elegance, it did not
enumerate specific prin-
ciples at a more practical level as the membership had hoped,
and so the Suggested
Code was not adopted.

In 1940, A Suggested Code was replaced by A Tentative Code,
also published
in AJN (ANA, Committee on Ethics, 1940). This 1940 version
of the Code
incorporated verbatim some sections from the Suggested Code.
Both codes
were organized around the theme of categories of relationships,
such as nurse-
to-profession or nurse-to-patient. The emphasis of the 1940

Code, however;
demonstrated a more overt concern for the status and public
recognition of
nursing as a profession. As with the 1926 Suggested Code,
comments were sought
from AJN readers.

Subsequent debate, inquiries, and expressions of concern
formed the basis for
an entirely rewritten version in 1949. The revised Tentative
Code was submitted to
ANA members, professional groups, schools of nursing, and
healthcare agencies
for comment. In addition, input was solicited through the use of
a questionnaire
mailed to groups and individuals, resulting in 4,759 responses
(Flanagan, 1976).
The Code for Professional Nurses was unanimously accepted by
the ANA House
of Delegates in 1950 (ANA, 1950). At last, the profession had
an official code
of ethics! The style of the 1950 Code differed dramatically from
that of the two
previous, unadopted versions. It consisted of a brief preamble
and 17 succinct,
enumerated provisions. This Code relinquished the overt use of
professional rela-
tionships as its organizing framework.

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

IntRoDuctIon

It did, however, incorporate many elements of relationships
within its provisions.
Following adoption of the 1950 Code, debates were held and
comments were periodi-

cally sought from AJN readers. Responses from readers and
others formed the basis
for a minor emendation to the Code, made in 1956. A 1950
provision, which proscribed
advertising, was revised at this time. This provision originally
read:

Professional nurses do not permit their names to be used in
connection with
testimonials in the advertisement of products. (ANA, 1950).

The provision was revised to read:

Professional nurses assist in disseminating scientific knowledge
through any
form of public announcement not intended to endorse or
promote a commercial
product or service. Professional nurses or groups of nurses who
advertise profes-
sional services do so in conformity with the standards of the
nursing profession.

Apart from that small change, the first major revision of the
1950 Code was
developed in 1960 (ANA, 1960).

Between 1950 and 1960, attention shifted from concern for the
content of the
Code to concern about its enforcement in the practice setting.
Subsequent changes
in the ANA bylaws incorporated provisions relating to the
obligations of associa-
tion members to uphold the Code. Thus, in 1964, the ANA
Committee on Ethics
developed the Suggested Guidelines for Handling Alleged
Violations of the Code for

Professional Nurses (ANA, 1964).

The next major revision of the Code was formally adopted in
1968. This revision
dropped the term “professional” from the title to indicate that
the Code applied to
both technical and professional nurses. The 1968 revision also
omitted the preamble
of the 1960 Code, and condensed the number of provisions from
17 to 10 (ANA,
1968). Although the 1968 revision shortened the number of
provisions, it still car-
ried forward all the concerns of the 1960 Code, incorporating
them either implicitly
or explicitly. However, an important omission in the 1968 Code
pertained to the
personal ethics of the nurse. The 1968 Code was the first
version to omit references
to the “private ethics” of the nurse, and the demand that the
nurse “adhere to stan-
dards of personal ethics which reflect credit upon the
profession” (ANA, 1950). The
personal sphere was no longer deemed to fall within the purview
of professional
scrutiny. Given the early focus of nursing educators and
administrators on ques-
tions of the moral purity of the probationer, trainee, and
graduate, this is both a
significant and substantive change. Additionally, the 1968 Code
was the first version
that did not explicitly mention the physician; “members of other
health professions”
are mentioned, but the physician is not singled out (ANA,
1968). During the 1970s,

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any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

IntRoDuctIon

significant changes in nursing and its social context made
another revision to the
Code necessary.

In 1976, a new version of the Code was formally adopted.
Among other changes,
this version of the Code created a new emphasis on the
responsibility of the
patient to participate in his or her own care. The notions of
nursing autonomy
and the nurse-as-advocate were addressed as well. The 1976
Code also shifted to
a predominant (though not consistent) use of the term client
rather than patient,
and a consistent use of nonsexist terminology (ANA, 1976).The
1985 revision of the
Code retained the provisions of the 1976 version, yet included
revised interpretive
statements. In some cases, these new interpretive statements
significantly clarified,
redirected, or altered the sense of the original provisions. For
instance, the 1976
interpretive statement for provision 11 declared that “quality
health care is man-
dated as a right to all citizens” (ANA, 1976). The 1985
interpretive statement made
citizenship irrelevant to any consideration of access to or
distribution of nursing or
healthcare services (ANA, 1985).

In 1995, a Task Force for the Revision of the Code for Nurses
was convened to
evaluate the need for a revision of the Code. The Task Force
determined that not

only did the interpretive statements need revision, but the
Provisions themselves,
unchanged for 23 years, also needed revision. The Task Force
identified a number
of concerns that needed to be addressed in a new revision.
These included a need
to expand the Code’s reflections of approaches to ethics that
would include virtue
and feminist, communitarian, and social ethics. The committee
wished to see an
enlarged concern for global health; for the conditions that
produce disease, illness,
and trauma; and for nurse participation in health policy.
Economic constraints
that could result in a workplace environment that posed a risk to
patients or
nurses needed increased attention. In addition, the Task Force
wanted the Code
to encompass all nurses, in all positions, in all venues, and the
work of professional
nursing associations. In some places, certain moral language
needed clarification,
such as “refusal to participate,” which needed to incorporate a
discussion of “consci-
entious objection” as a moral ground for “refusal to
participate.”

The Task Force was also concerned with reuniting “personal”
and “professional”
ethics and heightening recognition that the nurse has duties to
self. The Task
Force undertook this thorough revision of the Provisions as well
as the interpre-
tive statements with an acute awareness of the tradition of
nursing ethics and a
commitment to retaining our moral identity from the past and

continuing to bring
it into the present. This revision of the Code was faced with a
different process of
approval from previous Codes. In the reorganization of the
structure of ANA, the
new Code and its interpretive statements would go before the
House of Delegates

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

IntRoDuctIon

for approval. Previous codes required approval of the House for
the provisions,
but not for the interpretive statements.

The interpretive statements had previously been subject to
revision and approval
by the Committee on Ethics alone. However, in the
reorganization, the Committee
on Ethics was dissolved. The new revision of the Code’s
provisions and interpre-
tive statements was formally adopted by the ANA House of
Delegates in 2001. The
Code of Ethics for Nurses must of necessity undergo periodic
revision in order to
remain relevant. However, the Code is framed in such a way as
to address categories
of concern, rather than specific events or changes in the
workplace. This is done to
keep the Code “elastic” so that it need not be changed with
every wind that blows.
The Code might mention “natural disasters” and discuss a
nurse’s responsibilities
in such disasters, but it would not mention specific earthquakes,
hurricanes, or
tsunamis. The Code will address nursing “in clinical settings,”

but will not men-
tion specific settings such as intensive care units, retail nursing,
or parish nursing.
In that way, the Code would not need revision every time a new
venue for nursing
arose. The Code will address treatments or interventions
generically, or categories of
treatment such as “the administration of food and fluid,” but
will no longer specify
specific treatments lest the code need to be revised every time a
new treatment is
developed. In general, it is understood that the broader
provisions of a Code will
require revision substantially less frequently than will the more
specific interpre-
tive statements.

To date, these have been the successive revisions of the Code:

1893—Florence Nightingale Pledge (informal standard)

1926—A Suggested Code (unadopted)

1940—A Tentative Code (unadopted)

1950—Code for Professional Nurses

1956—Code for Professional Nurses, amended

1960—Code for Professional Nurses, revised

1968—Code for Professional Nurses, revised

1976—Code for Nurses with Interpretive Statements

1985—Code for Nurses with Interpretive Statements, revised

2001—Code of Ethics for Nurses with Interpretive Statements

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any means, electronic or mechanical,

including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

IntRoDuctIon

Though these versions of the Code vary in their articulation of
the duties and
values of the profession, they also contain important features
that remain relatively
unchanged. For instance, while nurses always were urged not to
discriminate on
the basis of creed, nationality, or race (ANA, Committee on
Ethics, 1940), contem-
porary nursing has broadened that concern to disallow
discrimination on the basis
of any personal attribute, socioeconomic status, or nature of the
health problem
itself (ANA, 1976). The 1985 Code claims that “all national,
ethnic, racial, religious,
cultural, political, educational, economic, developmental,
personality, role, and
sexual differences” are unjust grounds for discriminating among
those in need of
care (ANA, 1985).

The 2001 Code is even more emphatic: “The need for health
care is universal,
transcending all individual differences. The nurse establishes
relationships and
delivers nursing services with respect for human needs and
values, and without
prejudice” (ANA, 2001). The primary ethical principle of
justice remains a central
concern; it is the expression of that principle that has developed
over the succes-

sive revisions of the Code. Within the Code for Nurses,
whatever the version,
there is a deep and truly abiding concern for the social justice at
every level;
for the amelioration of the conditions that are the causes of
disease, illness, and
trauma; for the recognition of the worth and dignity of all with
whom the nurse
comes into contact; for the provision of high-quality nursing
care in accord with
the standards and ideals of the profession; and for just treatment
of the nurse.
These are consistent and historic concerns of the profession that
have been
reflected, more strongly at some times than at others, in the
successive revisions
of the Code. The “new Code” reflects the “old Code” in its
continuity with
nursing’s moral past; thus, the 2001 Code is a shiny, new,
genuine antique.

The Code for Nurses reflects both constancy and change—
constancy in the
identification of the ethical virtues, values, ideals, and norms of
the profession,
and change in relation to both the interpretation of those
virtues, values, ide-
als, and norms, and the growth of the profession itself. It is
comforting to note
that the moral duties and values of the profession were set in
place long before
the dizzying and sometimes chaotic forces of contemporary
science and technol-
ogy added to the burdens of clinical decision making. Though
no easy task, ethi-
cal decision making in the nursing profession is not adrift—it is

firmly anchored
to the distinguished, distinctive, and definitive moral and
ethical tradition of

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part of this book may be reproduced or utilized in any form or

any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

IntRoDuctIon

the nursing profession as represented in the Code of Ethics for
Nurses. As you
read each of the chapters that follow, you will see in them
nursing’s moral past,
present, and future.

Marsha D.M. Fowler
Professor of Ethics
Spirituality and Faith Integration and Senior Fellow
Institute for Faith Integration
Azusa Pacific University
Azusa, CA

Associate Pastor
First Congregational Church of Los Angeles
Los Angeles, California

References

American Nurses Association. 1950. ANA House of Delegates
Proceedings, Vol. I.
New York: ANA.

American Nurses Association. 1960. ANA House of Delegates
Proceedings. New
York: ANA.

American Nurses Association Committee on Ethics. 1964.
Suggested Guidelines

For Handling Alleged Violations of the Code for Professional
Nurses. New
York: ANA.

American Nurses Association. 1968. ANA House of Delegates
Reports, 1966–1968.
New York: ANA.

American Nurses Association. 1976. The Code for Nurses with
Interpretive
Statements. Kansas City, MO: ANA.

American Nurses Association. 1985. The Code for Nurses with
Interpretive
Statements, revised. Kansas City, MO: American Nurses
Publishing.

American Nurses Association. 2001. The Code of Ethics for
Nurses with
Interpretive Statements. Washington, DC: Nursesbooks.org.

American Nurses Association Committee on Ethics. 1926. A
Suggested Code.
American Journal of Nursing 26(8): 599–601.

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

IntRoDuctIon

American Nurses Association Committee on Ethics. 1940. A
Tentative Code for
the nursing profession. American Journal of Nursing 40(9):
977–980.

Flanagan, L. 1976. One Strong Voice. Kansas City, MO: ANA.

Gretter, L. 1910. Florence Nightingale Pledge: Autograph

manuscript dated 1893.
American Journal of Nursing 10(4): 271.

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including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from

the publisher.

Provision
One
The nurse, in all professional relationships, practices

with compassion and respect for the inherent dignity,

worth, and uniqueness of every individual, unrestricted

by considerations of social or economic status, personal

attributes, or the nature of health problems.

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

History of this Commitment
The Nightingale Pledge, which is patterned after medicine’s
Hippocratic oath, is
generally accepted as the first nursing code of ethics. While it
contains a pledge
that the nurse devote herself to the welfare of those committed
to her care, it does
not explicitly mention compassion and respect for human
dignity. Similarly, the
earliest code drafted by the American Nurses Association in
1926 mentions only
devotion. A Tentative Code, published in The American Journal
of Nursing in 1940
but never adopted, contains the following statements:

The nurse should carry out professional commitments and
activities with
meticulous care, with a generous measure of performance, and
with fidel-
ity toward those whom she serves. Honesty, understanding,
gentleness, and

patience should characterize all of the acts of the nurse. A sense
of the fitness
of things is particularly important (ANA, 1940; p. 978).

The nurse has a basic concern for people as human beings,
confidence in
the fundamental power of personality for good, respect for
religious beliefs
of others, and a philosophy which will sustain and inspire others
as well as
herself (ANA, 1940; p. 980).

In the 1950 Code for Professional Nurses, a substantive revision
of A Tentative
Code, we find for the first time:

Need for nursing service is universal. Professional nursing
service is there-
fore unrestricted by considerations of nationality, race, creed or
color (ANA,
1950; p. 110).

This statement became the first provision of the 1968 Code for
Professional Nurses:

The nurse provides services with respect for the dignity of man,
unrestricted
by considerations of nationality, race, creed, color or status
(ANA, 1968).

Provision One
Carol R. Taylor, PhD, MSN, RN

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Guide to the Code of Ethics for Nurses 3

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

In 1976, the Code added the following important content to this
provision:

The nurse provides services with respect for human dignity and
the uniqueness
of the client unrestricted by considerations of social or
economic status, personal
attributes, or the nature of health problems (emphasis added)
(ANA, 1976; p. 3).

In addition to signaling the uniqueness of each recipient of
nursing care (then
newly termed “the client”), the 1976 Code also recognized that
things other than
nationality, race, creed, color, and status can result in
unacceptable differences in
treatment. This provision remained the same in the 1985 Code.
In the 2001 revision,
the scope was broadened to include “all professional
relationships” so that “respect” is
now broadened to include “inherent dignity (a critical modifier),
worth, and unique-
ness.” A significant addition was the phrase “practices with
compassion and respect.”
The addition of the virtue compassion was related to the serious
scholarship currently
being done by nurse ethicists in virtue theory and care ethics.
Also noteworthy was the
replacement of the term client with “every individual,” so that
the Code now states that:

The nurse, in all professional relationships, practices with
compassion and
respect for the inherent dignity, worth, and uniqueness of every
individual,
unrestricted by considerations of social or economic status,

personal attributes,
or the nature of health problems (emphasis added) (ANA, 2001).

It is important to recognize that the drafters of the Code of
Ethics for Nurses
have continued to identify respect for persons as a core ethical
principal, includ-
ing respect for autonomy in this principle (Interpretive
Statement 1.4, Right to
Self-determination). Although The Belmont Report (National
Commission for
Behavioral Research, 1979) identified respect for persons,
beneficence and justice as
the three basic ethical principles, Beauchamp and Childress in
their Principles of
Biomedical Ethics, now in its fifth edition (2001), popularized
four principles of
biomedical ethics: autonomy, beneficence, nonmaleficence, and
justice.

As bioethics in the United States evolved, autonomy replaced
respect for persons
in most lists of core principles. While the emphasis on
autonomy was understand-
able in a country struggling to correct the abuses of
paternalistic medicine, its
narrower focus ignores bigger challenges related to inherent
dignity and worth.
Strikingly absent from popularized versions of the principles of
bioethics is respon-
siveness to human vulnerability. The Code of Ethics recognizes
the many factors
that result in injustices in health care and holds nurses to a high
standard of com-
passion and respect for all—especially those most vulnerable.
As recent national

studies continue to prove, great disparities in health outcomes
in the United States
continue—making Provision 1 an ideal not yet realized (AHRQ,
2006).

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4 Guide to the Code of Ethics for Nurses

PRovIsIon onE Carol R. Taylor, PhD, MSn, RN

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Nurse ethicist Barbara Jacobs recommends respect for, or the
restoration of,
human dignity, as a common central phenomenon to unite and
reflect nursing
theory and practice (Jacobs, 2001). Consilience, a way to unify
the knowledge
that is needed to support this phenomenon, is suggested as one
example of a pos-
sible approach toward a philosophy of nursing that embraces
multiple forms and
sources of knowledge in all-encompassing morality that
ultimately ennobles the
lives of all human beings in covenantal relationships with
nurses both in theory
and in practice.

Thinking Beyond This Provision
Most nurses will tell you that they entered nursing to “help
others,” and few at first
will admit to being biased or discriminatory in their
professional relations. Honest
reflection, however, results in most of us realizing that we
respond to patients and
other professional caregivers differently based on numerous
factors, not the least of
which are race and ethnicity, age, financial status, position/title,
body size, health,
and other personal attributes. We probably all think of those

with whom we inter-
act professionally as falling into one of three categories: people
for whom we’d do
anything—even at great personal cost; people whom we give
their due; and people
we serve grudgingly, if at all. It is to be hoped that few nurses
can identify individu-
als with whom they interact professionally who fall into a
fourth category: people
they aim to harm by disrespectful behavior or worse.

To the extent that we admit to some degree of difference in our
ways of relating
to others, Provision 1 presents us with a challenging ideal:

The nurse, in all professional relationships, practices with
compassion and
respect for the inherent dignity, worth, and uniqueness of every
individual,
unrestricted by considerations of social or economic status,
personal attributes,
or the nature of health problems (emphasis added).

Provision 1 is not claiming that every nurse needs to have
“warm and fuzzy” feel-
ings for all encountered professionally—that would be
unrealistic. Certain patients,
members of their families, and even other healthcare
professionals, will fill us with
frustration, anger, sometimes even disgust and revulsion, but
the Code mandates
that we have a professional obligation to move beyond these
feelings and, at the
very least, to recognize the humanity of others and respond with
compassion and
respect. At times, this can be a heroic effort and may even

require the support of
the professional caregiving team.

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Guide to the Code of Ethics for Nurses 5

© 2008 American Nurses Association. All rights reserved. No

part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

It is helpful for nurses to be reflective concerning the
fundamental assump-
tions about people they bring to practice. Reflect on the
following statements and
check those with which you agree. Compare your list with that
of a colleague and
explore any differences. Talk about the consequences of the
assumptions you hold
for yourself, your patients, your colleagues, and the public at
large. Which of your
assumptions are consistent with Provision 1 of the Code of
Ethics? How should
colleagues respond to individuals with convictions that violate
Provision 1 of the
Code of Ethics?

u Every human being, merely by virtue of
being human, merits my equal and
full respect.

u The more vulnerable people are because of
illness, frailty, or other
marginalizing factors, the more they command my
compassion and respect.

u The more vulnerable people are because of
illness, frailty, or other
marginalizing factors, the less they command my
compassion and respect.

u I agree that I need to be compassionate
and respectful to those innocently
affected by disease, injury, or frailty—so long as
self-abusive behaviors did
not cause the disease or infirmity

u People need to earn my respect.

u It is only human and ethically justifiable to
respect people differently.

Interpretive Statement 1.4, the right to self-determination,
mandates that nurses
be knowledgeable about the moral and legal rights of all
patients to be self-determin-
ing. Many critics of contemporary health care bemoan the
failure of all healthcare
professionals, including nurses, to promote patients’ authentic
autonomy. Respect
for autonomy in many cases is now reduced to not interfering
with a patient’s
expressed choices. This is a far cry from what nurse ethicist
Sally Gadow initially
described as existential advocacy:

The ideal which existential advocacy expresses is…that
individuals be assisted
by nursing to authentically exercise their freedom of self-
determination. [A]
uthentic… [means] a way of reaching decisions…truly one’s
own—decisions
that express all…one believes important about oneself and the
world. …
(Gadow, 1980; p. 85).

How many nurses today know their patients well enough to

facilitate authentic
autonomy? And how many nurses value existential advocacy
such that they are
willing to fight for institutional cultures that demand nothing
less.

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6 Guide to the Code of Ethics for Nurses

PRovIsIon onE Carol R. Taylor, PhD, MSn, RN

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Applying the Provision:
Rethinking Professional Relationships
and What has Historically Been Termed
“The Therapeutic Use of Self”
In every human encounter, we convey one of three messages:
(1) Go away, my
world would be better without you; (2) You are an object, a task
to be done, you
mean nothing to me; or (3) You are a person of worth, I care
about you. The more
vulnerable people are, the more we can become their world of
meaning. Since
disease, injury, and illness can separate people from affirming
experiences that
enhance their sense of worth (family relationships, work, other
achievements),
how we present ourselves as health professionals to individuals
needing care truly
matters. A quick moment of reflection will help you to identify
individuals in
your own life whom you perceive as being either therapeutic or
toxic presences.
How do you think your patients and colleagues would evaluate
your presence?
What do you leave in your wake: affirmation, peace, joy,
warmth, support, the
experience of being cared about as well cared for? In healthcare

settings, it is
critical for nurses to relate to patients as a healing presence.
Two stories follow
to illustrate this point.

A friend of mine named Laurie, who has cancer, wrote to me
after a visit to an
infusion therapy center:

The nurse came into my room and touched me on the forearm. It
wasn’t a
furtive nurse searching for a vein thing. It wasn’t “I’m a nurse,
you’re a patient,
too bad” thing. It was “I’m a human being, you’re a human
being, how are
you?” thing. And that one touch rendered tolerable everything
else she had to
do that morning.

Powerfully illustrated in this example are the profound
consequences of human
touch and compassionate, respectful presence. Contrast this
illustration with
the next.

Another friend diagnosed with advanced ovarian cancer spent
two long, hard
years dying. She was president of our college, had a PhD in
biology, was from
Worcester, Massachusetts, and had that delightful New England
sense of reserve
and privacy. She was one of the most gentle, loving human
beings I have ever had
the blessing to know. She had intestinal obstructions and was in
and out of the
hospital constantly. I remember spending hours simply sitting

behind her to lend
physical support as she retched over an emesis basin. She
instructed me to tell my
students the following:

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Guide to the Code of Ethics for Nurses 7

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

When I first got sick, it didn’t matter how people treated me
because I knew
who I was. But now that I’ve grown weaker I become whomever
people make
me. If a nurse walks into my room and moves me like meat, I
become meat!

It made me want to cry that I or a member of my profession had
the capacity to
take a Lillian and transform her to a slab of meat by virtue of
how I gazed, what I
said or failed to say, or how I touched. This is the power that is
ours. At the end of
the shift, have people been left better or worse for having
experienced us?

Reflect on the following case studies in light of Provision 1 of
the Code of Ethics.

Case Example 1
Jean Thatcher is a morbidly obese, 47-year-old, single, white
attorney with multiple scle-

rosis. She is frequently admitted to your hospital for
complications related to her multiple

sclerosis and obesity. Since she quickly “exhausts” the patience
and best efforts of the

staff, she is “rotated” among several units all of whom know her
well and loathe her

inpatient stays on their unit. The staff’s best efforts to educate
her about appropriate

self-care and preventive practices have fallen on deaf ears. She
refuses to cooperate

when her support is elicited for bathing, position changes, and
the like. Her one visi-

tor, her mother, believes that the staff discriminates again her
daughter and complains

frequently to management. Both the patient and her mother
frequently threaten to sue

the hospital for neglect and discrimination. Jean admits that she
is refusing to eat or

help with bathing and positioning. She said she has “had
enough” and wants to give

up. Most of the staff have already “given up” and ask “why we
should we try to help

Jean when she has been clear about not wanting our help?”
Today, one nurse was

overheard saying, “I’m not going to sprain my back trying to
get her to move when she

refuses to cooperate. She can lie in her filth for all I care.” The
nurse manager calls a

meeting to explore how the team can best respond to the
challenges of caring for Ms.

Thatcher. In what practical ways does Provision 1 of the Code
of Ethics influence the

standard of care for Ms. Thatcher and similar patients? Is Ms.
Thatcher’s wish to “give

up” an autonomous act of self-determination that should be
supported by her nurses? OCo
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8 Guide to the Code of Ethics for Nurses

PRovIsIon onE Carol R. Taylor, PhD, MSn, RN

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Case Example 2
Mr. Rivera staggers into the emergency room at 2:00 a.m.
complaining of belly pain.

He speaks Spanish only. Well known to the ER staff, Mr. Rivera
is homeless and has a

history of alcoholism and violence. He has been blacklisted at
several of the local shel-

ters for homeless men. The night is cold and there is freezing
rain. The resident called

to examine Mr. Rivera does not “work-up” the complaint of
“belly pain,” instead saying

that, once again, Mr. Rivera only wants a warm bed for the
night, a bath, something

to eat and meds to make him “feel good.” The E.R. nurse
manager instructs a nursing

student to “clean up” Mr. Rivera when the day shift arrives. The
nursing student finds

him combative when aroused and asks for help only to be told to
“do the best she

can.” His stools are dark and she suspects blood in the stool, but
is told only to babysit

the patient until he is discharged. In what practical ways does
Provision 1 of the Code

of Ethics for Nurses influence the standard of care for Mr.
Rivera and similar patients?

Does Mr. Rivera’s previous history justify the lack of care he is
receiving this admission?

Is it justified to expect the nursing student to meet his needs
unaided? How should the

student’s clinical instructor respond to the student when she
complains about the staff’s

lack of compassion, professionalism, and aid? O

Case Example 3
You are the director of nursing in a large nursing home. Your
units are staffed primarily

with licensed practical nurses and nursing assistants. Recently
several nursing assistants

have come to you complaining about unequal treatment in
assignments and privileges.

You know that there are some racial tensions among the staff,
which is predominantly

persons of African American and Hispanic identity, and suspect
that these may be

contributing to the conflict. While the nursing home allegedly
has a “zero tolerance”

policy for discrimination, you know that this is not always the
case. What guidance does

Provision 1 of the Code of Ethics offer to promote respectful
professional relationships

among the staff and residents? O

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Guide to the Code of Ethics for Nurses 9

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

References

All online references were accessed in December 2007.

Agency for Healthcare Research and Quality (AHRQ). 2006.
National
Healthcare Disparities Report. 2006. Rockville, MD: AHRQ.
http://www.
ahrq.gov/qual/nhdr06/nhdr06.htm.

American Nurses Association. 1926. A Suggested Code: A code
of ethics
presented for the consideration of the American Nurses’
Association.
American Journal of Nursing 26(8): 599–601.

American Nurses Association. 1940. A Tentative Code for the
nursing profession.
American Journal of Nursing 40(9): 977–80.

American Nurses Association. 1950. Code for professional
nurses. ANA House of
Delegates Proceedings, Vol. 1; New York: ANA.

American Nurses Association. 1968. Code for professional
nurses, Revised. ANA
House of Delegates Proceedings, Vol. 1; New York: ANA.

American Nurses Association. 1976. Code for Nurses with
Interpretive
Statements. Kansas City, MO: American Nurses Publishing.

American Nurses Association. 1985. Code for Nurses with
Interpretive
Statements, Revised. Washington, DC: American Nurses
Publishing.

American Nurses Association. 2001. Code of Ethics for Nurses
with Interpretive
Statements. Washington, DC: American Nurses Publishing.

Beauchamp, T.L. and J.F. Childress. 2001. Principles of
Biomedical Ethics, 5th
ed. New York: Oxford University Press.

Cooper, L.A., and N.R. Powe. 2004. Disparities in Patient
Experiences, Health
Care Processes, and Outcomes: The Role of Patient-Provider
Racial, Ethnic, and
Language Concordance. New York: The Commonwealth Fund.

Gadow, S. 1980. Existential advocacy: Philosophical

dimensions of nursing
practice. In Nursing Images and Ideals, S. Spicker and S.
Gadow, eds. NY:
Springer Publishing Company.

Jacobs, B. 2001. Respect for human dignity: A central
phenomenon to
philosophically unite nursing theory and practice through
consilience of
knowledge. Advances in Nursing Science 24(1): 17–35.

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http://www.ahrq.gov/qual/nhdr06/nhdr06.htm

10 Guide to the Code of Ethics for Nurses

PRovIsIon onE Carol R. Taylor, PhD, MSn, RN

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Kaiser Health Disparities Report: A Weekly Look at Race,
Ethnicity and Health.
http://www.kaisernetwork.org/Daily_reports/rep_disparities.cfm

National Commission for the Protection of Human Subjects of
Biomedical
and Behavioral Research. 1979. The Belmont Report: Ethical
Principles and
Guidelines for the Protection of Human Subjects of Research.
Washington, DC:
U. S. Government Printing Office.

Smedley, B.D., A.Y. Stith, and A.R. Nelson, Eds. 2002.
Unequal Treatment:
Confronting Racial and Ethnic Disparities in Health Care.
Washington, DC:
National Academies Press.

About the Author
Carol R. Taylor, PhD, MSN, RN, is a faculty member of the
Georgetown University

School of Nursing and Health Studies and Director of the
Georgetown University
Center for Clinical Bioethics. She is a graduate of Holy Family
University (BSN),
the Catholic University of America (MSN), and Georgetown
University (PhD in
philosophy with a concentration in bioethics). Bioethics has
been a focus of her
teaching and research since 1980 linked to her passion to “make
health care work”
for those who need it. Special interests include healthcare
decision making and
professional ethics.

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© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

11

Provision
Two
The nurse’s primary commitment is to the

patient, whether an individual, family, group,

or community.

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12 Guide to the Code of Ethics for Nurses

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

History of this Commitment
From the beginning of professional nursing in the 1870s in the
United States, after
the Civil War when nurses served in military hospitals, nursing
care was limited only
to those sick or injured individuals who were usually cared for
in homes through
“private duty nursing.” The nurse was customarily employed by
the family, through
a “registry,” at the request of a physician. Often the physician
would request a spe-
cific nurse for one of “his patients.” In this relationship, there

were four potentially
competing ethical loyalties: patient, registry, physician, self.

Later, both patient care and nursing moved into hospitals.
Nurses continued
to be employed as private duty nurses, even within hospitals,
until World War II,
after which nurses predominantly became employees of the
hospital rather than the
patient or patient’s family. Now the nurse faced loyalties to an
institution instead
of a registry, a physician whom the nurse may or may not have
known, the patient,
and self. In the days of registries and, subsequently, in
hospitals, nurses could be
blackballed, sometimes solely at the request of a physician,
sometimes for rea-
sons unrelated to practice. This heightened to need for nurses to
be “loyal” to the
physician. It has only been in recent years that a physician
could not march into
a nursing administration office and demand the firing of a
particular nurse. Such
power placed nurses in a terrible position—not only did the
nurse have to “obey”
and not oppose a physician, but the nurse also had to “please”
the physician with
a proper attitude of deference. Loyalty to the patient could be
jeopardized where
nurses believed their livelihood to be at stake. In addition,
nurses were expected to
serve, sometimes without remuneration, placing yet another
strain on the nurse’s
loyalty to the patient. And yet, nursing, in its literature and its
practice consistently
articulated a primary commitment to the patient. After the

1950s, health care, or
more specifically, illness care, has become far more complex
than in the days of the
inception of modern nursing in the United States in the 1870s.
Nursing has moved
out of diploma programs and into colleges and universities, and
uniform mandatory
registration and licensure has been instituted across the nation.

Provision Two
Anne J. Davis, PhD, DS, MS, RN, FAAN

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Guide to the Code of Ethics for Nurses 13

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Both medicine and nursing have developed specialties and
subspecialties, so the
patients (and the nurses) now deal with a battalion of physicians
in each case. Third
party payors have entered into the mix, including both insurance
companies and
government agencies. Unionization and collective bargaining on
behalf of nurses
has increased. Accrediting bodies, both for institutions and for
professions, have also
become a part of the system. Many formerly independent
hospitals have either gone
out of business or coalesced into multihospitals and
multiagency megacompanies.
Restrictions may now be placed on care for economic rather
than clinical reasons.
And, importantly, there has been a rise in technological
interventions available and
both rising costs and access to care has become a problem for
many. Increasingly,
“competition” between ethical “loyalties” for nurses have

become ever more robust
and complex. In addition, though illness care remains the focus
of the “healthcare
system,” there is an awareness of the importance of preventive
care.

Preventive care was not greatly valued until an understanding of
disease etiology
came about in the 1870s and 1980s when Robert Koch and
Louie Pasteur worked
out the germ theory. Florence Nightingale, who was at Scutari
and the Crimea
in 1854, had no scientific knowledge of the germ theory, nor did
she support the
idea later, yet she was among the first to value prevention and
to see the benefit
of keeping people out of hospitals, which were often defined
then as death houses.
Before she became the famous “Lady with the Lamp,” she had
become convinced
that improved public health measures were the royal road to
making Britain a
healthier nation, and became known in London social circles for
her panoramic
expertise in this field. Her much read Notes on Nursing
(Nightingale, 1860) and
her reorganization of the military health system reflected this
knowledge and her
value of disease prevention. Her vision enlarged the definition
of the patient role
and redefined the nursing role.

Once modern public health systems were established in the
United Kingdom
and the United States, the roles and functions of nurses
expanded to include not

only the sick, but the well; and not only individuals, but groups
of people; with
emphasis on cleanliness, vaccination, and prenatal and well-
baby care. Though
the nurse’s role had expanded, the professional and ethical
emphasis continued to
be on the “patient,” who might now be a family unit, a group, a
community, or an
individual.

In her book, Nursing Ethics, the American nurse Isabel
Hampton Robb wrote:

I want to emphasize the fact that the nursing for all patients—
rich or poor,
in the hospital or in their own houses—is in the main identical...
From the
very outset let her [the nurse] determine that she will be no
respecter of per-

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14 Guide to the Code of Ethics for Nurses

PRovIsIon two Anne J. Davis, PhD, DS, MS, RN, FAAN

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

sons, but will treat all her patients with impartiality. While in
the hospital,
the nurse should always make it her rule to think of every
patient—even the
poorest and most unattractive—not as a mere case, interesting
only from a
scientific standpoint, but as an individual sick human being,
whose wishes,
fancies and peculiarities call for all the consideration possible
at her hands.
(Robb, 1900; pp. 213–14)

These words demonstrate the central place of all patients, with

unique and indi-
vidual attributes, in nursing and nursing ethics.

In each ANA Code since the first one in 1950, the patient,
whether individual,
family, group, or community, has been at the center of the
nursing profession’s eth-
ics. That is still the case today, but life in general, nursing
practice in particular, and
the structure of the healthcare system, have become far more
complex and the new
ANA Code reflects these changes.

Thinking Behind This Provision
Though it has been the case that, throughout modern nursing in
the United States,
nurses have been morally obligated to put the patient first, the
previous versions of
the Code commingled this obligation with others. The Task
Force for the Revision of
the Code felt strongly that the primacy of the patient was of
sufficient importance,
historicity, and priority that it necessitated an emphatic and
unequivocal statement
in the provisions. Thus, the previous Provision 2 was bumped to
third place and
the duty to the patient placed second.

Historically, nurses had ethical obligations that placed emphasis
on attending to
the patients’ needs, and yet the context of nursing was not
necessarily supportive
of this obligation. Today, the nurse’s ethical obligation to the
patient, first, is even
more complex to negotiate. Our present day ethics has moved
from a fairly recent

physician-oriented, paternalistic model in which physicians,
using the ethical prin-
ciple of nonmaleficence or “do no harm,” knew what was “best
for the patient.” As
nursing expanded its educational offerings, developed
specialized practice areas,
escalated its research, and even developed forms of independent
practice, nurses
generally moved into the realm of independent nursing
functions while retaining the
so-called dependent functions of carrying out medical orders. In
recognizing its own
right to participate in decision making and formulate plans of
patient care, nursing
moved to ethics that recognized patient’s rights, including the
right to know and
discuss their health status and make healthcare decisions.
Simultaneously, nurses
began coming to a greater awareness of “nursing rights,”
particularly as they related

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Guide to the Code of Ethics for Nurses 15

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

to the delivery of high-quality health care. This changed ethics
model functions
in the midst of increased clinical complexities that include
economic constraints
and managed care environments. This does not mean that nurses
see patients (or
themselves) as sidelined by events and priorities, but it does
mean that nurses must
learn to deal with economic pressures that may compete with
moral values or with
patients’ rights. The patients and their rights must remain
central. At the same time,

ethical obligation to the patient is primary, but it is not the sole
ethical obligation.

In this latest edition of the Code, Provision 5 has been added
with the potential
of creating additional ethical conflicts between the needs and
rights of the patient
and the nurse as it describes a nurse’s duty to self. The function
of duties to self is
not some sort of entitlement; it is care for the self in such as
way as to enable nurses
to fulfill other moral duties. At times, nurses have, wrongly,
placed their own needs
before those of the patient in situations as simple as failing to
confront a physician
colleague who is indifferent or worse to the needs of the
patient. Such situations,
and others like it, that present the nurse with possible
conflicting obligations raise
several questions. First, does the nurse’s primary obligation
always mean a focus on
the patient, as has historically been the case, even to the harm
of the nurse? A “no”
answer to this would require a strong ethical argument to
support it. There may be
an exception to this primary commitment, but a nurse would
have to think long and
hard about the ethical reason to act on this exception.
Importantly, even in situations
of conflicting moral claims, where the nurse must act in a
morally self-regarding
manner, the nurse must never abandon the patient. This means
that if one nurse
cannot, on ethical grounds, engage in some treatment, activity,
or procedure, then
another nurse or caregiver must be found who does not object to

such involvement.

Nurses have multiple ethical obligations, sometimes competing,
sometimes con-
flicting, including those to the patient, the organization or
institution in which they
work, other healthcare professionals, and the nursing
profession. Today, as nurs-
ing becomes increasingly entrepreneurial, a nurse’s own
“business priorities” could
conceivably come into conflict with the needs of the patient.
Sometimes the nurse
must decide to whom she or he owes a primary obligation
(Davis et al, 1997). The
Code says the primary obligation is to the patient. Nursing work
always occurs in
some social structure and this fact can make it difficult always
to put the patient
first in a nurse’s ethical obligations. When nurses focus on what
they think will be
the consequences of an ethical act, sometimes they may need
courage (a virtue) in
order to act. They also need to draw support from the nursing
community within
which they work. In order to make this provision of the Code
have full meaning,
nursing leaders in all care giving settings will need to create
environments in which
candid, reflective, and open ethical discussions can take place.

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16 Guide to the Code of Ethics for Nurses

PRovIsIon two Anne J. Davis, PhD, DS, MS, RN, FAAN

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

How do nurses think about an ethical problem to arrive at some
conclusion
that they believe to be the ethically right action? Ethical

decision making requires
knowledge and refection including knowledge of clinical
practice, institutional
policies and procedures, the field of ethics, the Code of Ethics
for Nurses, and an
understanding of the self and one’s own values. While the
patient remains at the
center of this thinking, other people need to be considered,
including the same
self-consideration on the part of the nurse.

Applying the Provision:
The Nurse-Patient Relationship
The nurse–patient relationship creates the basic unit in which
much of nursing
practice and ethics occurs. A nurse’s ethical sensitivity is the
first requirement in the
application of this provision that places the patient at its center.
Sometimes, nurses
define a problem as a clinical one without seeing the ethical
aspects in it. If the
ethical issues that exist are missed, then that part of the
situation is not attended to
by the nurse. If the nurse is clinically competent, but ethically
insensitive or oblivi-
ous, then this provision will not have a part in the decision
making and actions
that are needed to deal with the whole patient situation. If
nurses are sensitive to
the ethical issues or concerns involved in a given situation, the
next step is them
to pay attention to their own reactions to this situation. This
reaction informs the
nurse that something is wrong or missing ethically. This
sensitivity and intuitive
reaction comes from our values and socialization as children

into adulthood. This
informal, basic ethics education is further developed in nursing
school where stu-
dents are taught and socialized into the values and ethics of
nursing. Sometimes,
these values are deep enough that we may not be aware of them
until they arise in
a specific situation. It is at this point that one needs to examine
both the situation
and the reaction that one has had to it more closely.

To examine the ethics of the situation, one needs some way of
viewing the ethical
issues. This calls for knowledge of the clinical situation, the
people involved, and
the patient’s values and wishes. Nurses can use ethical
principles, such as respect
for patient autonomy, nonmaleficence (the noninfliction of
harm), beneficence (or
doing good), justice, truth telling, and promise keeping
(Beauchamp and Childress,
2001). To use these principles, one needs some understanding of
what each of
these principles mean and how they interact. This requires basic
ethics educa-
tion. For example, the ethical principle “respect for autonomy”
is very important,
but it is not absolute. This means that, in some limited and
carefully thought-out

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Guide to the Code of Ethics for Nurses 17

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

situations, patient autonomy can be overridden in the service of
another, more
stringent, ethical principle, to do no harm. In using the ethical

principle “do no
harm” to override a patient’s autonomous choice, health
professionals need to be
very clear that it is the patient who is being kept from harm and
not the caregiving
staff. Additionally, it is so much “easier” simply to tell people
what they should do
than to explain their clinical situation to them and have them
participate in the
decision making process. This is true whether the patient is an
individual, family,
group, or community.

But creating easy situations for healthcare professionals is not
what ethics is
about. Nurses use ethical principles such as “respect for
autonomy,” “do not harm,”
and “doing good” as they engage in ethical reflection and
deliberation. They also
use aspects of “caring ethics” that is developing as an
alternative ethical theory.
These aspects are: attentiveness, responsibility, competence,
and responsiveness.

Ethical problems often relate to the tensions between
responsibilities, as well as
the multiple commitments of people who live or work in a
network of relationships.
It becomes necessary to interpret the different view points of all
those involved
with an ethical problem. It is also necessary to understand that
our own values,
obligations, loyalties, and ideals arise from multiple sources, as
do those of others.
In situations with people from cultures that differ from that of
the nurse, value

and obligation structures that come into play can be further
complicated. Values
underlie our ethical analyses, choices, and actions. Not all
values are shared; thus,
different people may choose or act in ways that would not be
the choices or actions
of the nurse What may seem strange to one person may be
perfectly reasonable to
another, given that person’s world view, culture, and values
(Davis, 2003).

When nurses deal with a group or community as the patient,
notions of justice
may come into play. Where resources are limited or managed,
the principle of dis-
tributive justice is particularly important. Distributive justice
refers to the sharing
of burdens and benefits in the allocation of resources,
sometimes, but not always,
under conditions of scarcity or rationing. Customarily terms
such as “fair,” “equi-
table,” “just,” and “fitting” are used with regard to “justice” in
the distribution of
resources. The nurse needs to think through how to be fair in
any issue of resource
allocation, including the nurse’s skill and attention or time.

In thinking through ethically problematic situations, the nurse
will need to
answer some questions. What, if any anything, should I do to be
ethical in this
situation? Why?

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18 Guide to the Code of Ethics for Nurses

PRovIsIon two Anne J. Davis, PhD, DS, MS, RN, FAAN

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Thinking about these basic questions may help in this process:

u What do I know about this patient
situation?

u What do I know about the patients’
values and moral preferences?

u What assumptions am I making that need
more data to clarify?

u What are my own feelings (and values) about
the situation and how might
they be influencing how I view and respond to
this situation?

u Are my own values in conflict with those
of the patient?

u What else do I need to know about
this case and where can I obtain this
information?

u What can I never know about this
case?

u Given my primary obligation to the patient,
what should I do to be ethical?

Case Example 1
The 87-year-old patient has end-stage lung cancer and is
nearing the terminal phase,

though not yet considered “terminally ill” for the purposes of
admission to hospice. He

tells the nurse that he is tired and does not want any more
treatment, but he does want

to be “kept comfortable.” He indicates that he is tired of trying
to fight the cancer and

feels that his present life has no quality. Also, he says, “I have
lived a good, long life

and I am ready to go.” His adult children have had a conference
with the physician and

said they want everything done for their father. The physician
tends to go along with

these adult children. What does the nurse need to know about
this clinical situation?

What are the values and obligations at stake in this case? What
values or obligations

should be affirmed and why? How might that be done? O

Case Example 2
The 32-year-old patient is in persistent vegetative state and has
been for some years.

