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Ethics in Nursing

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Contact Hours: 10

This online independent study activity is credited for 10 contact hours at completion.

Course Purpose

To provide healthcare professionals with knowledge of common ethical terminology, the American Nurses Association Code of Ethics with Interpretive Statements, and The International Council for Nurses Code of ethics through case study review.

Overview

Nurses are often obligated to make ethical decisions. It is vital that nurses have the analytical thinking ability and skills to be able to appropriately respond to the vast everyday decisions regarding a patient’s well-being that must be made. With the use of ethical principles, theories, and codes, nurses and patients are better able to make informed decisions in care. To prepare and assist the nurse in making ethical decisions, the American Nurse Association and the International Council for Nurses independently developed Codes of Ethics to use as a guide when ethical dilemmas arise. Ethical terminology, and each of the codes of ethics are discussed through case study review.

Objectives

Upon completion of the activity, the learner will be able to:

  • Describe ethics and its impact on the nursing profession
  • Review the history of ethics within nursing
  • Describe the American Nurse Association’s position on Ethics within Nursing
  • Review the International Councils for Nurses global influence on Ethics in Nursing

Policy Statement

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Disclosures

Fast CE For Less, Inc. and its authors have no disclosures. There is no commercial support.

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Introduction

Nurses save lives. But helping others goes far beyond providing medical treatment. Every day, nurses deal with matters of ethics and human rights. To help nurses address these often-complicated issues, the American Nurses Association and the International Council for Nurses have independently developed Codes of Ethics for Nurses to use as a guide in ethical decision making. This course provides an overview of ethical terminology, the American Nurses Association Code of Ethics with Interpretive Statements, and the International Council for Nurses Code of Ethics, and seeks to better inform and prepare the nurse for ethical decision making.

Ethics

A philosophical study discipline: ethics is an approach to understanding, analyzing, and comparing right vs wrong. Ethical determinations are used through theories and codes of conduct. Ethical directives are not always evident, and some will disagree about what is right, and what is wrong. These factors can lead some to believe that ethics can be based on personal opinions. Nurses must do more than practice ethics based on their own personal intuition, opinions, or beliefs; they must understand the concepts, principles, and ethical theories, so that they can identify and evaluate ethical dilemmas relevant to current nursing practices. Ethical theories and ethical codes guide nurses to make decisions when faced with ethical dilemmas, and ethical principles make it easier for nurses to make decisions when confronted with a difficult situation.

Ethical Terminology

Amoral: Refers to actions normally judged as immoral, but with lack of concern for outcomes/remorse.

Autonomy: The freedom to express personal decisions without outside interference and act in a self-determined manner. Patient autonomy includes having comprehensive and truthful information when an informed consent is obtained. The elements of informed consent include:

a. Threshold elements:

  1. Competence
  2. voluntariness

b. Information elements:

  1. Disclosure
  2. Recommendation
  3. Understanding

c. Consent elements:

  1. Decision
  2. Authorization

Beneficence: To take an action that benefits the welfare of another.

Casuistry: An approach that is used to make decisions based on the analysis and evaluation of individual cases, such as landmark cases to which similar cases are compared for guidance. This approach is often used by healthcare ethics committees to analyze ethical issues ‘from the bottom up’ as opposed to the traditional way of using rules and principles for guidance.

Critical Theory: Also called critical social theory, is a broad term that identifies theories that address the domination caused by powerful groups of people and the oppression of other groups. The critical theory promotes emancipation.

Ethical Relativism: A belief that it is acceptable for morals and ethics to differ. There are two types of ethical relativism, ethical subjectivism, and cultural relativism.

  • Ethical subjectivism: People can create their own opinion on morality based off an action, rather than an evaluation of ethics.
  • Cultural relativism: What is considered wrong in one culture may not be wrong in another culture.

Ethical Objectivism: A belief that universal moral principles exist. Three examples of objective ethical theories are Deontology, Natural Law Theory, and Utilitarianism.