The patient’s outdated advance directive is confusing on the
issue of food and fluid,

though clear about not wanting to be on a ventilator if she were
in a coma. Her hus-

band wants the feeding tube removed, but is unable to say that it
would have been

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Guide to the Code of Ethics for Nurses 19

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information

storage and retrieval system, without permission in writing from
the publisher.

the patient’s wish. He says that it is his decision for her. Her
two adult siblings and par-

ents reject this as a possibility because, they say, “human life is
sacred” and that their

daughter believed this. They say their daughter is alive and
should receive nursing care,

including feeding. The healthcare team does not know what to
do ethically and fear

being sued by either the husband, siblings, or the parents. What
do you need to know

about this clinical situation? What are the values and
obligations at stake in this case?

What values or obligations should be affirmed and why? How
might that be done? O

Case Example 3
The national nursing shortage problem has arrived at the local
hospital and the Vice

President for Nursing is having difficulties staffing all units
adequately, even though two

units have been closed altogether. She can either spread the
nurses around the hospi-

tal and keep all the remaining units open with fewer nurses on
each unit than is really

safe, or she can close some additional units and place those
nurses on other units to

have an adequate nursing staff. This choice would be safer for
admitted patients, but

other patients could not be admitted due to closed units. In
order to reason through

this problem of resource allocation, the nurse administrator
must rely on the ethical prin-

ciples of justice, nonmaleficence, and beneficence. This VP for
Nursing must consider

the welfare of the institution, the nursing staff, and the patients.
How would you assess

this situation morally. In your ethical analysis, what would be
acceptable options? What

would not be acceptable? How might the Code for Nurses
inform the VP’s decision?

What choice of action might promote the most good while
creating the least harm? O

Case Example 4
This year there is a severe shortage of influenza vaccine. The
policy from the Central

Health Department is to restrict this vaccine only to pregnant
women and people who are

60 years of age or older until such time as additional vaccine

might become available.

The potential availability of additional vaccine in the coming
weeks is uncertain. The nurse

himself is worried about exposure to the flu from the clinic
population as he is at higher

risk of exposure than the general population. Due to the nursing
shortage, he is the only

“shot nurse” for this extremely busy vaccination clinic. His is
35. He is considering giving

himself the vaccine, or asking a colleague to do it. If you were
that nurse, how would you

reason, ethically, about taking the vaccine yourself? What
arguments would you make

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20 Guide to the Code of Ethics for Nurses

PRovIsIon two Anne J. Davis, PhD, DS, MS, RN, FAAN

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

for and against taking the vaccine? What do you believe to be
the strongest argument?

How might the Code assist you in making a decision? O

Summary
The patient—individual, family, group, community—stands at
the center of nurs-
ing’s ethics. There are several ways for nurses to reason through
ethical problems
to reach an ethical solution. First, nurses need to be aware that
each situation is
an ethical problem and then they need to obtain as much

information as possible
about the clinical facts as well as ascertaining the values and
wishes of the patient
or the patient’s surrogate in order to think the problem through.
There is a body of
knowledge, nursing ethics, that they can use for this decision
making process. Two
nursing ethics approaches were briefly mentioned above—
principle based ethics
and caring ethics (Davis et al, 2006).

The patient, broadly defined, will remain at the center of
nursing ethics; how-
ever, nurses will continue to face ethical problems that they
need to think through
carefully using their Code of Ethics for Nurses and other
sources of knowledge.

References
Beauchamp, T., and J. Childress. 2001. Principles of Biomedical
Ethics. 5th ed.

New York: Oxford University Press.

Davis, A.J. 2003. International Nursing Ethics: Context and
Concerns. In Approaches
to Ethics, V. Tschudin, ed., pp. 95–104. London: Butterworth-
Heinemann.

Davis, A.J., M.A. Aroskar, J. Liaschenko, and T. Drought.
1997. Ethical Dilemmas
and Nursing Practice. 4th ed. Stamford, CT: Appleton & Lange.

Davis, A.J., V. Tschudin, and L. deRaeve, eds. 2006. Essentials
of Teaching and
Learning Nursing Ethics: Perspectives and Methods. London:

Elsevier.

Nightingale, F. 1860. Notes on Nursing: What It Is and What It
Is Not. London:
Harrison & Sons.

Robb, I.H. 1900. Nursing Ethics: For Hospitals and Private Use,
pp. 213–214.
Cleveland: E.C. Koeckert, Publisher.

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Guide to the Code of Ethics for Nurses 21

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Suggested Reading
Benjamin, M.J., and J. Curtis. 1991. Ethics in Nursing, 3rd ed.
New York: Oxford

University Press.

Tuckett, A.G. 2004. Truth-telling in clinical practice and the
arguments for and
against: A review of the literature. Nursing Ethics 11(5): 500–
13.

Volbrecht R.M. 2002. Nursing Ethics: Communities in
Dialogue. Old Tappan,
NJ: Prentice Hall.

About the Author
Anne J. Davis, PhD, DS, MS, RN, FAAN, and Professor
Emerita, taught at the
University of California for 34 years. Beginning in 1962, Dr.
Davis’s career focused on
international work with appointments in Israel, India, Nigeria,
Ghana, Kenya, Japan,
Korea, China, and Taiwan. These rich experiences led to the

development of her over-
riding interest in cultural diversity and nursing ethics. She is a
graduate of Emory
University in Atlanta (BS, Nursing), Boston University (MS,
Psychiatry), and University
of California, Berkeley (PhD, Higher Education). Dr. Davis has
been the recipient of
numerous awards, including an honorary Doctor of Science
from Emory University
and election as a Fellow in the American Academy of Nursing.

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© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

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© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

23

The nurse promotes, advocates for, and strives to

protect the health, safety, and rights of the patient.

Provision
Three

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24 Guide to the Code of Ethics for Nurses

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

As a modern document, the 2001 Code of Ethics tends to be less
directive than
other professional codes. A review of the codes of ethics of
other allied health pro-
fessionals (for example, physical therapists and speech and
language specialists)
reveals that these professions tend be much more prescriptive in
language about
what is allowable or discouraged behaviors in their respective
health professions.
This can cause some questioning from nurses who believe that a
code of ethics
should be rather directive. The Code of Ethics Task Force
deliberately created a
code that focused on moral concepts that undergird the
profession and did not
attempt to make statements that would bind the individual nurse

in all situations
to a single course of action.

Even a deliberative document that states as its goal the
provision of a moral
framework must provide some specific behaviors for the
members to consistently
adhere to. In Provision 3, the reader will find language and
some guidelines for the
nurse who is working in any practice arena.

The Task Force recognized that, even in a document that was
fairly revolution-
ary in its writing, it was necessary to bring forward concepts
and language that
the members of the profession would recognize from the last
and previous Codes.
More importantly, the authors had to honor many of the
traditional moral beliefs
and behaviors that nurses had been taught and were familiar
with. So in this provi-
sion, concrete terms are used with updated nuances in the
interpretive statements.
Concepts such as protection of privacy and concern for subjects
in healthcare
research, as well as the professional values nurses have
developed regarding deal-
ing with impaired colleagues are taken from their separate
places in the 1985 Code
and grouped together here in Provision 3.1

To begin with, what are unifying concepts that help fit
Provision 3 and its inter-
pretive statements properly into the Code? First of all, the title
of the Provision
contains language that focuses the nurse’s actions on encounters

with patients.
This Provision finalizes the process begun in Provisions 1 and
2, declaring to all

Provision Three
John G. Twomey, PhD, PNP

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Guide to the Code of Ethics for Nurses 25

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

that the ultimate moral duties of professional nurses involve
working with people
who need nursing care. The first three Provisions reiterate what
nursing, through
the American Nurses Association, has been stating for decades:
When individuals
need nursing care, only a professional registered nurse is
educationally and morally
capable of providing such care. This is a claim that can be
traced directly back to
Florence Nightingale and her successors, such Adelaide
Nutting, Lavinia Dock, and
others. Thus, our updated Code serves to link nurses practicing
in the 21st century
to our roots two centuries ago.2

But historical traditions need some substance that is recognized
by the profes-
sion and its members if the legacy given to us is going to be
meaningful in today’s
practice. The conceptual model that Provision 3 follows is one
that nursing has
embraced for many years. The phrase used in this provision “to
protect” is delib-
erately chosen because of its recognized place in nursing
practice. As the nursing

profession matured in the second half of the 20th century, its
members embraced
the concept of protection as a core part of nursing. The Task
Force wanted to be
very particular in its use of terms around protection. Once
assumed to be defined
within the concept of advocacy, the concept of protection is
expanded in Provision
3 to include all patients. This concept is extended to not just
those with diminished
health capacities, but to all who encounter the nurse and need
assistance to protect
their universal health needs, including but not limited to
protection of information,
need for education about health, and protection from those
healthcare providers
who are incompetent and/or impaired. So protection takes on a
comprehensive
definition within the Code.

Before moving on to a discussion of each interpretive statement,
there must
also be some mention of the ethical basis for the ideas in the
provision, as well
as the overall values reflected within the concept of protection.
The 2001 Code
uses a variety of ethical theories and concepts to reflect the
diverse moral beliefs
that American nurses bring to their practice. Despite this
diversity, there are some
unifying themes that will be described within this reader.
Provision 3 reflects the
bioethical theory based on the use of principles.3 This approach
is probably the
most widely used approach to bioethics among clinicians in the
Western world and

its specific primary principles are widely embraced in clinical
practice and often by
institutional bioethics committees as well. While the concept of
protection fits well
within the principle-based system, the reader must be clear
about how a specific
principle supports protection as it is described in the 2001
Code.

While many nurses would recognize the principle of
nonmaleficence, which is
often articulated as the duty of “the noninfliction of harm,” it
would be incorrect
to attribute this principle as the theoretical root of Provision 3.
Instead, the ethical

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26 Guide to the Code of Ethics for Nurses

PRovIsIon thREE John G. Twomey, PhD, PNP

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

principle of respect for autonomy drives this provision.
Provisions 1 and 2 define a
basic part of the nurse-patient relationship as respect for
individuals, their dignity
and worth. The moral foundation for this respect is grounded in
the basic value
of human dignity and in this sense the individual characteristics
of the patient are
irrelevant. All persons have worth and dignity. Indeed, what the
nursing profes-
sion wants its members to do as part of this respect for
autonomy is to preserve
and safeguard it. An essential piece of autonomy is that those
who possess it do so
because they have, have had, or will develop the capacity to
make decisions for and
about themselves. Respect for autonomy is necessary because

the nature of health
and threats to it mean that the capacity to remain autonomous
does not always
remain fully intact. So Provision 3 uses a principled approach,
through its protec-
tion of and respect for autonomy, as its ethical basis.

Privacy and Confidentiality:
Interpretive Statements 3.1 and 3.2
The first two parts of this provision refer to safeguarding
information. In the prior
two versions of the Code, the concept of protecting the patient’s
personal information
had been given an entire provision. Because the Task Force
wanted to emphasize the
concept of protection, it expanded the provision containing this
concept to include
situations where the need for safeguarding the patient may
occur. This expansion
resulted in Provision 3 being the longest in the 2001 Code.

To emphasize the complexity of protecting patient information,
the definitions
of privacy and confidentiality are separated and explained.
Privacy relates to those
aspects of a patient’s life and information that he or she can
control. It is that control
that the nurse is charged with helping to preserve. Honoring a
patient’s privacy can
be as simple as only asking questions that are clinically
relevant, but can also extend
to constructing policies that maintain privacy, such as hospital
environment policies.
Confidentiality is a term that refers to making sure that once a
patient has shared
personal information, such data is used only in ways that are

authorized by the patient.

To provide an example of respect for privacy, consider the
questions that arise
if Mrs. Cummings comes to the surgical clinic for a
preoperative breast surgery
visit. During the visit and exam, the nurse notes a large bruise
along her lower
rib cage and she shares with the nurse that her husband inflicted
it last night in
a fight about the surgery. She explains that he does not want her
to have prophy-
lactic breast surgery after she tested positive for the BRCA1
gene mutation, which
means she is at higher risk for breast cancer than the general
population. After the
nurse determines that the bruise has no physiological
implications for surgery and

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Guide to the Code of Ethics for Nurses 27

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

that Mrs. Cummings has arranged to go to her sister’s home for
immediate post-op
care, the nurse should agree when Mrs. Cummings’ requests that
no mention of the
fight be placed in her medical record. That is her right and if
she wishes to keep
the information private, she may. Withholding this information
from the medical
record does not require that the nurse simply ignore what has
happened. The nurse
is obligated to review the nursing and health literature on
domestic violence and to
follow up in so far as the patient will permit. Additional
assessment is called for. For

instance, the nurse should ascertain whether this is a single
episode or a habitual
situation, whether children are at risk in the home, and so forth.
This should not
simply be dropped: The nurse may offer Mrs. Cummings
additional options, such
as referral to counseling, and may engage in patient education
regarding domes-
tic violence should such education not be resisted. In some
states laws covering
domestic violence mandate healthcare professionals to report
even a suspicion of
domestic violence that is discovered in the process of
caregiving. These laws differ
from state to state, but nurses need to be aware of these laws.

Contrast this example with the issue of confidentiality that the
genetics nurse
confronted when Mrs. Cummings originally requested the
BRCA1 genetic test and
stated that she did not want the result to be placed in her
medical record, because
she feared that she might face future discrimination in work or
in obtaining life
or health insurance if the test were positive. While this might
appear again to
be a request for privacy, it becomes an issue of confidentiality
if the policy at the
Breast Cancer Genetics Clinic is that all test results must be in a
patient record,
even if the patient pays for them personally. Now the nurse
must discuss with Mrs.
Cummings how the information will be preserved and limits to
its protection, if
she chooses to be tested at this particular clinic. While the duty
to protect, here, is

still owed to the patient, this example shows that the nurse must
be very proactive
in being aware of how information will be preserved and
protected and in what
ways.4 Such a duty extends beyond the clinical encounter to
efforts such as par-
ticipating in establishing institutional policies or even state
laws that that protect
confidentiality. Thus, in this situation, the patient is protected
by being informed in
advance, and the nurse protects future patients by participating
in policy formula-
tion with regard to confidentiality of clinical information.

The interpretive statements on privacy and confidentiality are
necessarily broad
so that they can serve as useful guidance in a range of contexts
and situations. The
Code does not specify concrete and absolute rules about how to
protect patient infor-
mation in a “one rule fits all situations” approach. The
complexity of this issue has
recently been highlighted by the institution of the Health
Information Portability
Accountability Act and its Privacy Rule.5 Nurses, like all
healthcare providers, have

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28 Guide to the Code of Ethics for Nurses

PRovIsIon thREE John G. Twomey, PhD, PNP

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

had to attend in-service educational offerings about the
implications of the Rule
so that they can advise patients about who may access their
health information.
In the midst of the well-publicized efforts to implement the
Rule, it must not be

forgotten that medical information passes through many hands
and the nurse
is only one participant in the process of storing this data. Often
the nurse’s most
significant contribution is to be able to advise the patient as to
where their data
will be stored, who will have access to it, and with whom it will
be shared. This
facilitates better decision making by the patient. In the prior
example of Mrs.
Cummings and her concern about her genetic test results, the
nurse may be able
to advise her that the clinic policy is that no information is
released to employers
or insurance companies unless she signs a release form. This
policy would allow
those in the health team to have access to necessary patient
information while
providing a certain level of protection that the patient can
control.

Many policies exist to help patients to protect their health
information. These
policies may affect the ability of the nurse to carry out his or
her ethical duties.
Another factor that complicates this duty is that the duty to
maintain confiden-
tiality is not absolute. Specifically, in some instances when a
third party may suf-
fer harm if information discovered in the process of nursing
care is withheld from
the other involved individual, there may be a legal as well as a
moral duty to
protect the other person. It is incumbent upon the nurse to
clarify the duty to pro-
tect and to understand both its moral and legal dimensions.

There is a related category of exceptions to absolute
confidentiality. All states have
mandatory reporting laws that the nurse must honor if child
abuse or neglect is sus-
pected and many jurisdictions have extended such limits to
confidentiality to cases
where nurses become privy to threats to the health and safety of
elders.6 What if the
nurse is concerned about the safety of the patient’s health after
a clinical encounter?
Can the information that the diabetic patient does not want the
nurse to report to
the clinic physician that she has stopped testing her blood sugar
be withheld? In
general, nurses cannot withhold information that would
negatively impact patient
safety or directly affect the quality of care. Information clearly
related to the patient’s
care must be shared with the physician, but it is best if this
information comes from
the patient. In exploring the reasons why the patient has stopped
testing her blood
sugar, and why she does not wish this specific information
disclosed to the physi-
cian, the nurse must assess the patient, ascertaining why she has
stopped testing
her blood sugar levels. Perhaps she has stopped for a simple and
correctable reason
(such as the cost of supplies). The nurse should then discuss
with the patient the
physician’s need for this information and the serious
consequences of withholding it.
The patient should be urged and enabled by the nurse to share
this key information.

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Guide to the Code of Ethics for Nurses 29

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information

storage and retrieval system, without permission in writing from
the publisher.

Where clinical care is compromised, the nurse has a duty to
advise the patient not
to withhold this information, and to explain that the nurse has a
duty to maintain
the quality of patient care, including disclosing the information
as a last resort. In
addition to counseling the patient that disclosing the
information would be essential
to her safe clinical management, the nurse could consult the
immediate supervisor
or perhaps ultimately the institution’s bioethics committee if
assistance is needed in
resolving conflicts of this nature.

Other examples of limits on confidentiality include public
health laws that
mandate reporting of certain health conditions such as an
infectious disease, like
tuberculosis, within a community. On the other hand, there are
some special cases.
where specific medical information, such as HIV status, cannot
be shared without
specific state policies to the contrary,7 no matter how high you
judge the potential
threat to a third party.

Protection of Participants in Research:
Interpretive Statement 3.3
The 1976 Code for Nurses included guidelines for the nurse
working with partici-
pants in research in its seventh provision, which addressed the
role of the nurse
in promoting the scientific knowledge of the profession. The

relocation of this
concern to the third provision in the current Code reflects the
increased activity of
nurses as nurse-researchers, or as members of a research team,
and the increase in
research activity in all settings, including community hospitals
and agencies, not
just “research institutions.” Patients are more likely today than
ever before to be
faced with a decision whether or not to take part in research that
might be related
to their condition or care. Because of the complexity of options
that occur when
research is combined with care, inclusion of this interpretive
statement under this
provision focuses the primary role of the nurse in all research
activity on insuring
that subjects are aware of the potential risks and are protected
to the greatest extent
possible from those risks. Nurse researchers are also obligated
to reduce risk in their
studies to the lowest level possible.

This interpretive statement has two paragraphs. The first
focuses on duties that
any nurse who is in a relationship with a research participant
must carry out.
Focusing on the concept of informed consent as a significant
tool in facilitating the
ability of the research subject to make decisions, the nurse is
identified as a key par-
ticipant in the ongoing consent process. Note that consent is, in
fact, ongoing and
not a one-time activity. In effect, the nurse who has an ongoing
relationship with the
patient-as-research-subject is given the heavy responsibility of

assessing the person’s

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30 Guide to the Code of Ethics for Nurses

PRovIsIon thREE John G. Twomey, PhD, PNP

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or

any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

ability to understand the ongoing dynamic of the research
process. This contrasts
with the research team, which often spends little time with the
participant and
often do not make ongoing evaluations of the level of the
subject’s understanding.8

Consider the following scenario that many nurses encounter. An
elderly man is
admitted to your unit after a hip replacement procedure. During
his stay, you note
that every day at noon, a nurse comes to the unit and
administers an oral medica-
tion. You inquire about the medicine and the nurse explains that
the man is on a
double-blind, placebo-controlled research trial to study the
effect of norepinephrine
on depression in people from 65 to 90 years. You read the
protocol and note that
it employs a crossover methodology and because your patient is
ending his sixth
week on the study medication, in two days, he will be switched
to the other blinded
medication arm. That afternoon, as you do some post-operative
care with the man,
you mention the research study. He smiles and his wife notes,
“We’re so happy they
asked him to be in the study. He’s improved so much. We’re so
lucky that he got the
right medication.” You ask how they feel about the upcoming
switch to the other

medication and they look at you with surprise. The wife says,
“No, no. The study
was to find out what was the best for him and now we know.”

This patient and his wife are showing signs of a phenomenon
known as thera-
peutic misconception. This occurs when a research subject fails
to understand that
the goal of a research protocol is not to provide him with
individual benefit and
assumes that the job of the researcher is the same as the
caregiver—to give him
only those interventions that will improve his health.9 In this
situation, the fam-
ily clearly anticipates that the patient will be kept on the
medication that helped
him and do not understand the change of medication that may
not provide the
same effects and actually may result in a reversal of his
improvement. Nurses
have a role in protecting patients whether involved in research
or in clinical tri-
als, and to advocate that all provisions for informed consent be
observed. The
research nurse or the nurse member of a research team is in
relationship with
the patient-as-human-subject and the family and is expected to
assure that the
participant’s active and consistent interpretation of the goals of
the research or
clinical trial is clear.

If this were your patient, this part of Provision 3 imparts an
imperative to act
that provides several options. One is to discuss the protocol
with the family, but

that is probably only a beginning. Because the patient obviously
signed the consent
form without a full understanding of the protocol, the
researchers must be notified
and asked to meet with the patient and his wife to review the
details of the study.
If the nurse is unsatisfied that the explanation given to the
patient is complete and
understandable, she should express her concerns to the principal
investigator of

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Guide to the Code of Ethics for Nurses 31

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

the study. If the nurse’s concerns are not resolved,
the nurse should then contact
the facility’s human subject’s protection committee or
Institutional Review Board
(IRB) that originally approved the details of
the research, including the wording
of the consent form, and express her misgivings.

The second paragraph contains more information about
the research review and
protection process. Since 1976, nurses have become
much more involved in the con-
duct of nursing research, as the number of nursing
doctoral programs has increased
and the National Institute of Nursing Research has
opened at the National Institutes
of Health. From a regulatory perspective,
the Belmont Report of The National
Commission for the Protection of Human Subjects of
Biomedical and Behavioral
Research provided the theoretical basis for the
regulations published in 1983 that

govern human subjects research in the United
States.10 While most codes of ethics
for health professions mention the ethical conduct
of research, the more extended
detail of this provision makes the Code of Ethics
for Nurses unique in the attention
given to this topic.

The interpretive statement can be misinterpreted,
however. By continuing to
identify the object of research as a patient, it
may appear to have less relevance
for healthy subjects whom the nurse may
encounter. But even the short relation-
ships formed in the outpatient setting should not
inhibit the nurse from advising
subjects about their rights as human subjects.
With regard to children, parents do
not give consent (despite the label on the form)
since consent refers only to one’s
own agreement. Parents almost always must provide
permission for their children
to be research subjects, and the Code of
Federal Regulations (FCR) requires that
researchers “solicit the assent of children” who
are capable of assenting. Morally,
a child’s refusal of assent should be
considered binding. The FCR further states
that “if the IRB determines that the… intervention
or procedure involved in the
research holds out a prospect of direct benefit
that is important to the health or
well-being of the children and is available only in
the context of research, the
assent of the children is not a necessary
condition for proceeding with the research”

[italics added]. In addition, the FCR states that “if
the IRB determines that a research
protocol is designed for conditions or for a
subject population for which parental
or guardian permission is not a reasonable
requirement to protect the subjects ( for
example, neglected or abused children), it may
waive the consent requirements…
provided an appropriate mechanism for protecting
the children who will participate
as subjects in the research is substituted… “
[italics added]. From the perspective of
ethics, in any research setting, even young
children should be included in the research
enrollment process by educating them about their
participation to the level of their
developmental understanding and capacity.11

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32 Guide to the Code of Ethics for Nurses

PRovIsIon thREE John G. Twomey, PhD, PNP

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Standards and Review Mechanisms:
Interpretive Statement 3.4
This important interpretive statement could be placed under
several of the provi-
sions in the Code. Here the development and maintenance of
basic competencies for
nursing is discussed. In addition, there follows the description
of basic competencies
with an accounting of activities that more experienced nurses
should be engaged in.
Nurses in varied roles must participate in or facilitate the
involvement of others in
activities that contribute to superior patient care. While the
activities listed under
this interpretive statement certainly could be used to support

other provisions, such
as those later in the Code that focus more on the professional
status of nursing itself,
the Task Force decided to reinforce that these activities are not
just self-protecting
or self-promoting, but are patient-centered actions that
rightfully belong under the
provision that focuses on protection of patient rights and well-
being.

The first paragraph in this interpretive statement has a
seemingly straightforward
directive: All nurses, whether educators, administrators, or
clinicians share equal
responsibilities to ensure that the daily care provided to patients
comes from nurses
who have had to meet standards that the professional nursing
group has agreed
upon. Educators must make certain that their curricula contain
the theoretical
and clinical knowledge necessary for novices to enter the
profession as competent
beginning practitioners. Nursing administrators must also assess
and provide for
the ongoing educational needs of clinicians to move into the
increasingly complex
world of today’s healthcare institutions.

The background message in this paragraph is that no matter
what their specific
activity and responsibility, nurses practice nursing care and that
all nursing care
is patient-centered. The American Nurses Association, which
sponsors the Code
of Ethics, and its federal and state units, has a central theme
that it represents all

registered nurses. At a time when the needs of patients and
healthcare organiza-
tions has spawned the need for increasing subspecialization
within the profession,
there has been a growth of specialty groups that claim to speak
for their members,
even to the point of writing their own standards and codes of
ethics.12 One result of
this trend has been for the “bedside” nurses, providing
“generalist” care, to believe
that they are not well represented by an organization that is run
by highly educated
nurses who seem distant from any patient care. The Task Force
wanted to reiterate
that the Code is for all registered nurses, in all specialties, in all
roles, whether their
work affects patients directly or indirectly. So the nurse
educator who lectures on
health policy is practicing nursing as well as the nurse
supervisor who spends much
time maintaining proper staffing levels. All nurses participate in
weaving a tapestry

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Guide to the Code of Ethics for Nurses 33

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

of care that protects patients throughout their encounter with the
healthcare system
when in relationship with a nurse.

This philosophy of professional equality is carried forth in the
second paragraph of
the interpretive statement. While, again, designated nursing
leaders have responsibility
for maintaining access of their staff to the ongoing mechanisms
of care promotion and

review, it is both a right and responsibility of today’s highly
prepared nurse to partici-
pate in all institutional activities that affect patient care.
Indeed, patient care is being
carried out in the conference room when nurses, physicians, and
other care providers
meet to discuss and plan for new models of care delivery as
well as completing reviews
of current models. Nurses are expected to identify barriers to
optimal patient care,
nursing and otherwise, and step up and demand that such
obstructions be eliminated,
and work toward that end. Part of the ethical responsibility of
today’s highly educated
registered nurses is to be active leaders in health care, not
passive followers.

The final paragraph of this interpretive statement seems to have
anticipated
the recent Institute of Medicine report on patient morbidities
related to healthcare
system errors.13 This section anticipates that conscientious
nurses will at times rec-
ognize that patients have been exposed to harms because of
suboptimal practices
within the healthcare institution and that the nurse must be an
agent of change to
protect other patients suffering from similar, preventable errors.
Nurses have an
ethical obligation to identify the source of the error and take
steps to eliminate it,
specifically through established institutional pathways. A
specific proscription of
this interpretive statement is on keeping the knowledge of the
error or question-
able practice secret. The following vignette shows the difficult

issues that this part
of the statement identifies.

Case Example 1
You have been hired as a newly graduated inpatient nurse
practitioner. You feel that

your graduate program and its preceptors had provided you with
a modern, progres-

sive set of practice skills. As you get oriented, you are told that
people here work on

a team and may often be providing care to patients who are
shared with other provid-

ers. That is not a problem most of the time, but you note that
patients who have been

worked up and have their care plan written primarily by nurse
Virginia are not being

cared for by state-of-the-art protocols and sometimes are being
handled in ways that are

invalidated by the nursing research literature. You are not sure
what to do, for Virginia

is one of the senior nurses and, though a peer, is crotchety and
doesn’t communicate

well in team meetings. O

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34 Guide to the Code of Ethics for Nurses

PRovIsIon thREE John G. Twomey, PhD, PNP

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

In this vignette, there is reason to believe that patients are at
risk of injury either
directly or by failure to adhere to current standards of practice.
Harm has not yet
occurred, but you anticipate that it may. Does the new nurse
practitioner have a
duty to intervene? If so, how should the nurse practitioner’s
efforts be directed?

The new nurse practitioner clearly has an ethical obligation to
the patients on this
unit, even if they are not her direct responsibility. She has
graduated with a working
knowledge of state-of-the-art clinical practice and has
recognized that such practices
are being withheld from the patients on her unit. The issue is
what steps should she
take? Initially, concerns should be expressed to the nurse
directly and she should
be given the opportunity to discuss this and to change if needed.
The Code is not
a document to detail the specific steps to be taken, but the
interpretive statement
makes plain that processes should be in place from an
administrative standpoint
for the nurse to go to a supervisor, if she believes that Virginia
proves unreceptive
to suggestions about possible changes to her practice. If the
direct supervisor does
not facilitate any intervention, then nurses in higher levels of
leadership should be
approached. Intermediate steps could be to hold in-service
programs on current
practices for the entire staff, establish institutional standards of
practice, and peer
review, and hope that Virginia responds with some changes.

This paragraph of interpretive statement section 3.4 introduces
one of the
most important topics contained within the Code. The issue of
self-oversight by
the nursing profession is very complex, being interwoven
among all of the many
agencies responsible for evaluation of nursing practice. The
intricacies involved in
oversight of nurses are part of the ethical behaviors of a
profession and its mem-
bers. Interpretive statement section 3.4 begins to detail the ways
that nurses may
be involved in such oversight, noting that most errors are a
result of both human
behavior and environmental factors and that any remediation
efforts must address
both of these aspects. But is also makes it clear, as do the last
two sections of this
interpretive statement, that individual nurses are responsible for
seeing that such
remediation does take place.

Acting on Questionable Practices and Addressing
Impaired Practice: Interpretive Statements 3.5 and 3.6
Provision 3 is the longest of the nine provisions in the Code,
and fully half of the
provision is taken up with ethical guidelines for protecting the
patient through
taking steps to remediate poor practice. There are several
probable reasons for
such a commitment to patient advocacy on the part of nurses
and such a dedicated
statement to the public about these issues. These reasons
include the constant

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Guide to the Code of Ethics for Nurses 35

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information

storage and retrieval system, without permission in writing from
the publisher.

skilled presence of the nurse in the patient’s care, the close and
intimate nature of
the nurse–patient relationship, the ability of the nurse to
observe and assess the
patient’s strengths and vulnerabilities, and the complexity of
the healthcare sys-
tem that make it difficult for patients to navigate the system or
even to advocate
for themselves. Another reason is that, traditionally, the
provision of nursing has
been ill-controlled by the profession, so that nursing care is
delivered by many
people, some with minimal qualifications, but the public has
been unable to discern
such differences in who actually is or is not a registered nurse.
Another reason is
that despite licensure laws, the provision of nursing has often
been controlled by
employers, who can allow anyone to wear scrubs, carry a
stethoscope, and provide
care associated with a nurse without any identification beyond
wearing a tag with
a first name on it. This can and does confuse the image and
expectations of the
public about nursing care.

Finally, the nursing profession has been unable to elevate, or
even make consis-
tent, the educational requirements for nurses. The effect is that
nursing represents
the largest group of healthcare professionals, but the group is a
loosely organized
collection of people with multiple backgrounds and skills. It is

not surprising that
the profession has great difficulty implementing consistent
standards of care when
such care cannot be assumed to be within the capabilities of the
less well-educated
and prepared caregivers who provide nursing care.

Provision 4 addresses the ethical aspect of the delegation of
nursing care. This
provision, specifically these two sections, make firm,
unmistakable statements that
say that nurses will protect their patients from direct,
unprofessional care. This is
the professional organization adamantly taking responsibility,
through its individual
members, for stopping in its tracks any behaviors that threaten
patient safety

Interpretive Statements 3.5 and 3.6 contain much similar
language. Comparable
content involves identification of possibly dangerous behavior
by an individual
nurse, the realization that the behavior must be addressed, and
pathways to do so.
There is a hierarchy of actions that a nurse can take that begins
internally through
consultation with supervisors and moves up the administrative
chain. If no reso-
lution results from following internal processes and the
behavior continues, then
the nurse is encouraged to go outside the institution to other
agencies that govern
both patient care and professional nursing. The specific
agencies to be consulted
depend upon the nature of the state structure for oversight of
health care and

professional behavior. They would generally include the bureau
of professional
licensure, boards of quality assurance, or a board of health.
Your state nursing
association can also provide guidance and one should not
hesitate to approach
them, even if one is not a member. Finally, in some instances,
reporting is man-

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36 Guide to the Code of Ethics for Nurses

PRovIsIon thREE John G. Twomey, PhD, PNP

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

dated to state agencies, sometimes by the nurse directly and
sometimes through
a particular institutional unit. Here, the nurse needs to be
familiar with state and
county regulations and institutional procedures and policies.
Review the following
case and contrast it to Case Example 1.

Case Example 2
You are making a home visit to a patient who was discharged
after having a stroke and

falling. This fall caused a hip fracture and the patent still has
significant pain, but you

believe that he should be able to begin more ambulation in his
home. You review his

level of narcotic pain medication that has been charted as given
several times a day

by one of the visiting nurses. As you begin your assessment, the
patient complains of

excessive pain and wishes to stop the ambulation exercises you
are doing with him.

You determine that he is having significant pain and ask him if
he thinks that he needs

more medicine. He says,” I haven’t taken any medicine since
last week except Tylenol.

That’s all the nurse says I need.” By your assessment, the
patient is clear, aware, and not

forgetful. You then examine all his medications and find that
even though prescribed,

there are no narcotics, only Tylenol. O

What are your responsibilities to this patient and your
profession? There are sig-
nificant differences in the last two cases. The first case involves
subtle but real
differences in care performance, but such differences might
only be apparent to
members of the nursing profession. Also, unless Virginia’s
behavior hurts a patient
and results in a malpractice case, it will not draw the interest of
outside authori-
ties. The actions described in Case Example 2 are much
different. Not only has the
patient been injured, there is strong circumstantial evidence that
a serious crime
may have been committed in the theft of narcotics. There are
also reasonable indi-
cations that other patients may also be at risk from this
unnamed nurse because it
is possible, but not certain, that the nurse who may be stealing

the narcotics, may
also be using these narcotics and may be practicing while
impaired.

There is no leeway available to the nurse in this situation.
Interpretive Statements
3.5 and 3.6 are clear that in the first case, a nurse can approach
Virginia privately
to attempt to change her behavior. However, in the latter case,
the potentially
criminal nature of the actions of the nurse takes such discretion
away. An imme-
diate report must be made to the supervisors and the situation
pursued officially.
In the case of the theft of narcotics, a report must be made to
civil authorities and
possibly to the nursing or other boards (depending upon state
laws) through the

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Guide to the Code of Ethics for Nurses 37

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

appropriate institutional or agency procedures for reporting
outside the agency. In
addition, a police report may be in order. A tougher case, from
an ethical perspec-
tive, may be presented in a scenario such as in the following
case.

Case Example 3
You work closely with several people at your small clinic and
have started meeting

socially to have a few drinks. You notice one of your fellow
nurses, Brad, tends to drink

more than the rest of the group. He lives nearby, walks home,
and never seems abusive,

so you never mention it until one day you return from lunch and
you see Brad leaving a

bar. In the clinic, you return a patient record to Brad and you
smell liquor on his breath.

He takes the record, smiles, and says, “Thanks. I needed this
record. I’m seeing her in

ten minutes.” What concerns do you have as you return to your
desk? The quality of

Brad’s patient care has never been questioned and patients
always compliment him.

What professional obligations do you have and how should they
be carried out? O

Interpretive Statement 3.6 infers that if you clearly believe that
if Brad is impaired,
then you have an obligation to report his condition to a
superior. Of course, while
the primary goal in both Case Examples 2 and 3 is patient
protection, a secondary
goal is to provide the involved nurses with necessary services to
help overcome any
impairment affecting performance. The difference is in how
imminent any actions
must be. The former case obviously needs immediate action.
But how quickly, or
cautiously, must the nurse act in Brad’s case? Interpretive
statement 3.6 does not
provide a timeline, but notes that the profession, in addition to

many healthcare
and state professional organizations, is dedicated to providing
remedial services to
impaired professionals, not punishing them.

Any nurse who reads Interpretive Statements 3.5 and 3.6 will
probably pause
when it becomes apparent that the actions mandated within
these sections could be
very difficult to carry out. Part of most individual’s
professional identity is a sense
of loyalty to one’s fellow workers. Indeed, the moral principle
of fidelity is a very
important moral concept. But when fellow professionals act in
ways that endanger
patients as well as themselves or others, then obligations to the
patient, the nursing
profession, and the employing institution, supersede loyalty to a
peer.

The Task Force recognized that the psychological pressure to
protect a co-
worker is not the only force that sometimes weakens the
willingness of a nurse
to confront behaviors that present immediate risk of harm to
patients. Another
powerful coercive factor is the fear of retaliation for “blowing
the whistle” on those

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38 Guide to the Code of Ethics for Nurses

PRovIsIon thREE John G. Twomey, PhD, PNP

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

acting dangerously. It is not uncommon for a nurse to fear
retaliation if she were
to report that the actions of an established senior worker or even
a superior who is

incapacitated while at work or who practices unsafely.14
Interpretive statement 3.6
places responsibility for those nurses in leadership positions
within institutions and
state licensure agencies to ensure that policies are in place to
protect nurses who
take the courageous step of reporting illegal, incompetent, or
impaired practice.

In summary, Provision 3 of the Code of Ethics for Nurses
continues the legacy
of nurses having a moral basis for the traditional role of
protecting patients’ rights
and interests, including the patients’ physical safety. This
provision grounds these
ethical duties within the principle of respecting patient
autonomy in conjunction
with the nurse having a personal moral agency that guides
nursing actions in ways
that transcend institutional rules. This moral agency is
embedded in the historical
roles of nursing and is patient centered. The profession of
nursing draws its moral
force from the ethical actions of its individual members.

Endnotes
All online sources cited were accessed in December 2007.

1. Daly, B.J. 1999. Ethics: Why a new code? Code for
Nurses. American Journal
of Nursing 99(6): 64, 66.

2. Hamilton, D. 1994. Constructing the mind of nursing.
Nursing History
Review II: 3–28.

3. Beauchamp, T.L., and J.F. Childress. 2001. Principles of
Biomedical Ethics,
5th ed. NY: Oxford University Press.

4. ISONG (International Society for Nurses in Genetics).
2007. Privacy and
confidentiality of genetic information: The role of the nurse.
http://www.
isong.org/about/ps_privacy.cfm.

5. Artnak, K.E., and M. Benson. 2005. Evaluating HIPAA
compliance: A guide
for researchers, privacy boards, and IRBs. Nursing Outlook
53(2; Mar–Apr):
79–87 (31 ref ).

6. Wieland, D. 2000. Abuse of older persons: An overview.
Holistic Nursing
Practice 14 (4; July): 40–50 (43 ref ).

7. Herek, G.M., J.P. Capitanio, and K.F. Widaman. 2003.
Stigma, social risk,
and health policy: Public attitudes toward HIV surveillance
policies and the
social construction of illness. Health Psychology, 22(5; Sept):
533–40 (38 ref ).

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John G. Twomey, PhD, PNP PRovIsIon thREE

Guide to the Code of Ethics for Nurses 39

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

8. Veatch, R. 1987. The Patient As Partner: A
Theory of Human-Experimentation
Ethics. Bloomington, IN: Indiana University Press.

9. Appelbaum, P.S., C.W. Lidz, T. Grisso. 2004.
Therapeutic misconception

in clinical research: Frequency and risk factors.
IRB: A Review of Human
Subjects Research 26(2; Mar–Apr): 1–8.

10. Cassell, E.J. 2000. The principles of the
Belmont Report revisited: How
have respect for persons, beneficence, and justice
been applied to clinical
medicine? Hastings Center Report 30(4; Jul–Aug):
12–21 (3 ref ).

11. Code of Federal Regulations, Title 45: Public
Welfare, Part 46: Protection of
Human Subjects, Rev. 23 June, 2005, Subpart D,
Sections 46.401–409.

12. Broome, M.E., E. Kodish, G. Geller, L.A.
Siminoff. 2003. Children in
research: New perspectives and practices for informed
consent. IRB: Ethics
and Human Research 25(5; Sept–Oct): Sup. S20–
25.

13. Anonymous. 2004. Keeping patients safe:
Institute of Medicine looks at
transforming nurses’ work environment. Quality Letter
for Healthcare
Leaders 6(1): 9–11.

14. Ahern, K., S. McDonald. 2002. The beliefs
of nurses who were involved in a
whistleblowing event. Journal of Advanced Nursing
38(3; May): 303–309.

About the Author
John G. Twomey, PhD, PNP, is an Associate Professor at the

Graduate Program in
Nursing at the MGH Institute of Health Professions in Boston,
Massachusetts. Dr.
Twomey’s doctoral work was in bioethics. He teaches bioethics
and research and
serves on several human subjects research protection
committees. He has completed
two National Institute of Nursing Research-supported
postdoctoral fellowships in
genetics. A member of the International Society of Nurses in
Genetics, he does
research in the area of the ethics of genetic testing of children.
He is the editor of
the Ethics Column in the Society’s quarterly newsletter.Co

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© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,

including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

41

The nurse is responsible and accountable for individual

nursing practice and determines the appropriate delegation

of tasks consistent with the nurse’s obligation to provide

optimum patient care.

Provision
Four

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42 Guide to the Code of Ethics for Nurses

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Provision Four
Laurie A. Badzek, JD, LLM, MS, RN, NAP

Provision History
The framework for the inclusion of accountability and
responsibility in the nursing
ethical code is based upon many of the observations made by
Florence Nightingale
in the late 1800s. Nightingale dedicated her life to the
advancement of the patient’s
physical, emotional, and environmental well-being.
Nightingale’s advances were
the direct result of actions that improved quality care and the
provision of edu-
cation to those caring for persons of ill health. As detailed in
Notes on Nursing,
Nightingale recognized the importance of the choices made by a
nurse in the daily

care of patients and the accountability of the nurse for the
outcomes of such care
provided based on those choices.

The observations and documentations that Florence Nightingale
made over a
century ago recognized accountability as an essential
characteristic of the nurse, and
has enabled nursing to evolve into a strong, trusted profession,
even in the face of
current realities that complicate accountability and
responsibility. Both the foresight
and ingenuity Nightingale demonstrated resulted in an
acknowledgement of the
importance of accountability in providing high-quality care. The
ethical account-
ability that nurses have today for the decisions and judgments
they make can be
directly traced to the writings of Nightingale.

In addition to a historical context dating back to Nightingale’s
time, account-
ability and responsibility for nursing care have a more recent
context in the current
laws related to licensure, contracts, and malpractice.
Increasingly frequent lawsuits
against healthcare providers that result in high monetary awards
to injured plaintiffs
make the application of nursing skill and judgment, including
delegation of tasks,
even more challenging. Nurses who lack competency or who fail
to provide appro-
priate professional nursing care may be subject to legal liability
as determined by
the courts as well as licensure actions determined by the State
Board of Nursing,

which may potentially impact the ability of the nurse to
practice. Nursing practices
that reflect incompetence or other such failures of care does not
meet the moral
standards of the profession as embodied, in part, by this Code of
Ethics.

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Guide to the Code of Ethics for Nurses 43

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Laurie A. Badzek, JD, LLM, MS, RN, NAP PRovIsIon FouR

Content of Provision 4
Provision 4 of the Code of Ethics for Nurses addresses the
individual responsi-
bilities and obligations of the nurse. Although much of nursing
is collective and
involves relationships with others, the inclusion of
responsibility and account-
ability in the Code of Ethics for Nurses informs the nurse that
responsibility for
the individual actions and judgments made minute by minute,
hour by hour, and
daily over a lifetime of practice belongs solely to the individual
nurse making the
decisions. The Code of Ethics for Nurses helps define the
relevant ethical obli-
gations and duties nurses have not only to the public, but to
themselves as well.
Expanded knowledge of responsibility and accountability in
nursing helps not
only the profession, but also the general public to better
understand the level to
which nurses as professionals hold themselves and one another
accountable and
responsible for nursing practice.

Accountability is often identified as an attribute of a profession.

The acceptance
of accountability by the members of the profession is an implied
contract with the
public (Burkhart and Nathaniel, 2002). The Code of Ethics for
Nurses sets forth
explicitly the values and obligations of the nurse. The Code of
Ethics for Nurses
also provides a clear statement of what the public can expect
from the nurse and
the nursing community in relation to their professional practice.

Public confidence is a necessity for any profession and is
especially important
in health care where the services provided are of a personal and
sensitive nature.
Accountability of nurses for patient care outcomes enables them
to hold an
autonomous position in the healthcare industry. Nursing has
time and again
been selected as the most trusted profession in several national
polls, including
the Gallup Poll (2006), thus demonstrating that nursing as a
profession is held
in extremely high confidence by the public at large.

An ethical dilemma occurs when two or more moral obligations
or values conflict
or compete and the appropriate choice in the situation is
unclear. Exercising moral
accountablity means the nurse will make a reasoned judgment
about what is right
and will act accordingly. An individual nurse’s determination of
what is right may
or may not be the same decision that others, including those to
whom the nurse
is accountable, believe is the right decision. Moral

accountability does not mean
congruence with others, but rather that nurses will be able
adequately to defend
and justify their decisions on moral grounds.

Ethical accountability requires decision making on the part of
the nurse. Application
of an ethical framework or decision-making process to issues of
moral concern is help-

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44 Guide to the Code of Ethics for Nurses

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

PRovIsIon FouR Laurie A. Badzek, JD, LLM, MS, RN, NAP

ful to the analysis of an ethical question. Application of a
reflective ethical framework
to questions about what the nurse should do results not only in
decisions that the
nurse feels are right or good, but also in actions that can be
justified by the nurse.
Preferably, ethical analysis by the nurse should not require an
emergency situation,
but rather thoughtful applications of an ethical framework or
decision making pro-
cess with reflection on values and principles as a means to
resolving conflict should
be part of a nurse’s daily routine. Obviously, in the clinical
setting, time is often a
luxury; therefore, prior familiarity with ethical theory and a
framework for ethical
decision makingis essential. For example, making ethical
determinations at the time
a when treatment is ordered “stat” or staffing decisions must be
made are examples
of decisions that do not afford the luxury of lengthy
deliberation.

Interpretive Statements
The purpose of the interpretive statements related to Provision 4
of the Code
of Ethics for Nurses is to develop more fully the meaning of
accountability and
responsibility in nursing practice in order to provide consistent,
universal applica-
tion of the provision’s intent. The interpretive statements
provide nurses with a
social context for application of the provisions in practice and
help to define them
within the expanded roles of the nursing profession.

Practical Application of Interpretive Statements

Acceptance of Accountability and Responsibility
Accountability is both related to answerability and
responsibility. Accountability is
judgment and action on the part of the nurse for which the nurse
is answerable to
self and others for those judgments and actions. Responsibility
refers to the specific
accountability or liability associated with the performance of
duties of a particular
nursing role and may, at times be shared in the sense that a
portion of responsibil-
ity may be seen as belonging to another who was involved in the
situation. Nursing
practice is individualized and the responsibilities of the nurse
are role dependent.
The individual role of the nurse carries with it specific duties
and obligations. To
meet the role obligations of the nursing profession, the nurse
must be familiar
with the scope and standards of the profession as well as those
of the specific role

carried out by the nurse. Regardless of nursing role, the nurse
must adhere to the
scope and standards of practice when performing or assigning
the duties within
that role in order to ensure safe, high-quality patient care.
Depending on the role of

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Guide to the Code of Ethics for Nurses 45

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Laurie A. Badzek, JD, LLM, MS, RN, NAP PRovIsIon FouR

the nurse, the standards are layered and become more
complicated as the expertise,
complexity, and expectations of that role increases.

Nurses are expected to be able to justify actions based upon
nursing skill and
knowledge and the application of the nursing process, critical
thinking, and nurs-
ing knowledge to the care they provide. For example, at a
novice or entry level, a
professional nurse would have: an understanding of the current
scope and stan-
dards of practice, the Code of Ethics, and Nursing’s Social
Policy Statement; the
basic knowledge and skills needed to demonstrate competency
in the practice of
nursing and a working knowledge of the laws and policies that
govern nursing
practice. Thus, a newly licensed nurse would not be expected to
be able to make
a decision about whether the healthcare organization in which
they worked had
acted appropriately or had instead put nurses and patients at risk
when a man-
agement decision was made to pull a nurse from direct care for
other nonpatient

care-related duties. Conversely, nurses who choose to develop
expertise or to
specialize would add to the basic level of their understanding
advanced knowledge
and skill defined by the nursing literature and specific specialty
standards and
guidelines that extend beyond the level defined for generic
entry into the nursing
profession. Thus, a nurse manager or senior level nursing
administrator would be
expected to be able to evaluate whether the removal of a nurse
from staffing was
a right or wrong decision.

Instilling professional nursing accountability into direct or
indirect patient care
helps to ensure accurate, safe, high quality service. The nurse is
held accountable for
making adjustments to practice based upon changing systems of
care. Technology,
medicine, and health care are constantly changing, and so must
the nurse’s knowl-
edge and practice change with the environment. When practice
changes occur the
nurse may need to seek education and consultation prior to
accepting responsi-
bilities. Ultimately, nurses carry out their duties or assign
activities to others using
nursing knowledge and judgment to assess, evaluate, and
determine the appropriate
course of action. Even where tasks are assigned to others, the
nurse who delegates
or assigns these retains accountability and responsibility for
those them; this is to
say, that tasks and activities can be delegated or assigned, but
duties cannot.

Accountability for nursing Judgment and Action
Accountability for nursing judgment and action means that
nurses act under a code
of ethical conduct that is grounded in moral principles of
fidelity (faithfulness) and
respect for dignity, worth, and self-determination of patients.
Interpretive state-

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46 Guide to the Code of Ethics for Nurses

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

PRovIsIon FouR Laurie A. Badzek, JD, LLM, MS, RN, NAP

ment 4.2 makes clear that accountability and responsibility for
nursing practice
are an extension of the first three provisions of the Code of
Ethics for Nurses which
relate to the fundamental values and commitments of the nurse.
At every point of
practice, from novice to expert practitioner, the nurse is
expected to bear respon-
sibility for the care provided and the practice activities (both
direct and indirect)
irrespective of the particular role the nurse is fulfilling. The
moral standard of the
profession is one to which nurses must hold themselves and
their peers in order to
be held accountable in for their practice.

In order to avoid moral conflict or distress, the nurse must
uphold personal
values and belief systems, regardless of the organizational
policies and procedures.
If a nurse becomes aware of a conflict between a personal belief
and an organi-
zational policy, the nurse must rely on nursing values and
practice standards to

strive for a higher level of accountability (Hook and White,
2003). Some decisions
related to making choices in nursing practice where there are
conflicts between
nurses and the organization may result in consequences to the
nurses including
but not limited to reprimand and dismissal. Individual
accountability and respon-
sibility for practice may require nurses to choose what they
believe is the right and
just path even though that choice may not be what the
organization or employer
desires from them.

Consider situations where nurses finds themseves at odds with
the policies of
the healthcare organization. A nurse working in a newborn
nursery discovers that
the mother of a newborn infant admits to using cocaine
frequently prior to the
child’s birth. The nurse believes it is in the best interest of the
baby to test the baby
for cocaine. The healthcare organization’s policy is that no
laboratory tests can be
performed on a newborn without the express order of the
attending physician. The
nurse contacts the attending physician who refuses to order the
blood test because
in his words he “doesn’t want to waste his time dealing with the
bureaucracy.”
The nurse is concerned for the baby’s welfare and knows that
the baby will likely
be discharged with the mother later in the day with no follow-up
care. The nurse
also knows that the State Department of Child Welfare will not
attend to the situ-

ation unless the infant has a positive drug screen on record. The
nurse’s supervisor
believes the situation to be a matter of judgment and that it is
within the physician’s
prerogative to refuse to order the test. The supervisor suggests
that the nurse give
up any attempts to convince the physician.

The nurse may find that an effort to protect and advocate for the
newborn may
carry the risk of being considered insubordinate. Does the
accountability for nurs-
ing judgment and action change in this case when the nurse is a
student reading

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Guide to the Code of Ethics for Nurses 47

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Laurie A. Badzek, JD, LLM, MS, RN, NAP PRovIsIon FouR

the chart in preparation for a clinical assignment, when the
nurse is experienced, or
when the nurse is the supervisor in this case? Consider further
the consequences of
moral action if the physician reports the nurse for the unlawful
practice of medicine
because of informing the child’s grandparent that a specific
request should be made
for a drug screen prior to the infant’s discharge in order to
ascertain what care and
treatment the child will be needed. Contrast the nurse’s risks
against the risk to the
child’s health assuming the newborn has a sufficient blood level
that would indicate
symptoms of withdrawal. Does the risk change if the infant
begins to suffer with-
drawal from the narcotic without care or proper treatment? In
this situation and

others, the nurse may find it necessary to act on behalf of the
patient even though
the consequences might put them at personal risk. Consultation
by the nurse with
the institution’s ethics committee may be an appropriate course
of action if sufficient
time and committee resources are available to assist in
deliberation on this dilemma.

Responsibility for nursing Judgment and Action
Universal recognition of the significance of individual
accountability or liability
for the duties inherent in the nursing role validates nursing as a
profession. With
the recognition of nursing as a profession comes the additional
responsibility for
nurses individually to self-assess for competence. Attached to
assessment is the
responsibility to seek consultation and continuing education
where the nurse finds
a lack of knowledge on any pertinent subject. Being responsible
for nursing judg-
ments and actions implies that the nurse is answerable for
nursing action associated
with the duties of a particular role. Being answerable
individually for one’s nurs-
ing knowledge and actions increases the respect and autonomy
sought by nurses
both from the public and within the arena of healthcare
professionals. Embodied
in public respect is the need for nurses to be competent in their
care. Competence
implies continued self-assessment of nursing abilities and the
quest to update skills,
including those of a technical nature. Self-assessment is the
continued review of

competence related to nursing judgments, including decisions to
delegate nursing
activities or tasks (Curtis, 2004).

Liability occurs when the nurse breaches a duty or obligation
associated with
the performance of a particular nursing role. Legal liability can
take several forms.
The legal action can be administrative as in a licensure
proceeding; civil as in
a malpractice action; criminal if the conduct of the nurse is
defined in criminal
law; or employment related. Legal liability stems from
violations of the law and
breaches of legal duty, and not necessarily from moral or ethical
obligations.

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48 Guide to the Code of Ethics for Nurses

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

PRovIsIon FouR Laurie A. Badzek, JD, LLM, MS, RN, NAP

Often, the law and ethics overlap, especially in areas of health
care such as dying,
privacy and confidentiality, and human rights. Ideally, the legal
system would
follow ethical thinking and consensus. Unfortunately, what is
ethical may not be
either covered in law or inadequately covered in law. In fact,
some laws may actually
be unethical. The law is useful as a consideration of fact and
precedent for ethical
decision making; however, laws do not direct or control nursing
ethics or mor-
als. The Code of Ethics for Nurses is a statement of moral
obligations and duties
intended to guide the practice of nursing; it is not a legal
document.

The following example illustrates competence: A junior nursing
instructor, Ida,
with two years of teaching experience is responsible for
overseeing a group of stu-
dents during their clinical rotation. Previously, Ida had nine
clinical students in a
clinical group. One of Ida’s prior students made a serious
medication error when she
ignored and violated a school policy that required approval of
the instructor prior to
the administration of medication. The school and the hospital
are still investigating
the incident and the student has been suspended pending further
investigation and
action by the admission and progression committee.

Ida is vaguely aware of a state board of nursing ruling limiting
clinical groups to
10 students, but believes she must be mistaken since her chair
has assigned her 12
students. Although, intimidated by her chairperson, Ida makes a
weak request for
support for teaching such a large group. When chastised by the
chair, the instruc-
tor withdrawals her request for faculty support. The 12 new
students are placed
on an adult medicine unit for their clinical. Students in prior
groups rated the unit
as an excellent unit for student learning. Ida, anxious about her
potential liability,
makes a conscious decision that the students will have
inadequate experience to
perform assessments and assist the patients with activities of
daily living. Ida does
not believe the students can be adequately supervised; therefore,

she determines
most clinical experiences will only be observational. Other
clinical experiences
indicated in the syllabus include administering medications,
charting, and nurs-
ing treatment procedures. The students pass the clinical rotation
with excellent
grades and enter their second year of nursing school unprepared
to move into the
junior-level objectives having had only observational clinical
experiences without
actual supervised practice.

Has Ida, the nursing instructor, neglected her responsibility in
providing appro-
priate clinical experience and skills to the students? The nursing
instructor has failed
to assess self-competence and seek appropriate resources for
herself. In addition,
the instructor has failed to properly utilize the learning
resources. The actions of
a prior student to disregard academic policy would not impact
the accountability

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© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Laurie A. Badzek, JD, LLM, MS, RN, NAP PRovIsIon FouR

of the instructor’s nursing judgment and accountability since
the student’s act was
self-chosen and against a school policy that was communicated
in class and in the
syllabus. The student willfully violated the policy in an
inappropriate exercise of
autonomy. A nursing student who freely and deliberately
chooses with full knowl-
edge to act in a manner that directly violates school policy

would be individually
accountable and responsible for the consequences of those
actions.

In the scenario, the school administrator should be held
accountable for failing
to meet the responsibility of the administrator role. The
administrator is respon-
sible to hire and support qualified instructors. Newly hired
faculty should be
given appropriate support, mentoring, and resources to carry out
clinical teaching
requirements. The administrator must provide support for the
instructor or, in the
alternative, relieve the instructor of clinical instruction duties if
the instructor is not
clinically competent to carry out those duties necessary to help
the class achieve
completion of the mandatory skills set forth in the curriculum.
If the administra-
tor is acting in a manner prohibited by law in assigning a ratio
of 1:12 rather than
the legally mandated 1:10 or less, then obviously that
administrator is acting in an
irresponsible matter that could lead to legal liability related to
role performance,
and is in violation of the expectations of the code for
administrative accountability
and responsibility.

Delegation of nursing Activities
Nurses must accept accountability for patient care even when
they direct or

delegate activities and tasks to others. The ANA defines
delegation as “transferring

the responsibility for the performance of an activity from one
person to another
while retaining accountability for the outcome” (ANA, 1995).
Delegation generally
involves the assignment of activities or tasks related to patient
care to less skilled
healthcare workers. The registered nurse cannot delegate
responsibilities related to
making nursing judgments except to another qualified registered
nurse. Examples of
nursing activities that cannot be delegated to less skilled
healthcare workers include
but are not limited to assessment and evaluation of the impact
of interventions on
care provided to the patient.

Delegation can significantly impact the quality of care since
many healthcare
facilities require a team approach to nursing and do not support
a nurse working
independently as the sole provider of care. This is to say that
social and institu-
tional factors may make the moral dimensions of accountability
and responsibility
in delegation particularly challenging. Delegation of nursing
activities require the

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50 Guide to the Code of Ethics for Nurses

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

PRovIsIon FouR Laurie A. Badzek, JD, LLM, MS, RN, NAP

nurse to consider not only the tasks at hand, but also the ability
and competence of
those to whom the tasks are assigned. Effective delegation can
increase productivity
because it allows staff of varying skill levels to succeed in
doing a few smaller tasks

well rather than multiple tasks poorly (Quallich, 2005).
Assignment or delegation
does not mean the nurse is giving up accountability or
responsibility. The nurse is
still accountable for any decision to delegate activities and
remains responsible for
supervising or monitoring those to whom tasks were delegated.
Accountability exists
not only in what the nurse can or cannot delegate, but also in
knowing what tasks
or activities other less skilled healthcare workers on the team
are capable of doing.
Employer policies or directives that state what activities a
person is competent to
do within a job classification are not sufficient to relieve the
nurse of responsibility
for making independent judgments about delegation and
assignment of nursing
tasks. The complexity of delegating nursing tasks has prompted
the development
of many models of delegation that appear in both the literature
and state nursing
regulations across the country.

Nurses who function as managers or administrators have a
particular responsibil-
ity to facilitate appropriate assignments and delegation. This is
sometimes compli-
cated by difficult institutional policies around staffing, and can
be compounded by a
nursing shortage. The role of the manager or charge nurse, past
and present, takes
on one of the highest levels of delegation in the nursing
profession. Nightingale in
Notes on Nursing (1869) states that being in charge is not just
about doing nurs-

ing tasks by oneself or appointing tasks to others, but also
includes ensuring that
others complete the duties to which they were appointed.

The difficulty of making determinations related to delegation
can be demon-
strated in the following example. Nancy, a registered
professional nurse, has a
six-patient assignment on a busy inpatient medical/surgical unit
on the day shift.
Nancy’s unit is short a clinical associate; however, Nancy is
fortunate to be assigned
a clinical associate from the outpatient neurology unit. About
halfway through the
shift, Nancy discharges one patient from the unit. Shortly after
the discharge, she
is notified by the admission clerk that a new patient will be
admitted to the empty
bed. While Nancy is doing her assessment on the newly
admitted patient, she is
notified by the clinical associate of a greater than one degree
Celsius elevation in
temperature of a patient receiving a blood transfusion.

The patient receiving the transfusion is a middle-aged male
surgical patient
receiving his second unit of blood due to a postoperative
hemoglobin of 7.0mg/
dl following a total hip replacement. The first unit of blood was
tolerated without
incident. The new admission is an elderly female with a
complicated past medi-

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Guide to the Code of Ethics for Nurses 51

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Laurie A. Badzek, JD, LLM, MS, RN, NAP PRovIsIon FouR

cal history with an elbow fracture as the result of a fall. The
patient was admitted
through the emergency room following an ambulance transport.
The new admission
is complaining of pain “all over” and is requiring an extended
period of Nancy’s time
in order to complete the assessment and admission process.
Nancy asks the clinical
associate to recheck the male patient and make a determination
whether or not the
charge nurse should be given the information regarding the
patient receiving the
transfusion and the elevated temperature.

Upon completing the admission process and administering pain
medication to
the new admission, Nancy returns to the nurse’s station to
record a report for the
oncoming afternoon shift. After Nancy finishes her report, she
is informed that
the family of the newly admitted patient has arrived and is
requesting to speak with
the patient’s nurse about the plan of care. Nancy returns to the
new patient’s room
to speak with the family and fails to follow up on the febrile
patient.

This situation raises questions about appropriate delegation of
care. Has the
nurse appropriately transferred responsibility and accountability
for the febrile
patient to another person? Can the nurse expect the clinical
associate to make
a determination regarding the patient and the necessity of
informing the charge
nurse so that perhaps some action could be taken related to the

care of the patient
receiving the blood transfusion? Obviously, the nurse would be
responsible for the
judgment she made to continue with her assessment of the new
admission versus
taking an action that would provide the patient who has
demonstrated the poten-
tial for a blood reaction with appropriate nursing care. The
attempt to delegate
the responsibility to a clinical associate is unacceptable since
only a task and not
a judgment can be delegated to a less skilled healthcare worker.
Perhaps the sce-
nario will be resolved as the nurse intended and the charge
nurse would assume
responsibility for the assessment and care of the febrile patient.
However, Nancy
did not act to assure that this would happen if the rise in
temperature did not, in
fact, signal a transfusion reaction. Consider the consequences if
the scenario does
not go as the Nancy intended and the febrile patient is not
provided care until the
nurse completes her discussion with the newly admitted
patient’s family. What if
the condition of the febrile patient worsens? What if the
reaction to the blood is
severe resulting in shock and even death? The need to attend to
a potential trans-
fusion reaction greatly outweighs a need to finish an assessment
and admission.
What options could or should Nancy have considered with
regard to the patient
receiving the transfusion or the patient being admitted?

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52 Guide to the Code of Ethics for Nurses

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

PRovIsIon FouR Laurie A. Badzek, JD, LLM, MS, RN, NAP

Case Example
the Manager with Insufficient staff
Susan, a nurse manager for a busy adult trauma unit, is facing
staffing shortages for

the upcoming schedule. Susan cannot cover all three shifts with
a complement of two

nurses. Susan knows that if she does not have two nurses per
shift that the RN on duty

would not be able to leave the unit and that the nurse may not
get a break from nursing

responsibilities over the course of the 8-hour shift. No new
applications for employment

have been received by the manager by the time the schedule is
due to be posted. Susan

is aware that even with new hires, there will be a delay in
fulfilling the staffing needs

due to the orientation process that all new hires are required to
attend. The unit previ-

ously functioned using an established staffing pattern based on
the acuity of the patients.

Susan has voiced concerns to the Vice President of Nursing and
Allied Services over

the lack of staff, but is given no immediate solutions and told to
deal with it. Seeing no

alternative to the impending crisis, the manager institutes a
change in staffing patterns

without notifying the staff. The patient to staff ratio will be
significantly increased and,

at night, the RN will be the sole nurse on the unit without relief.
Nurses will rotate the

night shift. Following two serious incidents on the night shift, a
staff nurse anonymously

reports Susan’s actions as unsafe practice to the State Board of
Nursing. As a result of

the impending investigation by the Board, Susan talks to the
hospital licensing facility

and the local newspaper about the staffing situation at the
hospital. Consequently, the

hospital receives bad press and is contacted by the hospital
licensing authority. As a

result, Susan is fired. O

What options were available to Susan when she was told to
“deal with it” in being
short-staffed? Who is accountable and responsible for the rise in
incidents on the
night shift? Was it appropriate for the staff nurse to report
Susan to the Board?
Was it appropriate for Susan to talk to the hospital licensing
organization and the
local newspaper? Was Susan’s firing appropriate?

Summary
The commitment to the nursing profession starts with a strong
and clear under-
standing of the ethical code of conduct, including responsibility
and accountability
for individual nursing practice. If nurses are not held
accountable for their actions,
nursing can not be considered a profession. The nurse’s
obligation to provide opti-
mal patient care is often challenged by limited resources and a
strained healthcare
system. The Code of Ethics for Nurses demands that nurses
practice in a responsible

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Guide to the Code of Ethics for Nurses 53

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Laurie A. Badzek, JD, LLM, MS, RN, NAP PRovIsIon FouR

and ethical manner. As recognized first by Florence Nightingale
and today by our
society, the prestige of the profession of nursing depends on a
universal commit-
ment to accountability and responsibility. As depicted in the
case study examples,
accountability issues may arise at any level or role within the
nursing profession.
The nurse must always be aware of the potential outcome in any
given situation and
be willing to take responsibility for individual actions and
knowledge. Regardless
of the role held within the nursing profession, accountability for
all aspects of indi-
vidual nursing practice leads to the successful completion of the
nurse’s obligation
to provide optimum patient care (ANA, 2001).

References

All online references were accessed in December 2007.

American Nurses Association. 2001. Code of Ethics for Nurses
with Interpretive
Statements. Washington, DC: American Nurses Publishing.

American Nurses Association. 1995. Position statements:
Registered nurse
utilization of unlicensed assistive personnel. Washington, DC:
ANA. http://
www.nursingworld.org/ readroom/position/uap/uapuse.htm.

Burkhart, M.A., and A.K. Nathaniel. 2002. Ethics and Issues in
Contemporary
Nursing, 2nd ed. Albany, NY: Delmar.

Curtis, E., and H. Nicholl. 2004. Delegation: A key function of
nursing. Nursing
Management 11(4): 26–31.

Gallup Poll (December 14, 2006). Nurses top list of most honest
and ethical
professions.
http://www.galluppoll.com/content/?ci=25888&pg=1.

Hook, K.G., and G.B. White. 2003. Code of Ethics for Nurses
with Interpretive
Statements: An independent study module. Washington, DC:
ANA. http://
www.nursingworld.org/ mods/mod580/cecdefull.htm.

Nightingale, F. 1869. Notes on Nursing: What It Is, And What It
Is Not. New
York: Dover Publications.

Quallich, S.A. 2005. A bond of trust: Delegation. Urologic
Nursing 25(2): 120–23.

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54 Guide to the Code of Ethics for Nurses

© 2008 American Nurses Association. All rights reserved. No

part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

PRovIsIon FouR Laurie A. Badzek, JD, LLM, MS, RN, NAP

About the Author
Laurie A. Badzek, JD, LLM, MS, RN, NAP, is currently
Director of the American
Nurses Association Center of Ethics and Human Rights, a role
in which she
previously served from 1998–99. During that time, Badzek was
instrumen-
tal in developing a plan that ultimately resulted in the approval
of a new Code
of Ethics for Nurses by the 2001 House of Delegates. Currently
a tenured, full
professor at the West Virginia University School of Nursing,
Badzek, a nurse
attorney, teaches nursing, ethics, law, and health policy. Having
practiced in
a variety of nursing and law positions, she is an active
researcher, investigat-
ing ethical and legal healthcare issues. Her current research
interests include
patient and family decision making, nutraceutical use, mature
minors, genom-
ics, and professional healthcare ethics. Her research has been
published in
nursing, medical, and communication studies journals, including
Journal of Nursing
Law, Nephrology Nursing Journal, Annals of Internal Medicine,
Journal of Palliative
Care, and Health Communication.

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any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

55

The nurse owes the same duties to self as to others,

including the responsibility to preserve integrity and safety,

to maintain competence, and to continue personal and

professional growth.

Provision
Five

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56 Guide to the Code of Ethics for Nurses

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Provision Five
Marsha D.M. Fowler, PhD, MDiv, MS, RN, FAAN

The Suggested Code of 1926 states that “the most precious
possession of this
profession is the ideal of service, extending even to the
sacrifice of life itself.”1 This
somewhat overwrought statement does correctly identify the
central moral motif
of the profession: the ideal of service. And yet, it also presents
us with one of the
central tensions of the profession, that of serving over against
extending one’s self
too far or of risking harm to self. Need service extend even to
the sacrifice of life
itself ? On the absolutely practical side, this would be a serious
hindrance for nurse
recruiters! Setting aside extraordinary circumstances under
which nurses might
chose to risk their lives, nurses do have a duty to tend to their
own well-being, not
to place themselves in harm’s way, or, as the provision asserts,

nurses have duties to
self that ought to be observed.2 The principle of duties to self
(sometimes called “the
principle of self-regarding duties”) can be divided into four
main features: a duty of
moral self-respect, a duty of professional growth and
maintenance of competence,
a duty of maintaining wholeness of character, and a duty of the
preservation of
one’s integrity. These are collectively understood as a single
duty of “duties to self.”

Duties to Self
The first and only substantive work on the obligation of duties
to self in the nurs-
ing literature is Andrew Jameton’s essay “Duties to self:
Professional Nursing in the
Critical Care Unit.”3 Jameton notes that some philosophers,
such as John Stuart
Mill, have denied “that it is meaningful to talk of duties to
self,” but that others,
including Aquinas, Kant, and Hume, “assert the meaningfulness
of speaking of
duties to oneself.”4 The arguments against a notion of duties to
self center on our
inability to enforce such duties, specifically, that it is not
meaningful to speak of
self-coercion and, secondly, that we cannot release ourselves
from such duties.
Arguments for a notion of duties to self emphasize that while I
cannot force myself
to meet such a duty, even so, I am answerable for not meeting
them and that duties
to self are an instrumental good, that is, a good that serves to
support my duties to
others. Note that duties to self differ from self-centeredness or

entitlement in that

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Guide to the Code of Ethics for Nurses 57

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information

storage and retrieval system, without permission in writing from
the publisher.

Marsha D.M. Fowler, PhD, MDiv, MS, RN, FAAN PRovIsIon
FIvE

they specifically support my moral duties to others. The
strongest argument for a
notion of duties to self resides in the concept of universal
obligations. If an obliga-
tion applies to everyone, then I am not exempt from the
collective “everyone,” and
those duties apply to myself as well. Immanuel Kant’s second
formulation of the
categorical imperative (his rule for moral rule-making) makes
clear the inclusion
of one’s self in the universal: “Act so that you treat humanity,
whether in your own
person or in that of another, always as an end and never as a
means” [italics added].5

The nursing ethics literature from the 1800s to the present has
affirmed an obli-
gation of duties to self. One of the earliest such references is
found in Trained Nurse
and Hospital Review, July 1889. The article by “H.C.C.” (an
otherwise unidentified
superintendent of a training school in Boston), is entitled
“Ethics in nursing: A
nurse’s duties to herself: Talks of a superintendent with her
graduating class.”6 The
focus of the article is on rest and bodily care as essential to the
health of the nurse
for the sake of the ability to meet her duties to patients. (In that
period, nurses were
exclusively female.) Particular concern is directed toward the

dedicated, energetic
nurse who may overextend and risk personal health in the
course of care-giving.
H.C.C. writes: “Please remember I am only speaking to the
good nurses—the enthu-
siastic one—poor nurses, lazy nurses, have no temptation to
overwork themselves.
They may die of indigestion but they will not die of
exhaustion.”7 Many of the early
nursing ethics books echoed an emphasis upon duties to self.
Isabel Robb’s oft
reprinted Nursing Ethics: For Hospital and Private Use (1900)
places considerable
emphasis on a range of duties to self.8

This emphasis on self-regarding duties has for decades remained
prominent in
nursing ethics literature, including the earliest codes. The
Tentative Code of 1940,
one of the early unadopted codes for nursing, includes a section
on the nurse’s
responsibilities to herself. It states: “A nurse is to keep herself
physically, mentally,
and morally fit, and to provide for spiritual, intellectual, and
professional growth.
She should institute savings plans which will bring her financial
security in her old
age.”9 While the emphasis on duties to self persists in the
nursing literature, espe-
cially in textbooks, it departs from the later codes. The
incorporation of a provision
on self-regarding duties in the present code is indeed a
“reappearance” rather than
something “new.”

Interpretive Statement 5.1: Moral Self-Respect

This section introduces this duty and grounds it in the self-
inclusiveness of universal
duties: what I owe to others as moral duties, I likewise owe to
myself as a moral duty.
Without so stating, this would mean that all of the provisions
that apply to patients

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58 Guide to the Code of Ethics for Nurses

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

PRovIsIon FIvE Marsha D.M. Fowler, PhD, MDiv, MS, RN,
FAAN

would also apply to oneself. For instance, Provision 1 states
that “the nurse, in all
professional relationships practices with compassion and
respect for the inherent
dignity, worth, and uniqueness of every individual.”10 Self-
respect, then, becomes
one of the many duties owed oneself.

The focus of the interpretive statement is on explaining the
several distin-
guishably different areas of concern. Jameton has identified
three such aspects
of duties to self: integrity, self-regarding duties, and identity.
Identity refers to
the coherent integration of one’s personal and professional
identity—what I am
morally as a person, I am morally as a nurse. According to
Jameton, identity
includes concerns for maintaining ideals, the meaningfulness of
work, expression
of one’s opinion, concern for wrongs committed by others, and
participation in
moral judgment in the work setting. Self-regarding duties refers
to “duties [that]
have a content that affects or applies to oneself primarily,” here

competence is of
specific concern. Integrity includes wholeness of character,
attention to one’s own
welfare or self-care, and emotional integrity reliant upon
maintaining relational
boundaries.11 The current provision is indebted to Jameton for
his pioneering
work, and incorporates his three aspects in three somewhat
different divisions:
professional growth and maintenance of competence, wholeness
of character, and
preservation of integrity.

Interpretive Statement 5.2: Professional Growth
and Maintenance of Competence

Previous codes, such as the Suggested Code of 1926 and the
Tentative Code of
1940, have included a responsibility for ongoing professional
growth. The Suggested
Code states:

Professional growth and development are promoted by
membership in pro-
fessional organizations, both state and local, by attendance at
meetings and
conventions and by constant reading on professional subjects.
Yet further
growth may be assured by attendance on institutes and
postgraduate courses.12

Though the context is that of professional growth as a duty to
self, it does not
so much discuss professional growth as it does how one might
go about growing
professionally.

The Tentative Code of 1940 is not quite so specific; it declares
a “requirement of
continuous study and growth” and a duty for the nurse “to
provide for spiritual, intel-
lectual and professional growth,” as noted above.13 In several
codes, such as that of
1950, the nurse is responsible for “continued reading, study,
observation, and inves-

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Guide to the Code of Ethics for Nurses 59

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Marsha D.M. Fowler, PhD, MDiv, MS, RN, FAAN PRovIsIon
FIvE

tigation,” not strictly as a duty to self, but rather as a duty to
the profession in order
that the social/professional status of nursing, and the status of
the individual nurse as
a professional, may be maintained.14 Notice, however, that it
moves beyond continued
study and reading for self-development, or even to better serve
the patient; instead,
it casts the duty in terms of maintaining the stature of nursing
as a profession, as
well as the social prestige of nursing. Nursing has, of course,
struggled for years for
the social recognition accorded professions. The Tentative Code
even opens with the
assertion “Nursing is a profession,” and then goes on to defend
that assertion with a
sizable amount of material that is not actually appropriate to a
code of ethics.15 Here,
the concern is for the profession and its professionalism, not for
the nurse, so it could
be argued that, in this particular statement formulation, it may
not be a duty to self.

The emphasis upon professional growth as a duty to self shifted
over the years
in two ways. First, it shifted from a duty to self to a duty to the
profession for the
sake of the profession. Second, it shifted in the direction of an
increasing concern
for competence, not only for the sake of the profession, but also
for that of the
patient as well. Though they have been used as if
interchangeable, “professional
growth” and “competence” are not the same. Competence is the
rock bottom level
of acceptable practice, the level below which no practitioner
should fall. Professional
growth moves the nurse beyond mere competence, as a
minimum standard of prac-
tice, toward excellence and is thus directed toward an ideal of
practice. The Code
of 1985 merges professional growth and competence and their
ends, stating that:

For the client’s optimum well-being and for the nurses’ own
professional
development, the care of the client reflects and incorporates
new techniques
and knowledge in health care as these develop, especially as
they relate to
the nurse’s particular field of practice. The nurse must be aware
of the need
for continued professional learning and must assume personal
responsibility
for currency of knowledge and skills.16

Though the Codes have presented professional growth as
necessary to compe-

tence for the sake of the profession’s stature and for the welfare
of the recipient
of nursing care, Jameton argues that competence is instead a
self-regarding duty,
primarily directed toward oneself. He writes:

Competence is...primarily...an attribute of self to be cultivated,
and second-
arily as a means of affecting patients…. Nursing, as a practice,
provides a set
of “internal” goods that are satisfying in themselves. Internal
goods are the
intrinsic excellences of good nursing practice, as distinguished
from external
rewards such as salary, the gratitude of patients, and so forth.
The existence

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60 Guide to the Code of Ethics for Nurses

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

PRovIsIon FIvE Marsha D.M. Fowler, PhD, MDiv, MS, RN,
FAAN

of intrinsic conceptions or excellence makes it possible for
nurses to regard
development of competence as a matter of self-development
rather than sim-
ply a matter of achieving external rewards through affecting
others.17

Without denying that competence affects others, this new Code
of Ethics more
clearly and vigorously casts competence as a self-regarding
duty, essential to self-respect
and self-esteem, professional status, and the meaningfulness of
work. It ties profes-
sional growth to a commitment to life-long learning reminiscent
of the early nursing

ethics literature. Professional growth is not limited to the
knowledge and skill neces-
sary for patient care, but also includes “issues, concerns,
controversies, and ethics.”18

The emphasis upon competence, per se, was given even more
emphasis in the
1960 Code for Professional Nurses and succeeding codes.
Provision 8 of that 1960
Code states: “The nurse maintains professional competence and
demonstrates con-
cern for the competence of other members of the nursing
profession.”19 Over the
next several decades, competence as articulated in the Codes
takes four emphases:
the professional competence of the nurse; the competent nurse
forced by circum-
stances (e.g., staff reductions) to practice less competently; the
duty to act upon
observed incompetence of nurses, physicians, or others; and the
duty to delegate
tasks only in accord with the competence of others. Only the
first and second of
these refers to a self-regarding duty of competence. As a self-
regarding duty, the
Code of 2001 calls for ongoing and authentic self-evaluation
and peer review as a
means of evaluating one’s performance.

Interpretive Statement 5.3: Wholeness of Character
Can a person who is a rogue, scoundrel, liar, and cheat in
personal life be a virtuous
nurse in professional life? It is unlikely. What we are
personally, we are profession-
ally. Our personal and professional identities are neither
separate, nor coextensive;

they are integrated and deeply commingled, mutually
influencing each other. The
person who has become “a nurse,” as opposed to the person who
“does nursing,” is
one who has incorporated and integrated the values of the
profession with personal
values. The Suggested Code of 1926 notes that “the nurse who
fails to find happi-
ness in her work is not truly a nurse.”20 Persons who do not
find happiness in their
work have always been of special concern to nursing educators.
It is unfortunate that
some nursing students are misplaced in nursing, finding little
congruence with the
values of the profession, and having insufficient personal
insight to see the conflict
between their personal identity and their budding professional
identity. Indeed, some
students never fully become nurses; in fact, some are alienated
toward nursing, and

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Marsha D.M. Fowler, PhD, MDiv, MS, RN, FAAN PRovIsIon
FIvE

yet they can develop the knowledge and skill to complete a
nursing education with
considerable success and to pass the Board exams with flying
colors.

Case Example 1
Consider the quandary of Prof. Svetlana Scythe. Senior student
Allison Baxter has enrolled

in Prof. Scythe’s Nursing Issues and Trends class and
Community Health clinical lab. Allison

has a GPA of 3.8, is technically proficient in clinical practice,
has reasonable communica-

tion and interpersonal skills in patient care, is able to prioritize
and manage a patient load,

and is generally quite capable in nursing theory and practice.
But, she hates nursing. She

had wanted to be a paramedic with the fire department, but
could not get in because of

the exceptionally competitive applications and the very long
waiting list. In the end, her

father pushed her into nursing school. For all her ability, she
does not identify with nurs-

ing, nor does she want to and, indeed, in discussions in the
Issues and Trends class, as

well as in the Community Health course, has an “attitude”
toward nursing and speaks ill

of the profession among her friends.

Prof. Scythe, as well as other faculty members over the years
have tried to counsel Ms.

Baxter as to whether she should consider leaving the school, but
she will not consider

leaving, in part because of parental pressure, in part because she
did not want to “start

all over” in school, and because it would shortly afford her an
acceptable income. In its

student handbook, the school affirms the ANA Code of Ethics
as one of their standards

of practice. In many ways, the Code enjoins nurses to work for
the welfare and advance

of the profession. The faculty are very concerned about
graduating this student, but can

they refuse to graduate a student who has an excellent academic
record, but who has

an anti-nursing attitude and does not embrace the values of
nursing, based on a generic

school affirmation of the Code? Unfortunately no. O

Laws only demand that they be obeyed, and not that one be a
good person besides.
Ethics, of course, demand that we be good persons, beyond the
expectations of
“requirements.” The Code of 1985 states:

Nursing is responsible and accountable for admitting to the
profession only
those individuals who have demonstrated the knowledge, skills,
and com-
mitment considered essential for nursing practice. Nurse
educators have a
major responsibility for ensuring that these competencies and a
demonstrated
commitment to professional practice have been achieved before
entry of an

individual into the practice of professional nursing.21

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62 Guide to the Code of Ethics for Nurses

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information

storage and retrieval system, without permission in writing from
the publisher.

PRovIsIon FIvE Marsha D.M. Fowler, PhD, MDiv, MS, RN,
FAAN

Course and program requirements of schools function like the
law: you must
meet them but they cannot demand that you be a “good nurse”
in the sense of
affirming nursing and embracing a nursing identity. However,
where a student
clearly fails to identify with nursing, vigorous and consistent
attempts should be
made from the earliest point onward to counsel the student to
leave the program
with the hope of moving them earlier into another more suitable
discipline, with
less time lost. In addition, faculty can decline to give letters of
recommendation if
there is no evidence of change. In situations such as this, it is
more than likely that
the graduate will not find work meaningful, and in fact may
come to hate it, and
may leave the profession. She or he may also stay in this “bad
marriage,” but that
is a matter of choice.

Not everyone is suited to nursing; admissions criteria and
screening should be
sufficiently rigorous as to ascertain a student’s “fit” with
nursing, and postadmis-
sion follow-ups and advising must be vigilant to redirect
students when necessary.
A more intentional and hearty emphasis on embracing the
values and ethics of the

profession, including the Code, from the earliest courses on
would strengthen the
curriculum and might serve as a deterrent to those who in the
end will not “become
nurses” in the moral sense. There is also an important place for
courses on nurs-
ing history in this endeavor. While the case presents a moral
quandary for nursing
educators, as the 1985 Code makes evident, it is implied in the
language of the
Code of 2001 that Allison’s failure to come to a congruence
between personal and
professional identity indicates an unfortunate failure in duties to
self and forecasts
an unhappy professional future for her.

As an additional example, a similar situation sometimes can
occur in nursing in
some of the accelerated generic master’s degree programs that
take in persons with
baccalaureates in non-nursing disciplines. Consider the case of
Bob, an aerospace
engineer with a Master’s degree who was laid off in the last
defense-contract cycle of
lay-offs. He saw a colleague apply to nursing school, asked
about entry level salaries,
and decided that nursing would be a quick and easy fix to his
situation. He entered
an accelerated generic program. He easily mastered the essential
and technical skills,
did exceptionally well academically, and moved very rapidly
through the program.
However, he did not become socialized into the value structure
of the profession.
The program, though accelerated, did attend to professional
socialization and the

values of the program, but Bob did not. He retained the value
structure of his prior
discipline, rocket science, and consistently remarked that
“nursing is not rocket sci-
ence.” His relationship with patients was one of superiority and
“hard facts,” lacking
warmth and compassion. In these days of “outsourcing,” not all
persons come into
nursing with altruistic or pristine motives, nor do they need to.
However, in nursing

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Marsha D.M. Fowler, PhD, MDiv, MS, RN, FAAN PRovIsIon
FIvE

education, it is crucial that attention be given to “formation.”
Nursing values must be
cultivated and inculcated in these adult learners, and integrated
into their personal
value structure so that they assume a proper nursing identity, if
they themselves, the
patient, and the profession, are to be well served.

We bring our whole selves to nursing, not just our professional
identity. That
means that we bring our personal and our professional moral
values in one package
to the issues, concerns, and dilemmas that confront us in
practice. The new Code
states that “duties to self involve an authentic expression of
one’s own moral point-
of-view in practice.”22 Sometimes, this moral point of view is
more professional than
personal, and, other times, more personal than professional in
derivation.

Case Example 2
Consider Father Mac James, a patient on dialysis following
nephrectomy for renal car-

cinoma. Because of congenital cysts in his other kidney it was
expected that he would

have to remain on dialysis for life. At one point he became
clinically depressed and

was successfully treated with electroconvulsive therapy when
medications failed to be

effective. At the time, he felt that he wanted to “give up,” but
also felt an obligation as a

retired priest to accept treatment. For two years, despite
suffering from postdepression,

he continued with dialysis. One day, when the CNS visiting
nurse, Abby Davids, saw him,

he told her that he wanted to stop dialysis on July 23, following
his 40th anniversary as

a priest. He said that his quality of life was unacceptable, would
not improve, and that he

had lived long enough. He said he had “a sense of peace” about
his decision. His family

was deeply distressed and tried to coerce him into change his
mind. After all, “he isn’t

that old,” they said. The physicians started antidepressant
medication, but to no effect;

he did not change his mind. In the clinical care conference, all
parties were agreed that

they wanted Father Mac to continue his dialysis, except Abby.
She has had several dis-

cussions with him and believes that his was a reasoned,
reflective position, consistent

with his beliefs and values, even if he could live a number of
years longer on dialysis.

However, at the patient care conference, she felt the full weight
of the consensus against

her. Should she speak up?