  • Deontology: Means the study of duty that focuses on rules and concedes that people can only be moral through dutiful actions.
    • Consequentialism: Consider consequences to be an indication of the moral value of an action.
  • Natural Law Theory: Universal type of justice grounded in the laws of nature that describes the rightness of actions being self-evident because of morality being placed in the order of nature.
  • Utilitarianism: To promote the greatest good for the greatest number of people and produce the least amount of harm from an action. There are two types of utilitarianism: act utilitarianism and rule utilitarianism.
  • Act Utilitarianism: Belief that an action in a circumstance should be chosen based on good consequences instead of a moral rule. The goal of act utilitarianism is to achieve the most happiness in any given situation.
  • Rule Utilitarianism: The belief that there are certain rules that must be followed and following the rules will create the best outcomes for most people. Rule utilitarians are amenable to causing more suffering than happiness in a situation to avoid breaking a rule.

Ethics: An active process that supports beliefs and assertions with sound reasoning. An ethical decision must be justified through logic and theory. Ethics can be categorized into three areas of Inquiry: Normative Ethics, Metaethics, and Descriptive Ethics.

  • Normative Ethics: Describes values and behaviors that are good or bad through inquiry about how what character one should have, and how one should behave in certain situations.
    • Common Morality: Develop historically and are familiar normative behaviors and beliefs that a society generally agrees upon, such as obligation, kindness, and charity.
    • Metaethics:Means about ethics, concentrated on understating the language of morality through evaluation of the meaning of ethically related theories and concepts, such as the meanings of good and happiness.
    • Descriptive Ethics:  A scientific inquiry that is used to describe how people behave or what they think about morality, such as a nurse’s decision to tell a patient the truth about a terminal illness.

Human Dignity: Part of the first provision to the Code of Ethics for Nurses with Interpretive Statements, refers to the honor given when providing body privacy, personhood, and the perception of how one looks, behaves, and express and respects themselves and others when they are being watched by another person.

Justice: Refers to fairness and treating people equally and without prejudice, and the equal distribution of burdens and benefits. There are two forms of justice: distributive justice and social justice.

  • Distributive Justice: Having a fair allocation of resources.
  • Social Justice: Burdens and benefits must be distributed equally among society members, allowing everyone to have the same rights, opportunities, and benefits.

Immorality: Opposite of morality, means one’s behavior is opposite professional, cultural, social, or religious ethical standards and principles.

Intentional Nondisclosure: Only legal when patients waive their rights to be informed, or in emergency situations. Any error that involves serious preventable adverse effects must be reported to the patient and an organization reporting system.

Moral Suffering: A feeling of anguish and uneasiness when a nurse attempts to sort out his/her own emotions when placed in a morally unsatisfactory situation that is beyond their control.

  • Moral Distress: Emotional and physical suffering that occurs when a nurse experiences compromised moral integrity.

Moral Integrity: An ethical competency that is considered the cornerstone of all virtues. Features include intent, good character, and performance. Moral integrity includes the following:

  • Benevolence: A morally valuable character trait that benefits others.
  • Honesty: The substance of relationships that equips people to achieve a just society through action and resolve. Even when opposed by others.
  • Moral Courage: Inherent to nursing; describes when nurses act upon ethical principles to do what is right.
  • Truthfulness and Truth Telling: Being ethically obligated to tell the truth and not intentionally deceive anyone.
  • Wisdom: Often called practical wisdom; requires intellectual ability contemplation, and deliberation to achieve a goal.

Morals: Specific behaviors, beliefs that are judged to be good or bad through systematic ethical analysis.

Narrative Ethics: Is like casuistry and assesses how moral character and actions fit with cultural stories based on personal lives. One will make choices on beliefs because of environmental interactions with other people.

Nonmaleficence: A principle that is used to communicate an obligation to do no harm. This includes the need to avoid negligent care, harm when providing treatment, decisions to provide or withdraw from treatment, and decisions in the use of heroic treatment.

Paternalism: When a healthcare provider believes that they know what is in the patient’s best interest and takes actions that even unintentionally, are in violation of a patient’s right to self-determination. There are two types of paternalism: soft paternalism and hard paternalism.

  • Soft Paternalism: Used to protect a patient who is unable to make reasonable decisions for themselves, such as in addiction and depression.
  • Hard Paternalism: Purposeful interventions prevent harm even when a patient’s risky choices are informed, voluntary and autonomous.

Patient Advocacy: Assumes the primacy of patient interest in allowing them to make informed decisions and requires the nurse to work collaboratively with other healthcare professionals to address the healthcare needs of patients.

Patient Self­­-Determination Act: Was passed by the US Congress in 1990 and facilitates a patient’s autonomy though the use of advanced directives. Every adult patient must receive information on state laws that cover the right to make healthcare decisions, treatment options, and the ability to write advance directives.

Principlism: Rules based on conduct that come from identifying obligations and duties. Principles are usually related to documents, such as documents that reflect positions on human rights.

Prima Facie: Something that is viewed as being correct until proven otherwise.

Professional Boundaries: Limits that protect the space between a nurse’s professional power and a patient’s vulnerabilities. Professional boundaries help create a safe connection between the nurse and patient because they give each person in the relationship a sense of legitimate control.

Reasoning: The use of abstract thought to creatively think about and answer questions or problems and create strategies for desired outcomes. It involves thinking for oneself and basing conclusions on logical foundations.

Moral Reasoning: Reasoning that is focused on ethical or moral issues

The Health Insurance Portability and Accountability Act (HIPPA) of 1996:  Protects all identifiable health information, such as electronic, paper, or oral, that is transmitted to ensure patient privacy when necessary information to meet the patients’ needs is used.

The Patient Protection and Affordable Care Act (ACA): Signed into law in 2010, the ACA was intended to initiate comprehensive healthcare reform through improving quality and lowering healthcare costs and providing greater access to healthcare.

Therapeutic Privilege: Allows a physician to withhold health information a patient if he/she believes that divulging in the information could cause harm to an emotionally unstable patient.

Unethical: Describes ethics in a negative form when character or behavior is contrary to a code of conduct or admiral traits.

Value: Something that is highly regarded and refers to judgments about what is good or desirable. Professional values are outlined in the American Nurses Association’s Code of Ethics for Nurses with Interpretive Statements.

Virtue Ethics: Addresses behaviors one must pose to be good. Virtues develop as a response to circumstances, persist through challenges, and can be strengthened or weakened by responses to actions. Examples of virtues are benevolence, fidelity, compassion, and patience.

History of the Nurses Code of Ethics

Professional nursing education began in the 1800’s at Florence Nightingale’s school in England, it focused on professions-shaping ethical concepts and values. Modern nursing was established at the end of the 1800’s, and during that time ethics became a major topic in nursing. In 1899, the International Council of Nurses (ICN) was established, and it pioneered the development of the code of ethics for nurses. The first book on nursing ethics was written at the turn of the 20th century, and addressed relationships between the nurse, patient, physician, and public. The ICN updated the code of ethics in 1973 and shifted from a focus on obedience to physicians to its current focus on patient needs. In 1926, the American Journal of Nursing (AJN) published a suggested code that was never adopted. A tentative code was published in 1940 by the AJN, but again, the code was never adopted. The American Nurses Association (ANA) adopted its first code of ethics in 1950. Three additional code of ethics revisions occurred before the creation of the interpretive statements in 1976. The word ethics was added to the 2001 publication and the seventh edition of the code of ethics was published in 2015.
In the most recent code of ethics, the ANA outlined 9 nonnegotiable provisions, each with interpretive statements for illustration of detailed narratives for ethical decision making. The first 3 provisions focus on the nurse-patient relationship, the second 3 provisions focus on the accountability of practice toward others, oneself, and the work environment, and the last 3 provisions focus on duty to the profession, collaboration, and social justice. Nonnormative ethics and deontology largely serve as the basis for the code. The interpretive statements are detailed enough to guide decision making on a wide range of topics; however, they are not all-inclusive, and should not be used to predict every single ethical decision or action of a nurse. The Code requires the nurse to remain attentive and loyal to all patients that they care for and be watchful for ethical issues and conflicts of interest that can cause negative relationships with patients and decisions in care. The following is a brief overview of the ANA Code of Ethics with interpretive statements.

American Nurses Association Code of Ethics with Interpretive Statements

Provision 1:

The Nurse Practices with Compassion and Respect for the Inherent Dignity, Worth, and Unique Attributes of Every Person.

1.1 Respect for Human Dignity

Respect for the inherent dignity, unique attributes, worth, and human rights of all individuals are the core of the nursing practice. The nurse must support the right to dignity by respecting the values and needs of each individual that they encounter, whether that person is a colleague or a patient; provide leadership in the development and implementation of changes in public and health policies that support respect for human dignity.