Yes. This does not mean that her view will prevail. This does
not mean that they

are guaranteed to listen. Even when persons of moral good will
come together to

discuss life and death issues, there may be disagreement. One
does not have a duty

to self to express personal values so that others might be
persuaded differently. The

duty to self is to express one’s professional moral point of view,
to preserve one’s

authenticity; in other words, to be true to one’s self. In addition,
doing so maintains

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64 Guide to the Code of Ethics for Nurses

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

PRovIsIon FIvE Marsha D.M. Fowler, PhD, MDiv, MS, RN,
FAAN

open moral dialogue, which is not achieved if different views
are suppressed. In

some cases, this moral expression may be the only explicitly
nursing moral voice,

a voice that might not be heard if the nurse fails to speak up.
Sometimes, however,

the moral point of view being expressed arises from the nurse’s
personal values in

a professional context. O

Case Example 3
Consider Michael Tucker, a hospice nurse and a lifelong
Evangelical Christian in a largely

Jewish facility. For Michael, issues of faith are as much matters
of life and death as can-

cer is. In the hospice setting, Michael has ample opportunity to
present his faith to his

patients and he is ready to do so, but wonders what is or is not
morally appropriate.

Stan Grossman is his patient. He was reared without religious
influences, but identifies

himself as Jewish. He is acutely anxious as he sees his life
drawing to a close and is

reaching out for “answers.” Another patient, Miriam Swartz,
also Jewish, who likewise

seeks answers, but does not feel “panicked” as Stan does, asks
Michael about his faith

and if it “works” for him. Sophie Adleman knows that her faith
is of support to her as

she is dying and wants Michael to pray with her and to call the
Bikur Cholim because

“the Rabbis teach us that visiting a sick person removes 1/60th
of his or her illness”

and she figures that she needs “only 48 more visitors to be
healed.” Michael needs to

know if he can speak of his faith to Stan or Marv. Also, is it a
violation of his own values

to call the Bikur Cholim for Sophie and to pray with her?

Morally, may Michael speak of his own Christian faith with
Stan? Probably not. Given

Stan’s anxious state of mind, it is quite possible that Michael’s
expression of his own faith

would be coercive to him. If Michael judges that Stan is looking
for spiritual answers,

he should start with the answers closest to Stan’s own
background. If after adequate

exploration, it does not suffice, he can enlarge the discussion if
Stan so requests. Michael

ought to consider the nature and depth of the conversation and
secure a professional

chaplain for Stan if warranted and welcome. Vulnerable patients
may not be evange-

lized. Doing so is not an expression of a duty to self to be who
one is, rather it is taking

unfair advantage of a wounded individual; many religions take a
dim view of this. May

Michael permissibly respond to Miriam with an expression of
his personal faith? Probably

yes. Miriam has asked a personal question of Michael and looks
for a personal answer.

Michael is free authentically to express who he is, even in
matters of religious faith—or

politics—if asked. Miriam has asked a question inviting a
religious response and expla-

nation. Michael may give this freely, yet only in a way that
preserves Miriam’s freedom.

We bring our whole selves to patient care. Michael is a nurse,
but he is also a Christian

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Marsha D.M. Fowler, PhD, MDiv, MS, RN, FAAN PRovIsIon
FIvE

nurse, and that is who he must be for the patient who inquires of
him, and that is who

he must be for himself. In some instances, being a member of
one religion or another

need not be made explicit to be consistent with one’s self
identity. Many times, the

religion can be transparent to the patient, yet it remains the
grounding motive for the

care of others. What about Sophie? Does Michael jeopardize his
faith commitment or

values by supporting Sophie’s explicitly Jewish religious needs?
Can he pray with her

and remain authentic? Michael has two kinds of religious
commitments: those of his own

faith and spirituality, and those of his faith that would extend
the faith to others. Sophie

is not interested in his faith; she is interested in her own. Given
this, Michael does not

jeopardize or deny his own Christian identity in supporting
Sophie in her religion, even

in praying with her. His duty to self in preserving his own
wholeness of character is not

affected by doing so. Since Sophie is not interested in having
Michael extend his faith

to her, he may not do so. However, he may be a person of faith
with another person of

faith, bringing their separate faiths together for Sophie’s good.
In doing this, Michael does

not deny his religious value of extending his faith, rather he
affirms that the extension of

his faith is for those who choose to receive it. Like information
in informed consent, it is

to be “offered,” not imposed. In not offering it where it is not
welcome, Michael does not

violate any duty to self. Indeed, by refraining from offering
faith where it is not welcome,

Michael affirms the freedom that must exist in faith. Michael
can call the Bikur Cholim,

he can pray with Sophie, and he can refrain from evangelism
and remain authentically

who he is. Early codes made explicit the demand that nurses
respect the religious and

other beliefs of the patient. Later codes broadened to include a
respect for a large range

of personal attributes including religious and cultural values. O

While this case focuses on religion as an aspect of “wholeness
of character” of the
nurse, religion is but one example. Some nurses are not

religious; what if the nurse
in this case was an atheist? Any strong, enduring commitment
that forms a part
of who the nurse is as a person plays a role in wholeness.
Whether it be politics,
vegetarianism/veganism, ecofeminism, pacifism, atheism,
agnosticism, or any other
strongly held commitment, all are a part of who the nurse is
authentically and may
be shared, or must be withheld from sharing, on the same sorts
of grounds as that
of religion: “nurses are generally free to express an informed
personal opinion as
long as this preserves the voluntariness of the patient and
maintains appropriate
professional and moral boundaries.”23 The role of the nurse is
to assist patients in
reflecting on their own values, not those of the nurse.

Patients request other kinds of personal information from nurses
as well.
Increasingly, patients demonstrate well-developed internet
skills in sleuthing health
problems and illness treatments. Greater or lesser degrees of
discernment of the

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

PRovIsIon FIvE Marsha D.M. Fowler, PhD, MDiv, MS, RN,
FAAN

quality of the information make their way to the nurse in the
context of health and
illness counseling and patient education. Nurses will be asked
about alternative or
adjunctive therapies, the orange pill, herbals, therapeutic teas,
and a virtually endless

range of treatments. So, just what do you think about the orange
pill? Is the nurse
free to offer an opinion?

Nurses have professional “relationships” with patients. If this is
not the case,
then the patient could just as well ask the question of a
computer. But patients do
not want a computer, they want a living, breathing human nurse.
Nurses are gener-
ally free to express their informed personal opinion in the face
of patient inquiries
on matters related to health and illness. In professional
relationships, however,
the boundaries are professional and must be maintained as such.
Patient freedom
must also be maintained and expressions of personal
professional opinion must
preserve the patient’s voluntariness. Duties to self demand that
nurses be who they
authentically are and, in turn, that patients are permitted to be,
and supported in,
who they authentically are.

Interpretive Statement 5.4: Preservation of Integrity
Integrity is an internal quality, differing from honesty, which is
interpersonal
in nature. Thus, integrity is, primarily, a self-concern and a
self-regarding duty.
Preservation of integrity as a duty to self requires a lived
conformity with the
values that one holds dear, both personal and professional.
Professional nursing
values, while individually held, are shared among nurses, so
that a duty to self that
is jeopardized in the work setting for one nurse may by

circumstances apply to all
nurses in that setting.

For much of the history of modern nursing, staffing patterns for
“general duty”
nursing have posed problems for nurses. In a report on the
nursing supply in 1928,
Burgess wrote the following:

General floor duty is often the last resort of the desperate
private duty nurse.
There are reasons for this. In all too many hospitals the
superintendent of
nurses is expected to get along with an inadequate number of
assistants. The
result is that the nurses on floor duty are working under
tremendous pres-
sure, and as the number of patients swells above normal it is
inevitable that
much of the nursing service on the ward will be inadequate and
improperly
given. Good nurses refuse to work that way… the fact is that
general duty
[i.e., hospital nursing] is not considered respectable. It is
despised not only
by the nurses themselves but by the hospital authorities. Some
hospitals

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
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storage and retrieval system, without permission in writing from
the publisher.

Marsha D.M. Fowler, PhD, MDiv, MS, RN, FAAN PRovIsIon
FIvE

actually pay the servants and maids and orderlies on their wards
as much as
they pay graduate nurses.24

Too many patients, inadequate number of assistants,
overworked nurses, too
much pressure—a description from the 1920s that sounds
remarkably contemporary!

The Code of 1985 makes clear the responsibility of nurses and
the nursing pro-
fession to participate (individually and collectively) in
establishing “conditions of
employment that (a) enable the nurse to practice in accordance
with the standards
of nursing practice and (b) provide a care environment that
meets the standards
of nursing service.”25 The concern in Provisions 9 and 10 of
the 1985 Code are for
the preservation of the integrity of nursing. The Code of 2001
furthers these con-
cerns by applying them to the preservation of the integrity of
nurses, especially
those placed in an economically constrained environment that
pressure nurses to
practice in ways that violate their professional integrity. Like
the Tentative Code,
this new code overtly recognizes the moral threats posed by
economic constraints
in the practice setting, an observation that is lacking in the 1985
Code, as well as
earlier versions.

The Code of 2001 also introduces two concepts that are
relatively new: that
of integrity-preserving compromise and “conscientious
objection.” In raising the
notion of integrity-preserving compromise, the new Code
recognizes the competing
values that confront nurses, and acknowledging that their values

might not prevail.
However, nurses need not bow to all other values. Nursing
values are to be preserved
and nurses are expected to negotiate compromises that will in
fact preserve them.
This requires, of course, a “community of moral discourse,”
where nurses speak up
and one profession’s values do not trump those of others.

The second recent concept is not actually new, but rather
involves the intro-
duction of new terminology. “Conscientious objection” is most
frequently applied
to the refusal on moral or religious grounds to bear arms or to
go to war. Prior to
the American Revolution, conscientious objectors in this
country often came from
“pacifist” churches such as the Quakers, Mennonites, and
Brethren. As a conse-
quence, these churches have a long tradition of scholarly
literature on conscientious
objection. When not applied to war or to bearing arms,
conscientious objection
refers to the moral or religiously based refusal to participate in
an activity otherwise
required, perhaps even by the law. Thus, in nursing,
conscientious objection would
be the refusal to participate in some aspect of patient care on
moral or religious
grounds. This refusal might be based on a moral or religious
objection to a spe-
cific intervention categorically (e.g., abortion), or moral
objection to a particular

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

PRovIsIon FIvE Marsha D.M. Fowler, PhD, MDiv, MS, RN,

FAAN

intervention with a specific patient (as in requiring Father
James above to continue
dialysis), or a moral objection to a pattern of behavior (e.g.,
habitual short staff-
ing that forces substandard nursing practice that endangers
patient well-being).

Conscientious objection, whether expressed individually or
collectively, always
involves the refusal to violate a deeply held moral value,
personal or professional.
Previous codes have always provided a “moral way out” for
nurses who were con-
fronted with any one of the three examples noted above.
Previous Code specified
that, where there is a categorical objection to a particular
intervention (e.g., abor-
tion), such objection should be made at the time of employment
and that, in no
case, should the nurse abandon the patient. This new Code
enlarges the discussion,
gives it a conceptual framework in conscientious objection, and
rightly expresses
it as an aspect of duties to self. It also notes that conscientious
objection does not
insulate a nurse against consequences for having refused to
participate in an aspect
of nursing practice or patient care.

The benefit of clearly identifying a doctrine of conscientious
objection is that it
gives nurses a way to conceptualize and articulate a “refusal to
care,” more accu-
rately a “refusal to participate” in a specific aspect of patient

care. In the days
before advance directives, when patients were, in hospital
parlance, “full code”
because a do-not-resuscitate order was not written when it
should have been
(e.g., no statistical chance of success, or the patient did not
want it), nurses might
badger the physician to write one, only to encounter foot-
dragging. When the
patient went into cardiac arrest, some nurses felt the only way
out of the dilemma
was to engage in a “slow code.” Conscientious objection
provides a way out of this
bind by affording the nurse an opportunity to make a strenuous
objection known
on moral grounds, and then to make it stick. In other words,
conscientious objec-
tion permits nurses to preserve their integrity in the face of a
clinical activity or
situation to which they have moral objections to participation.

Conclusion
Nursing has historically maintained that the nurse owes the
same duties to self as to
others. In this provision, the new Code reintroduces a concern
for duties to self that
have always been of historical importance, but had receded from
our gaze. However,
unlike early discussions of duties to self that focused on the
physical health of the
nurse, continued education, and savings for old age, this more
contemporary aspect
of the Code directly extends the discussion into areas of
wholeness of character,
identity, and integrity not seen in the earlier literature. It
recasts competence as a

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Guide to the Code of Ethics for Nurses 69

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from

the publisher.

Marsha D.M. Fowler, PhD, MDiv, MS, RN, FAAN PRovIsIon
FIvE

self-regarding duty and not simply as an instrumental good in
service to others.
Indeed, this provision focuses on the full range of duties to self
as nurse-focused,
rather than profession- or patient-focused. At first glance, this
provision might
seem an innovation. Not so. It is something old, something
renewed, something
borrowed from history, and something true.

Endnotes

1 American Nurses Association. 1926. A suggested code.
American Journal of
Nursing 26(8): 599–601. (For a fuller discussion of the
obligation or option to
care in the face of risk to the nurse, consult the reference in the
next endnote.)

2. American Nurses Association. 2006. Risk and
Responsibility in Providing
Nursing Care. Silver Spring, MD: ANA.

3. Jameton, Andrew. 1985. Duties to self: Professional
nursing in the critical
care unit. In Ethics at the Bedside, Marsha Fowler and June
Levine-Ariff, eds.,
pp. 115–135. Philadelphia: JB Lippincott.

4. Ibid, pp. 117–18.

5. Kant, Immanuel. 1998. Groundwork of the Metaphysics of
Morals, Mary J.
Gregor, ed. Cambridge, England: Cambridge University Press.

6. H.C.C. 1889. Ethics in nursing: A nurse’s duty to herself:
Talks of a superintendent
with her graduating class. Trained Nurse and Hospital Review
3(1: July): 1–5.

7. Ibid. Not paginated.

8. Robb, Isabel Adams Hampton. 1900. Nursing Ethics: For
Hospital and
Private Use. New York: E.C. Koeckert.

9. American Nurses Association. 1940. A Tentative Code.
American Journal of
Nursing 40(9): 980.

10. American Nurses Association. 2001. Code of Ethics for
Nurses with
Interpretive Statements, pp. 18–20. Washington, DC: ANA.

11. Jameton. Duties to self, pp. 120–32.

12. American Nurses Association. 1926. A Suggested Code, p.
600.

13. American Nurses Association. 1940. A Tentative Code, pp.
977, 980.

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70 Guide to the Code of Ethics for Nurses

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

PRovIsIon FIvE Marsha D.M. Fowler, PhD, MDiv, MS, RN,
FAAN

14. American Nurses Association. 1950. The Code for

Professional Nurses. New
York: ANA.

15. American Nurses Association. 1940. A Tentative Code, pp.
977–78.

16. American Nurses Association. 1985. Code for Nurses with
Interpretive
Statements, p. 9. Kansas City, MO: ANA.

17. Jameton, Duties to self, p. 124.

18. American Nurses Association. 2001. Code of Ethics for
Nurses, p. 18.

19. Ibid.

20. American Nurses Association. 1960. Interpretation of the
statements of the
Code for Professional Nurses, p. 11. New York: ANA.

21. American Nurses Association. 1926. A Suggested Code, p.
600.

22. American Nurses Association. 1985. Code for Nurses, p.
13.

23. Ibid., p. 19.

24. American Nurses Association. 2001. Code of Ethics for
Nurses, Interpretive
Statement 5.3, p. 19.

25. Burgess, Mary Ayers. 1928. The hospital and the nursing
supply. Transaction
of the American Hospital Association, pp. 440–41. Chicago:

AHA.

26. American Nurses Association. 1985. Code for Nurses, p.
14.

About the Author
Marsha D.M. Fowler, PhD, MDiv, MS, RN, FAAN, is Senior
Fellow and Professor
of Ethics, Spirituality, and Faith Integration at Azusa Pacific
University. She is a
graduate of Kaiser Foundation School of Nursing (diploma),
University of California
at San Francisco (BS, MS), Fuller Theological Seminary
(MDiv), and the University
of Southern California (PhD). She has engaged in teaching and
research in bioethics
and spirituality since 1974. Her research interests are in the
history and development
of nursing ethics and the Code of Ethics for Nurses, social
ethics and professions,
suffering, the intersections of spirituality and ethics, and
religious ethics in nursing.
Dr. Fowler is also a Fellow in the American Academy of
Nursing.

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any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

71

The nurse participates in establishing, maintaining, and

improving healthcare environments and conditions of

employment conducive to the provision of quality health

care and consistent with the values of the profession

through individual and collective action.

Provision
Six

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,

including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Provision Six
Linda L. Olson, PhD, RN, CNAA

An ethical work environment contributes to safe, high quality
patient care as well
as to patient and staff satisfaction. The 2001 ANA Code of
Ethics for Nurses can
aid nurses in examining the practices in their workplace, guide
their actions when
interacting with patients and colleagues, and assist in the
assessment of the work-
place ethics.

When the ANA Code was revised in 2001, a heightened
emphasis on the profes-
sional responsibility for creating and maintaining an ethical
work environment was
incorporated, especially into the sixth provision. This provision
has three sections
in the form of its interpretive statements. The first section deals
with the influence
of the environment on moral virtues and values. The second
section discusses the
influence of the environment on ethical obligations. The third
section discusses
concepts related to nurses’ interactions with colleagues, peers,
and others in the
workplace, as well as to their individual and collective
responsibility for the health-
care environment.

Historical Context of Provision 6

Previous versions of the ANA Code of Ethics for Nurses (1968,
1976, 1985) focus
on the role of the staff nurse in the hospital setting. The 2001
Code recognizes
that nurses in all roles and settings face ethical issues and
conflicts that should
be addressed. It also recognizes the changing context within
which health care is
provided and nurses practice. Thus, the revised Code applies to
nurses who are in
practice, education, administration, research, consultation, and
all other settings
where nurses work, including situations of self-employment.

The Code of Ethics has historically changed in response to the
social context in
which nursing is practiced, and is therefore a dynamic and
living document (Fowler,
1999; ANA, 2000). Both the 1976 and 1985 versions of the
Code of Ethics recog-
nized that nurses may participate in collective action as a means
to achieve control

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Linda L. Olson, PhD, RN, CNAA PRovIsIon sIx

of nursing practice and employment conditions that are
“conducive to high quality
nursing care” and to meeting the professional standards of
nursing practice. Previous
versions of the Code included content related to nurses’
economic and general wel-
fare. Today’s healthcare environment is one in which it is
imperative to attend to
concerns for providing quality patient care in ways that are
cost-effective. Concerns

for both patient and staff safety are emphasized. In order to
continue to serve as a
resource for nurses in the current healthcare context, it was
thought important to
include a provision about the importance of the work
environment as an influence
on nurses’ ethical and professional practice. The revised
International Council of
Nurses (ICN) Code of Ethics (2006) also emphasizes the role of
the work environ-
ment as an influence on nurses’ ethical practice. The Task Force
for the revision
of the Code concluded that nurses’ responsibility for creating
and maintaining an
ethical work environment needed to receive greater attention in
the 2001 version
of the Code of Ethics for Nurses.

Interpretive Statement 6.1: Influence of
the Environment on Moral Virtues and Values
Interpretive Statement 6.1 addresses the importance of nurse
participation in con-
structing an environment that will contribute to the flourishing
of the virtues and
values central to the nursing profession and its practice. While
the focus of the
interpretive statement is on the influence of environment on
moral virtues and
values, there is an underlying interrelationship that is
understood. The work envi-
ronment acts upon the nurse; the nurse acts upon the work
environment. The work
setting can either obstruct or support nursing values and virtues.
The nurse can
either remain silent when the work environment is obstructive
or work to change

the environment. The Code is clear in its expectation of moral
activism.

The interpretive statement identifies some of the values central
to nursing:
human dignity; well-being; and respect for persons, health, and
independence. The
interpretive statement also identifies some of the virtues and
excellences essential
to good nursing: wisdom, honesty, courage, compassion,
patience, and skill. It
assumes that the nurse, shaped by nursing education, brings
these values, virtues,
and excellences to the work setting; the nurse does not come to
the work or clinical
setting as a “clean slate.” These values, virtues, and excellences
lead some persons
to choose nursing and other healthcare professions in the first
place, particularly
those with dispositions of helpfulness, kindness, courage,
compassion, caring, and
integrity. These moral virtues can be nurtured—or challenged,
or thwarted—through
the experiences one has in becoming a professional nurse
(through the educational
environment) and working in a healthcare organization.

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

PRovIsIon sIx Linda L. Olson, PhD, RN, CNAA

Some ethical theories give priority to who we are morally over
what we are to
do. Moral character is the core of who we are as a person and is
expressed in who
we are and what we do, even when no one else sees. The virtues
that form the basis

of moral character are developed and learned throughout life
from family nurtur-
ing and relationships with others. For some, these virtues are
developed through
faith and education, specifically the process of socialization
into the values of the
profession.

Although the ANA Code of Ethics does not support one specific
ethical theory,
virtue ethics provide some perspective on the relationship
between the individual
nurse’s values and those of the organization and employer. The
ancient Greek phi-
losopher Aristotle described the theory of virtue ethics as
habits, which are learned,
providing the core of who we are as persons, in essence our
moral character. In virtue
ethics, moral character is learned or habituated and should not
be confused with
“personality traits.” At the core of character is the concept of
integrity. Leaders are
expected to have personal and professional integrity and to
exhibit behavior that
is congruent with stated beliefs, or, in other words, leading by
their own example,
role modeling, or “walking the talk.” One particularly effective
way to communi-
cate personal and professional virtue and values is through
modeling them in one’s
behavior. When managers or colleagues recognize the
contributions of a coworker
by offering words of encouragement or listening to the opinions
of others in a
nonjudgmental way, they are demonstrating their value of
respect for persons. In

creating and managing an ethical work environment,
organizational leaders serve
to promote the personal and professional integrity of the
employees by supporting
a moral milieu that fosters these values and virtues.

Professional nurses make decisions that significantly affect the
lives of others on
a daily basis. Just as personal ethics occur within the context of
relationships with
others, professional ethics occurs within the context of
relationships with whom
one works (Gini, 2003). Although one may know the right thing
to do, the context
of the decision often puts nurses in ethically difficult situations.
When there is a
conflict between what is best for the patient versus the
requirements and demands
of the institution, the physician, and/or one’s own self-interest,
one’s professional
and personal integrity can be tested. Ethical behavior may
require nurses to have
the courage to confront their colleagues when they behaving
inappropriately or in
an unsafe manner. By expressing the values that underlie the
profession of nursing
and its practice, the Code of Ethics serves as a framework to
guide nurses in their
everyday practice.

Watson, in her Ethics of Caring, bases the Theory of Human
Science and Human
Care on ten carative factors. Watson refers to caring as the
“essence of nursing

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Linda L. Olson, PhD, RN, CNAA PRovIsIon sIx

practice,” and as a “moral ideal rather than a task-oriented
behavior” (Neil, 2002;
p. 147). Caring is considered one of nursing’s core values. As
such, one must dem-
onstrate caring in several spheres of practice, to include caring
for patients, col-
leagues, ourselves, and the organization or employer. In
Watson’s Nursing (1999)
spirituality, caring, and the nature of the interpersonal
relationships nurses have
with their patients are recognized as key to healing and healthy
behaviors. Acting
with respect, caring, and compassion applies not only to one’s
interactions with
patients and families, but also to colleagues, co-workers,
assistants, students,
and others. Thus, within the context of this interpretive
statement, caring is both
a value and an excellence. (Within a duty-based or principle-
based ethics, caring
can also be considered to be a duty.)

In the context of the current healthcare environment, healthcare
professionals
must balance their values related to caring for patients and
serving as their advo-
cates, within the business policies of their work setting.
Achieving this balance can
sometimes create tension. Some work settings obstruct
maintenance of nursing
values, some challenge them and demand compromise. How far
that compromise
might go is important; compromise should ideally be integrity
preserving. The

tension between professional and work setting values may raise
the question of
whether nurses can continue to practice as morally good agents
in situations where
cost-constraints restrict care and staffing. Cost-cutting measures
may lead to a lack
of sufficient numbers of qualified and available professional
nurses.

Nurses have traditionally faced situations of competing values,
loyalties, and
obligations within the workplace, with conflict occurring
amongst these on a
daily basis. In order to meet the needs of both the patient and
the healthcare
worker, a collaborative and supportive work environment is
essential. Numerous
articles have been published and studies conducted to identify
the characteris-
tics of healthy work environments. Characteristics of healthy
work environments
include effective leadership, interpersonal relationships and
communication, as
well as collaborative practice relationships among nurses and
physicians (AACN,
2005). The manner in which one interacts with and relates to
others, as well as
the day-to-day ethical challenges and crisis-focused life and
death issues, are the
issues that can shape the ethical environment of the workplace.
Several profes-
sional organizations and agencies, including the American
Nurses Association,
the Institute of Medicine, the American Association of Critical
Care Nurses, and the
American Organization of Nurse Executives, have identified the

importance of creat-
ing a healthy and positive work environment. The American
Nurses Credentialing
Center (ANCC) Magnet Recognition Program gives recognition
to organizations
that demonstrate outstanding quality in nursing practice and
provides a framework
for creating cultures of excellence. The ANA Bill of Rights for
Registered Nurses

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

PRovIsIon sIx Linda L. Olson, PhD, RN, CNAA

was developed as a policy statement with specific attention to
the workplace envi-
ronment (ANA, 2001).

In corroboration of the expectations of the Code of Ethics, The
Bill of Rights for
Registered Nurses emphasizes nurses’ rights to:

u Practice in a manner that fulfills their
obligations to society and to those
who receive nursing care.

u Practice in environments that allow them to
act in accordance with
professional standards and legally authorized scopes
of practice.

u A work environment that supports and facilitates
ethical practice, in
accordance with the Code of Ethics for Nurses
and its interpretive
statements.

u Freely and openly advocate for themselves
and their patients, without fear
of retribution.

u A work environment that is safe.

u Negotiate the conditions of employment.

In seeking out and choosing a place of employment, nurses
should become
familiar with the values and culture of the institution in which
they seek to work.
Just as individuals have their own values and principles on
which to base behavior
and decisions, organizations also have statements of values and
a mission for which
they exist. The nurse may review the organization’s mission
statement, organiza-
tional values, and goals when considering employment. Another
way to assess the
organizational culture of a company is to obtain information
through talking with
staff, leaders, managers, and other key players in order to obtain
an impression of
what type of person fits in at this organization. The way an
organization’s leaders
treat their staff is an indicator of the organizational culture.
When staff feel they
are treated fairly and with respect, they translate this onto the
way they treat their
patients. The importance of the work environment in
influencing nurses’ work and
patient outcomes is reflected in the concepts of organizational
fit and organizational
culture, mission, values, and goals. As members of a healthcare
institution, nurses

are expected to promote and support the organization’s mission
and goals. As is the
case with individuals, institutions do not always live up to their
stated values. It is
not always possible to ascertain an institution’s level of
congruence with its public
statements of values in advance of accepting a position.

When nurses find themselves in an environment in which they
perceive a conflict
between their personal and professional values and those of the
institution, they first
need to assess the source of that conflict. When an institution
has a value structure

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Linda L. Olson, PhD, RN, CNAA PRovIsIon sIx

that does not match that of the nurse, it might be better to seek
employment else-
where. However, when a situation arises because of an
institutional failing to live
up to its stated values, such as promising “high-quality patient
care,” but regularly
suffers from nurse understaffing, that creates a conflict with the
values of the pro-
fession that the nurse has an obligation to attempt to correct.
Where nurses works
in a subpar environment and have made attempts to change it,
then other avenues
should be pursued depending upon the gravity of the situation.

There are several strategies that may be applied. One such
strategy is to discuss
the perceived conflict with the immediate supervisor and, then,
to follow the appro-

priate lines of communication within the employment setting.
Depending on the
situation, this may involve following either the nursing,
medical, and/or adminis-
trative chain of command in the facility. Additional strategies
include reporting the
situation to regulatory agencies, such as The Joint Commission
or appropriate local
or state health department or other agency. The Constituent
Member Associations
affiliated with the American Nurses Association can also
provide assistance and sup-
port in identifying strategies. The institution’s ethics committee
is also a resource
for consultation and guidance when one is faced with difficult
issues that adversely
affect patients or staff. The most appropriate option is generally
to stay in one’s
setting and work to change the environment, especially when
patient safety and
quality of care are threatened. In some cases, when changes are
not forthcoming,
the most appropriate strategy may be to seek employment
elsewhere.

Interpretive Statement 6.2:
Influence of the Environment on Ethical Obligations
Interpretive Statement 6.2 recognizes that the policies and
practices of a work
environment have an influence on ethical obligations. The
professional atmosphere
of an organization influences employee behavior and beliefs,
and, thus, ethical
decision making. The organizational culture is reflected in way
things are done in
the work setting. It consists of the norms and values, as well as

the mechanisms
by which the organization carries out its work. Policies,
procedures, conditions of
employment, structures for decision making, and the types of
behaviors that are
supported constitute the culture of an organization. The climate
of an organization
is judged by employee perceptions of how the policies and
procedures are actu-
ally carried out, along with their effectiveness. It influences
how one feels to be a
member of that particular organization. One crucial aspect of an
organization is
its ethical climate, a concept that can be defined as how
employees perceive the
behaviors and practices associated with how ethical issues are
handled (Olson 1995).
Brown (1990) described five conditions that must be present in
the work environ-

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

PRovIsIon sIx Linda L. Olson, PhD, RN, CNAA

ment in order for awareness, reflection, and discussion about
ethical issues to
occur. These conditions are (a) power (the right to having the
information needed
to understand a situation, as well as to say what needs to be
said), (b) trust (the
confidence to disagree with others, without fear of reprisal), (c)
inclusion (those
with an interest in the decision are included in the process), (d)
role flexibility
(the ability to take different points of view, and to change it
based on additional
information), and (e) inquiry (an atmosphere of questioning and

learning).

Interpretive Statement 6.3:
Responsibility for the Healthcare Environment
Interpretive Statement 6.3 addresses nurses’ individual and
collective responsibility
for contributing to the healthcare environment. Each individual
nurse has a role in
creating an ethical environment. Nurses, as both members of
society and healthcare
professionals, face ethical issues and dilemmas on a daily basis.
These range from
basic issues, such as treating colleagues, patients, and families
with respect and
truth-telling, and patient advocacy, to more complex issues,
such as those associated
with end-of-life care. Inherent within these issues are competing
loyalties among the
best interests of patients and the obligations toward physicians
and the employing
organization. Provision 2 makes clear the imperative that the
first obligation is to
the patient (see Chapter 2). In reality, this is often difficult,
particularly when one
is faced with balancing multiple obligations in the workplace.

Each individual nurse has a role in creating and contributing to
an ethical envi-
ronment. It is recommended that nurses assess their own values
as well as those
of the organization in order to determine whether they will be
supported in their
roles as patient advocates and moral agents (Hamric, 1999;
Maier-Lorentz, 2000).
What does an ethical work environment mean, and what are its
characteristics?

In light of the current worldwide shortage of nurses, as well as
individual staffing
shortages in many institutions, the importance of nurses
maintaining an ethical
work environment is unsurpassed.

There are primarily two strategies for solving the current
shortage of qualified
and available nursing personnel. One strategy is to increase the
supply of profes-
sional nurses through enhancing the capacity of nursing schools
to accept more
students. This supply-side strategy also requires an increase in
the numbers of
qualified faculty. The second strategy, a demand-side strategy,
is to improve the
workplace environment, thereby retaining nurses in the
organization, as well as
in the profession. Changing the culture of the workplace
environment to one that
demonstrates increased recognition and rewards for nurses who
excel in practice

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Linda L. Olson, PhD, RN, CNAA PRovIsIon sIx

will ultimately improve the quality of patient outcomes and
enhance nurse recruit-
ment and retention.

One way to promote an ethical environment is to use the ANA
Code of Ethics
for Nurses as a resource for guidance. In order to use the Code
as an organiza-
tional resource, it should be readily available to all nurses.
Awareness of the Code

and how to use it to guide practice is increased through
reviewing it during facility
orientations and educational programs, incorporating it into job
descriptions, and
including it as a component of the philosophy and conceptual
framework for the
practice of nursing within the organization. When nurses are
encouraged to think
about how their practice reflects the Code, they are more likely
to develop a sense of
ethical awareness and view it as a source of support when faced
with ethical issues
and conflicts. To engage in ethical decisions, nurses must be
knowledgeable about
the issues involved and how the decision-making process works,
as well as how to
use organizational mechanisms, such as hospital ethics
committees, consultation
resources, and formal and informal lines of communication. It is
also important that
nurses have input into organizational decision making and have
the opportunity to
participate with policy and procedure committees.

The demands of the Code that nurses actively participate in
establishing and
maintaining the moral environment have been reinforced by
recent research on
the necessity of “speaking up.” The Silence Kills study
identified seven categories of
“crucial conversations” that, when avoided, can profoundly
affect patient care. These
categories are: broken rules, mistakes, lack of support,
incompetence, poor team-
work, disrespect, and micromanagement (Maxfield et al, 2005).
Indeed, speaking

up is a moral obligation. This research evidence supports the
moral importance of
expressing concern regarding untoward behavior, decisions, or
actions on the part
of colleagues and the consequences for patient care of not doing
so.

Role of the Manager in Creating
an Ethical Environment
Perhaps the most important role in creating, enhancing, and
maintaining an ethi-
cal environment is that of the first-line manager. The nurse
manager is not only
responsible for safe patient care that is cost-effective and of
high quality, and also
for assuring that the nurses who deliver that care are competent
and adhere to
professional standards of practice. The nurse manager plays a
key role in retain-
ing qualified nurses, as well as in promoting their job
satisfaction. There is already
literature that provides evidence of a relationship between
levels of nurse staffing
and patient outcomes (Aiken et al., 2002). Research has also
shown that employees

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

PRovIsIon sIx Linda L. Olson, PhD, RN, CNAA

who perceive their leaders as basing their decisions on ethical
values and practices
are more satisfied with their jobs (Vitell and Davis, 1990).
Nurse managers, who
are in first-line positions in hospital or other healthcare
settings, are perceived
as having the most crucial and difficult positions by virtue of

being the liaisons
between the direct caregivers and the administration. Conflicts
often arise between
the nurse managers’ obligations to their staff, their patients, and
their employ-
ers. When such conflicts arise, it is important that mechanisms
are in place to
facilitate open communication and support in an atmosphere
where issues can
be addressed and resolved appropriately. The goals of safe,
high-quality care and
satisfied patients, employees, and physicians, are considered to
be important orga-
nizational outcomes. Balanced reports and scorecards to
accrediting agencies,
employer groups, and the public highlight these aspects of a
healthcare organization’s
mission and goals.

Promoting a nonthreatening atmosphere in which nurses and
others can mutu-
ally express and share their concerns is an important component
of an ethical
work environment. In addition, such communication helps
employees perceive
they have a role in the success and viability of the organization
as well. Provision 6
also addresses the role of accountability. Just as individual
professional nurses are
expected to be accountable for their practice, managers must
clearly communicate
the responsibilities expected of their staff and hold them
accountable for their
performance.

Case Example 1

collaborative Practice Relationships
A large academic medical center established a mechanism
whereby nurses and physi-

cians met regularly to discuss and plan the treatment goals and
interventions for their

patients. In this atmosphere of mutual problem-solving,
communication, respect for each

others’ viewpoints, and sharing of observations and
assessments, nurses felt they were

an equal part of the patient care team. As a result of this
collaborative mechanism of

shared decision making, nurses also reported fewer instances of
moral distress and

outrage. Moral outrage is an emotional response associated with
the inability to do

what one perceives as the right thing to do as a result of
organizational constraints. A

collaborative and supportive environment is essential in order to
effectively meet the

needs of patients, families, and the community.

Three months ago a new, extremely well-known specialist
physician was hired and

brought a physician assistant with him. The medical staff is
elated that this physician

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Linda L. Olson, PhD, RN, CNAA PRovIsIon sIx

has agreed to join them and see him as both a clinical plus and
public relations boost

for the hospital. From the start, the physician made rounds with
his physician assistant

and asked that the nurses not participate because the physician
“did not want to be

delayed in his rounds” by the presence of nurses. Free
communication exists between

the physician and the physician’s assistant, but not with the
nurses. The nurses have

been instructed that if they wish to communicate with the
physician they must go

through the physician assistant. The nurses have become
increasingly frustrated and

feel cut out of patient care. They believe that the level of
medical care remains high,

but they also perceive that the goal of high-quality nursing care
is being obstructed.

Furthermore, they resent having to communicate with a
physician assistant instead of

the physician, and have proceeded to contact the physician
directly. This has angered

the physician and hardened the position he is taking. The nurse
manager and the unit

CNS have both spoken with the physician, but he will not
budge. The second time they

attempt to raise concerns on behalf of the nursing staff, the
physician becomes imperi-

ous and demeaning. What, if anything, should be done,
individually or collectively, by

the nurses to remedy this situation? O

Case Example 2
compassionate and Respectful Interactions
with students, Mentoring, Role Modeling, and
Modeling of the Profession’s core values
A nursing school initiates a mentoring program whereby all
undergraduate students

meet in assigned groups with a faculty mentor each semester in
their program. This

mechanism is a way to provide students (and future nurses) with
a sense of empower-

ment and a source of support, as well as permitting them to
express themselves in a

safe environment, without fear of reprisal. It is also a means by
which the values of the

profession can be transmitted. This mechanism provides
students with a forum of trust

and respect for expressing their feelings and of preserving their
dignity. However, one

group of junior students is experiencing distress. Their mentor,
a senior faculty member

and department chairperson, has an outside business and asks
for “volunteers” to work

in his “community health center,” predominantly funded by
federal grants, where, they

are expected to do unsupervised well-child health assessments.
The students believe

that refusing to volunteer will have negative consequences, so
they comply. The students

feel inadequate to the task, but the faculty person states that this
is “related clinical

experience that is supervised.” In addition, one of the students
found the grant proposal

on the internet and discovered that it contains provisions in the
budget for registered

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

PRovIsIon sIx Linda L. Olson, PhD, RN, CNAA

nurses to conduct these assessments. This is a powerful faculty
member; other faculty

refuse to discuss this with the students. What ought the students
do? O

Conditions of Employment
A component of Provision 6 is that conditions of employment
must be conducive
to the provision of quality patient care and consistent with the
professional values
related to individual and collective action. As employees,
nurses have a right to have
input into decisions related to conditions of employment,
professional practice, and
patient care. This not only contributes to nurse job satisfaction,
but also to organi-
zational commitment and retention. When nurses perceive the
conditions in their
practice setting as unfavorable, inequitable, and unsafe, they
may seek representa-
tion through collective action, including collective bargaining
as a way to assure
their opinions about workplace conditions and patient care are
heard. The most
important consideration here is the relationship that nurses as
direct caregivers
have with management and administration.

The use of the term “collective action” encompasses a variety of
mechanisms
by which nurses participate in organizational decisions
regarding their workplace
conditions. The formal mechanisms associated with collective
bargaining, work-
place advocacy programs, and shared governance provide ways
to empower nurses
to participate in decisions affecting their work conditions and
patient care (Green
and Jordan, 2004; Williams, 2004; Budd et al, 2004).

A collective bargaining agreement is a negotiated legal

mechanism that results
in empowering nurses so that they have a voice in decisions that
affect their work
conditions and control over their practice. When conditions
within the employment
setting are perceived as unacceptable and nurses and
administrators do not trust
or respect each other in ways that facilitate effective
communication and problem-
solving, nurses sometimes turn to unionization as a means of
gaining negotiating
power. Nurses seek representation by unions for many reasons,
including solving
problems regarding wages, workload and staffing, and
addressing issues related to
practice, such as safe, quality patient care and an ethical
environment in which
to work. Admittedly, collective bargaining has sometimes
focused on benefits to
nurses and staff, to the exclusion of concerns for the ethical
environment. The
reasons for collective action, in whatever form it takes, fall into
two main cat-
egories: workplace issues that affect the nurse alone (e.g.,
wages, benefits, hours,
treatment) and those that affect nursing care and patient welfare
(e.g., staffing
patterns, participation in decision making, governance). The
collective bargain-

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Guide to the Code of Ethics for Nurses 83

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Linda L. Olson, PhD, RN, CNAA PRovIsIon sIx

ing contract becomes a tool whereby nurses can achieve positive
conditions in the
workplace through a negotiated process. It is incumbent upon

nurses to press the
collective bargaining unit to attend to the ethical environment
of the workplace,
in addition to other concerns. Negotiating a collective
bargaining contract may
result in improved conditions of employment for nurses and
provide a means to
achieve goals that result in improved patient care outcomes as
well. These goals are
of interest also to nurse managers and the organization.
Whereas the values inher-
ent within the Code include caring, respect, trust, and
collaboration, the process of
collective bargaining guarantees a legal contract between the
two parties that can
support these values.

In order to ensure that the contract negotiations stay within an
ethical frame-
work, it helps to view the process as one in which nurses are
achieving the best
possible conditions of employment for themselves, while also
creating policies and
standards that result in improved patient care. For example,
when nurses negoti-
ate to set staffing standards as a component of their collective
bargaining contract,
they are also creating an environment that provides safe, high-
quality patient care
and supports nurse recruitment and retention.

The term “workplace advocacy” refers to programs aimed at
facilitating nurses’
involvement in workplace decisions that affect patient care and
providing indi-
vidual nurses with resources to help them to be advocates for

themselves in their
work environments. These strategies may be part of a program
that involves
professional organizations at the local, state, and national
levels. The Center for
American Nurses (CAN) is a formal program of the American
Nurses Association.
It provides various services to assist nurses in self-advocacy
through focusing on
staffing, workflow design, the physical environment, and
personal, social, and
organizational factors.

Shared governance is another formal structure that achieves the
goal of shar-
ing decision making through mechanisms such as nurse practice
councils in which
nurses from all levels of the organization contribute to
decisions concerning the work
environment. Other shared governance councils may focus on
policies, procedures,
research, quality improvement, education, recruitment, and
retention.

In the ideal world, nurses and their managers and administrators
would always
collaborate successfully on issues related to workplace
conditions and patient
care policies in order to achieve mutually satisfactory outcomes.
Shared gover-
nance models embody the concept of participatory decision
making. Mechanisms
of shared governance include staff bylaws and structures, such
as councils, that
involve employees in developing policies and procedures, build
collaborative

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84 Guide to the Code of Ethics for Nurses

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from

the publisher.

PRovIsIon sIx Linda L. Olson, PhD, RN, CNAA

relationships among staff and management, and foster
organizational autonomy.
Shared governance is viewed as a strategy that provides
mechanisms for empower-
ing nurses. It is also considered a key indicator of excellence,
as embodied by the
achievements of Magnet hospitals. Shared governance models
and collective bargain-
ing agreements can co-exist in the same organization, so long as
union leaders work
along with managers and staff nurses to create the model (Budd
et al, 2004; O’Grady,
2001). This is one type of systems-level organizational culture
change that can improve
the environment in which nurses provide patient care (Institute
of Medicine, 2004).

Shared Governance and Collective Bargaining
in the Same Hospital
The use of shared governance and collective bargaining in the
same institution
can be fruitful. For example, the nurses at one large academic
medical center
hospital originally organized using collective bargaining for
purposes of improving
their wages and benefits. After that, the nurses stated their
desire to have input
into decisions on patient care issues and other polices and
procedures that affected
practice. They also wanted to be recognized for their expertise
and competence,
as well as for their seniority in the hospital. As a result of

collaboration among
managers and staff, as well as the desire of the hospital to
pursue Magnet Recog-
nition status, a decision was made to establish unit-based
councils as a mechanism
for staff nurses to have input into decisions about patient care.
With the belief
that empowering nurses in decision making would also result in
improved patient
outcomes, the leaders of the collective bargaining unit, the
nurse leaders and the
administrators met to discuss concepts of shared governance.

Although direct care nurses were already involved in several
committees through-
out the hospital, these discussions resulted in the creation of a
professional practice
model that included unit-based councils, with representatives
who were members
of councils concerned with quality council, nurse practice,
education and profes-
sional development, research, and recruitment and retention. A
staff nurse served
as chairs of each council and participated in the overall nursing
leadership council,
which also included nursing administrators. Though
development of this council,
surveys indicated that nurses felt empowered to make changes
in their work environ-
ment that ultimately resulted in improved patient and nurse
satisfaction. Notice the
rich variety of mechanisms and structures that were put in place
in this situation.
With these changes, nurses reported feeling they had control
over their practice and
autonomy in their decision making. Through the collaborative

relationship that had
developed among clinical nurses and management, a level of
mutual respect and

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Guide to the Code of Ethics for Nurses 85

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part of this book may be reproduced or utilized in any form or

any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Linda L. Olson, PhD, RN, CNAA PRovIsIon sIx

trust was present. Clinical nurses perceived they had real input
and participation
in decisions related to their roles in patient care. When it was
time for their appli-
cation and site visit, they were successful in achieving Magnet
recognition. This
success was attributed to the collective bargaining commitment
of nurses and the
nursing administrative leadership to work collaboratively
toward building a shared
governance structure. Although conflicts still occurred, there
was a mechanism in
place for voicing of concerns and providing input in an
atmosphere of respect and
renewed trust.

The American Nurses Association, through its various programs
and structures,
advocates for safe working conditions for both nurses and
patients through collec-
tive bargaining, workplace advocacy (both formal and
informal), and in serving as a
resource providing guidance for nurses with practice-related
problems. Through its
formal position statements, Code of Ethics, Bill of Rights,
Scope and Standards of
Practice (ANA, 2004), Social Policy Statement (ANA, 2003),
and legislative action,
this professional nurses association serves as an advocate for

nurses and patients.
In addition, the Magnet Recognition Program developed and
administered by the
American Nurses Credentialing Center serves to recognize
healthcare organizations
that demonstrate excellence in nursing care and practice
(ANCC, 2007). The Magnet
Recognition Program serves as a klieg light sweeping the dark
skies of Hollywood
saying “Look at us; this is where you want to be.” In summary,
Provision 6 is about
the role of the nurse in creating, promoting, and maintaining an
ethical environment
for practice. The three interpretive statements that explicate this
provision address
the influence of the work environment on nurses’ ethical
practice, as well as the role
of the nurse in contributing to the creation of an ethical
environment for practice.

References

All online references were accessed in December 2007.

Aiken, L.H., S.P. Clarke, D.M. Sloane, J. Sochalski, and J.H.
Silber, 2002. Hospital
nurse staffing and patient mortality, nurse burnout, and job
dissatisfaction.
Journal of the American Medical Association 288(16): 1987–93.

American Association of Critical-Care Nurses. 2005. AACN
Standards for
establishing and sustaining healthy work environments.
www.aacn.org.

American Nurses Association. 2000. Code of Ethics Project

Task Force. A New
Code of Ethics for Nurses. American Journal of Nursing 100(7):
69–72.

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86 Guide to the Code of Ethics for Nurses

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or

any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

PRovIsIon sIx Linda L. Olson, PhD, RN, CNAA

American Nurses Association. 2001. Bill of Rights for
Registered Nurses.
Washington, DC: American Nurses Publishing.

American Nurses Association. 2001. Code of Ethics for Nurses
with Interpretive
Statements. Washington, DC: American Nurses Publishing.

American Nurses Association. 2003. Nursing’s Social Policy
Statement.
Washington, DC: American Nurses Publishing.

American Nurses Association. 2004. Nursing: Scope and
Standards of Practice.
Washington, DC: Nursesbooks.org.

American Nurses Credentialing Center. 2007. Magnet
Recognition Program:
Recognizing excellence in nursing service.
http://www.nursecredentialing.org/
magnet/index.html.

Arwedson, I.L., S. Roos, and A. Björklund. 2007. Constituents
of healthy
workplaces. Work 28(1): 3–11.

Brown, M.T. 1990. Working Ethics. San Francisco: Jossey-
Bass.

Budd, K.W., L.S. Warino, and M.E. Patton. 2004. Traditional
and non-traditional
collective bargaining: Strategies to improve the patient care
environment.
Online Journal of Issues in Nursing, 31 January, 9(1).

Fowler, M.D. 1999. Relic or resource? The Code for Nurses.
American Journal of
Nursing 99(3): 56–57.

Gates, D. 2006. Changing the work environment to promote
wellness: A focus
group study. AAOHN Journal 54(12): 515–20.

Gini, A. 2003. My Job, My Self. NY: Routledge.

Green, A., and C. Jordan. 2004. Common denominators: Shared
governance and
work place advocacy-strategies for nurses to gain control over
their practice.
Online Journal of Issues in Nursing, 31 January, 9(1).

Hamric, A.B. 1999. The nurse as a moral agent in modern health
care. Nursing
Outlook 47(3): 106.

Institute of Medicine. 2004. Keeping Patients Safe:
Transforming the Work
Environment of Nurses. Washington, DC: National Academies
Press.

International Council of Nurses (ICN) 2000. ICN Code of Ethics
for Nurses.
Geneva, Switzerland: ICN.

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Guide to the Code of Ethics for Nurses 87

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Linda L. Olson, PhD, RN, CNAA PRovIsIon sIx

Kane-Urrabazo C. 2006. Management’s role in shaping
organizational culture.
Journal of Nursing Management 14(3; Apr): 188–94.

Maier-Lorentz, M.M. 2000. Creating your own ethical
environment. Nursing
Forum 35(3), 25–28.

Maxfield, D.J. Grenny, R. McMillan, K. Patterson, and A.
Switzler. 2005. Silence
Kills: The Seven Crucial Conversations for Healthcare.
http://www.aacn.org/
aacn/pubpolcy.nsf/Files/
SilenceKillsExecSum/$file/SilenceKillsExecSum.pdf.

Neil, R.M. 2002. Jean Watson: Philosophy and science of
caring. In Nursing
Theorists and their Work. 5th ed., pp. 145–64. Springfield, MO:
Mosby.

Oandasan, I. 2007. Teamwork and healthy workplaces:
Strengthening the links
for deliberation and action through research and policy.
Healthcare Papers 7,
Special Issue: 98–103.

O’Grady, T.P. 2001. Collective bargaining: The union as
partner. Nursing
Management 32(6), 30–32.

Olson, L.L. 1995. Hospital nurses’ perceptions of the ethical
climate of their work
setting. Image: The Journal of Nursing Scholarship 30(4): 345–

49.

Patterson, K., J. Grenny, A. Switzler, and R. McMillan. 2002.
Crucial Conversations:
Tools for Talking When Stakes Are High. New York: McGraw-
Hill.

Reina, M.L., and C. Barden. 2007. Creating a healthy
workplace. Trust: the
foundation for team collaboration and healthy work
environments. AACN
Advanced Critical Care 18(2; Apr–Jun): 103–8.

Ulrich, B.T., R. Lavandero, K.A. Hart, D. Woods, J. Legget,
and D. Taylor. 2006.
Critical care nurses’ work environments: A baseline status
report. Critical
Care Nurse 26(5), 46–57.

Vitell, S.J., and D.L. Davis. 1990. The relationship between
ethics and job
satisfaction: An empirical investigation. Journal of Business
Ethics 9, 489–94.

Watson, J. 1988. Nursing: Human Science and Human Care: A
Theory of
Nursing. New York: National League for Nursing.

Watson, J., and M.A. Ray. 1989. The Ethics of Care and the
Ethics of Cure:
Synthesis in Chronicity. New York: National League for
Nursing.

Williams, K.O. 2004. Ethics and collective bargaining: Calls to
action. Online
Journal of Issues in Nursing 23 July.

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um/$file/SilenceKillsExecSum.pdf

88 Guide to the Code of Ethics for Nurses

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,

including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

PRovIsIon sIx Linda L. Olson, PhD, RN, CNAA

About the Author
Linda L. Olson, PhD, RN, CNAA, is currently Professor and
Dean of the School of
Nursing at North Park University in Chicago, Illinois.
Previously, she taught courses
in healthcare policy and economics, leadership, and nursing
service administration
at the graduate and undergraduate levels as an Associate
Professor at St. Xavier
University in Chicago. She has prior experience in nursing
service administration,
practice, and consultation. Dr. Olson received her PhD and
MBA from the University
of Illinois at Chicago, and her baccalaureate and master’s
degrees in nursing from
Northern Illinois University. Her area of research interest is the
work environment,
particularly focusing on organizational culture and ethics. As
part of her dissertation
work, she developed the research instrument, the Hospital
Ethical Climate Survey,
which has also been used by several researchers, nurses, and
others in the United
States and internationally. She was a member of the ANA Task
Force to Revise the
Code of Ethics, as well as the Congress on Nursing Practice and
Economics, and has
held numerous leadership positions at local, state, and national
levels. In addition,
she serves as an appraiser for the Magnet Recognition Program.

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any means, electronic or mechanical,
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the publisher.

89

The nurse participates in the advancement of the

profession through contributions to practice, education,

administration, and knowledge development.

Provision
Seven

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90 Guide to the Code of Ethics for Nurses

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Provision Seven
Theresa S. Drought, PhD, RN, and
Elizabeth G. Epstein, PhD, RN

Provision History
Nursing has changed tremendously in the last twenty years.
Advanced degrees
at the master’s and doctoral levels, as well as advanced practice
nursing, have
created expanding opportunities for nurses to contribute to
health care, educa-
tion, research, public awareness, and health and social policy in
unprecedented
ways. Nursing research has blossomed. Nurses hold prominent
positions, both
appointed and elected, in government, philanthropy, and social
policy institutes.
One of these, the National Institutes of Health’s National
Institute for Nursing
Research (NINR), is focused on nursing research. Nursing
issues are prominent
on the agendas of Congress, the United Nations, and such
influential private orga-
nizations as the Robert Wood Johnson Foundation, the Pew

Charitable Trusts, and
the RAND Corporation.

In the initial review of the Code of Ethics of 1985, it was
recognized that
the previous Provision 7 (“The nurse participates in activities
that contribute to
the ongoing development of the professional’s body of
knowledge.”) required
expansion and clarification for several reasons. First, this
provision placed
emphasis on the importance of knowledge development without
acknowledg-
ing the many other ways nurses can advance the nursing
profession. The current
formulation recognizes the multifaceted complexity of
contemporary nursing
practice and seeks to make the provision relevant to nurses in
all settings and
roles. Second, the individual nurse has just as much of an
obligation to the pro-
fession as the profession has to the individual nurse. This
reciprocity was not
addressed in the previous formulation, but it is a significant
aspect of the current
formulation. Third, education, practice, and administration, as
well as knowl-
edge development are inherently interdependent. Little forward
movement in
the profession can be made if new knowledge is not translated
into practice.
Educators must be aware of the realities of practice as well as
the latest advances
in research. Administrators must create an environment that is
supportive of the

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Theresa S. Drought, PhD, RN, and Elizabeth G. Epstein, PhD,
RN PRovIsIon sEvEn

ongoing educational needs of nurses and conducive to rapid
implementation of
innovation. Quality patient care is dependent upon the
development of effective
educational methods; efficient, cost-effective system
administration, and research
to guide the provision of nursing care. Finally, patient well-
being is dependent
upon a vibrant, evolving nursing profession that is responsive
and able to antici-
pate the emerging needs of society and healthcare systems. The
profession can
only advance through the participation of nurses who are open
to learning, and
incorporating new knowledge. Clearly, the future of the
profession is dependent
upon more than the work of a few individuals; it requires the
active engagement
of all nurses.

Provision Content
Provision 7 challenges the nurse to participate in the
profession’s contribu-

tions to society by being actively engaged with its progress and
development.
One purpose of the Code is to reinforce the bonds between the
individual who
chooses to enter the nursing profession, the practice of the
individual nurse,
and the social roles and obligations of nurses within society.
This provision creates a

moral link between the nurse as a person, the individual practice
of the nurse, and
the nursing profession as a whole. This link is necessary in
order for the nurse to
hold a coherent sense of professional obligation that
complements the individual’s
sense of self.

Note how Provisions 4, 5, 8, and 9 are closely linked in
Provision 7. The nurse as
a moral agent is described in Provision 5. Provision 4 describes
the moral obliga-
tions of the nurse as a practitioner. Provision 8 describes the
nurse’s moral obliga-
tion to society. Provision 9 describes the responsibilities of the
nursing profession
to both the individual nurse and society in general. Provision 7
provides the neces-
sary linkage between individual competence and evolving
professional standards of
practice, in addition to giving nurses a responsive and
collaborative role in health
policy for the overall advancement of the profession. It also
clarifies the interde-
pendent relationship between the ability of the nursing
profession to contribute to
society and the well-being and development of the individual
nurse and the pro-
fession as a whole. Just as a nurse who is undertrained,
unsupported, and isolated
cannot contribute to the patient’s well-being, a profession that
is undeveloped,
fragmented, and lacking in the commitment and support of its
practitioners will
be limited in its ability to benefit society.

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© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

PRovIsIon sEvEn Theresa S. Drought, PhD, RN, and Elizabeth
G. Epstein, PhD, RN

It is not expected that the individual nurse will be proficient in
all areas of nursing
or engaged with each facet of development required for
advancement of the profes-
sion (education, practice, administration, and knowledge
development). However,
the nurse cannot afford to be indifferent to the advancement of
the profession; our
systems of health care change rapidly and nursing as a
profession must anticipate
and adapt to these changes in order to meet the needs of
patients. The expecta-
tion laid out in Provision 7 is that the individual nurses will
bring their talents and
experience to the ongoing conversation about nursing practice
and standards that
is needed to advance the profession as a whole. Individual
competence cannot be
maintained without the nurse’s awareness of changes in
professional practice, stan-
dards, and health policy. Advancements in these areas cannot be
attained without
input from all areas of nursing practice. The demands of nursing
exceed the capacity
of any individual working in isolation. The interdependence
between nurses, their
practice, the profession, and the many facets of nursing
knowledge is implicit in
both Provisions 7 and 9.

Interpretive Statements
The three interpretive statements are like the layers of an onion

and serve to amplify
the meaning of Provision 7 and illustrate its application to
nursing practice. Each
exposes a different layer of involvement for the nurse. It is this
layered component
of practice that provides for a vibrant, flourishing profession.
As you peel back the
layers, you expose the center of nursing—patient care. Yet
without these outer lay-
ers to protect it, the center could not survive. So, while the
initial provisions of the
Code explicitly focus on patient care as the center of nursing,
succeeding provisions
also have the patient at the center.

The first interpretive statement directs the nurse to the
outermost layer of inter-
action between the profession and society; it calls on the nurse
to be actively involved
in health policy and the organizations that serve as an interface
between nursing
practice and the public. The second interpretive statement
directs the nurse to the
regulation and scope of individual professional practice; it calls
on the nurse to be
actively involved in the development and implementation of
professional standards.
The third interpretive statement shields the center of nursing; it
directs the nurse
to develop, adapt, and utilize the research necessary for the
provision of safe and
effective patient care.

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Guide to the Code of Ethics for Nurses 93

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Theresa S. Drought, PhD, RN, and Elizabeth G. Epstein, PhD,
RN PRovIsIon sEvEn

Interpretive statement 7.1: Advancing the
Profession through Active Involvement in
nursing and in healthcare Policy
There are many ways to be involved in nursing and healthcare
policy inside and
outside the work environment. A minimal approach in the work
environment
would be to incorporate activities related to standards, quality
initiatives, and the
results of nursing research into direct patient care. Programs
such as The National
Patient Safety Goals and the National Database of Nursing
Quality Indicators pro-
vide standards and tools to guide practice as well as encourage
improvements in
patient safety and quality care. At a higher level, nurses can
conduct research to
collect outcome data for establishing better standards and
practices. Institutional
participation in programs such as Magnet Recognition or the
AACN Synergy Model
serve to both utilize and inform health policy and patient care
standards. Research
conducted by nurses provides the necessary linkage between
nursing education,
staffing, and patient safety and outcomes (Aiken et al, 2003;
Rogers et al, 2004,
Rothschild et al, 2006).

Some nurses may feel they wouldn’t know where to begin in
engaging with pub-
lic policy. However, utilizing the knowledge of health issues
gained from nursing
when carrying out civic responsibilities, engaging friends and
family in informed

discussions on health policy matters, exercising the right to
vote, informing oneself
about legislative and ballot issues, and writing to elected
representatives on issues
related to nursing can have a significant effect on health policy.
At a slightly higher
level of involvement, there are several avenues open to the
nurse, such as providing
expert testimony at legislative hearings, participating in the
political action com-
mittees of professional associations, coordinating community
health programs or
education campaigns related to issues affecting nursing. Non-
healthcare forums
also benefit from nursing involvement; nurses make important
contributions
through participation on local school boards and regional or
national advocacy
groups addressing environmental and economic issues affecting
society generally.
Finally, nurses must strive to become active participants at the
highest levels of
healthcare policy in this country by running for elected office,
taking leadership
positions at health policy agencies, and researching and writing
about issues affect-
ing health policy.

These types of activities bring the nursing perspective to the
forefront and help
to advance the profession in at least two ways. First, it makes
nurses’ contribu-
tions to health care and patients both tangible and visible which
helps to promote

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94 Guide to the Code of Ethics for Nurses

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

PRovIsIon sEvEn Theresa S. Drought, PhD, RN, and Elizabeth
G. Epstein, PhD, RN

the value of nursing in the eyes of the public and other
healthcare professionals.
Second, recognition of nurses as valuable, contributing
participants in health
policy increases public support of the profession which will
serve to strengthen
nursing’s effectiveness.

Interpretive statement 7.2: Advancing the
Profession by Developing, Maintaining, and
Implementing Professional standards in clinical,
Administrative, and Educational Practice
A hallmark of professionalism is self-management and -
regulation; commitment to
these activities is necessary for a vital, flourishing nursing
practice. Allowing others
to mandate the requirements or establish the boundaries of
professional practice
does not serve nurses or the patients who benefit from nursing
care. Nurses must
be the primary architects of the standards that define
professional practice.

Again, there are multiple ways to meet the obligation to
advance the profession
as detailed in this interpretive statement. At a minimum,
knowing and adhering
to the professional standards applicable to the nurse’s practice
setting and role
meets this obligation. The advancement of the profession can be
attained by the
conscientious practice, innovation, and refinement of each
individual in accord with

established standards and guidelines. Peer review creates
accountability mechanisms
linking individual practice to professional standards. Self-
regulation is a hallmark
of professionalism and key to advancement. Self-regulation
includes holding one’s
self and peers accountable for meeting the standards of the
profession. A mid-level
commitment could be met by the nurse’s involvement with the
development of
standards within a particular practice setting; participation in
workplace quality
committees and shared governance systems; or the collection
and utilization of
nurse sensitive patient care data. A slightly higher level of
commitment could be
met by providing commentary on legislative (the Nurse Practice
Acts), regulatory
(Medicare, Medicaid, JCAHO), or organizational (ANA and
other professional orga-
nizations) proposals to change standards or introduce guidelines
affecting nursing
practice. Finally, nurses can meet this obligation by (a)
educating other nurses to
utilize practice standards and hold them accountable for doing
so, (b) conducting
research on the efficacy of nursing interventions, and (c)
engaging in healthcare
system evaluation and design and implementing healthcare
systems of care that
are based on sound standards of practice.

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Guide to the Code of Ethics for Nurses 95

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Theresa S. Drought, PhD, RN, and Elizabeth G. Epstein, PhD,
RN PRovIsIon sEvEn

Interpretive statement 7.3: Advancing the Profession
through knowledge Development, Dissemination, and
Application to Practice
Nursing combines the art of caring with the science of health
care. The nursing pro-
cess is dependent upon theoretically sound and scientifically
proven methods that
embrace the goals of nursing: the prevention of illness, the
alleviation of suffering,
and the protection, promotion, and restoration of health in the
care of individuals,
families, groups, and communities. Research on the efficacy of
existing programs
and new ways of understanding disease, health, the human
response to illness, and
innovations in nursing care are necessary.

At first blush, it could be construed that this provision is quite
demanding and
requires nurses to be actively engaged in research. In truth,
maintaining a compe-
tent practice combined with ongoing self-education and the
utilization of results
from nursing research assures that this requirement is realized.
In the most basic
sense, this provision can be met by conscientiously reading
nursing journals to
be aware of new approaches in health care, incorporating
research-based inter-
ventions into professional duties, replacing outdated practices
with new ones
that have proven efficacy, attending clinical conferences, and
remaining open
to change in the work setting. At a higher level of involvement,
the nurse could
participate in journal clubs, practice development committees,

or regional spe-
cialty organizations to learn about new findings; facilitate
nursing research in the
work setting; or review current literature when developing
policies, procedures,
and programs. Finally, the nurse can actively engage in
knowledge development
by conducting formal, independent, or collaborative research to
find solutions to
problems encountered at work and contributing to the literature
that supports
nursing practice.

Applying Provision 7
The following examples demonstrate how, in a wide variety of
everyday nursing
practices, this provision might be applied.Co

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96 Guide to the Code of Ethics for Nurses

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

PRovIsIon sEvEn Theresa S. Drought, PhD, RN, and Elizabeth
G. Epstein, PhD, RN

Case Example 1

utilizing Particular Expertise
Elaine has been a clinical staff nurse in a busy neurology unit
for the past six years.

She is dedicated to her work and has developed especially good
skills in working with

families to communicate with and care for their loved ones who
are patients in the unit.

She has pursued educational opportunities to continue to
develop this expertise and is

active in the regional chapter of a neurology specialty

organization.

There are several ways that Elaine could advance the nursing
profession through

leadership as discussed in Interpretive Statement 7.1. She could
serve as a mentor

for new nurses in the neurology unit who are learning how to
teach family members

to provide care for their loved ones. She could coordinate a
collaborative effort with

other nurses, social workers, and physicians (see Provision 8) to
create an educational

in-service on techniques effective in teaching families how to
provide daily care. She

could work within the hospital system to amend the discharge
documentation, so that

it includes specific competencies families must be taught prior
to a patient’s discharge.

Elaine could also extend her leadership into the health policy
arena. She could pro-

vide testimony at legislative and budgetary hearings regarding
state and federal support

programs for the neurologically impaired. Her knowledge and
unique perspective on the

needs of family members providing care to neurologically

injured patients would be a

valuable contribution to decisions on programs affecting this
population. In these ways,

Elaine would be taking the lead in improving care for neurology
patients and advancing

the profession by exemplifying nursing’s unique abilities in
caring for this population.

Elaine’s activities provide challenges and opportunities for
other nurses as well.

Elaine’s manager is affected by what Elaine does on the unit
and in the public arena.

Interpretive Statements 7.1 and 7.2 acknowledge that nursing
administrators should

“foster an employment environment that facilitates nurses’
ethical integrity and profes-

sionalism” as well as “establish, maintain, and promote
conditions of employment that

enables nurses…to practice in accord with accepted standards of
nursing practice.” In

this way, Elaine’s manager is pivotal to the utilization of
knowledge on the unit. In an

effort to make the most of Elaine’s interests and skills, the
nurse manager of the unit

could involve Elaine in writing a hospital policy addressing

educational programs with

families. The profession is advanced when efforts to promote
unit standards of nurs-

ing care are formalized in these types of guidelines. Involving
other nurses in these

processes can create a unit culture that values both individual
expertise and shared

development of practice.

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Guide to the Code of Ethics for Nurses 97

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Theresa S. Drought, PhD, RN, and Elizabeth G. Epstein, PhD,
RN PRovIsIon sEvEn

The commitment on the part of a manager who engages staff in
these activities cre-

ates a culture of excellence that can influence administrative
decisions in the unit and the

larger organization. The nurse manager recognizes the fact that
teaching families how to

feed, dress, and move the patient takes time and practice, but
she prioritizes this teach-

ing as an important aspect of nursing care. The profession is
advanced when staffing

decisions accommodate the time needed for this type of
teaching to be accomplished.

The manager’s decisions have the potential to influence broader

organizational policies

as the values of nursing expertise and effective practice are
recognized and supported.

The organization can also be directly or indirectly involved in
Elaine’s activities out-

side of the unit. If Elaine chooses to become involved in the
health policy arena, she

may need some flexibility in her work schedule. This can
present a dilemma for the

manager who is charged with seeing to the needs of the patients
on the unit. However,

the administration’s support of Elaine’s activities has the
potential to benefit patients

indirectly, advance the nursing profession generally, and
provide positive public rela-

tions for the organization. Accommodating her schedule and
publicizing her activities

advances the culture of professionalism within the organization
by explicitly acknowl-

edging the contributions of nursing. O

Case Example 2

the nursing Instructor and the struggling student
Melissa is an instructor in the Nursing Skills Lab. She notices
that a fourth-year student

has fallen behind in her assignments and is not demonstrating
competence in her clinical

nursing skills. As outlined in Interpretive Statement 7.1, nurse
educators “have a specific

responsibility to enhance students’ commitment to professional
and civic values.” The way

Melissa chooses to interact with this and other students should
be guided by Provision

7. Interacting with her students in a respectful and professional
manner will influence

their perception of professional behavior and can serve to
advance or hold back the

profession. A professionally responsible way for Melissa to
address the student’s diffi-

culties would be to contact her outside of the lab in order to
discuss why she has fallen

behind and what needs to be done to correct the problem. By
doing this, the student is

acknowledged as a valued member of the class while being held
accountable for her

work. Melissa demonstrates her commitment to professional
values through the sensi-

tivity and professionalism with which she approaches her
students as well as the way

she holds them accountable. The student and Melissa both have
important obligations

that affect the advancement of the profession; the student’s
commitment to the nursing

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98 Guide to the Code of Ethics for Nurses

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

PRovIsIon sEvEn Theresa S. Drought, PhD, RN, and Elizabeth
G. Epstein, PhD, RN

profession may be strengthened by knowing that Melissa is an
advocate who will help

her work through problems. Modeling ways of problem solving,
providing supportive and

respectful help, and maintaining boundaries of accountability,
demonstrate a skill-set the

student may draw upon in the future.

However, Interpretive Statement 7.2 also states that the nurse
educator should pro-

mote and maintain standards of nursing education and should
ensure that nursing gradu-

ates are fully prepared and competent. Keeping this in mind,
Melissa has some serious

responsibilities to consider. As stated in Provision 2, Melissa’s
primary responsibility is

to the patient, so this commitment affects how she handles
students’ difficulties in skills

lab. There are several courses of action that could be followed:
she could coach the

student, give her extra time to complete assignments when
necessary, or work with her

on a remedial basis; she could fail the student for this course
and allow her to repeat

it; or she could recommend that the student be released from the
program. Melissa’s

actions will depend in large part on the level of the student’s
commitment and ability.

What is most important, however, is that, whichever option is
followed, the standards

and professionalism of nursing practice are upheld. O

Case Example 3
complacency in the nIcu
Deborah is a newborn intensive care (NICU) nurse. She is
skilled at feeding and caring

for medically stable infants, but is much less proficient with
infants who are critically ill

or whose condition changes rapidly. Deborah has a reputation in
the NICU that she can

teach almost any infant to take oral feedings. As one physician
says, “She can success-

fully feed a rock.” She almost never reads the professional

journals and argues that her

hands-on experience is more relevant than any research article
could ever be. Several

of her colleagues agree. They say, “What’s the use, anyway?
There are no incentives

to read articles and use what we learn on this unit!”

The manager in the NICU is distressed to overhear this
conversation, especially

since a recent analysis showed that this NICU’s mortality rates
are moderately worse

than other units of similar size and acuity. She resubmits a
request to hire a Clinical

Nurse Specialist (CNS) that she had submitted six months
earlier and drafts a report to

the nursing vice president to support her request citing the
urgency of the situation. O

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Guide to the Code of Ethics for Nurses 99

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Theresa S. Drought, PhD, RN, and Elizabeth G. Epstein, PhD,
RN PRovIsIon sEvEn

There are several questions to ask:

u Do the attitudes of Deborah and the other nurses
in the unit advance the
profession?

u What are the obligations of the manager

and the future CNS in this
situation?

u Could the unit mortality rate be decreased if
the nurses took a more active
role in advancing the profession?

Although she provides excellent care for some infants and may
even be revered
for her ability to feed the difficult ones, Deborah is not
upholding Provision 7.
While it is not necessary for Deborah and her colleagues to
participate actively
in knowledge development if they lack the preparation, skill, or
inclination, they
are responsible for disseminating and applying new knowledge
in their practice.
Despite the fact that Deborah has not found research to be
relevant, she still has
valuable input to share, so long as she has read and seriously
critiqued the articles.
When reading a research article, it is important for the nurse to
critique the meth-
ods and results because the utility and practicality of the
findings must be evalu-
ated. It is also important, however, to think more deeply about
the implications of
the findings. Is a new technique worth trying in a certain
population? Is an article
worth discussing with colleagues? Deborah and her colleagues
are not advancing
the nursing profession through knowledge development by
dismissing every article
they have ever read as useless. Relying on skills learned years
ago is not acceptable
in today’s practice environments where advances in technology

and standards of
practice are constantly being achieved.

What can the manager and the new CNS do to improve the staff
’s advancement
of the nursing profession through active contributions to
knowledge development?
First, they may start a journal club. The CNS could choose a
relevant article and
have a roundtable discussion once a month. Results of this
discussion could be
posted in a central location for all staff to see. While it may not
be well received
at first, repeated exposure to relevant journal articles and
productive discussions
of them may help staff realize the benefits of staying up-to-date
on the latest skills.
Second, the manager could address the lack of incentive to use
newly learned skills
and knowledge by recruiting Deborah to work with the CNS to
develop a Feeding
Preemies Tips guideline for the nursing staff. It should be noted
that Deborah
might have something to contribute to the nursing literature on
feeding infants
and that this might be a good point for motivation to begin
researching the nurs-
ing literature, starting with the subject of feeding infants, and
then nursing issues
in general. A staff meeting to explore ways to engage the nurses
in reviewing

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100 Guide to the Code of Ethics for Nurses

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

PRovIsIon sEvEn Theresa S. Drought, PhD, RN, and Elizabeth
G. Epstein, PhD, RN

professional standards data and their relation to the quality of
care might stimulate
the staff ’s interest in learning about what constitutes state-of-
the-art practice and
could also serve to improve morale. The manager could act as
an advocate for the
nursing staff by appealing to the hospital administration
regarding monetary sup-
port for attending regional conferences. The CNS could work to
initiate research
in the unit that utilizes the expertise already present while
encouraging the nurses
in a way that promotes respect for the value of knowledge
development

Although the unit’s mortality data do not imply that the nurses
are providing
substandard care, the facts should motivate them to consider
whether their gen-
eral complacency about the value of research has caused them to
miss important
new techniques or approaches that would have a tangible effect
on patient care.
Blame cannot be placed on any one individual, but the
cumulative effect of indiffer-
ence to advancement of the profession by the staff, the manager,
and nursing vice
president has the potential to cause real harm to patients. The
actions of nurses
in higher levels of administration are directly implicated when a
culture of com-
placency and uninformed practice exists.

Summary
Provision 7 has evolved from a statement that identifies the
nurse’s obligation to

contribute to the “ongoing development of the professional’s
body of knowledge”
to a statement that acknowledges the interdependence of the
different nursing
roles, recognizes the reciprocal obligations of the nurse to the
profession and vice
versa, and gives credence to the multifaceted complexities of
contemporary nursing.
The current provision extends beyond the obligation to
contribute to knowledge
development alone and includes other activities that serve to
advance the nursing
profession within education, administration, and even civic life.
In doing so, the
Code of Ethics now recognizes that (a) knowledge development,
education and
administration are intertwined, (b) each area can make
important contributions
to nursing, and (c) not all nurses have an interest in knowledge
development via
research, but each individual nurse has special interests and
talents that can and
should be used to advance the nursing profession. Provision 7 is
now relevant for
all nursing roles and is applicable to all individual nurses.

This provision encourages individual nurses to use their own
talents and interests
to create the moral link between their personal life, their
individual practice, and
the nursing profession as a whole. Provision 7 does not obligate
nurses to actively
engage in education, administration, and knowledge
development. In fact, it is sel-
dom possible for an individual nurse to excel in all three areas.
More often, nurses

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Guide to the Code of Ethics for Nurses 101

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from

the publisher.

Theresa S. Drought, PhD, RN, and Elizabeth G. Epstein, PhD,
RN PRovIsIon sEvEn

are drawn to one particular area and can make significant
contributions in that
area. Provision 7 welcomes the individuality of each nurse. The
three interpretive
statements discussed in this chapter highlight the multiple ways
in which nurses can
contribute to the advancement of the profession, whether
through participation in
health policy application and development, engagement in the
refinement of pro-
fessional standards, or through the development, dissemination,
and adaptation of
knowledge. In this way, individual nurses can fulfill their
obligations to themselves
while contributing to the advancement of this vital profession.

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American Nurses Association (ANA). 1999. The National

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American Nurses Credentialing Center (ANCC). 2007.
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Freidson, E. 1988. Professional Powers: A Study of the
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Greenwood, E. 1957. Attributes of a profession.
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Joint Commission on Accreditation of Hospital Organizations.
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Miller, B.K., D. Adams, and L. Beck. 1993.
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National Institute of Nursing Research. 2007.
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Pavalko, T.M. 1971. Sociology of Occupations and
Professions. Itasca, IL: Peacock.

Pew Charitable Trusts. 2007. http://www.pewtrusts.com/.

RAND Corporation. 2007. Health and health
care research area. http://www.

rand.org/ research_areas/health/.

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http://www.certcorp.org/certcorp/certcorp.nsf/vwdoc/SynModel
?opendocument
http://www.jointcommission.org/PatientSafety/NationalPatientS
afetyGoals/
http://www.rand.org/research_areas/health/

102 Guide to the Code of Ethics for Nurses

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

PRovIsIon sEvEn Theresa S. Drought, PhD, RN, and Elizabeth
G. Epstein, PhD, RN

Robert Wood Johnson Foundation. 2007.
Nursing interest area. http://www.rwjf.
org/ portfolios/interestarea.jsp?iaid=137.

Roberts, J.I., and T.M. Group. 1995. Feminism and
Nursing: An Historical
Perspective on Power, Status, and Political
Activism in the Nursing Profession.
Bloomington, IN: Indiana University Press.

Rogers, A.E., W. Hwang, L.D. Scott, L.H. Aiken,
and D.F. Dinges. 2004. The
working hours of hospital staff nurses and patient
safety: Both errors and
near errors are more likely to occur when
hospital staff nurses work twelve or
more hours at a stretch. Health Affairs 23(4):
202–212.

Rothschild, J.M., A.C. Hurley, C.P. Landrigan, J.W.
Cronin, K. Martell-Waldrop,
C. Foskett, E. Burdick, C.A. Czeisler, and D.W.
Bates. 2006. Recovery from
medical errors: the critical care nursing safety
net. Joint Commission Journal

on Quality & Patient Safety 32(2): 63–72.

About the Authors
Theresa S. Drought, PhD, RN, is currently an Assistant
Professor at the University
of Virginia School of Nursing. She has long been interested in
the ethical issues related
to professionalism in health care, serving as a nurse consultant
to the California
Medical Association’s Council on Ethical Affairs, chair of the
ANA\C Ethics Committee
(ANA/California), and as a member of the American Nurses
Association Task Force
that produced the 2001 Code of Ethics for Nurses. Her
publications and research
address issues of professionalism and ethics in nursing and end-
of-life decision making.
Her current research focuses on decisions made by stranger
surrogates. She received
her PhD in nursing from the University of California at San
Francisco in 2000.

Elizabeth G. Epstein, PhD, RN, received her PhD in Nursing
from the University
of Virginia in 2007. In August 2007, she took a position as
Assistant Professor at the
University of Virginia School of Nursing. Her doctoral
dissertation and continuing
interests are in ethics and end-of-life issues in the pediatric
setting. In particular,
she is interested in studying moral distress and moral
obligations among healthcare
providers, as well as determining how care-based ethics is
evident in pediatric end-
of-life care. She is a member of the American Society for
Bioethics and Humanities.

She serves as a facilitator for Conversations in Clinical Ethics,
a multidisciplinary
group at the University of Virginia that meets to discuss ethical
issues that arise in
the hospital setting.

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© 2008 American Nurses Association. All rights reserved. No

part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

103

The nurse collaborates with other health professionals

and the public in promoting community, national, and

international efforts to meet health needs.

Provision
Eight

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104 Guide to the Code of Ethics for Nurses

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Provision Eight
Mary C. Silva, PhD, RN, FAAN

In the 16 years between the publication of the 1985 ANA Code
for Nurses with
Interpretive Statements and the publication of the 2001 ANA
Code of Ethics for
Nurses with Interpretive Statements, the world, its ethnicity, the
healthcare sys-
tem, the nursing profession, and the conceptualizations of ethics
within nursing
have changed mightily (Haidt et al, 2003; Manglitz, 2003).
Advances in science
and technology have increased globalization; cultural diversity
in the United States
and elsewhere has proliferated; new systems of care have
altered how health care is
delivered; nursing shortages have affected the profession; and

approaches to ethics
previously less visible (i.e., feminist, communitarian, and social
ethics) have made
their way into the nursing mainstream.

Although Provision 11 of the 1985 Code for Nurses and
Provision 8 of the 2001
Code of Ethics sound similar, except for the addition of the
word international,
the interpretive statements of Provision 8 have changed
substantially based on the
factors noted above. Both interpretive statements mention
nurses’ commitment
to meeting health needs; however, the 2001 Code clearly
specifies that the nurse’s
commitment extends beyond specific individual patients’ needs:

The nurse has a responsibility to be aware not only of specific
health needs
of individual patients but also of broader health concerns such
as world hunger,
environmental pollution, lack of access to heath care, violation
of human rights,
and inequitable distribution of nursing and healthcare resources
[italics
added] (ANA, 2001; p. 23)

In addition, the 2001 Code also takes note of many of the causes
of disease or
trauma including “barriers to health, such as poverty,
homelessness, unsafe living
conditions, abuse and violence, and lack of access to health
services” [italics added]
(p. 24). With the exception of access to health care, none of
these barriers were
specified in the 1985 interpretive statement for this provision.

The interpretive statements in this revision also address another
important con-
cept that was omitted in the 1985 Code: cultural diversity and
the nurse’s responsi-
bility to respond to it. According to Provision 8 of the 2001
Code:

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Mary C. Silva, PhD, RN, FAAN PRovIsIon EIght

The nurse also recognizes that health care is provided to
culturally diverse
populations in this country and in all parts of the world. In
providing care, the
nurse should avoid imposition of the nurse’s own cultural
values upon others.
The nurse should affirm human dignity and show respect for the
values and
practices associated with different cultures and use approaches
to care that
reflect awareness and sensitivity (ANA, 2001; p. 24).

Clearly the world has changed and nursing’s awareness of the
moral dimensions
of those changes is reflected in this revision of the Code.

Major Ethical Tenets Underlying Provision 8
The current literature contains many books and articles, both
theoretical and
applied, related to ethical tenets (Baily, 2003; Bodenheimer,
2003; Diekelmann,
2002; Veatch, 2003) and to the relationship between ethics and
public health
(Callahan and Jennings, 2002; Levin and Fleischman, 2002;
Oberle and Tenove,

2000). Nurses, however, are most familiar and comfortable with
ethical principles
as set forth by Beauchamp and Childress (2001). In fact, the
principle of respect
for persons as well as the principles of autonomy, beneficence,
nonmaleficence,
justice, truth telling, promise keeping, and confidentiality
formed the ethical bases
for the 1985 Code. To these principles, nursing ethics are now
concerned with other
approaches, including a variety of critical social theories, such
as critical (Frankfurt
School), postcolonial, feminist, and communitarian social
ethical theories, which
are reflected in this revision of the Code.

Feminist Ethics
For many reasons, nurses have been reluctant to embrace
feminism and its eth-
ics. One reason may be a lack of self-awareness of the biases
that are adopted by
nurses from dominant culture or even the medical system itself.
These are biases
that may perpetuate social injustices rooted in gender, racial, or
class distinctions.
Another reason may be the negative stereotypes that extremists
have unfortunately
given to all forms of feminism.

Feminists (who may be women or men) are concerned about the
barriers that
close doors and, thus, systematically discriminate against or
devalue women as a
group. Many feminists are also concerned about systematic
discrimination against
men. Thus, the goal of feminism for many proponents is to

examine the societal
values and structures that cause oppression primarily to women,
but also to men
on the basis of gender, and to take constructive social action
against them in order

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

PRovIsIon EIght Mary C. Silva, PhD, RN, FAAN

to promote better relationships between women and men and
contribute to a more
just society.

The shift from feminism to feminist ethics is almost seamless.
According to
Volbrecht: “Feminist ethics strives for social transformation
that will empower
all people to live freer, fuller lives” (2002, p. 162). Obviously,
the societal factors
listed in the new interpretive statement, such as world hunger,
cultural imposition,
lack of access to health care, human rights violations,
homelessness, poverty, and
violence, do not empower “all people to live freer, fuller lives.”
Each of the preced-
ing factors represent ethical, feminist, and nursing concerns.

Feminist ethics also focuses on the belief that the voices of
women should be
heard and be given due weight in any theoretical formulations
or practical appli-
cation of ethics. Perhaps the best known work about these
voices was penned
by Carol Gilligan (1982). Gilligan wrote about a theme that
women’s voices address,
one of responsibility for and a connection to others sustained

through caring
relationships.

This so-called ethics of care has had a profound influence on
ethical thinking
in nursing. Nurse proponents view caring as the essence of the
ethical ideal of
nursing. Although most often applied to individual, family, and
small group
relationships, one also can apply the concept of caring to the
social concerns
expressed in Provision 8. Although most nurses would agree
that caring about
patients is important, some nurses would not consider caring the
essence of
nursing. The reasons for this include: (a) nursing is not the only
profession that
cares, and (b) caring is not viewed as an empowering concept by
persons in
powerful positions that influence healthcare priorities and
practice.

communitarianism
Until recently, individualism dominated ethics in most of the
Western world,
particularly in the United States. This individualism can be seen
in the prior-
ity given the ethical principle of respect for autonomy and
individual rights.
However, within the past three decades, there has emerged a
movement away from
an excessive focus on what is good for the individual to a more
balanced empha-
sis on what is good for the community as well. According to
Beauchamp and
Childress, communitarians believe that “everything fundamental

in ethics derives
from communal values, the common good, social goals,
traditional practices,
and cooperative virtues” (2001, p. 362). In other words, the
good of the
community—whether one’s local community or the world
community—takes

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Mary C. Silva, PhD, RN, FAAN PRovIsIon EIght

precedence over the good of the individual, whether embodied
by personal rights
or individual autonomy. Some communitarians, however, take a
more moder-
ate stance in that they believe that the good of the community
and personal
rights and individual autonomy should both be considered to
ensure checks and
balances against the excesses of either. In keeping with the
preceding stance,
Provision 8, with its emphasis on “promoting community,
national, and interna-
tional efforts to meet health needs” (ANA, 2001; p. 23) takes
note of individuals’
health needs, but emphasizes broader health needs that
transcend individuals
and affect the world community (e.g., hunger, poverty,
violence).

social Ethics
For many scholars, social ethics is grounded in the discipline of
sociology. Here is
what two medical sociologists have to say:

We believe that sociology provides the most direct answer to

the question,
“Why bioethics?” The critical, relativizing stance of sociology
allows us to see
bioethics in the sweep of history and the context of medicine
[health care]
and society. A sociological approach lifts bioethics out of its
clinical setting,
examining the way it defines and solves ethical problems, the
modes of reason-
ing it employs, and its influence on medical [health care]
practice. (DeVries
and Subedi, 1998; p. xiii).

Whereas much of traditional bioethics has had a more narrow
focus (e.g., on
clinical ethical issues), social ethics focuses on the “social
bases of morality” (DeVries
and Subedi, 1998; p. xiv). It applies such concepts as race,
culture, roles, norms,
customs, class, social institutions, and power to the social
construction of moral
issues within “the economic, political, religious, and
institutional forces of a given
historical period” (Light and McGee, 1998; p. 9).