1.2 Relationships with Patients

Nurses establish patient relationships of trust by setting aside all biases and prejudices while providing services. This trust includes respecting patient decisions and supporting patient choices. Factors such as culture, religious or spiritual beliefs, value systems, lifestyle, sexual orientation or gender expression, social support system, and primary language are to be considered when planning individual, family and population-centered care. Respect for patient decisions does not require that the nurse agree with or support all patient choices. If the patient’s choices are self-destructive, the nurse must address the behavior and offer resources to help reduce or eliminate the risk.

1.3 The Nature of Health

Nurses assist patients in achieving the goal of living with the greatest sense of well-being possible. Nurses are leaders who help patients achieve the goal by optimizing the health and well-being of patients in their care and minimizing unwanted and unwarranted treatments and interventions regardless of the patient’s socioeconomic status, functional status, illness, or proximity to death. A nurse’s support is extended to the family and to significant others of the patient and is directed toward meeting needs comprehensively across the continuum of care.

1.4 The Right to Self-Determination

Respect for human dignity requires the recognition of specific patient rights, which include the right to self-determination. Patients have the legal and moral right to determine what will be done with and to their own body and to be given accurate, understandable, and complete information in a way that facilitates an informed decision. Patients also have the right to be assisted with weighing the benefits, risks, and any available options in their treatment, including the choice of no treatment. Also, patients have the right to refuse, accept, or end treatment without influence, deceit, duress, coercion, or prejudice, and to be given necessary support throughout the decision-making and treatment process. The best way to help a patient preserve the right to self-determination is for nurses to fully understand a patient’s legal and moral rights, and provide resources as needed, identify options, and address problems in the decision-making process so that the patient or their surrogate can make an informed medical decision.

1.5 Relationships with Colleagues and Others

Nurses help build ethical, compassionate, and effective medical environments by maintaining respectful, professional, and caring relationships with colleagues and by collaborating with other healthcare providers to meet shared goals of providing compassionate, transparent, and effective health services. Nurses value the distinctive contribution of individuals or groups as they seek to achieve safe, quality patient outcomes in all settings. This standard of conduct includes an affirmative duty to act to prevent harm.

Provision 1 Case Study Example

Mrs. Simpson is a 49-year-old who has stage IV lung cancer. Mrs. Simpson was diagnosed with lung cancer 12 months ago, and after receiving chemotherapy and surgical intervention, the cancer has aggressively returned. With the presence of the entire healthcare team, Mrs. Simpson was notified that her cancer was too advanced for further treatment options, and hospice services was discussed. Mrs. Simpson stated that she did not want to seek a second opinion or any other treatment options. She simply said, “I’m just so tired” and requested to become “Do not resuscitate, do not intubate” status. Mrs. Simpson requested to be transferred home where she could receive hospice services. Mrs. Simpson signed forms making herself ‘do not resuscitate, do not intubate’. All appropriate documents were correctly completed and filed. While waiting for transportation services home, Jennifer, Mrs. Simpson’s daughter arrived at the hospital to visit. Upon arrival, Jennifer found her mother, Mrs. Simpson cool to the touch and gasping for breath. Jennifer called for help, and the nurse and doctor immediately arrived. Jennifer exclaimed “Do something! You have to save my mother!” As the nurse who arrived at the room, what would be your interventions?

Provision 1 Case Study Example Response

The Nurse assigned to Mrs. Simpson must follow the ANA code of ethics 1.4; The right to self-determination, which states in part ‘Patients have the legal and moral right to determine what will be done with and to their own body and to be given accurate, understandable, and complete information in a way that facilitates an informed decision. Patients also have the right to be assisted with weighing the benefits, risks, and any available options in their treatment, including the choice of no treatment.’ Mrs. Simpson had previously discussed and requested not to have any medical interventions, should she stop breathing or her heart stop beating. That does not; however, mean that in Mrs. Simpsons current state of heath, no interventions should be given. The nurse should provide supplemental oxygen to Mrs. Simpson and administer any medications deemed necessary by the physician. The nurse and physician should also take time to explain to Jennifer what interventions that they are providing, and what Mrs. Simpson’s desires for medical management were. The nurse and physician should also include a resource person, such as a social worker to remain with Jennifer.