This broad view of moral issues is integral to Provision 8.
Nurses cannot holis-
tically understand the moral issues inherent in such global
healthcare problems
as hunger, poverty, and violence without a strong grasp of the
social forces
that contribute to these problems. Herein nurses have an
advantage; they are
educated to understand and apply sociocultural and ethical
concepts in their
practice. Provision 9 emphasizes nursing’s role in social ethics

through its
professional associations.

In summary, in order for readers to better understand the ethical
tenets under-
lying Provision 8, three interrelated perspectives were briefly
discussed: feminist

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

PRovIsIon EIght Mary C. Silva, PhD, RN, FAAN

ethics, communitarianism, and social ethics. What all three
perspectives have in
common is a focus on ethics that incorporates a larger societal
picture of what
constitutes morality.

Research on Ethical Issues
Related to Provision 8
Public and global health nursing and the research conducted in
these special-
ties are intrinsically related to this provision. Oberle and
Tenove analyzed data
from Canadian public health nurses, looking for ethical themes
that could be
found throughout their interviews. The five themes that emerged
were as follows:
(a) “relationships with healthcare professionals; (b) systems
issues, such as staffing
patterns; (c) character of relationships, such as knowing patients
more broadly in
smaller communities; (d) respect for persons, including being
nonjudgmental; [and]
(e) putting self at risk” (Oberle and Tenore, 2000; p. 428). The
authors concluded
by saying that there are many ethical concerns in public health

nursing and that a
systems approach supportive of ethical practice is necessary.
The themes that they
uncovered correlate well with several concepts in Provision 8:
need “for interdisci-
plinary planning and collaborative partnerships among health
professionals “ (p.
23); “promoting health, welfare, and safety of all people” (p.
23); “support of and
participation in community organizations and groups” (p. 24);
and “health care is
provided to culturally diverse populations” (ANA, 2001; p. 24).

The conclusions of this study support the research of Cooper
and colleagues
(2003). Theirs was an administrative ethics study conducted in
the United States.
The purpose of the study was to identify the ethical helps and
challenges that
managerial nurse leaders encounter in practice.

The three highest ranked ethical helps were: (a) “Your own
personal moral values
and standards” (p. 18), (b) “The fact that your immediate boss
does not pressure
you into compromising your ethical standards” (p. 18), and “An
organizational envi-
ronment/culture that does not encourage you to compromise
your ethical values to
achieve organizational goals” (p. 18). These ethical helps are
based on the nurse’s
management style and an organizational culture that values
ethics. In such envi-
ronments, nurses are free to commit themselves to Provision 8’s
goal of “promoting
the health, welfare, and safety of all people” (ANA, 2001; p.

23).

The result ranked first for ethical challenges was “intense
competition in the
healthcare industry which forces owners, managers, and
supervisors to focus on
the bottom line and not on ethics” (Cooper et al., 2003; p. 20).
Other challenges

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Mary C. Silva, PhD, RN, FAAN PRovIsIon EIght

(ranked 2 through 20) constituted less than 52% of the
respondents’ replies. The
effects of negative social values and structure related to ethics
would make it dif-
ficult for tenets of Provision 8 to be implemented.

Theory and Application Related to
Public Health, Violence, and Ethics

theory
According to Provision 8 “… the nurse supports initiatives to
address barriers
to health … such as… abuse and violence” (ANA, 2001; p. 24).
Abuse and vio-
lence in health care have been addressed by many authors (e.g.,
Berman, 2003;
Diekelmann, 2002; Lee and Saeed, 2001; Mercy et al, 2003;
Volbrecht, 2002)
and is viewed as a form of oppression. Oppression is the use of
power in an unjust
manner and is often a catalyst for violence. Violence is a type
of oppression that
is a threat to mental, physical, social, economic, or spiritual
health. It can occur

at the individual, family, community, or societal levels.
Violence can be vertical,
which means it can be perpetrated by groups among themselves.
It is blind to
gender, income, race, class, age, institutions, political
viewpoints, or culture.

Violence is a health problem and, when focused on populations,
a public or even
global threat. According to Interpretive Statement 8.2, violence
presents “existing
threats to health and safety” (ANA, 2001; p. 24) of a
community. Violence needs
to be understood broadly. According to Diekelmann: “power,
violence, and oppres-
sion accompany, although inadvertently, some of the ‘best
practices’ of health care”
(2002, p. xviii). For example, the emphasis on cure in health
care that uses the best
that science and technology have to offer may do profound
physical, psychological,
economic, and spiritual violence to those persons who cannot be
cured. We call this
“harming patients in the name of quality of life” (Fletcher et al.,
2002; p. 3). The
phrase also can be applied to nurses, communities, or cultures.

Application
Application of Provision 8 of the 2001 Code has been
documented by Lee and Saeed
(2001) in their article entitled “Oppression and Horizontal
Violence: The Case of
Nurses in Pakistan.” After an excellent overview of forms of
oppression, the authors
discuss the following characteristics of oppressed groups as
identified by Kaiser (1990):

(a) harming of human dignity, (b) feeling hopeless and
powerless, (c) internalizing lies
and stereotypes, (d) infighting, and (e) engaging in horizontal
violence where members

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

PRovIsIon EIght Mary C. Silva, PhD, RN, FAAN

of an oppressed group do violence to other members of the same
oppressed group.
Though this particular study focused on Pakistani nurses,
horizontal violence occurs
among nurses worldwide, in both developed and developing
countries.

When Lee and Saeed focused on oppression and violence in
Pakistan, espe-
cially as it relates to women and nurses, the four categories of
assessment that
they developed are relevant to the assessment of oppression and
violence in any
country worldwide.

u Historical—Is there evidence that oppression is
present and has roots
in history? Are there events in a group’s past
that have legitimized the
oppression they experience?

u Cultural—Are there cultural taboos that marginalize
a group? Are certain
groups restricted in their participation in society?

u Political—Is the political system democratic and
wholly egalitarian, or are
equality and social justice only for select groups?

Does the political system
protect all groups from various forms of
oppression, or are there laws that
are oppressive in nature for particular groups?

u Economic—Are there classes that, due to low
socioeconomic status, are
oppressed? Are there groups that are privileged as a
result of their economic
status? (Lee and Saeed, 2001; pp. 19–21)

From these dimensions of assessment, they recommended the
following strate-
gies to reduce oppression and to empower nurses as
professionals and providers
of health care:

u Organize alliance-building groups to
critically analyze the roots and forms
of… oppression.

u Group analysis and problem solving to develop
strategies that will eliminate
the unequal power bases that exist.

u Authentic dialogue between nurses and their
primary oppressor groups
to examine circumstances in which nurses live
and work, and assist group
members to unlearn misinformation and oppressive
behaviors.

u Develop unity within the groups so that power
from within and power
without can be used to challenge the status quo.

u Reconceptualize power and use of these new
concepts in nursing practice,
education, and research.

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part of this book may be reproduced or utilized in any form or

any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Mary C. Silva, PhD, RN, FAAN PRovIsIon EIght

u Organize nurses into alliances to participate
in health-policy planning.

u Develop position papers regarding the quality of
basic and advanced
nursing education or nursing work life.

u Develop proposals for additional budget allocations
to nursing.

u Assisting in developing 5-year health
plans for… [one’s] country.

u Conduct research to define issues and
concerns. Research such as
determining exact numbers and describing the
health workforce in…
[one’s] country is one example.

u Develop a media campaign to educate the
public regarding the nursing
profession; address the negative images and
stereotypes that predominate,
expose the origins of these images, and stress
nurses’ unique contribution to
health care. (Lee and Saeed, 2001; p. 23)

How might feminist, communitarianism, and social
ethics further inform these

recommendations regarding nurse-to-nurse violence and its
environment? How do
these recommendations reflect the Code of Ethics—or
not? What moral guidance
can be drawn from the code that does or does not
support these recommendations?

Theory and Application Related to
Public Policy and Ethics

theory
According to Interpretive Statement 8.2, “the nurse…
participates in institutional
and legislative efforts to promote health and meet national
health objective” (ANA,
2001; p. 24). Institutional and legislative efforts to promote
health through public
policy and ethics (both explicitly and implied) have been
addressed by many authors
(American Public Health Association, 2002; Milo, 2002;
Milstead, 2003; Shapiro,
1999; Silva, 2002; Tett et al, 2003). According to Shapiro:

The relationship between bioethics and [healthcare] public
policy has become
a rather broad subject that asks a rather simple question;
namely, which
moral imperatives that arise out of the study and consideration
of bioethical
issues should be reflected in [healthcare] public policies that
govern us all.
(Shapiro, 1999; p. 209)

Although the question is rather simple, the answers are more
complex because of

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

PRovIsIon EIght Mary C. Silva, PhD, RN, FAAN

a lack of moral consensus on many healthcare ethical issues.
This lack of moral
consensus is partly due to social, cultural, legislative,
economic, political, religious,
and institutional diversity in the United States and elsewhere in
the world. Nurses
can choose to focus on what divides us or what unites us. Some
nurses, however,
choose to focus on what unites us.

Weston (2002) chooses to focus on what unites nurses. Here are
some of his
thoughts:

u For one thing, the diversity of values is
probably overrated. Sometimes values
appear to vary just because we have different beliefs
about the facts (p. 8).

u Whether values are ‘relative’ or not, there is no
way out of some good hard
thinking (p. 10).

u Struggle and uncertainty are part of ethics,
as they are part of life (p. 5).

u Rules can’t replace thinking (p. 25).

u Whether we admit it or not, we do make
our own [moral] decisions….
Choosing is inescapable (p. 28).

Weston’s thoughts give pause to nurses and other healthcare

professionals who
are involved in “institutional and legislative efforts to promote
health” (ANA, 2001,
Provision 8; p. 24) through public policy that incorporates
diversity.

Application
The application of Provision 8 has been documented by Sikma
and Young in
their 2003 article entitled “Nurse Delegation in Washington
State: A Case Study
of Concurrent Policy Implementation and Evaluation.” Policy
implementation
and evaluation are congruent with the applied core functions of
public and global
health nursing. In addition, the Sikma and Young article fulfills
the following
tenet of Provision 8 of the 2001 Code: “The availability and
accessibility of high
quality health services to all people require both
interdisciplinary planning and
collaborative partnerships among health professionals and
others at the com-
munity, national, and international levels” (ANA, 2001; p. 23).
In this particular
case study, the focus is at the community level.

According to Sikma and Young, the impetus for change
regarding registered
nurses’ delegation of tasks to assistive personnel caring for
disabled and older indi-
viduals in their homes was the result of “both the evolving
nature of societal needs
and values and the related dynamic changes in community
health nursing practice”
(Sikma and Young, 2003; pp. 53–54). The authors made clear

that such changes

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© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information

storage and retrieval system, without permission in writing from
the publisher.

Mary C. Silva, PhD, RN, FAAN PRovIsIon EIght

and the evaluation and research associated with them could not
have occurred by
themselves; instead, ongoing interdisciplinary planning and
collaborative partner-
ships were needed among special interest groups, public
stakeholders, and the state
of Washington.

The fact that policy implementation and health policy
evaluation occurred con-
currently made the research conducted by the authors more
difficult because the
preceding three stakeholder groups were involved with the
research. Some of the
special interest groups included professional organizations and
nursing unions.
Public stakeholders included senior and disability advocacy
groups, as well as the
general public. The State of Washington’s involvement included
senators and rep-
resentatives, along with their staffs, as well as a variety of state
analysts and others
associated with health, elder, disability, quality control, and
regulation and licensing
services. In all, a total of 54 stakeholders were involved,
including a joint House-
Senate oversight committee to endorse the evaluation research
plan and monitor
the study’s progress.

Some of the concerns of the stakeholders included preserving

and respecting
autonomy for seniors and disabled persons, ensuring safety of
those clients, and
safeguarding the scope of nursing practice. Other concerns
involved adequate
education of the caregiver staff and regulatory and
reimbursement issues. In addi-
tion, special interest stakeholders had so many concerns about
the policy research
expertise of the authors and of the study design that the
stakeholders requested
their own expert to evaluate the soundness of the evaluation
study. Fortunately,
the study was deemed sound, but the authors had to employ
several strategies to
ensure stakeholder credibility.

The strategies employed by the authors (Sikma and Young,
2003) included the
following: (a) “identifying stakeholders and their agendas” (p.
57); (b) “translat-
ing research designs and methods” (p. 57); (c) “working through
the politics of
the group” (p. 58); (d) “ongoing communication with
stakeholders” (p. 59); and
(e) “dissemination of results to multiple audiences” (p. 59). The
authors concluded
by saying:

This case study illustrates the complexities of collaboration in
policy evaluation
research and highlights an effective partnership between
researchers, policy
makers, providers, and consumers in shaping legislation that
addresses mul-
tiple goals (Sikma and Young, 2003; p. 60).

The legislation shaped was entitled An Act Relating to Long-
Term Care. The
goals accomplished were a practice change in the State of
Washington’s legislation

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© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

PRovIsIon EIght Mary C. Silva, PhD, RN, FAAN

regarding community health registered nurses’ task delegation
to assistive person-
nel caring for elders and persons with disabilities in their homes
and a concurrent,
rigorous policy evaluation of that change.

How might feminism, communitarianism, and social ethics
inform, challenge, or
guide the strategies employed by these authors? What ethical
principles are operative
in this project? What ethical principles might be in conflict?
What are the values
that nursing would assert in this project? How might the Code
of Ethics inform,
challenge, or guide this project and any that might arise from it?

Theory and Application Related to Culturally
Diverse Populations and Ethics

theory
Provision 8 emphasizes culturally diverse worldwide
populations, respect for persons
and their ways of life, and cultural values, imposition,
sensitivity, and competence.
The concepts of cultural diversity and competence as they relate
to health care have
been addressed by many authors (Campinha-Bacote, 2003;

Chaffee, 2002; Pratt,
2002), although the relationships among the preceding four
concepts and ethics
tend to be implicit. Other authors have helped to close the gap
between culture
and ethics by making the relationship between them more
explicit (Bennett et al.,
2003; Haidt et al, 2003; Pang et al., 2003). Nurses are already
familiar with the
concepts that underlie culture such as customs, beliefs, values,
norms, and so forth
that are learned, widely shared, and transmitted from generation
to generation
within a certain social group. Nurses attuned to cultural
diversity recognize and
appreciate the differences between and among these social
groups. Although many
definitions of cultural diversity exist, the more expansive ones
are more in keeping
with the spirit of Provision 8 of the 2001 Code and include race,
socioeconomic and
occupational status, religious affiliation, political orientation,
physical size, gender,
age, and language.

Of these factors, one in the current literature that has received
considerable
attention is race (Baldwin, 2003; Manglitz, 2003; Treadwell and
Ro, 2003). Overall,
the major concern expressed in this literature is that race affects
the nature of
health problems and the quality of healthcare that one receives.
Baldwin discusses
how some races have an increased likelihood of cancer,
diabetes, HIV/AIDS, and
cerebrovascular and cardiovascular diseases. In addition, many

culturally diverse
persons in the United State are blamed for their poor health and
their reluctance
to use the predominant white healthcare system. Why? Because,
according to

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Guide to the Code of Ethics for Nurses 115

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Mary C. Silva, PhD, RN, FAAN PRovIsIon EIght

Manglitz being “White in America” constitutes a historical and
social-cultural
construction of privilege that usually goes unrecognized by
whites, but not by
people of color. Manglitz continues: “We need to develop ways
to rearticulate
a way to be White without dominating and subjugating people in
the process”
(Manglitz, 2003; p. 131). Although race was highlighted here as
an example,
any of the faces of cultural diversity could address the concept
of privilege (e.g.,
gender, age, occupational status) that is capable of oppression
of other persons,
groups, or societies. A characteristic of privileged groups is that
they impose their
cultural values on others. Provision 8 of the 2001 Code clearly
states that cultural
imposition should be avoided. And yet, as indicated above, the
unrecognized impo-
sition of culture and its norms is an enormous impediment to
correcting health
disparities and other social injustices.

Application
Provision 8 also states that nurses should “show respect for the
values and practices

associated with different cultures and use approaches to care
that reflect aware-
ness and sensitivity” (ANA, 2001; p. 24). Two approaches
nurses can use that are
in keeping with this Provision are careful listening to clients’
stories about cultural
diversity and use of sensitive assessment tools to help ensure
cultural awareness.

The nurse’s careful listening to clients’ stories about cultural
diversity is a type
of caring practice that helps to reveal the ethics embedded
within the stories. Let’s
listen to a true story of a Saudi Arabian doctoral nursing student
studying in the
United States:

For my internship, I was placed in a senior retirement center. I
was sitting in a
meeting with the American daughter and son of potential new
residents. The
daughter was very excited; she was telling me a story about how
they finally
convinced their parents to sell their home and belongings so
that they could
move into a retirement center. The daughter’s mood was
exuberant and she
was smiling. She turned to me and said, “Isn’t this wonderful?”
I was totally
shocked and I knew that my face revealed horror. In my country
parents would
never be asked to sell their homes or possessions. No one would
speak to me
if I did such a thing to my parents. I cried all the way home
(Anonymous).

The preceding story is interesting because it offers an
opportunity to see how a
person from another culture views an increasingly acceptable
norm in American
society—the placing of elderly parents into senior retirement
centers. This scenario
raised no ethical concerns for the daughter and son, but was
clearly a violation of

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116 Guide to the Code of Ethics for Nurses

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

PRovIsIon EIght Mary C. Silva, PhD, RN, FAAN

the ethical principle of respect for persons, or, more
specifically, respect for parents
and elders, in the Saudi culture. Although difficult, the student
eventually was able
to accept the American daughter and son’s decision because she
recognized the need
to respond to others in light of their cultural values and norms
and not her own. In
addition to sensitive, discerning listening, Chaffee offers some
good, yet simple and
cost-effective, advice: “In today’s ‘global village,’ there is one
universally recognized
gesture: the smile” (2002, p. 98).

In reviewing the preceding information related to culturally
diverse populations
and ethics, the reader is challenged to apply feminist ethics,
communitarianism, and
social ethics to the issues of race, ethnicity, and cultural
diversity in our healthcare
system. What values, priorities and cultural norms have you
embraced that need to
be “uncovered”? Where did you learn them? Do they conflict
with nursing values

as articulated in the Code of Ethics, the Social Policy
Statement, and other ANA
documents? What values, priorities, and cultural norms has
American nursing
embraced that need to be “uncovered”? How are these norms
made manifest? How
would feminism, communitarian, and social ethics assess our
profession’s norms?

Implications of Provision 8
Implications of Provision 8 of the 2001 Code of Ethics for
Nurses with Interpretive
Statements are as follows:

u Nurses need to expand their understanding of
major ethical tenets
underlying Provision 8: feminist ethics,
communitarianism, and social
ethics. These are less familiar to nurses than
are classic ethical theories
and principles. Yet, Provision 8 deals with health
needs and nurses’
responsibilities to the world community; thus, ethical
tenets that incorporate
a global viewpoint are needed to ensure a
healthy world and its environment.

u Because Provision 8 focuses on global health
concerns (e.g., world hunger,
environmental pollution, inequitable health care,
homelessness, poverty)
that have profound implications for the world’s health,
nurses must be
well prepared to incorporate and apply public
health knowledge to their
practice. This knowledge must be progressive to

meet not only known
health concerns and threats, but those of the
future as well.

u Provision 8 states that a responsibility of
the nurse is to participate in
legislative efforts related to health. Nurses
must continue to be involved
in public policy initiatives that promote the public
good. Nurses must also
recognize that ethics is the foundation for the
public good.

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Guide to the Code of Ethics for Nurses 117

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Mary C. Silva, PhD, RN, FAAN PRovIsIon EIght

u Provision 8’s focus on respect for cultural
diversity is essential in a
heterogeneous country like the United States. Many
of our country’s
ills, as well as those of the world, are due to
an attitude of privilege or
even imperialism toward other people. This trait breeds
alienation that
profoundly affects the quality of health care of
those persons, communities,
or societies who feel that they are treated as second-
class citizens. Provision
8 of the 2001 Code of Ethics for Nurses clearly
states that the nurse has
an ethical obligation to be aware of and
sensitive to diversity. The nursing
profession and individual nurses must act on this
obligation regardless of
the nurse’s role or work setting.

u Increased research related to ethics is
needed on health needs, concerns,
and the nurse’s responsibilities to the public
discussed in Provision 8.

If nurses take to heart all of the ethical tenets,
concepts, and implications embed-
ded in Provision 8 of the 2001 Code, they will be
moved to “collaborate with other
health professionals and the public in promoting
community, national, and inter-
national efforts to meet health needs” (ANA,
2001; p. 4).

References

All online references were accessed in December 2007.

American Nurses Association. 1985. Code for Nurses with
Interpretive
Statements. Kansas City, MO: ANA.

American Nurses Association. 2001. Code of Ethics for Nurses
with Interpretive
Statements. Washington, DC: American Nurses Publishing.

American Public Health Association. 2002. Policy statements
adopted by the
Governing Council of the American Public Health Association,
October 24,
2001. American Journal of Public Health 92: 451–83.

Baily, M.A. 2003. Managed care organizations and the rationing
problem.
Hastings Center Report 33(1): 34–42.

Baldwin, D.M. 2003. Disparities in health and health care:
Focusing efforts to
eliminate unequal burdens. Online Journal of Issues in Nursing
8(1; January
31): Article 1. http://
www.nursingworld.org/ojin/topic20/tpc20_1.html.

Beauchamp, T.L., and J.F. Childress. 2001. Principles of
Biomedical Ethics, 5th
ed. New York: Oxford University Press.

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118 Guide to the Code of Ethics for Nurses

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

PRovIsIon EIght Mary C. Silva, PhD, RN, FAAN

Bennett, J.A., M.L. Fleming, L. Mackin, A. Hughes, M.
Wallhagen, and J. Kayser-
Jones. 2003. Recruiting ethnically diverse nurses to graduate
education
in gerontological nursing: Lessons from a successful program.
Journal of
Gerontological Nursing 29(3): 17–22.

Berman, H. 2003. Getting critical with children: Empowering
approaches with a
disempowered group. Advances in Nursing Science 26(2): 102–
13.

Bodenheimer, T. 2003. The movement for universal health
insurance: Finding
common ground. American Journal of Public Health 93: 112–15.

Callahan, D., and B. Jennings. 2002. Ethics and public health:
Forging a strong
relationship. American Journal of Public Health 92: 169–76.

Campinha-Bacote, J. 2002. Cultural competence in psychiatric

nursing: Have
you “ASKED” the right questions? Journal of the American
Psychiatric
Association 8(16): 183–87.

Campinha-Bacote, J. 2003. Many faces: Addressing diversity in
health care.
Online Journal of Issues in Nursing 8 (1; January 31): Article 2.
http://www.
nursingworld.org/ojin/topic20/ tpc20_2.html.

Chaffee, M.W. 2002. Communication skills for political
success. In Policy and
Politics in Nursing and Health Care, 4th ed., 93–107. St. Louis,
MO: Saunders.

Cooper, R.W., G.L. Frank, C.A. Gouty, and M.M. Hansen. 2003.
Ethical helps
and challenges faced by nurse leaders in the healthcare industry.
Journal of
Nursing Administration 33(1): 17–23.

DeVries, R., and J. Subedi, eds. 1998. Bioethics and Society:
Constructing the
Ethical Enterprise. Upper Saddle River, NJ: Prentice Hall.

Diekelmann, N.L., ed. 2002. First Do No Harm: Power,
Oppression, and Violence
in Healthcare. Madison, WI: The University of Wisconsin Press.

Fletcher, J.J., M.C. Silva, and J.M. Sorrell. 2002. Harming
patients in the name
of quality of life. In First, Do No Harm: Power, Oppression, and
Violence in
Healthcare, pp. 3–48. Madison, WI: The University of
Wisconsin Press.

Gilligan, C. 1982. In a Different Voice: Psychological Theory
and Women’s
Development. Cambridge, MA: Harvard University Press.

Haidt, J., E. Rosenberg, and H. Hom. 2003. Differentiating
diversities: Moral
diversity is not like other kinds. Journal of Applied Social
Psychology 33(1): 1–36.

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Guide to the Code of Ethics for Nurses 119

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Mary C. Silva, PhD, RN, FAAN PRovIsIon EIght

Kaiser, S. 1990. Issues of culture and oppression in
organizations. http://www.
bizgrowth. com/html.

Lee, M.B., and I. Saeed. 2001. Oppression and horizontal
violence: The case of
nurses in Pakistan. Nursing Forum 36(1): 15–24.

Levin, B.W., and A.R. Fleischman. 2002. Public health and
bioethics: The
benefits of collaboration. American Journal of Public Health 92:
165–67.

Light, D.W., and G. McGee. 1998. On the social embeddedness
of bioethics. In
Bioethics and Society: Constructing the Ethical Enterprise, pp.
1–15. Upper
Saddle River, NJ: Prentice Hall.

Manglitz, E. 2003. Challenging White privilege in adult
education: A critical
review of the literature. Adult Education Quarterly 53(2): 119–

34.

Mercy, J.A., E.G. Krug, L.L. Dahlberg, and A.B. Zwi. 2003.
Violence and health:
The United States in a global perspective. American Journal of
Public Health
92: 256–61.

Milio, N. 2002. Where policy hits the pavement: Contemporary
issues in
communities. In Policy and Politics in Nursing and Health Care,
4th ed., pp.
659–68. St. Louis, MO: Saunders.

Milstead, J.A. 2003. Interweaving policy and diversity. Online
Journal of Issues
in Nursing 8(1; January 31): Article 4.
http://www.nursingworld.org/ojin/
topic20/tpc20_4html.

Oberle, K., and S. Tenove. 2000. Ethical issues in public health
nursing. Nursing
Ethics 7: 425–38.

Pang, S.M., A. Sawada, E. Konishi, D.P. Olsen, P.L. Yu, M.F.
Chan, and N. Mayum.
2003. A comparative study of Chinese, American, and Japanese
nurses’
perceptions of ethical role responsibilities. Nursing Ethics
10(3): 295–311.

Pratt, G. 2002. Collaborating across our differences. Gender,
Place and Culture
9(2): 195–200.

Shapiro, H.T. 1999. Reflections on the interface of bioethics,

public policy, and
science. Kennedy Institute of Ethics Journal 9(3): 209–24.

Sikma, S.K., and H.M. Young. 2003. Nurse delegation in
Washington State:
A case study of concurrent policy implementation and
evaluation. Policy,
Politics, & Nursing Practice 4(1): 53–61.

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http://www.bizgrowth.com/html

120 Guide to the Code of Ethics for Nurses

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

PRovIsIon EIght Mary C. Silva, PhD, RN, FAAN

Silva, M.C. 2002. Ethical issues in health care, public policy,
and politics. In
Policy and Politics in Nursing and Health Care, 4th ed., 177–84.
St. Louis,
MO: Saunders.

Tett, L., J. Crowther, and P. O’Hara. 2003. Collaborative
partnerships in
commumunity education. Journal of Educational Policy 18(1):
37–51.

Treadwell, H.M., and M. Ro. 2003. Poverty, race, and the
invisible men.
American Journal of Public Health 93: 705–7.

Veatch, R.M. 2003. The Basics of Bioethics, 2nd ed. Upper
Saddle River, NJ:
Prentice Hall.

Volbrecht, R.M. 2002. Nursing Ethics: Communities in
Dialogue. Upper Saddle
River, NJ: Prentice Hall.

Weston, A. 2002. A Practical Companion to Ethics, 2nd ed.
New York: Oxford
University Press.

About the Author
Mary C. Silva, PhD, RN, FAAN, received her BSN and MS
from the Ohio State
University and her PhD from the University of Maryland. In
addition, she undertook
postdoctoral studies at Georgetown University. She has taught
healthcare ethics at
the master’s and doctoral levels and published extensively in
the area of ethics, begin-
ning in the 1970s. She is currently Professor Emerita at George
Mason University
in Fairfax, Virginia. Dr. Silva is also a Fellow in the American
Academy of Nursing.

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

121

The profession of nursing, as represented by associations

and their members, is responsible for articulating nursing

values, for maintaining the integrity of the profession and

its practice, and for shaping social policy.

Provision
Nine

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122 Guide to the Code of Ethics for Nurses

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

PRovIsIon nInE Marsha D.M. Fowler, PhD, MDiv, MS, RN,
FAAN

Provision Nine

Marsha D.M. Fowler, PhD, MDiv, MS, RN, FAAN

Many of the elements of this provision are found in previous
versions of the Code
of Ethics, as will be shown shortly. However, the inclusion of a
provision directed
toward the profession through its associations, rather than
toward the individual
nurse, is dramatically new. The provisions of all previous Codes
have been directed
toward individual nurses, most often the nurse at the bedside. In
the later revi-
sions, some attention was given to nurse researchers, and then,
in the most recent
Codes, to nurse educators as well. The 2001 Code expands to
include all nurses in
all nursing positions, as well as the profession itself. This shift
in the Code reflects
the ongoing shift in U.S. nursing practice, much as earlier
Codes reflected their time.
For instance, earliest modern nursing, after the Civil War, took
place in the home
as “private duty nursing,” in which nurses were hired by the
family. Private duty
nursing dominated nursing practice until World War II, after
which the majority
of nursing shifted from the home to the hospital and nurses
became employees of
the hospital, known as “general duty” nursing. Prior to this
shift, hospitals were
largely staffed by students. Even into the 1970s, there was a
remnant of private duty
nursing, often called “specialing,” within hospitals. Private duty
nursing within the
hospital context rapidly disappears after the late 1960s with the
advent of the cen-

tralization of illness care, the inception of intensive care units,
and the subsequent
specialization and subspecialization within nursing.

The effect that the location of nursing in the home had upon
codes of ethics
was that they were written for a nurse who did not receive
direct supervision and
who had to make clinical and moral decisions on her (mostly)
own. Confidentiality
received particularly heavy emphasis as the nurse was in a
position to observe the
goings-on within a family home. In this early period, many
nursing educators were
physicians, though a nurse was often the “superintendent” of the
nursing school.
The shift toward nurses as nurse educators was slow in coming,
accelerating after
WWII, and reaching completion by the 1970s. As for research,
the role of a nurse
researcher did not rise until well after the 1950s. Thus, early
codes would not have
“needed” to address nurse educators or nurse researchers, or, of
course, nurse prac-
titioners or nurses in nonstandard positions. This Code, then,
departs from previous

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Guide to the Code of Ethics for Nurses 123

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Marsha D.M. Fowler, PhD, MDiv, MS, RN, FAAN PRovIsIon
nInE

Codes by including all nurses in all nursing positions
individually and all nurses
collectively through nursing associations. This provision goes
farther and specifi-
cally focuses on the role of professional associations in social

ethics.

Social ethics may be defined as the domain of ethics that deals
with “issues of
social order—the good, right, and ought in the organization of
human communities
and the shaping of social policies. Hence the subject matter of
social ethics is moral
rightness and goodness in the shaping of human society.”1
There are three major
functions of social ethics, all of which fall within the
legitimate, if not essential,
sphere of the professional nursing association: reform of the
profession, epidictic
discourse (which is a type of public values-based speaking), and
social reform.2

The first function of social ethics—reform of the profession—
assures that the
profession itself keeps its own house clean. Reform seeks to
bring the profession
and its practice, goals, and aspirations into conformity with the
values that it holds
dear. At times, this necessitates change within the professional
community itself,
seeking to move the profession toward an envisioned ideal, to
bring the “ought” into
conformity with the reality of the profession’s lived expression.
This aspect of social
ethics demands an intentional, ongoing, critical self-reflection
and self-evaluation
of the profession based on a range of critical theories that can
assist in an incisive,
rigorous self-assessment of the profession.

“Epidictic discourse,” the second function of social ethics,

refers to a form of
communication that takes place within and for the group.
Unfortunately, epidictic
has no synonym in the English language. Epidictic discourse
refers to that kind of
speech that reaffirms and reinforces the values that the
community itself embraces,
especially when they are confronted by competing values. It
“sets out to increase
the intensity of adherence to certain values, which might not be
contested when
considered on their own but may nevertheless not prevail
against other values
that might come into conflict with them.”3 Epidictic discourse
is essentially a “ral-
lying cry” that reinforces the group’s values to and for the
group. It strengthens
the values that are held in common by the group and the
speaker, thus “making
use of dispositions already present in the audience.”4 Epidictic
discourse galvanizes
the group to employ the group’s cherished values in order both
to bring about the
changes elicited by the first function of social ethics, and to
move the group into
the third function of social ethics—speaking the values of the
group into society at
large to help bring about social change that is congruent with
the group’s values.5

Examples of epidictic speech in public address abound. A few
examples include:
Martin Luther King’s “I Have a Dream”; John Kennedy’s “Ich
bin ein Berliner”;
Franklin Roosevelt’s Pearl Harbor address to the Nation;
Douglas MacArthur’s

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any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from

the publisher.

PRovIsIon nInE Marsha D.M. Fowler, PhD, MDiv, MS, RN,
FAAN

farewell address to Congress; Patrick Henry’s “Give Me Liberty
or Give Me Death.”
Epidictic discourse is not solely the domain of famous men.
These women’s speeches
are excellent examples as well: Jane Addams’ “The Subjective
Necessity for Social
Settlements”; Susan Anthony’s “On Women’s Right to Vote”;
Eleanor Roosevelt’s
“The Struggle for Human Rights”; Sojourner Truth’s “Ain’t I a
Woman?”; and
Margaret Sanger’s “The Children’s Era.”

The third aspect of social ethics is that of social reform. In this,
the profession
critiques society and attempts to bring about social change that
is consistent with
the values of the group. For instance, if the group affirms
affordable, accessible
health care for all, it would assess the current state of the
healthcare system for
cost, distribution, and fairness of costs; access and ease of
access by all sectors of
society, including those with limitations such as mobility, age,
literacy, etc. and
including ethnic and minority constituencies; and openness of
the system to all,
including resident noncitizens, tourists, and others. It is
expected that all nurses
will be involved in this aspect of the profession’s social ethics.
However, the actual
implementation of social criticism and social change generally

depends upon collec-
tive action, usually through a professional association. In order
to engage in social
criticism and to bring about social change, the profession must
have knowledge
based in theories that can guide and deepen social analysis and
critique. Here
we often see postcolonial, feminist, liberation, Marxist, or
critical social theories
employed, both to assess and critique society as well as the
profession itself. (Note
that these are the same theories that would be used to critique
the profession
itself.) In order to bring about social change, these theories and
a knowledge of
political and policy processes becomes essential. The resources
of the professional
association, including its political action committees, would
then be drawn upon
to support action for social change. It is important for this
aspect of the profes-
sion’s social ethics that nurse educators include in nursing
curricula content on
ethics relating to issues of justice, social theories, nursing
history related to social
involvement of nursing and nurses, health policy formulation,
and the state and
federal political process. These three functions of social ethics
(reform within,
epidictic discourse, and social reform) are incorporated into the
first part of the
interpretive statement Assertion of Values.

Interpretive Statement 9.1: Assertion of Values
All three functions of social ethics are incorporated, in brief,
into this section. But

why this provision? Why any concern for social ethics in a code
of ethics for nursing?

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,

including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Marsha D.M. Fowler, PhD, MDiv, MS, RN, FAAN PRovIsIon
nInE

Nursing ethics in the United States has always been intimately
concerned with
the shape of society and its affect upon health and illness, that
is, with social ethics.
The profession’s historical and continuing involvement with
working for the health
of all is remarkable and it is the stuff of “pride of profession.”
This abiding concern
for social ethics is reflected in early nursing ethics curricula. In
1917, the National
League for Nursing Education (NLNE) established curricular
requirements for eth-
ics in nursing education within its Standard Curriculum for
Schools of Nursing. The
standard called for 10 hours of ethics instruction in the second
year, a number of
hours coequal to that of other major topics such as medical
nursing. The basic lec-
tures were to include content on ethical theory, personal ethics,
professional ethics,
clinically applied ethics, and social ethics.6 Topics to be
covered in the social ethics
content included “the social virtues” and “ethical principles as
applied to commu-
nity life.” State boards of registered nursing also specified
curricular requirements in
social ethics. The California State Board of Health’s Bureau of
Registration of Nurses
1916 curricular requirements in social ethics included:

“democracy and social ethics,”
“modern industry,” “housing reform,” and “the spirit of youth
and the city streets.”7

Interpretive Statement 9.2:
The Profession Carries Out Its Collective
Responsibility through Professional Associations
The social ethics of a profession is most often, though not
exclusively, exercised
through its professional associations; that is, through collectives
of nurses rather
than by individual nurses themselves. As a part of keeping our
own house, profes-
sional associations shepherd the creation and ongoing revision
of such core materials
as standards of practice, criteria for accreditation of nursing
educational programs,
certification processes, code of ethics, and social contract (such
as ANA’s Nursing’s
Social Policy Statement). Collectively, in nursing these are
intended to produce a
baseline of safe nursing practice as a measure of the
profession’s responsibility to
society to evaluate its practice and practitioners. The Code of
Ethics is a distinctive
kind of professional standard as it establishes moral guidelines
for members of the
profession and it publicly states the values of the profession.
The nursing profession,
through its first and official spokes-organization, the American
Nurses Association,
has always viewed the Code as having the utmost importance.

The history of the Code begins with the meeting of delegates
and representatives
of the American Society of Superintendents of Training Schools

for Nurses, who
convened to establish a professional association for nurses. The
Nurses’ Associated
Alumnae of the United States and Canada (later the ANA and
the Canadian

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

PRovIsIon nInE Marsha D.M. Fowler, PhD, MDiv, MS, RN,
FAAN

Nurses’ Associations, respectively) was formed and the articles
of incorporation
were written at that meeting. In the articles of incorporation,
they identified their
purposes, the first of which was “to establish and maintain a
code of ethics.”8 Thus,
establishing and maintaining a Code for the profession is the
premier task of the
Association. Two attempts to establish a Code (1926, 1940)
failed before the Code
for Professional Nurses was officially adopted by the ANA
House of Delegates in
1950. Subsequent to its adoption, the Code has undergone
revision approximately
every 10 years in order to remain morally responsive to the
context and setting of
nursing. Some revisions have been minor, others have been
major. With the incep-
tion of the inclusion of “interpretive statements,” the provisions
of the Code have
remained the same over long periods of time, while the
interpretive statements have
undergone substantial revision. That first Code and its
successive revisions publicly
made explicit the moral “contract between the profession and
society” as a part of

the profession’s overall accountability to society.

Interpretive Statement 9.3: Intraprofessional Integrity
This section of the provision’s interpretive statements alludes to
the fact that nursing
(like all social structures) is comprised of “meaning and value
structures,” as well as
“power structures.” The meaning and value structures of a
profession (as expressed by
its representative group, the professional association) are those
aspects of the nursing
association that embody the ideals, values, and ethics of the
profession. This would
include not only the Code of Ethics and the Social Policy
Statement, but also the ANA
Center for Ethics and Human Rights, the moral policies and
position statements pub-
lished by the Association, its ethics committees, and so on.
Meaning and value struc-
tures articulate the values, moral ideals, and moral requirements
of a group, and also
serve to inform and guide, critique—and sometimes to correct—
the goals, practices, or
activities of a profession. Meaning and value structures are
juxtaposed against power
structures, which are those social structures that embody,
utilize, or direct power in
any of its forms. Power comes in many forms, including
politics, economics, social
prestige, honor, respect, expertise, and authority. Power
structures enable a group to
achieve its goals. Without adequate meaning and value
structures, power structures
can exercise runaway self-interest. Without power structures,
meaning and values
structures are dead in the water. Meaning and value structures

must work recipro-
cally with power structures to advance the goals of a group in
accord with its ideals.9

To “encourage the professional organization and its members to
function in
accord with [its] values,” the professional association is to
“promote awareness
of and adherence to the Code of Ethics and to critique the
activities and ends of

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
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storage and retrieval system, without permission in writing from
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Marsha D.M. Fowler, PhD, MDiv, MS, RN, FAAN PRovIsIon
nInE

the professional association itself.”10 Awareness of the Code
begins, properly, in
early nursing education. Awareness is furthered by ANA’s
distribution of the Code
“bookmarks,” and other Code-related materials, and by posting
the full text of the
Code of Ethics with Interpretive Statements on the ANA
website.11 Promoting
adherence to the Code has taken a number of forms. In the
1960s, the ANA
actually formulated a document process and guidelines for
reporting what were
thought to be violations of the Code.12 The Guidelines open
with the quote:
“Unfortunately, there are always those whose ethical practice is
far less than accept-
able. Yet a profession must assume responsibility for
guaranteeing to the public that
all services rendered by its members are of high quality.”13
This document was not
subsequently revised and fell out of print. Today, adherence to

the Code is generally
fostered by “moral suasion;” that is, by persuasion and pressure
for adherence to
moral standards, which cannot be compelled or forced. The
moral consequences
of a proven violation of the Code are reprimand or censure by
the organization or
expulsion from membership. This does not necessarily affect a
nurse’s work-a-day
world as the consequences are limited to the nurse’s
relationship with the profes-
sional association. However, moral violations will affect one’s
stature, respect, and
honor among peers, and can affect self-respect.

The interpretive statement states that:

Legitimate concerns for the self-interest of the association and
the profession are
balanced by a commitment to the social goods that are sought.
Through critical
self-reflection and self-evaluation, associations must foster
change within them-
selves, seeking to move the professional community toward its
stated ideals.14

Bundled up in the phrase “legitimate concerns for the self-
interest of the asso-
ciation and the profession…” is a long history of concern for a
just and equitable
wage/salary for nurses. Previous Codes have emphasized
“working conditions”15 and
“conditions of practice conducive to high quality nursing
practice,”16 as well as “the
importance of working conditions to recruitment to nursing, and
the social stature

of the profession.”17 The more immediate and pressing concern
underneath these
statements, however, has been for just wages/salaries for nurses.

The Suggested Code of 1926 is rather more direct:

Economic independence is admittedly one of the first duties of
every citizen...
Self-realization and the most complete development of
individual capacities
are the ideals of present-day society for all of its members.
There is no ground
for expecting the nurse to be an exception to this rule nor its
corollary that
self-development can best be nurtured in the soil of economic
self-respect...

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

PRovIsIon nInE Marsha D.M. Fowler, PhD, MDiv, MS, RN,
FAAN

[but] no worker is welcome to the ranks of nursing who does not
put the
ideal of service above that of remuneration.18

The Tentative Code of 1940 makes statements that give an
underlying view of
some of the problems nurses faced:

In some instances, the economic status of the patient
undoubtedly will
command the gratuitous services of nurses; but the officers of
endowed
institutions or hospitals...have no claim upon the nurse for
unremunerated
services....If an institution organized to provide adequate

service for the
sick, including nursing care, for any reason cannot fulfill this
obligation, it
should not expect to commandeer the unremunerated, or
markedly under-
paid, services of nurses.19

This is a snapshot of a problem faced by nurses in the 1940s
(and earlier).
This, of course, does not happen today. Or does it? There is no
moral difference
between the picture given by the Tentative Code and institutions
today that expect
“the unremunerated, or markedly underpaid, services of nurses”
by denying nurses
“overtime” pay, while expecting overtime service. Provision 9
of the 1950 Code
states: “the nurse has an obligation to give conscientious
service and in return is
entitled to just remuneration.”20 Indeed. However softened by
the “work condi-
tions” language in the 1960 Code and later versions, issues of
just compensation,
“economic self-respect,” salary-compression, gender equity,
work equivalency
salaries, and a “savings plans which will bring her financial
security in old age”
still loom large for the nursing profession.

The interpretive statement also calls for “critical self-reflection
and self-evalua-
tion” of associations to “foster change within themselves,
seeking to move the pro-
fessional community toward its stated goals.”21 Historically,
the American Nurses
Association has been involved in self-reflection and social

change.

In the late 1800s and early 1900s, when the United States
engaged in the legal
enslavement of racial minorities, women were legally defined as
chattel and denied
suffrage, and gender-based social roles were rigidly defined
with the legal exclusion
of women from some roles (e.g., physician); there were laws
against teaching about
or possessing contraceptives, little or no protection of children
in sweat shops under
labor laws, and no laws against domestic violence or animal
cruelty. Eventually,
American society came to address these ills in at least some
modest measure, though
remnants of some remain today, over 125 years later. The
nursing association that
formed 107 years ago has worked for the correction of some of
these ills.

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Marsha D.M. Fowler, PhD, MDiv, MS, RN, FAAN PRovIsIon
nInE

The Tentative Code states that “a truly professional nurse with
broad social
vision will have a sympathetic understanding of different
creeds, nationalities, and
races and in any case she will not permit her personal attitude
toward these vari-
ous groups to interfere with her function as a nurse.”22 In the
adopted 1950 Code,
it states in the preamble that: “Need for nursing is universal.
Professional service
is therefore unrestricted by considerations of nationality, race,

creed, or color.”23

Successive codes reiterate this basic position and even enlarge
it to encompass a wide
range of other forms of social disadvantagement, stigma,
prejudice, and oppression.

At one point, however, these statements were not in alignment
with the cur-
rent situation of society, which still permitted and, sometimes,
legally authorized
various organized social manifestations of prejudice. At that
time, the profes-
sional association operated on a federated model where the
parent organization
did not have members, rather nurses were members of state
nurses associations
(SNAs) which simultaneously conferred American Nurses
Association (ANA)
membership. States established their own criteria for
membership. Some of these
constituent states had denied membership in the organization to
those who were
fully qualified, but were of African descent, in whole or in part.
The Association
could not control the state associations’ criteria for
membership. What ought
the Association do? Alternatives were for the Association to
ignore the situation
and proceed as usual. It could have also changed its
organizational structure, a
massive undertaking, or revised the then current Code. What
ought the Association
to have done?

Nursing as a profession has long espoused a principal of

egalitarianism, even
when society openly permitted or even authorized a wide range
of prejudicial
“isms”: racism, sexism, sectarianism, etc. This, of course, flew
in the face of the
societal reality of dramatic social inequalities. In a profession
that has remained
predominantly Anglo, Christian, and female, this persistent
egalitarianism is
somewhat unexpected. And yet, it is interesting to speculate,
and fodder for
research, that because nursing has remained female dominant, it
identifies with
social groups that, like women, have been socially
disadvantaged. Therefore,
with this commitment to equalitarianism, it posed a painful
moral quandary for
the American Nurses Association when some SNAs barred fully
qualified black
nurses from membership, thereby denying them ANA
membership in the feder-
ated model. What ought a professional association do? In 1948,
the American
Nurses Association made provision for black nurses to have
direct membership in
ANA, without SNA membership. If an association proclaims
that nurses should
not discriminate on prejudicial grounds against those not of the
dominant race,

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

PRovIsIon nInE Marsha D.M. Fowler, PhD, MDiv, MS, RN,
FAAN

creed, color, or religion, it cannot sanction such discrimination
within its own

organization. The first task of social ethics is to clean one’s
own house, which is
what the ANA did. As the 2001 Code puts it: “Through critical
self-reflection and
self-evaluation, associations must foster change within
themselves, seeking to move
the professional community toward its stated ideals.”24 The
action of the 1948 ANA
exemplified the values expressed in this provision, even though
there was no such
provision in the first Code for Professional Nurses in 1950.

Interpretive Statement 9.4: Social Reform
Nursing’s history is rich with examples of nurses who have,
individually, brought
about social–moral change. Many of the early women, and some
men, counted as
nurses, actually preceded the establishment of nursing schools
in the United States.
Even so, their achievements are credited to nursing. These
include Dorothea Lynde
Dix, Walt Whitman, Clara Harlowe Barton, Araminta (Harriet)
Ross Tubman, Capt.
Sally Tompkins, and Mary Ann Ball Bickerdyke, among others.
Of the women who
received formal nursing education, three historic figures will
serve as examples of
individuals who, by themselves, wrought social change.

u Margaret Higgins Sanger was shocked that women
were unable to obtain
accurate and effective birth control, which she
believed was foundational to
the freedom and independence of women. She
challenged the 1873 Federal
Comstock law that banned the dissemination of

contraceptive information.
She published a monthly paper, The Woman Rebel,
in which she advocated
for women’s right to use contraception. She was
indicted for violating
postal obscenity laws, jumped bail, and escaped to
England. Subsequently,
she worked tirelessly in England and then again in
the United States for
women’s rights to contraceptive information and
contraceptives.25

u Lillian D. Wald was asked to organize a nursing
program to meet the
needs of the impoverished immigrant population of
Manhattan in the late
19th century. She observed the terrible conditions
under which the city’s
poor survived. Wald was deeply moved and decided
to dedicate her life to
providing health and social services to the city’s
poor. In 1893, with Mary
Brewster, she established The Henry Street
Settlement, which eventually
became the Visiting Nurse Service of New York
City. Wald pioneered the
creation of public health nursing, visiting
nursing, and the social service
system. By 1916, the Settlement had 250 nurses
and offered health care,
housing, education, employment assistance, and
recreational activities to
thousands of the city’s poor families and individuals.

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Marsha D.M. Fowler, PhD, MDiv, MS, RN, FAAN PRovIsIon

nInE

u Isabel Adams Hampton Robb served as Superintendent at
the Illinois
Training School in the Cook County Hospital;
then became the first
superintendent of the new nursing school at Johns
Hopkins Hospital in
Baltimore. After her marriage, she became a
professor of gynecology at Case
Western Reserve University. She brought about
major changes in the process
and curriculum of nursing education. Robb
organized a nursing section at
the International Congress of Charities, Corrections
and Philanthropy of the
World Columbian Exposition held in Chicago.
The section became the first
nursing organization, the Society of Superintendents
of Training Schools
(eventually the National League for Nursing
Education and, then, the
National League for Nursing). Robb became the
first president of the Nurses
Associated Alumnae of the United States and
Canada (now the ANA), was
a cofounder of the American Journal of Nursing
Company, and was one of
the founders of the International Council of Nurses.
She helped nursing to
become an organized profession at the turn of
the last century.

Individuals can sometimes bring about social
change, eventually accruing a
like-minded group behind them. However, social

change is also brought about by
well-placed collective action.

From the early days of the Code, nurses were
seen to have civic responsibilities
as well as duties of citizenship, both of which
received emphasis. Participatory citi-
zenship by nurses has been a consistent and
important thread through the various
versions of the Code. By 1960, the Code
became explicit with regard to a nurse’s
duty to attend to legislative matters, individually
and collectively.

As a professional person, the nurse’s special
background enables her to have a
greater understanding of the nature of health
problems. This understanding
poses a particular responsibility to interpret and
speak out in regard to legis-
lation affecting health. The resources of the
professional association enables
the nurse to work with colleagues in
assessing current or pending health
legislation and its effect upon the community
and to determine the stand
that should be taken in the interest of the
greatest possible good. Sometimes
this stand may lead to concerted action with other
health groups. At other
times, nurses may find it necessary to work alone
to support principles which
the profession believes will result in the greatest
benefits to patient care.26

In its interpretive statement for Provision 9, the 2001 Code of

Ethics is both
more direct and more succinct on the responsibility of the
professional association
in shaping healthcare policy and legislation, an example of the
third function of
social ethics. It embraces the emphasis on citizenship
responsibilities of previous

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any means, electronic or mechanical,
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PRovIsIon nInE Marsha D.M. Fowler, PhD, MDiv, MS, RN,
FAAN

Codes, but is more incisive and aggressive about
collective/professional association
responsibility. It bears restatement:

Nurses can work individually as citizens or collectively through
political action
to bring about social change. It is the responsibility of a
professional nursing
association to speak for nurses collectively in shaping and
reshaping health care
within our nation, specifically in areas of healthcare policy and
legislation that
affect accessibility, quality, and the cost of health care. Here
the professional
association maintains vigilance and takes action to influence
legislators, reim-
bursement agencies, nursing organizations, and other health
professions. In these
activities, health is understood as being broader than delivery
and reimburse-
ment systems, but extending to health-related sociocultural
issues such as viola-
tion of human rights, homelessness, hunger, violence, and the
stigma of illness.

While the new Code does not precisely redefine health, it
extends the vision of
health and of working for the health of all to include both health
broadly defined
and, more specifically, the social causes of ill health:
homelessness, hunger, violence,
stigma, and the violation of human rights. A concern for
poverty would be intrinsic
to these concerns.

Has the Association done this? A look at the ANA government
affairs web page is
instructive. It has two divisions: Federal Advocacy and State
Government Relations.
At these web pages, there is access to the ANA legislative and
regulatory agenda for
the current session of Congress. There are issues analyses,
legislative tracking, vote
scorecards and information for all members of Congress,
legislative updates, federal
agency monitoring, a link to the Federal Register, a Nurses’
Strategic Action Team,
and an ANA Political Action Committee. In terms of state
legislation regarding health
care, the ANA State Relations webpage has links to a host of
political resources, a
means of identifying one’s state and federal legislators, a list of
nurse-legislators by
state, information in each state’s legislation from 1996 to the
present, transcripts of
ANA testimony before state legislators (and Congress), and
more. Over the past two
decades, ANA has become exceedingly well organized for
influencing the shape of
legislation affecting health care, nursing practice, and

education. This has been aided
by the rise of the Internet that allows greater and more
immediate communication
with ANA members (and anyone who accesses the website)
regarding legislative
issues. The ANA has been active in giving testimony before
legislators, in communi-
cating with individual legislators, and in bringing the collective
concern of nurses to
bear upon health legislation. The Association is meeting its duty
to be vigilant and to
engage with the legislative process. Are the activities of the
Association effective in
this arena? The duty is to be involved—not necessarily to
succeed. ANA is involved

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Marsha D.M. Fowler, PhD, MDiv, MS, RN, FAAN PRovIsIon
nInE

on behalf of nursing and nurses. As to whether ANA per se is
successful in effecting
change, that remains an excellent arena for evaluation research.

Provision 9 of the new Code of Ethics incorporates concerns of
earlier Codes for
participatory citizenship, for meeting civic responsibilities, for
speaking out, both
individually and collectively, regarding health and nursing-
related legislation. It
also encompasses the historic activism of nurses in bringing
about social change.
However, this provision crystallizes the role of professional
associations (not just
the ANA) in social ethics on behalf of the profession. In doing
so, it addresses the

three functions of social ethics. This Code of Ethics, finally,
gives greater emphasis
to what has historically been a preeminent concern of nursing;
the shape of society
as it affects health.

Endnotes

1 Gibson, W. 1966. Elements for a Social Ethics, p. 215.
New York: Macmillan.

2. Fowler, M.D.M. 1972. Nursing and social ethics. In The
Nursing Profession:
Turning Points, N.A. Chaska, ed., pp. 24–30, St. Louis: C.V.
Mosby.

3. Perlman C., and L. Olbrechts-Tyteca. 1969. The New
Rhetoric: A Treatise on
Argumentation, p. 51, Notre Dame: Notre Dame University.

4. Ibid.

5. Fowler, 1972. Nursing, p. 24–30.

6. National League for Nursing Education. 1917. Standard
Curriculum for
Schools of Nursing. New York: NLNE.

7. Bureau of Registration of Nurses, California State Board
of Health. 1916.
Schools of Nursing Requirements and Curriculum, pp. 7–8, 19–
21, 66–67,
83–85, 105–106. Sacramento: State Printing Office.

8. Convention of Training School Alumnae Delegates and
Representatives from

the American Society of Superintendents of Training Schools
for Nurses.
1896. Proceedings of the Con- vention, 2–4 November 1896, p.
7. Harrisburg:
Harrisburg Publishing.

9. Fowler, M. 2006. Ethics, the profession and society. In
The Teaching of
Nursing Ethics: Content and Methods, Anne Davis, Louise de
Raeve, and
Verena Tschudin, eds. London: Elsevier.

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134 Guide to the Code of Ethics for Nurses

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

PRovIsIon nInE Marsha D.M. Fowler, PhD, MDiv, MS, RN,
FAAN

10. American Nurses Association. 2001. Code of Ethics for
Nurses with
Interpretive Statements, p. 25. Washington, DC: ANA.

11. American Nurses Association website.
http://nursingworld.org/ethics/ecode.
htm.

12. American Nurses Association. 1964. Suggested Guidelines
for Handling
Alleged Violations of the Code for Professional Nurses. New
York: ANA.

13. Ibid, p. 1.

14. American Nurses Association. 2001. Code of Ethics, p. 25.

15. American Nurses Association. 1985. Code for Nurses with
Interpretive
Statements, p. 14, Kansas City, MO: ANA.

16. American Nurses Association. 1976. Code for Nurses with
Interpretive
Statements, pp. 16–17. Kansas City, MO: ANA.

17. American Nurses Association. 1960. Interpretation of the
Statements of the
Code for Professional Nurses, p.13. New York: ANA.

18. American Nurses Association. 1926. A Suggested Code.
American Journal of
Nursing 26(8): 599–601.

19. American Nurses Association. 1940. A Tentative Code.
American Journal of
Nursing 40(9): 978.

20. American Nurses Association. 1950. The Code for
Professional Nurses. New
York: ANA.

21. American Nurses Association. 2001. The Code of Ethics
for Nurses, p.25.

22. American Nurses Association. 1940. A Tentative Code, p.
980.

23. American Nurses Association. 1950. The Code for
Professional Nurses.

24. American Nurses Association. 2001. Code of Ethics, p. 25.

25. Katz, Esther, ed. 2002. The Selected Papers of Margaret
Sanger, Volume I: The
Woman Rebel, 1900–1928. Chicago: University of Illinois.

26. American Nurses Association. 1960. The Code for
Professional Nurses, p. 9.

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Guide to the Code of Ethics for Nurses 135

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or

any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Marsha D.M. Fowler, PhD, MDiv, MS, RN, FAAN PRovIsIon
nInE

About the Author
Marsha D.M. Fowler, PhD, MDiv, MS, RN, FAAN, is Senior
Fellow and Professor
of Ethics, Spirituality, and Faith Integration at Azusa Pacific
University. She is a
graduate of Kaiser Foundation School of Nursing (diploma),
University of California
at San Francisco (BS, MS), Fuller Theological Seminary
(MDiv), and the University
of Southern California (PhD). She has engaged in teaching and
research in bioethics
and spirituality since 1974. Her research interests are in the
history and development
of nursing ethics and the Code of Ethics for Nurses, social
ethics and professions,
suffering, the intersections of spirituality and ethics, and
religious ethics in nursing.
Dr. Fowler is also a Fellow in the American Academy of
Nursing.

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

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any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

137

code of Ethics for nurses
with Interpretive statements
(American Nurses Association, 2001)

Appendix A

Citation note: The content of this appendix (pages 138–169) is a
reproduction of the 2001 publication

Code of Ethics for Nurses with Interpretive Statements, (ISBN:
978-1-55810-176-0), which is in print as a
stand-alone publication. The per-page content of each version,
however, will differ, due to the differ-
ent sizes and layout of the two publications. One can cite from
or use as a reference either the 2001
primary source or this version. What is important is to ensure
that any citation of or reference to Code
of Ethics for Nurses with Interpretive Statements denotes the
2001 publication and copyright date, not
the date of Guide to the Code of Ethics for Nurses:
Interpretation and Application.

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138 Guide to the Code of Ethics for Nurses

APPEnDIx A:
coDE oF EthIcs FoR nuRsEs wIth IntERPREtIvE stAtEMEnts

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Library of Congress Cataloging-in-Publication Data

Code of ethics for nurses with interpretive statements.
p. ; cm.
ISBN 1-55810-176-4
1. Nursing ethics. I. American Nurses Association.
[DNLM: 1. Ethics, Nursing. 2. Ethics, Professional. WY 85
C669 2001]
RT85 .C63 2001
174’.2–dc21

2001046340

The American Nurses Association (ANA) is a national
professional association. ANA’s Code of Ethics for
Nurses and the accompanying Interpretive Statements refl ect
the thinking of the nursing profession
on various issues and should be reviewed in conjunction with
state board of nursing policies and

practices. State law, rules, and regulations govern the practice
of nursing, while the Code of Ethics
guides nurses in the application of their professional skills and
personal responsibilities.

Published by Nursesbooks.org
The Publishing Program of ANA
American Nurses Association
8515 Georgia Avenue
Silver Spring, MD 2910-3492
1-800-274-4ANA
http://www.nursesbooks.org/

©2001 American Nurses Association. All rights reserved. No
part of this book may be reproduced or
utilized in any form or any means, electronic or mechanical,
including photocopying and recording, or
by any information storage and retrieval system, without
permission in writing from the publisher.

First printing August 2001. Second printing February 2002.
Third printing November 2003. Fourth
printing December 2004. Fifth printing April 2007.

ISBN-13: 978-1-55810-176-0 CEN21 30M 04/07R
ISBN-10: 1-55810-176-4

ANA is the only full-service professional
organization representing the nation’s 2.9 million
Registered Nurses through its 54 constituent
member associations. ANA advances the nursing
profession by fostering high standards of nursing
practice, promoting the economic and general
welfare of nurses in the workplace, projecting
a positive and realistic view of nursing, and by
lobbying the Congress and regulatory agencies on

health care issues aff ecting nurses and the public.

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Guide to the Code of Ethics for Nurses 139

© 2008 American Nurses Association. All rights reserved. No

part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Acknowledgments

Members of the Code of Ethics Project Task Force
Barbara Daly, PhD, RN (Chairperson)
Elaine Connolly, MS, RN, ANA (Board of Directors)
Theresa Drought, PhD, RN
Marsha Fowler, PhD, MDiv, MS, RN, FAAN
Patricia Murphy, PhD, RN, CS, FAAN, ANA (Board of
Directors)
Linda Olson, PhD, RN
Kathleen Poi, MS, RN, CNAA
Gloria Ramsey, RN, JD
Mary Cipriano Silva, PhD, RN, FAAN
Colleen Scanlon, RN, MS, JD (Consultant)
Molly Sullivan, RN
John Twomey, PNP, PhD

ANA Staff
Laurie Badzek, RN, MS, JD, LLM
Director (1998–1999; 2003–present)
Center for Ethics and Human Rights

Gladys White, PhD, RN
Former Director, (2000–2003)

Angela Thompson
Ethics Coordinator (1997–2001)Co

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any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

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Guide to the Code of Ethics for Nurses 141

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Contents

Code of Ethics for Nurses 143

Preface 145

Provision 1 147
1.1 Respect for human dignity
1.2 Relationships to patients
1.3 The nature of health problems
1.4 The right to self-determination
1.5 Relationships with colleagues and others

Provision 2 150
2.1 Primacy of the patient’s interests
2.2 Confl ict of interest for nurses
2.3 Collaboration
2.4 Professional boundaries

Provision 3 152
3.1 Privacy
3.2 Confi dentiality
3.3 Protection of participants in research
3.4 Standards and review mechanisms
3.5 Acting on questionable practice
3.6 Addressing impaired practice

Provision 4 156
4.1 Acceptance of accountability and responsibility
4.2 Accountability for nursing judgment and action
4.3 Responsibility for nursing judgment and action
4.4 Delegation of nursing activities

Provision 5 158
5.1 Moral self-respect
5.2 Professional growth and maintenance of
competence

5.3 Wholeness of character
5.4 Preservation of integrity

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142 Guide to the Code of Ethics for Nurses

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© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Provision 6 161
6.1 Infl uence of the environment on moral
virtues and values
6.2 Infl uence of the environment on ethical
obligations
6.3 Responsibility for the healthcare environment

Provision 7 163
7.1 Advancing the profession through active
involvement in nursing

and in healthcare policy
7.2 Advancing the profession by developing,
maintaining, and

implementing professional standards in clinical,
administrative, and
educational practice

7.3 Advancing the profession through knowledge
development,
dissemination, and application to practice

Provision 8 164
8.1 Health needs and concerns
8.2 Responsibilities to the public

Provision 9 165
9.1 Assertion of values

9.2 The profession carries out its collective
responsibility through

professional associations
9.3 Intraprofessional integrity
9.4 Social reform

Afterword 167

Timeline 169
The Evolution of Nursing’s Code of Ethics

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Guide to the Code of Ethics for Nurses 143

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Code of Ethics for Nurses
PRovIsIon 1

The nurse, in all professional relationships,
practices with compassion and respect
for the inherent dignity, worth and uniqueness of
every individual, unrestricted by
considerations of social or economic status,
personal attributes, or the nature of
health problems.

PRovIsIon 2

The nurse’s primary commitment is to the patient,
whether an individual, family,
group or community.

PRovIsIon 3

The nurse promotes, advocates for and strives

to protect the health, safety and
rights of the patient.

PRovIsIon 4

The nurse is responsible and accountable for
individual nursing practice and deter-
mines the appropriate delegation of tasks
consistent with the nurse’s obligation to
provide optimum patient care.

PRovIsIon 5

The nurse owes the same duties to self as
to others, including the responsibility
to preserve integrity and safety, to maintain
competence and to continue personal
and professional growth.

PRovIsIon 6

The nurse participates in establishing, maintaining
and improving healthcare
environments and conditions of employment
conducive to the provision of qual-
ity health care and consistent with the values of
the profession through individual
and collective action.

PRovIsIon 7

The nurse participates in the advancement of
the profession through contributions
to practice, education, administration, and knowledge
development.

PRovIsIon 8

The nurse collaborates with other health
professionals and the public in promoting
community, national, and international eff orts to
meet health needs.

PRovIsIon 9

The profession of nursing, as represented by
associations and their members, is
responsible for articulating nursing values, for
maintaining the integrity of the
profession and its practice and for shaping social
policy.

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any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

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Guide to the Code of Ethics for Nurses 145

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Preface
Ethics is an integral part of the foundation of
nursing. Nursing has a distinguished
history of concern for the welfare of the sick,
injured, and vulnerable and for social
justice. This concern is embodied in the provision of
nursing care to individuals
and the community. Nursing encompasses the
prevention of illness, the allevia-
tion of suff ering, and the protection, promotion,
and restoration of health in the
care of individuals, families, groups, and
communities. Nurses act to change those
aspects of social structures that detract from health
and well-being. Individuals who
become nurses are expected not only to adhere to
the ideals and moral norms of

the profession but also to embrace them as a
part of what it means to be a nurse.
The ethical tradition of nursing is self-refl ective,
enduring, and distinctive. A code
of ethics makes explicit the primary goals,
values, and obligations of the profession.

The Code of Ethics for Nurses serves the
following purposes:

u It is a succinct statement of the ethical
obligations and duties of every
individual who enters the nursing profession.

u It is the profession’s nonnegotiable ethical
standard.

u It is an expression of nursing’s own
understanding of its commitment to
society.

There are numerous approaches for addressing
ethics; these include adopting
or subscribing to ethical theories, including
humanist, feminist, and social eth-
ics, adhering to ethical principles, and cultivating
virtues. The Code of Ethics for
Nurses refl ects all of these approaches. The words
“ethical” and “moral” are used
throughout the Code of Ethics. “Ethical” is
used to refer to reasons for decisions
about how one ought to act, using the above
mentioned approaches. In general,
the word “moral” overlaps with “ethical” but is more
aligned with personal belief
and cultural values. Statements that describe

activities and attributes of nurses in
this Code of Ethics are to be understood as
normative or prescriptive statements
expressing expectations of ethical behavior.

The Code of Ethics for Nurses uses the term
patient to refer to recipients of
nursing care. The derivation of this word
refers to “one who suff ers,” refl ecting a
universal aspect of human existence. Nonetheless, it
is recognized that nurses also
provide services to those seeking health as
well as those responding to illness, to
students and to staff , in healthcare facilities as
well as in communities. Similarly,
the term practice refers to the actions of
the nurse in whatever role the nurse

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

fulfi lls, including direct patient care provider,
educator, administrator, researcher,
policy developer, or other. Thus, the values
and obligations expressed in this Code
of Ethics apply to nurses in all roles and
settings.

The Code of Ethics for Nurses is a dynamic
document. As nursing and its social
context change, changes to the Code of Ethics
are also necessary. The Code of Ethics
consists of two components: the provisions and
the accompanying interpretive state-
ments. There are nine provisions. The fi rst

three describe the most fundamental
values and commitments of the nurse; the next
three address boundaries of duty
and loyalty, and the last three address aspects of
duties beyond individual patient
encounters. For each provision, there are interpretive
statements that provide greater
specifi city for practice and are responsive to
the contemporary context of nursing.
Consequently, the interpretive statements are subject
to more frequent revision than
are the provisions. Additional ethical guidance
and detail can be found in ANA or
constituent member association position statements
that address clinical, research,
administrative, educational, or public policy issues.

The Code of Ethics for Nurses with Interpretive
Statements provides a frame-
work for nurses to use in ethical analysis and
decision-making. The Code of Ethics
establishes the ethical standard for the profession.
It is not negotiable in any setting
nor is it subject to revision or amendment
except by formal process of the House
of Delegates of the ANA. The Code of Ethics
for Nurses is a refl ection of the proud

ethical heritage of nursing, a guide for nurses
now and in the future.

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Code of Ethics for

Nurses with Interpretive
Statements

1 The nurse, in all professional relationships, practices with
compassion and respect for the inherent dignity, worth, and
uniqueness of every individual, unrestricted by considerations
of social or economic status, personal attributes, or the nature
of health problems

1.1 Respect for human dignity

A fundamental principle that underlies all nursing
practice is respect for the inher-
ent worth, dignity, and human rights of every
individual. Nurses take into account
the needs and values of all persons in all
professional relationships.

1.2 Relationships to patients

The need for health care is universal, transcending all
individual diff erences. The nurse
establishes relationships and delivers nursing
services with respect for human needs
and values, and without prejudice. An individual’s
lifestyle, value system and religious
beliefs should be considered in planning health
care with and for each patient. Such
consideration does not suggest that the nurse
necessarily agrees with or condones
certain individual choices, but that the nurse
respects the patient as a person.

1.3 the nature of health problems

The nurse respects the worth, dignity and rights

of all human beings irrespective
of the nature of the health problem. The worth
of the person is not aff ected by dis-
ease, disability, functional status, or proximity to death.
This respect extends to all
who require the services of the nurse for the
promotion of health, the prevention
of illness, the restoration of health, the
alleviation of suff ering, and the provision
of supportive care to those who are dying.

The measures nurses take to care for the patient
enable the patient to live with
as much physical, emotional, social, and
spiritual well-being as possible. Nursing
care aims to maximize the values that the patient
has treasured in life and extends

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any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

supportive care to the family and significant
others. Nursing care is directed
toward meeting the comprehensive needs of
patients and their families across
the continuum of care. This is particularly
vital in the care of patients and their
families at the end of life to prevent and relieve
the cascade of symptoms and
suff ering that are commonly associated with dying.

Nurses are leaders and vigilant advocates for the
delivery of dignifi ed and humane
care. Nurses actively participate in assessing and
assuring the responsible and

appropriate use of interventions in order to
minimize unwarranted or unwanted
treatment and patient suff ering. The acceptability
and importance of carefully
considered decisions regarding resuscitation status,
withholding and withdraw-
ing life-sustaining therapies, forgoing medically provided
nutrition and hydration,
aggressive pain and symptom management and
advance directives are increasingly
evident. The nurse should provide interventions to
relieve pain and other symptoms
in the dying patient even when those
interventions entail risks of hastening death.
However, nurses may not act with the sole intent of
ending a patient’s life even
though such action may be motivated by compassion,
respect for patient autonomy
and quality of life considerations. Nurses have
invaluable experience, knowledge,
and insight into care at the end of life and should
be actively involved in related
research, education, practice, and policy
development.

1.4 the right to self-determination

Respect for human dignity requires the recognition
of specifi c patient rights, particu-
larly, the right of self-determination. Self-
determination, also known as autonomy, is
the philosophical basis for informed consent in health
care. Patients have the moral
and legal right to determine what will be done with their
own person; to be given
accurate, complete, and understandable information in a

manner that facilitates an
informed judgment; to be assisted with weighing the
benefi ts, burdens, and available
options in their treatment, including the choice of no
treatment; to accept, refuse, or
terminate treatment without deceit, undue infl uence,
duress, coercion, or penalty;
and to be given necessary support throughout
the decision-making and treatment
process. Such support would include the opportunity
to make decisions with family
and signifi cant others and the provision of advice
and support from knowledgeable
nurses and other health professionals. Patients should
be involved in planning their
own health care to the extent they are able and
choose to participate.

Each nurse has an obligation to be
knowledgeable about the moral and legal
rights of all patients to self-determination. The
nurse preserves, protects, and sup-

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any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

ports those interests by assessing the patient’s
comprehension of both the informa-
tion presented and the implications of decisions. In
situations in which the patient
lacks the capacity to make a decision, a
designated surrogate decision-maker should
be consulted. The role of the surrogate is to make
decisions as the patient would,
based upon the patient’s previously expressed

wishes and known values. In the
absence of a designated surrogate decision-maker,
decisions should be made in the
best interests of the patient, considering the
patient’s personal values to the extent
that they are known. The nurse supports patient
self-determination by participating
in discussions with surrogates, providing guidance
and referral to other resources
as necessary, and identifying and addressing
problems in the decision-making
process. Support of autonomy in the broadest sense
also includes recognition that
people of some cultures place less weight on
individualism and choose to defer to
family or community values in decision-making.
Respect not just for the specifi c
decision but also for the patient’s method of
decision-making is consistent with the
principle of autonomy.

Individuals are interdependent members of the
community. The nurse recognizes
that there are situations in which the right to
individual self-determination may be
outweighed or limited by the rights, health
and welfare of others, particularly in
relation to public health considerations. Nonetheless,
limitation of individual rights
must always be considered a serious deviation
from the standard of care, justifi ed
only when there are no less restrictive means
available to preserve the rights of
others and the demands of justice.

1.5 Relationships with colleagues and others

The principle of respect for persons extends to
all individuals with whom the
nurse interacts. The nurse maintains compassionate
and caring relationships with
colleagues and others with a commitment to
the fair treatment of individuals, to
integrity-preserving compromise, and to resolving confl
ict. Nurses function in many
roles, including direct care provider, administrator,
educator, researcher, and con-
sultant. In each of these roles, the nurse
treats colleagues, employees, assistants,
and students with respect and compassion. This
standard of conduct precludes
any and all prejudicial actions, any form of
harassment or threatening behavior, or
disregard for the eff ect of one’s actions on
others. The nurse values the distinctive
contribution of individuals or groups, and
collaborates to meet the shared goal of
providing quality health services.

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

2 The nurse’s primary commitment is to the patient,
whether an individual, family, group, or community.

2.1 Primacy of the patient’s interests

The nurse’s primary commitment is to the
recipient of nursing and healthcare
services—the patient—whether the recipient is an
individual, a family, a group, or

a community. Nursing holds a fundamental
commitment to the uniqueness of the
individual patient; therefore, any plan of care must
refl ect that uniqueness. The
nurse strives to provide patients with
opportunities to participate in planning care,
assures that patients fi nd the plans acceptable
and supports the implementation
of the plan. Addressing patient interests requires
recognition of the patient’s place
in the family or other networks of relationship.
When the patient’s wishes are in
confl ict with others, the nurse seeks to help
resolve the confl ict. Where confl ict
persists, the nurse’s commitment remains to the
identifi ed patient.

2.2 confl ict of interest for nurses

Nurses are frequently put in situations of confl ict
arising from competing loyalties
in the workplace, including situations of confl
icting expectations from patients,
families, physicians, colleagues, and in many
cases, healthcare organizations and
health plans. Nurses must examine the confl icts
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 confl icts in ways that ensure patient
safety, guard the patient’s best
interests and preserve the professional integrity of
the nurse.

Situations created by changes in healthcare fi nancing
and delivery systems, such
as incentive systems to decrease spending, pose new
possibilities of confl ict between
economic self-interest and professional integrity. The
use of bonuses, sanctions, and
incentives tied to fi nancial targets are examples of
features of healthcare systems
that may present such confl ict. Confl icts of
interest may arise in any domain of
nursing activity including clinical practice,
administration, education, or research.
Advanced practice nurses who bill directly for
services and nursing executives with
budgetary responsibilities must be especially cognizant of
the potential for confl icts
of interest. Nurses should disclose to all
relevant parties (e.g., patients, employers,
colleagues) any perceived or actual confl ict of
interest and in some situations should
withdraw from further participation. Nurses in all
roles must seek to ensure that
employment arrangements are just and fair and do
not create an unreasonable
confl ict between patient care and direct personal
gain.

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storage and retrieval system, without permission in writing from
the publisher.

2.3 collaboration

Collaboration is not just cooperation, but it is
the concerted eff ort of individuals and
groups to attain a shared goal. In health

care, that goal is to address the health needs

of the patient and the public. The complexity of
healthcare delivery systems requires
a multi-disciplinary approach to the delivery of
services that has the strong support
and active participation of all the health
professions. Within this context, nursing’s
unique contribution, scope of practice, and
relationship with other health profes-
sions needs to be clearly articulated, represented
and preserved. By its very nature,
collaboration requires mutual trust, recognition,
and respect among the healthcare
team, shared decision-making about patient
care, and open dialogue among all
parties who have an interest in and a concern
for health outcomes. Nurses should
work to assure that the relevant parties are
involved and have a voice in decision-
making about patient care issues. Nurses should
see that the questions that need
to be addressed are asked and that the information
needed for informed decision-
making is available and provided. Nurses should
actively promote the collaborative
multi-disciplinary planning required to ensure the
availability and accessibility of
quality health services to all persons who have
needs for health care.

Intra-professional collaboration within nursing is
fundamental to eff ectively
addressing the health needs of patients and
the public. Nurses engaged in non-
clinical roles, such as administration or research,

while not providing direct care,
nonetheless are collaborating in the provision of
care through their infl uence and
direction of those who do. Eff ective nursing
care is accomplished through the
interdependence of nurses in diff ering roles—those
who teach the needed skills, set
standards, manage the environment of care, or expand
the boundaries of knowledge
used by the profession. In this sense, nurses in
all roles share a responsibility for
the outcomes of nursing care.

2.4 Professional boundaries

When acting within one’s role as a
professional, the nurse recognizes and
maintains
boundaries that establish appropriate limits to
relationships. While the nature of
nursing work has an inherently personal component,
nurse-patient relationships
and nurse-colleague relationships have, as their
foundation, the purpose of pre-
venting illness, alleviating suff ering, and
protecting, promoting, and restoring the
health of patients. In this way, nurse-patient
and nurse-colleague relationships
diff er from those that are purely personal
and unstructured, such as friendship.
The intimate nature of nursing care, the involvement
of nurses is important and

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sometimes highly stressful life events, and the
mutual dependence of colleagues
working in close concert all present the
potential for blurring of limits to pro-
fessional relationships. Maintaining authenticity and
expressing oneself as an
individual, while remaining within the bounds
established by the purpose of the
relationship can be especially diffi cult in
prolonged or long-term relationships.
In all encounters, nurses are responsible for
retaining their professional boundaries.
When those professional boundaries are
jeopardized, the nurse should seek assis-
tance from peers or supervisors or take
appropriate steps to remove her/himself
from the situation.

3 The nurse promotes, advocates for, and strives to
protect the health, safety, and rights of the patient.

3.1 Privacy

The nurse safeguards the patient’s right to
privacy. The need for health care does
not justify unwanted intrusion into the patient’s life.
The nurse advocates for an
environment that provides for suffi cient
physical privacy, including privacy for
discussions of a personal nature and policies
and practices that protect the confi -
dentiality of information.

3.2 confi dentiality

Associated with the right to privacy, the nurse
has a duty to maintain confi denti-
ality of all patient information. The patient’s well-
being could be jeopardized and
the fundamental trust between patient and nurse
destroyed by unnecessary access
to data or by the inappropriate disclosure of identifi
able patient information. The
rights, well-being, and safety of the individual
patient should be the primary factors
in arriving at any professional judgment concerning
the disposition of confi dential
information received from or about the patient,
whether oral, written or electronic.
The standard of nursing practice and the nurse’s
responsibility to provide quality
care require that relevant data be shared with those
members of the healthcare team
who have a need to know. Only information
pertinent to a patient’s treatment and
welfare is disclosed, and only to those directly
involved with the patient’s care. Duties
of confi dentiality, however, are not absolute and may
need to be modifi ed in order
to protect the patient, other innocent parties and in
circumstances of mandatory
disclosure for public health reasons.

Information used for purposes of peer review, third-
party payments, and other
quality improvement or risk management mechanisms
may be disclosed only under
defi ned policies, mandates, or protocols. These written
guidelines must assure that

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the rights, well-being, and safety of the patient
are protected. In general, only that
information directly relevant to a task or specifi
c responsibility should be disclosed.
When using electronic communications, special
eff ort should be made to maintain
data security.

3.3 Protection of participants in research

Stemming from the right to self-determination,
each individual has the right to
choose whether or not to participate in
research. It is imperative that the patient
or legally authorized surrogate receive suffi
cient information that is material to an
informed decision, to comprehend that information,
and to know how to discon-
tinue participation in research without penalty.
Necessary information to achieve an
adequately informed consent includes the nature of
participation, potential harms
and benefi ts, and available alternatives to taking
part in the research. Additionally,
the patient should be informed of how the data
will be protected. The patient has
the right to refuse to participate in
research or to withdraw at any time without
fear of adverse consequences or reprisal.

Research should be conducted and directed only by
qualifi ed persons. Prior to
implementation, all research should be approved

by a qualifi ed review board to
ensure patient protection and the ethical integrity of
the research. Nurses should
be cognizant of the special concerns raised by
research involving vulnerable groups,
including children, prisoners, students, the elderly,
and the poor. The nurse who
participates in research in any capacity should
be fully informed about both the
subject’s and the nurse’s rights and obligations in
the particular research study and
in research in general. Nurses have the duty to
question and, if necessary, to report
and to refuse to participate in research they
deem morally objectionable.

3.4 standards and review mechanisms

Nursing is responsible and accountable for
assuring that only those individuals who
have demonstrated the knowledge, skill, practice
experiences, commitment, and
integrity essential to professional practice are allowed
to enter into and continue
to practice within the profession. Nurse
educators have a responsibility to ensure
that basic competencies are achieved and to promote a
commitment to professional
practice prior to entry of an individual
into practice. Nurse administrators are
responsible for assuring that the knowledge and
skills of each nurse in the work-
place are assessed prior to the assignment of
responsibilities requiring preparation
beyond basic academic programs.

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storage and retrieval system, without permission in writing from
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The nurse has a responsibility to implement
and maintain standards of profes-
sional nursing practice. The nurse should
participate in planning, establishing,
implementing, and evaluating review mechanisms
designed to safeguard patients
and nurses, such as peer review processes or
committees, credentialing processes,
quality improvement initiatives, and ethics
committees. Nurse administrators
must ensure that nurses have access to and
inclusion on institutional ethics com-
mittees. Nurses must bring forward diffi
cult issues related to patient care and/
or institutional constraints upon ethical practice
for discussion and review. The
nurse acts to promote inclusion of appropriate
others in all deliberations related
to patient care.

Nurses should also be active participants in
the development of policies and
review mechanisms designed to promote patient
safety, reduce the likelihood of
errors, and address both environmental system factors
and human factors that
present increased risk to patients. In addition, when
errors do occur, nurses
are expected to follow institutional guidelines in
reporting errors committed or
observed to the appropriate supervisory personnel
and for assuring responsible

disclosure of errors to patients. Under no
circumstances should the nurse par-
ticipate in, or condone through silence, either
an attempt to hide an error or a
punitive response that serves only to fi x blame
rather than correct the conditions
that led to the error.

3.5 Acting on questionable practice

The nurse’s primary commitment is to the health,
well-being, and safety of the
patient across the life span and in all
settings in which healthcare needs are
addressed. As an advocate for the patient, the
nurse must be alert to and take appro-
priate action regarding any instances of incompetent,
unethical, illegal, or impaired
practice by any member of the healthcare team
or the healthcare system or any
action on the part of others that places the
rights or best interests of the patient in
jeopardy. To function eff ectively in this role, nurses
must be knowledgeable about
the Code of Ethics, standards of practice of the
profession, relevant federal, state and
local laws and regulations, and the employing
organization’s policies and procedures.

When the nurse is aware of inappropriate or
questionable practice in the provi-
sion or denial of health care, concern should be
expressed to the person carrying
out the questionable practice. Attention should be
called to the possible detrimen-
tal aff ect upon the patient’s well-being or best

interests as well as the integrity of
nursing practice. When factors in the healthcare
delivery system or healthcare
organization threaten the welfare of the patient,
similar action should be directed

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to the responsible administrator. If indicated, the
problem should be reported to an
appropriate higher authority within the institution or
agency, or to an appropriate
external authority.

There should be established processes for
reporting and handling incompetent,
unethical, illegal, or impaired practice within the
employment setting so that such
reporting can go through offi cial channels,
thereby reducing the risk of reprisal
against the reporting nurse. All nurses have a
responsibility to assist those who
identify potentially questionable practice. State
nurses associations should be
prepared to provide assistance and support in the
development and evaluation of
such processes and reporting procedures.When incompetent,
unethical, illegal, or
impaired practice is not corrected within the
employment setting and continues to
jeopardize patient well-being and safety, the
problem should be reported to other
appropriate authorities such as practice committees
of the pertinent professional

organizations, the legally constituted bodies
concerned with licensing of specifi c
categories of health workers and professional
practitioners, or the regulatory agen-
cies concerned with evaluating standards or practice.
Some situations may warrant
the concern and involvement of all such
groups. Accurate reporting and factual
documentation, and not merely opinion, undergird
all such responsible actions.
When a nurse chooses to engage in the
act of responsible reporting about situations
that are perceived as unethical, incompetent, illegal, or
impaired, the professional
organization has a responsibility to provide the
nurse with support and assistance
and to protect the practice of those nurses
who choose to voice their concerns.
Reporting unethical, illegal, incompetent, or impaired
practices, even when done
appropriately, may present substantial risks to the
nurse; nevertheless, such risks
do not eliminate the obligation to address serious
threats to patient safety.

3.6 Addressing impaired practice

Nurses must be vigilant to protect the patient,
the public and the profession from
potential harm when a colleague’s practice, in
any setting, appears to be impaired.
The nurse extends compassion and caring to
colleagues who are in recovery from
illness or when illness interferes with job
performance. In a situation where a
nurse suspects another’s practice may be impaired,

the nurse’s duty is to take action
designed both to protect patients and to assure
that the impaired individual receives
assistance in regaining optimal function. Such action
should usually begin with
consulting supervisory personnel and may also include
confronting the individual
in a supportive manner and with the assistance of
others or helping the individual
to access appropriate resources. Nurses are
encouraged to follow guidelines outlined

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storage and retrieval system, without permission in writing from
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by the profession and policies of the employing
organization to assist colleagues
whose job performance may be adversely aff ected
by mental or physical illness or
by personal circumstances. Nurses in all roles should
advocate for colleagues whose
job performance may be impaired to ensure that
they receive appropriate assis-
tance, treatment and access to fair institutional
and legal processes. This includes
supporting the return to practice of the
individual who has sought assistance and
is ready to resume professional duties.

If impaired practice poses a threat or danger
to self or others, regardless of
whether the individual has sought help, the nurse
must take action to report the
individual to persons authorized to address the
problem. Nurses who advocate

for others whose job performance creates a
risk for harm should be protected
from negative consequences. Advocacy may be a diffi
cult process and the nurse is
advised to follow workplace policies. If workplace
policies do not exist or are inap-
propriate—that is, they deny the nurse in question
access to due legal process or
demand resignation—the reporting nurse may obtain
guidance from the profes-
sional association, state peer assistance
programs, employee assistance program
or a similar resource.

4 The nurse is responsible and accountable for
individual nursing practice and determines the
appropriate delegation of tasks consistent with the
nurse’s obligation to provide optimum patient care

4.1 Acceptance of accountability and responsibility

Individual registered nurses bear primary
responsibility for the nursing care
that their patients receive and are individually
accountable for their own prac-
tice. Nursing practice includes direct care activities,
acts of delegation, and other
responsibilities such as teaching, research, and
administration. In each instance,
the nurse retains accountability and responsibility
for the quality of practice and
for conformity with standards of care.