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 patient. Nurses provide patients with opportunities to participate in planning and implementing care and support and have honest discussions about treatment options. When the patient’s wishes conflict with family members, the nurse will help to resolve the conflict recognizing the patient’s place within the family but will always stay committed to the patient.

2.2 Conflict of Interest for Nurses

Nurses can experience conflict from competing loyalties in the workplace. When a conflict occurs, nurses must examine the conflicts that arise between their own personal and professional values, the values of the patient, and the values of others who are also responsible for patient care and healthcare decisions. Nurses address such conflicts by disclosing the nature of the conflict to all relevant parties, ensuring patient safety and the patient’s best interests while preserving the professional integrity.

2.3 Collaboration

Nurses must foster collaborative planning to provide high-quality, safe, patient-centered health care. Collaboration requires mutual trust between the nurse, the patient, and the healthcare team through respect, recognition, transparency, shared decision-making, and open communication. Nurses facilitate informed decision-making by helping patients to obtain the information that they need to make choices consistent with their own values.

2.4 Professional Boundaries

Although the professional work of nursing is personal, nurses must recognize and maintain appropriate personal relationship boundaries. At their foundation, nurse-patient and nurse-colleague relationships promote, restore, and protect health. Nurses are responsible for maintaining professional boundaries in all communications and actions. Should a boundary be recognized, the nurse should seek the assistance of peers or supervisors in managing or removing themselves from the difficult situation.

Provision 2 Case Study Example

Susan Wilson is a seasoned travel nurse who was recently hired in the Trauma Intensive Care Unit. Susan has extensive trauma experience, working in the emergency room, intensive care unit, and travel nursing. She began travel nursing after experiencing a tumultuous divorce. Three weeks ago, Charles Oakley, a 45- year-old entrepreneur was brought into the ICU after experiencing multisystem trauma following a motorcycle crash. Susan has been assigned to Mr. Oakley on every shift of work, and periodically would talk about her family, travel, and even the circumstances of her divorce. After 3 weeks of being in the Trauma ICU and after multiple surgeries, Mr. Oakley is finally being transferred to the Med-Surg ward. Susan has grown fond of Mr. Oakley, and before his transfer she states, “Take care of yourself.” Mr. Oakley responds by reaching for Susan’s hand and asks “When I get out of here, can I take you out? You have been so nice to me. I just want to thank you and show my appreciation.” What ethical principle has Susan broken?

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

The need for health care does not justify unnecessary, unwanted, or unwarranted intrusion into one’s life. Privacy is described as the right to control access to, and disclosure or nondisclosure of, information pertaining to oneself and to control the timing, circumstances, and extent to which information may be disclosed. Nurses provide an invaluable service by helping safeguard their patients’ right to privacy. Nurses help develop and maintain policies and practices that protect both personal and clinical information.

For example, the nurse advocates for an environment that provides enough physical privacy, which includes privacy for personal discussions. Nurses also maintain confidentiality by not disclosing personal information that has been communicated within the nurse-patient relationship. The professional nurse has a duty to maintain confidentiality of all patient information, both personal and clinical in the work setting and off duty, only sharing relevant data with members of the healthcare team, and only through proper channels that follow established protocols. The duty to maintain confidentiality is not absolute and may be limited in circumstances to protect the patient or other parties, or by law or regulation, such as mandated reporting for safety or public health reasons. When circumstances require a breech in confidentiality, guidelines must ensure that the rights, safety, and well-being of the patient remain protected.

3.2 Protection of Human Participants in Research

Stemming from the principle of respect for persons, autonomy, and respect for self-determination, people have the right to choose whether to participate in research as human subjects. Participants in research must be given enough information to make informed decisions, and to understand that they have the right to decline or withdraw participation in research at any time without fear of consequences. Information needed by the research participant for informed consent includes the nature of participation; potential risks and benefits; any available alternatives to taking part in the study; full disclosure of incidental findings; return of all research results; and an explanation of how the data will be used and protected. Prior to research beginning, proposals must be approved by a formally constituted and qualified institutional review board to ensure protection of the participant and the ethical integrity of the research. Nurses must also be aware of the special concerns raised by research involving vulnerable groups, such as children, cognitively impaired persons, and the economically or educationally disadvantaged. Nurses have an obligation to report any researcher who violates a participant’s rights or is involved in research that is ethically questionable to appropriate oversight bodies. The nurse must also advocate for participants who wish to decline to participate or to withdraw from a study before completion.