Nurses are faced with decisions in the context of
the increased complexity and
changing patterns in the delivery of health care. As

the scope of nursing practice
changes, the nurse must exercise judgment in
accepting responsibilities, seeking
consultation, and assigning activities to others who
carry out nursing care. For
example, some advanced practice nurses have
the authority to issue prescription
and treatment orders to be carried out by other
nurses. These acts are not acts
of delegation. Both the advanced practice nurse
issuing the order and the nurse

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accepting the order are responsible for the
judgments made and accountable for
the actions taken.

4.2 Accountability for nursing judgment and action

Accountability means to be answerable to oneself
and others for one’s own actions.
In order to be accountable, nurses act under
a code of ethical conduct that is
grounded in the moral principles of fi delity
and respect for the dignity, worth, and
self-determination of patients. Nurses are accountable
for judgments made and
actions taken in the course of nursing
practice, irrespective of healthcare organiza-
tions’ policies or providers’ directives.

4.3 Responsibility for nursing judgment and action

Responsibility refers to the specifi c
accountability or liability associated with the
performance of duties of a particular role.
Nurses accept or reject specifi c role
demands based upon their education, knowledge,
competence, and extent of expe-
rience. Nurses in administration, education,
and research also have obligations
to the recipients of nursing care. Although
nurses in administration, education,
and research have relationships with patients that are
less direct, in assuming the
responsibilities of a particular role, they share
responsibility for the care provided
by those whom they supervise and instruct. The
nurse must not engage in practices
prohibited by law or delegate activities to others
that are prohibited by the practice
acts of other healthcare providers.

Individual nurses are responsible for assessing their
own competence. When
the needs of the patient are beyond the qualifi
cations and competencies of the
nurse, consultation and collaboration must be sought
from qualifi ed nurses, other
health professionals, or other appropriate
sources. Educational resources should
be sought by nurses and provided by institutions
to maintain and advance the
competence of nurses. Nurse educators act in
collaboration with their students to
assess the learning needs of the student, the
eff ectiveness of the teaching program,
the identifi cation and utilization of appropriate
resources, and the support needed

for the learning process.

4.4 Delegation of nursing activities

Since the nurse is accountable for the quality
of nursing care given to patients,
nurses are accountable for the assignment of
nursing responsibilities to other nurses
and the delegation of nursing care activities to
other healthcare workers. While

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storage and retrieval system, without permission in writing from
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delegation and assignment are used here in a
generic moral sense, it is understood
that individual states may have a particular legal defi
nition of these terms.

The nurse must make reasonable eff orts to
assess individual competence when
assigning selected components of nursing care to
other healthcare workers. This
assessment involves evaluating the knowledge,
skills, and experience of the indi-
vidual to whom the care is assigned, the
complexity of the assigned tasks, and the
health status of the patient. The nurse is
also responsible for monitoring the activities
of these individuals and evaluating the quality of
the care provided. Nurses may not
delegate responsibilities such as assessment and
evaluation; they may delegate tasks.
The nurse must not knowingly assign or
delegate to any member of the nursing

team a task for which that person is not
prepared or qualifi ed. Employer policies
or directives do not relieve the nurse of
responsibility for making judgments about
the delegation and assignment of nursing care
tasks.

Nurses functioning in management or
administrative roles have a particular
responsibility to provide an environment that
supports and facilitates appropriate
assignment and delegation. This includes providing
appropriate orientation to staff ,
assisting less experienced nurses in developing
necessary skills and competencies,
and establishing policies and procedures that protect
both the patient and nurse
from the inappropriate assignment or delegation of
nursing responsibilities, activi-
ties, or tasks.

Nurses functioning in educator or preceptor roles
may have less direct rela-
tionships with patients. However, through assignment of
nursing care activities
to learners they share responsibility and
accountability for the care provided. It
is imperative that the knowledge and skills of
the learner be suffi cient to provide
the assigned nursing care and that appropriate
supervision be provided to protect
both the patient and the learner.

5 The nurse owes the same duties to self as to others,
including the responsibility to preserve integrity
and safety, to maintain competence, and to continue

personal and professional growth.

5.1 Moral self-respect

Moral respect accords moral worth and dignity
to all human beings irrespective of
their personal attributes or life situation. Such respect
extends to oneself as well;
the same duties that we owe to others we owe to
ourselves. Self-regarding duties

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refer to a realm of duties that primarily concern
oneself and include professional
growth and maintenance of competence, preservation
of wholeness of character,
and personal integrity.

5.2 Professional growth and maintenance of competence

Though it has consequences for others, maintenance
of competence and ongoing
professional growth involves the control of one’s
own conduct in a way that is pri-
marily self-regarding. Competence aff ects one’s
self-respect, self-esteem, professional
status, and the meaningfulness of work. In
all nursing roles, evaluation of one’s
own performance, coupled with peer review, is a
means by which nursing practice
can be held to the highest standards. Each nurse is
responsible for participating in
the development of criteria for evaluation of

practice and for using those criteria
in peer and self-assessment.

Continual professional growth, particularly in
knowledge and skill, requires a
commitment to lifelong learning. Such learning
includes, but is not limited to, con-
tinuing education, networking with professional
colleagues, self-study, professional
reading, certifi cation, and seeking advanced
degrees. Nurses are required to have
knowledge relevant to the current scope and
standards of nursing practice, changing
issues, concerns, controversies, and ethics. Where
the care required is outside the
competencies of the individual nurse, consultation
should be sought or the patient
should be referred to others for appropriate
care.

5.3 wholeness of character

Nurses have both personal and professional
identities that are neither entirely
separate, nor entirely merged, but are integrated. In
the process of becoming a
professional, the nurse embraces the values of
the profession, integrating them with
personal values. Duties to self involve an
authentic expression of one’s own moral
point-of-view in practice. Sound ethical decision-
making requires the respectful and
open exchange of views between and among all
individuals with relevant interests.
In a community of moral discourse, no one
person’s view should automatically take

precedence over that of another. Thus the nurse
has a responsibility to express
moral perspectives, even when they diff er
from those of others, and even when
they might not prevail.

This wholeness of character encompasses relationships
with patients. In situ-
ations where the patient requests a personal
opinion from the nurse, the nurse is
generally free to express an informed personal opinion
as long as this preserves
the voluntariness of the patient and maintains
appropriate professional and

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any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

moral boundaries. It is essential to be aware
of the potential for undue infl uence
attached to the nurse’s professional role.
Assisting patients to clarify their own
values in reaching informed decisions may be helpful
in avoiding unintended
persuasion. In situations where nurses’
responsibilities include care for those
whose personal attributes, condition, lifestyle or
situation is stigmatized by the
community and are personally unacceptable, the
nurse still renders respectful
and skilled care.

5.4 Preservation of integrity

Integrity is an aspect of wholeness of character

and is primarily a self-concern of
the individual nurse. An economically constrained
healthcare environment pres-
ents the nurse with particularly troubling threats to
integrity. Threats to integrity
may include a request to deceive a patient, to
withhold information, or to falsify
records, as well as verbal abuse from
patients or coworkers. Threats to integrity
also may include an expectation that the nurse
will act in a way that is inconsis-
tent with the values or ethics of the profession,
or more specifi cally a request that
is in direct violation of the Code of Ethics.
Nurses have a duty to remain consistent
with both their personal and professional values
and to accept compromise only
to the degree that it remains an integrity-
preserving compromise. An integrity-
preserving compromise does not jeopardize the
dignity or well-being of the nurse
or others. Integrity-preserving compromise can be
diffi cult to achieve, but is more
likely to be accomplished in situations where
there is an open forum for moral
discourse and an atmosphere of mutual respect
and regard.

Where nurses are placed in situations of
compromise that exceed acceptable
moral limits or involve violations of the moral
standards of the profession, whether
in direct patient care or in any other forms of
nursing practice, they may express
their conscientious objection to participation. Where a
particular treatment,

intervention, activity, or practice is morally
objectionable to the nurse, whether
intrinsically so or because it is inappropriate
for the specifi c patient, or where it
may jeopardize both patients and nursing practice,
the nurse is justifi ed in refus-
ing to participate on moral grounds. Such
grounds exclude personal preference,
prejudice, convenience, or arbitrariness. Conscientious
objection may not insulate
the nurse against formal or informal penalty.
The nurse who decides not to take
part on the grounds of conscientious objection must
communicate this decision
in appropriate ways. Whenever possible, such a
refusal should be made known in
advance and in time for alternate arrangements to be
made for patient care. The
nurse is obliged to provide for the patient’s
safety, to avoid patient abandonment,

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including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

and to withdraw only when assured that alternative
sources of nursing care are
available to the patient.

Where patterns of institutional behavior or
professional practice compromise
the integrity of all its nurses, nurses should
express their concern or conscientious
objection collectively to the appropriate body or
committee. In addition, they should
express their concern, resist, and seek to bring

about a change in those persistent
activities or expectations in the practice setting
that are morally objectionable to
nurses and jeopardize either patient or nurse
well-being.

6 The nurse participates in establishing, maintaining, and
improving healthcare environments and conditions of
employment conducive to the provision of quality health
care and consistent with the values of the profession
through individual and collective action.

6.1 Infl uence of the environment on moral virtues and values

Virtues are habits of character that predispose
persons to meet their moral obliga-
tions; that is, to do what is right. Excellences
are habits of character that predispose
a person to do a particular job or task well.
Virtues such as wisdom, honesty, and
courage are habits or attributes of the morally
good person. Excellences such as
compassion, patience, and skill are habits of
character of the morally good nurse.
For the nurse, virtues and excellences are those
habits that affi rm and promote the
values of human dignity, well-being, respect,
health, independence, and other values
central to nursing. Both virtues and excellences, as
aspects of moral character, can
be either nurtured by the environment in which
the nurse practices or they can be
diminished or thwarted. All nurses have a
responsibility to create, maintain, and
contribute to environments that support the growth of
virtues and excellences and

enable nurses to fulfi ll their ethical obligations.

6.2 Infl uence of the environment on ethical obligations

All nurses, regardless of role, have a
responsibility to create, maintain, and con-
tribute to environments of practice that support
nurses in fulfi lling their ethical
obligations. Environments of practice include
observable features, such as working
conditions, and written policies and procedures
setting out expectations for nurses,
as well as less tangible characteristics such as
informal peer norms. Organizational
structures, role descriptions, health and safety
initiatives, grievance mechanisms,
ethics committees, compensation systems, and
disciplinary procedures all contrib-

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any means, electronic or mechanical,
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storage and retrieval system, without permission in writing from
the publisher.

ute to environments that can either present barriers
or foster ethical practice and
professional fulfi llment. Environments in which
employees are provided fair hear-
ing of grievances, are supported in practicing
according to standards of care, and
are justly treated allow for the realization of
the values of the profession and are
consistent with sound nursing practice.

6.3 Responsibility for the healthcare environment

The nurse is responsible for contributing to a

moral environment that encourages
respectful interactions with colleagues, support of
peers, and identifi cation of issues
that need to be addressed. Nurse
administrators have a particular responsibility
to assure that employees are treated fairly
and that nurses are involved in deci-
sions related to their practice and working conditions.
Acquiescing and accepting
unsafe or inappropriate practices, even if the
individual does not participate in the
specifi c practice, is equivalent to condoning
unsafe practice. Nurses should not
remain employed in facilities that routinely violate
patient rights or require nurses
to severely and repeatedly compromise standards of
practice or personal morality.

As with concerns about patient care, nurses should
address concerns about the
healthcare environment through appropriate channels.
Organizational changes are
diffi cult to accomplish and may require
persistent eff orts over time. Toward this
end, nurses may participate in collective action
such as collective bargaining or
workplace advocacy, preferably through a professional
association such as the state
nurses association, in order to address the
terms and conditions of employment.
Agreements reached through such action must be
consistent with the profession’s
standards of practice, the state law regulating practice
and the Code of Ethics for
Nursing. Conditions of employment must contribute to
the moral environment, the

provision of quality patient care and professional
satisfaction for nurses.

The professional association also serves as an
advocate for the nurse by seek-
ing to secure just compensation and humane
working conditions for nurses. To
accomplish this, the professional association may
engage in collective bargaining
on behalf of nurses. While seeking to assure
just economic and general welfare for
nurses, collective bargaining, nonetheless, seeks to
keep the interests of both nurses
and patients in balance.

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any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

7 The nurse participates in the advancement of the
profession through contributions to practice, education,
administration, and knowledge development.

7.1 Advancing the profession through active

involvement in nursing and in healthcare policy

Nurses should advance their profession by
contributing in some way to the leader-
ship, activities, and the viability of their professional
organizations. Nurses can also
advance the profession by serving in leadership or
mentorship roles or on commit-
tees within their places of employment. Nurses
who are self-employed can advance
the profession by serving as role models for

professional integrity. Nurses can also
advance the profession through participation in
civic activities related to health
care or through local, state, national, or
international initiatives. Nurse educators
have a specifi c responsibility to enhance
students’ commitment to professional and
civic values. Nurse administrators have a
responsibility to foster an employment
environment that facilitates nurses’ ethical integrity
and professionalism, and nurse
researchers are responsible for active contribution
to the body of knowledge sup-
porting and advancing nursing practice.

7.2 Advancing the profession by developing, maintaining, and

implementing professional standards in clinical, administrative,
and

educational practice

Standards and guidelines refl ect the practice of nursing
grounded in ethical commit-
ments and a body of knowledge. Professional
standards and guidelines for nurses
must be developed by nurses and refl ect nursing’s
responsibility to society. It is the
responsibility of nurses to identify their own scope
of practice as permitted by pro-
fessional practice standards and guidelines, by state
and federal laws, by relevant
societal values, and by the Code of Ethics.

The nurse as administrator or manager must
establish, maintain, and promote

conditions of employment that enable nurses
within that organization or commu-
nity setting to practice in accord with accepted
standards of nursing practice and
provide a nursing and healthcare work environment
that meets the standards and
guidelines of nursing practice. Professional autonomy
and self regulation in the
control of conditions of practice are necessary
for implementing nursing standards
and guidelines and assuring quality care for those
whom nursing serves.

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

The nurse educator is responsible for promoting
and maintaining optimum
standards of both nursing education and of nursing
practice in any settings where
planned learning activities occur. Nurse educators
must also ensure that only those
students who possess the knowledge, skills, and
competencies that are essential to
nursing graduate from their nursing programs.

7.3 Advancing the profession through knowledge development,

dissemination, and application to practice

The nursing profession should engage in
scholarly inquiry to identify, evaluate,
refi ne, and expand the body of knowledge that
forms the foundation of its disci-
pline and practice. In addition, nursing knowledge is

derived from the sciences
and from the humanities. Ongoing scholarly activities
are essential to fulfi lling a
profession’s obligations to society. All nurses
working alone or in collaboration with
others can participate in the advancement of
the profession through the develop-
ment, evaluation, dissemination, and application of
knowledge in practice. However,
an organizational climate and infrastructure conducive to
scholarly inquiry must
be valued and implemented for this to occur.

8 The nurse collaborates with other health professionals
and the public in promoting community, national,
and international eff orts to meet health needs.

8.1 health needs and concerns

The nursing profession is committed to
promoting the health, welfare, and safety
of all people. The nurse has a responsibility to
be aware not only of specifi c health
needs of individual patients but also of broader
health concerns such as world hun-
ger, environmental pollution, lack of access to health
care, violation of human rights,
and inequitable distribution of nursing and
healthcare resources. The availability
and accessibility of high quality health services to
all people require both interdis-
ciplinary planning and collaborative partnerships among
health professionals and
others at the community, national, and international
levels.

8.2 Responsibilities to the public

Nurses, individually and collectively, have a
responsibility to be knowledgeable
about the health status of the community
and existing threats to health and safety.
Through support of and participation in community
organizations and groups, the
nurse assists in eff orts to educate the public,
facilitates informed choice, identifi es

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any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

conditions and circumstances that contribute to illness,
injury and disease, fosters
healthy life styles, and participates in institutional
and legislative eff orts to pro-
mote health and meet national health objectives. In
addition, the nurse supports
initiatives to address barriers to health, such as
poverty, homelessness, unsafe living
conditions, abuse and violence, and lack of access
to health services.

The nurse also recognizes that health care is
provided to culturally diverse popu-
lations in this country and in all parts of
the world. In providing care, the nurse
should avoid imposition of the nurse’s own
cultural values upon others. The nurse
should affi rm human dignity and show respect
for the values and practices associ-
ated with diff erent cultures and use approaches to
care that refl ect awareness and

sensitivity.

9 The profession of nursing, as represented by associations and
their members, is responsible for articulating nursing values,
for maintaining the integrity of the profession and its practice,
and for shaping social policy.

9.1 Assertion of values

It is the responsibility of a professional
association to communicate and affi rm
the
values of the profession to its members. It is
essential that the professional orga-
nization encourages discourse that supports critical
self-refl ection and evaluation
within the profession. The organization also
communicates to the public the values
that nursing considers central to social change
that will enhance health.

9.2 the profession carries out its collective responsibility
through

professional associations

The nursing profession continues to develop ways to
clarify nursing’s accountability
to society. The contract between the profession
and society is made explicit through
such mechanisms as (a) The Code of Ethics for
Nurses, (b) the standards of nursing
practice, (c) the ongoing development of nursing
knowledge derived from nursing
theory, scholarship, and research in order to
guide nursing actions, (d) educational

requirements for practice, (e) certifi cation, and (f
) mechanisms for evaluating the
eff ectiveness of professional nursing actions.

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

9.3 Intraprofessional integrity

A professional association is responsible for
expressing the values and ethics of the
profession and also for encouraging the professional
organization and its members
to function in accord with those values and
ethics. Thus, one of its fundamental
responsibilities is to promote awareness of and
adherence to the Code of Ethics
and to critique the activities and ends of the
professional association itself. Values
and ethics infl uence the power structures of
the association in guiding, correcting,
and directing its activities. Legitimate concerns for
the self-interest of the associa-
tion and the profession are balanced by a
commitment to the social goods that are
sought. Through critical self-refl ection and self-
evaluation, associations must foster
change within themselves, seeking to move
the professional community toward its
stated ideals.

9.4 social reform

Nurses can work individually as citizens or
collectively through political action to

bring about social change. It is the
responsibility of a professional nursing
associa-
tion to speak for nurses collectively in
shaping and reshaping health care within
our nation, specifi cally in areas of healthcare
policy and legislation that aff ect
accessibility, quality, and the cost of health care.
Here, the professional association
maintains vigilance and takes action to infl uence
legislators, reimbursement agen-
cies, nursing organizations, and other health professions.
In these activities, health
is understood as being broader than delivery
and reimbursement systems, but
extending to health-related sociocultural issues such as
violation of human rights,
homelessness, hunger, violence, and the stigma of
illness.

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Afterword
The development of the Code of Ethics for Nurses
with Interpretive Statements is a
benchmark for both the American Nurses Association
and for the profession of nurs-
ing as a whole. The evolution of the Code dates
from 1893 when the “Nightingale
Pledge” was adopted, and from 1926 and 1940 when
tentative Codes were suggested
but not formally ratifi ed. This is the fi rst time in
the last 25 years that the entire
Code has been revised and the second time in the

last 50 years that an entirely new
document has been produced. This Code is the result of
fi ve years of work on the
part of the Code of Ethics Project Task Force, an
advisory board, state liaisons, and
ANA staff . It is the culmination of more than
ten fi eld reviews of drafts that were
circulated in hard copy and made available online,
incorporating comments from
hundreds of nurses across the United States
and abroad.

The ethical tradition that has been manifest in every
iteration of the Code is self-
refl ective, enduring, and distinctive. The ethical
standard established by the Code of
Ethics is nonnegotiable. This means that the Code
supports the nurse in a steadfast
way across various settings and in a variety of
nursing roles. This Code of Ethics is
for all nurses and is particularly useful at
the beginning of the 21st century because
it: reiterates the fundamental values and
commitments of the nurse (provisions
1–3); identifi es the boundaries of duty and
loyalty (provisions 4–6); and describes
the duties of the nurse that extend beyond
individual patient encounters (provisions
7–9). The achievement of a true global
awareness about the human condition and
the needs for health care is one of the most
important moral challenges of the 21st
century and this Code beckons nurses toward such an
awareness.

The Code of Ethics is the promise that nurses

are doing their best to provide
care for their patients and their communities, supporting
each other in the process
so that all nurses can fulfi ll their ethical and
professional obligations. This Code of
Ethics for Nurses with Interpretive Statements is
an important tool that can be used
now as leverage to a better future for nurses,
patients, and health care.Co

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any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

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part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Timeline:
The Evolution of Nursing’s Code of Ethics

Whatever the version of the Code, it has always
been fundamentally concerned with
the principles of doing no harm, of benefi
tting others, of loyalty, and of truthful-
ness. As well, the Code has been concerned with social
justice and, in later versions,
with the changing context of health care as well as
the autonomy of the patient
and the nurse.

“Nightingale Pledge, ” patterned after
medicine’s Hippocratic
Oath, is understood as the fi rst nursing
code of ethics.

Nurses’ Associated Alumnae of the
United States and Canada
(later to become the American Nurses
Association), whose fi rst purpose
was to establish and maintain a code of ethics.

Suggested Code” is provisionally adopted

and published in the
American Journal of Nursing (AJN) but is never
formally adopted.

Tentative Code” is published in AJN,
but also is never formally adopted.

Code for Professional Nurses, in the
form of 17 provisions that
are a substantive revision of the “Tentative
Code” of 1940, is unanimously
accepted by the ANA House of Delegates.

Code for Professional Nurses is
amended.

Code for Professional Nurses is revised.

Code for Professional Nurses is
substantively revised, condensing the
17 provisions of the 1960 Code into 10 provisions.

Code for Nurses with Interpretive
Statements, a modifi cation of
the provisions and interpretive statements, is
published as 11 provisions.

Code for Nurses with Interpretive
Statements retains the provisions of
the 1976 version and includes revised interpretive
statements.

Code for Nurses with Interpretive
Statements is accepted by the ANA
House of Delegates.

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any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

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any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

171

Index

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© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

A
abuse, 109
accountability, 41–54, 143, 156–158

acceptance of, 44–45, 156–157
nursing judgment and

action, 45–47, 157
accreditation, 13
administration, 90–91
advocacy, 83, 148
American Nurses Association (ANA),

126–127, 129, 132–133, 167
Aristotle, 74
autonomy, 3, 17, 26, 149

B
Badzek, Laurie A., 54
Belmont Report, 3
birth control, 130
Brewster, Mary, 130
business priorities, 15–16

C
caring, 74–75
character, wholeness of, 60–61, 159–160
children, consent, 31
client. see patient
Code of Ethics for Nurses with Interpretive

Statements (2001), 137–166
ANA and, 167
awareness, 127
ethical theories and concepts, 25
evolution, 169
history, 125–126
purpose, 145
see also Provision…

codes of ethics (ANA), 14
(1926), 127–128
(1940), 2, 128, 129
(1950), 2, 128, 129
(1960), 128, 131
(1968), 2
(1976), 3
(1985), 90, 104

collaboration, 103–120, 143, 151, 164–165
case example, 80–81

colleagues, relationships with, 149
collective bargaining, 82–83

shared governance and, 84–85
commitment, 11, 143, 150–151

history, 2–4, 12–14
communitarianism, 106–107
community, 149
compassion, 143, 147–149
competence, 98–100

maintenance of, 58–60, 159
confidentiality, 26, 27–29, 122, 152–153
conflicts of interest, 150
conscientious objection, 67–68, 160–161
consent, 31

children, 31
consilience, 4
cultural diversity, 104–105, 114–116
culture, 110

D
Davis, Anne J., 21
delegation, 49–51, 157–158
discrimination, 8
Drought, Theresa S., 102
duty

to patient, 14
to self, 55–70

E
economics, 110
education, 12–13, 90–91, 131
egalitarianism, 129–130
employers, 12
employment, conditions of, 67, 71–88

case examples, 80–82
place, 76

empowerment, 81–84, 106, 107
end-of-life care, 18, 63
environment. See healthcare environment
epidictic discourse, 123–124

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InDEx

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Epstein, Elizabeth G., 102
ethical (as term), 145
ethical conflicts, 15, 17–18
ethics

feminist, 105–106
physician-oriented model, 14
virtue, 74

expertise, utilizing, 96–97

F
fairness, 17
feminist ethics, 105–106
Fowler, Marsha D.M., 70, 135

G
Gadow, Sally, 5
general duty nursing, 122
governance, shared, 83–84

collective bargaining and, 84–85

H
harm, noninfliction of, 25–26
H.C.C. (on nursing ethics), 57
health, 132

needs and concerns, 164
problem, nature of, 147–148

healthcare environment, 143, 161–162
creating, 79–80
influence on ethical obligations,

77–78, 161–162
influence on moral virtues

and values, 73–77, 161
responsibility for, 78–79, 162

healthcare policy, 93–94, 163
Henry Street Settlement, 130
history, 130–133

hospitals, 12–13
human dignity, 147

I
identity, 58
illness care, 12, 13
immigrants, 130
impaired practice, 34–36, 155–156

case example, 36–38
integrity, 58

intraprofessional, 126–130, 166
preservation of, 66–68, 160–161

involvement, 93–94, 163

J
Jacobs, Barbara, 4
Jameton, Andrew, 56, 58, 59–60
justice, 17

K
Kant, Immanuel, 57
knowledge development, 90, 95, 164

L
liability, 42, 47–48
loyalty, 12, 13

M
manager, creating an ethical

environment, 79–80
meaning structures, 126
moral (as term), 145

moral concepts, 24
moral self-respect, 57–58, 158–159

N
National Institute for Nursing

Research (NINR), 90
National League for Nursing

Education (NLNE), 125
Nightingale, Florence, 13, 25, 42, 50, 53
Nightingale Pledge, 2
nonmaleficence, principle of, 25–26

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Guide to the Code of Ethics for Nurses 175

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

nursing profession
advancing, 93–95, 143, 163–164
history, 13, 122–123, 128, 130–131
identity, 61–62
individual and practice and, 90, 91, 92
reform, 123, 124
responsibilities of, 121–135, 143, 165–166
rights, 14–15, 76
staffing shortage, 19, 52, 78–79

nurse–patient relationship, 16–18, 65–66,
147, 151–152

O
obligations, 15–16
Olson, Linda L., 88
oppression, 109–111

P

patient, 145

client vs., xvi, 3, 59
cooperation, 7
information, 26–29, 64–66
interests, 150
nurse–patient relationship, 16–18, 65–66,

147, 151–152
primacy of, 14
rights, 143, 152–156

power, 12, 78, 107, 109, 110
power structures, 126
practice, 90–91, 145–146
preventive care, 13
principles, 25
private duty nursing, 122
privacy, 26–29, 152
private duty nursing, 12
profession. See nursing profession
professional associations, 125–

126, 126–130, 162, 165
professional boundaries, 151–152
professional development, 100–101
professional growth, 58–60, 159
professionalism, 8
professional relationships, 4–5, 6–7

proficiency, 92
protection, 25
Provision 1, 1–10, 26, 143, 147–149

case examples, 7–8
Provision 2, 11–21, 26, 143, 150–151

case examples, 18–20
previous, 14

Provision 3, 23–39, 143, 152–156
case examples, 33–34, 36–38

Provision 4, 41–54, 143, 156–158
case example, 52

Provision 5, 15, 55–70, 143, 158–161
case examples, 61–65

Provision 6, 71–88, 143, 161–162
case examples, 80–82

Provision 7, 89–102, 143, 163–164
case examples, 96–100

Provision 8, 103–120, 143, 164–165
implications, 116–117

Provision 9, 121–135, 143, 165–166
confidence, 43
health, 104, 108, 109–111
health systems, 13
policy, 111–114
responsibilities to, 164–165

Q
questionable practices, 34–36, 154–155

case example, 36–38

R
reform, 123, 124

refusal to care, 68
registry, 12
religion, 64–65
requirements, 61
research participants, 29–31, 153
respect, 1–3, 5
responsibility, 41–54, 143, 156–158

acceptance of, 44–45, 156–157
nursing judgment and

action, 47–49, 157
review mechanisms, 32–33, 153–154

case example, 33–34

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176 Guide to the Code of Ethics for Nurses

InDEx

© 2008 American Nurses Association. All rights reserved. No
part of this book may be reproduced or utilized in any form or
any means, electronic or mechanical,
including photocopying and recording, or by any information
storage and retrieval system, without permission in writing from
the publisher.

Robb, Isabel Adams Hampton,
13–14, 57, 131

role modeling, case example, 81–82

S
Sanger, Margaret Higgins, 130
self, duties to, 15, 55–70
self-determination, 5–6, 7, 148–149
self-regarding duties, 58
self-respect, 143, 158–161

moral, 57–58, 158–159
Silence Kills study, 79
Silva, Mary Cipriano, 120
social ethics, 107–108, 123–124
social reform, 124, 130–133, 166

specialing, 122
staffing shortage, 19, 52, 78–79
standards, 32–33, 94–95, 125,

153–154, 163–164
case example, 33–34

state nurses associations, 129
students, interaction with, 81–82, 97–98
Suggested Code (1926), 127–128

see also codes of ethics
surrogate, role of, 149

T
Task Force for the Revision of the Code, 14
Taylor, Carol R., 10
Tentative Code (1940), 2, 128, 129

see also codes of ethics

terminal illness, 18, 63
therapeutic misconception, 30
therapeutic use of self, 6–7
timeline, 169
touch, 6
Twomey, John G., 39

V
vaccine shortage, 19–20
values

assertion of, 124–125, 165
structures, 126

vegetative state, 18–19

violence, 109–111
virtue ethics, 74

W
Wald, Lillian D., 130
Watson, J., 74–75
wholeness of character, 60–61, 159–160
women

exclusion, 128
feminist ethics, 105–106

workplace advocacy, 83

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Guide to the Code of Ethics for Nurses
Interpretation and Application
editor: Martha D. M. Fowler, PhD, MDiv, MS, RN, FAAN

An essential resource for nursing classrooms, in-service
training, and

wherever nursing professionals use ANA’s Code of Ethics for
Nurses with

Interpretive Statements in their daily practice. Each chapter of
this classic

text discusses a single Code provision, including:

I History

I Purpose

I Theory

I Application

I Case studies

I Examples

For easy reference, the book also features:

I Provision statement with each chapter

I Full text of ANA’s Code of Ethics for Nurses with
Interpretive Statements

I Index of key concepts

From the classroom to professional practice, nurses will find
Guide to the

Code of Ethics for Nurses a powerful tool for learning how to
apply the values,

duties, and commitments of the Code of Ethics to their nursing
practice.

The Editor: Marsha Fowler, PhD, MDiv, MS, RN, FAAN, is
Senior Fellow

and Professor of Ethics, Spirituality, and Faith Integration at
Azusa Pacific

University. She has engaged in teaching and research in
bioethics and

spirituality since 1974. Her research interests are in the history
and

development of nursing ethics, the Code of Ethics for Nurses,
social ethics

and the professions, suffering, the intersections of spirituality
and ethics,

and religious ethics in nursing.

Look inside for more about the editor and the authors.

ANA’s Foundation of Nursing 2010

The ANA Foundation of Nursing Package is an essential
resource for every

registered nurse regardless of level, role, or setting. The three
books in the

Package guide nursing practice, thinking, and decision-making:

I Nursing: Scope and Standards of Practice, Second Edition

I Nursing’s Social Policy Statement: The Essence of the
Profession

I Guide to the Code of Ethics for Nurses: Interpretation
and Application

This package can be used as:

I Professional reference

I Classroom textbook

I In-service training guide

I Credentialing exam resource

I And much more

A must-have for nursing faculty, students, researchers, in-
service trainers,

chief nursing officers, nursing board members, and
interprofessional

colleagues, as well as agencies, organizations, regulators,
legislators,

lawyers, judges, and healthcare consumers.

8515 Georgia Avenue, Suite 400
Silver Spring, MD 20910-3492

1-800-274-4ANA (4262)
www.Nursingworld.org

ISBN-13: 978-1-55810-287-3 (eBook publication: August 2010)

http://www.nursesbooks.orgContentsAcknowledgmentsPrefaceIn
troductionProvision OneProvision TwoProvision ThreeProvision
FourProvision FiveProvision SixProvision SevenProvision
EightProvision NineAppendix AContentsIndex
Previous Page: Table of Contents: Next Page: Authors:
Acknowledgments: Introduction: Appendix A: Index: Code of
Ethics for Nurses: Preface: Provision 1: Provision 2: Provision
3: Provision 4: Provision 5: Provision 6: Provision 7: Provision
8: Provision 9: Afterword: Timeline:

VIRGINIA BOARD OF NURSING
GUIDANCE DOCUMENT # 90 -41
TITLE: The Nurse Practice Act and Patient Abandonment

The Board has received numerous inquiries regarding what
constitutes patient abandonment and the imposition of
mandatory overtime by employers. These inquiries usually are
the result of situations encountered by RNs, LPNs, as well as
CNAs in relation to their work assignments. Patient
abandonment is not defined in the Virginia Nurse Practice Act
(For patient abandonment to be a violation of the Nurse Practice
Act, it must be determined to meet either subsection 2:

“unprofessional conduct,” or subsection 5: “practicing in a
manner contrary to the standards of ethics or in such a manner
as to make his practice a danger to the health and welfare of
patients or to the public.” The term patient abandonment is
referred to in the Board regulations as a cause for discipline for
nurses (18 VAC 90-20-300) and CNA’s (18 VAC 90-20-360).

Mandatory overtime usually refers to situations when the
employer requires the nurse or CNA to remain on the job after
the end of their scheduled work hours. It has also been imposed
to require employees to come in to the workplace on
unscheduled work days or hours. This is usually a result of
staffing shortages at the facility. Nurses often ask if the
employer can actually require them to remain on the job, and
what will happen if they refuse to stay or come in to work. It is
frequently reported that they have been told if they refuse to
work, they will be fired, and reported to the Board for “patient
abandonment.”

The term “patient abandonment” should be differentiated from
the term “employment abandonment,” which becomes a matter
of the employer-employee relationship and not that of the Board
of Nursing. It should be noted that from a regulatory
perspective, in order for patient abandonment to occur, the
nurse or CNA must have first accepted the patient assignment
and established a nurse-patient relationship, then severed that
nurse-patient relationship without giving reasonable notice to
the appropriate person (supervisor, employer) so that
arrangements can be made for continuation of nursing care by
others. Providing appropriate nursing personnel to care for
patients is the responsibility of the employer. Failure of a nurse
to work beyond his/her scheduled shift, refusal to accept an
assignment, refusal to float to another unit, refusal to report to
work, and resigning without notice, are examples of
employment issues, and not considered by the Board to
constitute patient abandonment.

The nurse manager/supervisor is accountable for assessing the
capabilities of personnel in relationship to client needs and
delegating or assigning nursing care functions to qualified
personnel. The manager/supervisor’s responsibility also
includes making judgments about situational factors (e.g.,
fatigue, lack of sleep, lack of orientation and training to a
particular unit) that would influence the nurse’s capability to
deliver safe, effective care. The nurse manager should be aware
that he/she could be subject to disciplinary action by the Board
for assigning patient care responsibilities to staff when the
manager knows, or should reasonably know, that the assignment
may affect the competency of the nurse. Additionally, Joint
Commission on Accreditation of Healthcare Organization
Standards say that a nurse must be provided an orientation to
the unit they are assigned, as well as training and credentialing
in the specialized skills of the particular unit.

Licensed nursed and CNA’s are accountable for the nursing care
they provide. Before accepting an assignment, it is most
important that the nurse have the knowledge, skills, and
abilities to safely perform the tasks assigned. If a nurse arrives
for work and determines it would be unsafe to provide the care
assigned, the nurse should immediately contact the supervisor,
explain him/her concerns, and request assistance in planning
and providing safe, effective care based upon the available
resources in the agency. Such assistance might include
additional staff, additional assistance by other individuals for
specific activities, prioritizing care or activities and notifying
others regarding limitations to be imposed on providing optimal
care delivery during the period of understaffing. Regardless of
the staffing situation, when a nurse or CNA accepts an
assignment, he/she will be held to the standard of delivering
safe care, protecting patients from harm, monitoring client
responses to medical and nursing interventions, communication
with other professionals regarding patient status and accurate

documentation for care that has been delivered.

To summarize, patient abandonment can only occur after the
nurse has come on duty for the shift and accepted his/her
assignment. If the nurse or CNA leaves the area of assignment
during his/her tour of duty prior to the completion of the shift
and without adequate notification to the immediate supervisor,
it is possible the Board would consider taking disciplinary
action. However, when a nurse refuses to remain on duty for an
extra shift beyond his /her established schedule, it is not
considered patient abandonment should the nurse choose to
leave at the end of the regular shift, provided he/she has
appropriately notified the supervisor and reported off to another
nurse.

Adopted: March 20, 2001 (Authored by Shelley Conroy, RN,
PhD)

Reviewed: November 18, 2003

Revised July 1, 2015

The following sections of the Board of Nursing Regulations
govern what nursing tasks can be appropriately delegated by a
Registered Nurse to unlicensed persons (which may include
CNAs).

PART VII.
DELEGATION OF NURSING TASKS AND PROCEDURES.

18VAC90-20-420. Definitions.
"Delegation" means the authorization by a registered nurse to an

unlicensed person to perform selected nursing tasks and
procedures in accordance with this part.
"Supervision" means guidance or direction of a delegated
nursing task or procedure by a qualified, registered nurse who
provides periodic observation and evaluation of the performance
of the task and who is accessible to the unlicensed person.
"Unlicensed person" means an appropriately trained individual,
regardless of title, who receives compensation, who functions in
a complementary or assistive role to the registered nurse in
providing direct patient care or carrying out common nursing
tasks and procedures, and who is responsible and accountable
for the performance of such tasks and procedures. With the
exception of certified nurse aides, this shall not include anyone
licensed or certified by a health regulatory board who is
practicing within his recognized scope of practice.
18VAC90-20-430. Criteria for delegation.
A. Delegation of nursing tasks and procedures shall only occur
in accordance with the plan for delegation adopted by the entity
responsible for client care. The delegation plan shall comply
with provisions of this chapter and shall provide:
1. An assessment of the client population to be served;
2. Analysis and identification of nursing care needs and
priorities;
3. Establishment of organizational standards to provide for
sufficient supervision which assures safe nursing care to meet
the needs of the clients in their specific settings;
4. Communication of the delegation plan to the staff;
5. Identification of the educational and training requirements
for unlicensed persons and documentation of their
competencies; and
6. Provision of resources for appropriate delegation in
accordance with this part.
B. Delegation shall be made only if all of the following criteria
are met:
1. In the judgment of the delegating nurse, the task or procedure
can be properly and safely performed by the unlicensed person

and the delegation does not jeopardize the health, safety and
welfare of the client.
2. The delegating nurse retains responsibility and accountability
for nursing care of the client, including nursing assessment,
planning, evaluation, documentation and supervision.
3. Delegated tasks and procedures are within the knowledge,
area of responsibility and skills of the delegating nurse.
4. Delegated tasks and procedures are communicated on a
client-specific basis to an unlicensed person with clear, specific
instructions for performance of activities, potential
complications, and expected results.
5. The person to whom a nursing task has been delegated is
clearly identified to the client as an unlicensed person by a
name tag worn while giving client care and by personal
communication by the delegating nurse when necessary.
C. Delegated tasks and procedures shall not be reassigned by
unlicensed personnel.
D. Nursing tasks shall only be delegated after an assessment is
performed according to the provisions of 18VAC90-20-440.
18VAC90-20-440. Assessment required prior to delegation.
Prior to delegation of nursing tasks and procedures, the
delegating nurse shall make an assessment of the client and
unlicensed person as follows:
1. The delegating nurse shall assess the clinical status and
stability of the client's condition, shall determine the type,
complexity and frequency of the nursing care needed and shall
delegate only those tasks which:
a. Do not require the exercise of independent nursing judgment;
b. Do not require complex observations or critical decisions
with respect to the nursing task or procedure;
c. Frequently recur in the routine care of the client or group of
clients;
d. Do not require repeated performance of nursing assessments;
e. Utilize a standard procedure in which the tasks or procedures
can be performed according to exact, unchanging directions;
and

f. Have predictable results and for which the consequences of
performing the task or procedures improperly are minimal and
not life threatening.
2. The delegating nurse shall also assess the training, skills and
experience of the unlicensed person and shall verify the
competency of the unlicensed person in order to determine
which tasks are appropriate for that unlicensed person and the
method of supervision required.
18VAC90-20-450. Supervision of delegated tasks.
A. The delegating nurse shall determine the method and
frequency of supervision based on factors which include, but
are not limited to:
1. The stability and condition of the client;
2. The experience and competency of the unlicensed person;
3. The nature of the tasks or procedures being delegated; and
4. The proximity and availability of the registered nurse to the
unlicensed person when the nursing tasks will be performed.
B. In the event that the delegating nurse is not available, the
delegation shall either be terminated or delegation authority
shall be transferred by the delegating nurse to another registered
nurse who shall supervise all nursing tasks delegated to the
unlicensed person, provided the registered nurse meets the
requirements of 18VAC90-20-430 B 3.
C. Supervision shall include but not be limited to:
1. Monitoring the performance of delegated tasks;
2. Evaluating the outcome for the client;
3. Ensuring appropriate documentation; and
4. Being accessible for consultation and intervention.
D. Based on an ongoing assessment as described in 18VAC90-
20-440, the delegating nurse may determine that delegation of
some or all of the tasks and procedures is no longer appropriate.
18VAC90-20-460. Nursing tasks that shall not be delegated.
A. Nursing tasks that shall not be delegated are those which are
inappropriate for a specific, unlicensed person to perform on a
specific patient after an assessment is conducted as provided in
18VAC90-20-440.

B. Nursing tasks that shall not be delegated to any unlicensed
person are:
1. Activities involving nursing assessment, problem
identification, and outcome evaluation which require
independent nursing judgment;
2. Counseling or teaching except for activities related to
promoting independence in personal care and daily living;
3. Coordination and management of care involving
collaboration, consultation and referral;
4. Emergency and nonemergency triage;
5. Administration of medications except as specifically
permitted by the Virginia Drug Control Act (§54.1-3400 et seq.
of the Code of Virginia); and
6. Circulating duties in an operating room.

1

2

Written Assignment for Week 4
Used the resources listed in week 4 to assist you in answering
these questions-the answers should be used to study for the
midterm and final exam.
After answering the questions, please upload to the site listed
for the homework assignment.
The first section has to do with delegation, which we will have
covered in discussing ethical provisions 4-6. This is a very
important part of how you as a nurse will make decisions about
patient care and accountability for that care. Nursing school
and licensing questions will require that you understand
delegation, so please look at this as a very important subject
and read and answer for understanding, not just to answer the
questions.
Please explain these in your own words as much as possible.

1. What is delegation?
2. What is supervision?
3. What is the meaning of the term unlicensed person?
4. What are the 6 criteria that must be addressed by the entity
(the organization providing the care) before delegation of
nursing tasks can occur.
5. What are the 5 criteria that must be met before delegation can
occur.
6. What additional criteria are covered by sections C and D
7. What assessment is required prior to delegation?
8. What is involved in supervision of delegated tasks?
9. What nursing tasks cannot be delegated?

Using the Ethical and Legal Issues Power point, answer the
following
(There is more information on this power point than we will use
in NSG 100. NSG 110 will address legal issues and will not be
duplicated here. But legal and ethical issues can be intertwined.
Your focus for this class is the questions below.
1. What is an ethical dilemma?
2. What are you learning as a student in NSG 100 that you can
use to address an ethical dilemma?
3. Identify the current ethical issues we are currently facing
4. What are the 4 elements that must be proven in a case of
malpractice?
5. Identify critical ethical and legal patient-oriented issues.

Using the Code of Ethics power point and your book,
1. List each provision and the sentence that description of each
provision
2. Based on what we have discussed so far in class and your
review of the power point, describe one dilemma you think you
might encounter in nursing that you would depend on this code
to address. (This does not need to be long and involved, but
what situation do you think you might have to face as a nurse
that you could think back to this class and use what you have

learned to address it.)

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