3.3 Performance Standards and Review Mechanisms

The process of education is inherent to professional nursing. The process involves the ongoing development of knowledge, acquisition of skills, practice experiences, commitment, and personal integrity that is necessary for professional practice. Whether in academics or direct care settings, nurses must ensure that competence and commitment to professional standards exist. This fully recognizes the relationship between nurse competencies, performance standards, and educational preparation, and patient safety outcomes. Nurses are responsible and accountable for professional behavior and nursing practice.

3.4 Professional Responsibility in Promoting a Culture of Safety

Nurses must participate in the creation, implementation, and review of policies that emphasize patient health and safety and reduce errors. When a near miss or error occurs, the nurse must follow the institutional guidelines in reporting the event to the appropriate authority and ensure that the patient is notified. The nurse must also establish a process to investigate the cause(s) of the error or near miss and address any system-wide factors that could have contributed.

3.5 Protection of Patient Health and Safety by Acting on Questionable Practice

Nurses must be alert and act in all instances that place the rights or best interests of the patient in jeopardy, such as unethical, illegal, incompetent, or impaired practice or actions. To function effectively, nurses must be knowledgeable of the American Nurses Association’s Code of Ethics for Nurses with Interpretive Statements, which are standards of practice for the nursing profession, relevant local, federal, and state laws and regulations, and policies and procedures for an employing organization. When a nurse becomes aware of another’s inappropriate or questionable practice, the concern must be expressed to the person involved, as well as the responsible manager, administrator, or higher authority, with the focus on the patient’s best interests and integrity of the nursing practice. Nurses should use established processes for reporting and handling questionable practices. All nurses have a responsibility to assist whistleblowers that identify potentially questionable practices and behaviors that are factually supported to reduce the risk of reprisal against the reporting nurse. When the nurse acts responsibly and reports situations that is perceived as unethical, incompetent, illegal, or impaired, the professional organization has a responsibility to protect the nurse who reported their concerns through formal channels.

3.6 Patient Protection and Impaired Practice

Nurses have an obligation to protect the patient, the public, and the profession from potential harm when another’s practice appears to be impaired. The nurse’s duty is to protect patients and to ensure that the impaired healthcare provider receives assistance. Assistance includes consulting supervisory and administrative personnel, approaching the individual in a supportive manner and by helping the healthcare provider access the appropriate resources. The nurse should always extend caring and compassion to healthcare providers throughout identification, remediation, and recovery. All nurses must advocate for appropriate access to fair institutional and legal processes, assistance, and treatment. Advocacy includes supporting the return to practice of healthcare providers who seek assistance and, after recovery, are ready to resume professional duties.

Provision 3 Case Study Example

Jessica Robinson is a Nurse Practitioner in the emergency room. While working in triage, one of Jessica’s friends informs her that her sister-in-law is having severe abdominal pain and will arrive to the emergency room shortly. Upon arrival, Jessica evaluates the sister-in -law, prescribes medications, draws labs, performs a bedside abdominal ultrasound, and requests a healthcare team consult. After work, Jessica’s friend asks about her sister-in-law, asking “What happened to her? Is she pregnant? If she is, my brother is going to flip out! They have been trying to have a baby for a long time. Do you know the results of any of her tests? Gosh…I hope she’s OK. It would really be nice to be able to tell my brother what is going on with her.” What information can Jessica give to her friend that could ease her mind about her sister-in-law’s health concerns?

Provision 3 Case Study Example Response

Jessica must not divulge any information regarding the sister-in-law to her friend. Although the friend may have good intentions in providing health information to her brother, Jessica has an obligation to the sister-in-law and must follow the ANA Code of Ethics with interpretive statements provision 3.1 Protection of the Rights of Privacy and Confidentiality which states in part “The professional nurse has a duty to maintain confidentiality of all patient information, both personal and clinical in the work setting and off duty, only sharing relevant data with members of the healthcare team, and only through proper channels that follow established protocols.”

Provision 4

The Nurse Has Authority, Accountability, and Responsibility for Nursing Practice; Makes Decisions; and Takes Action Consistent with the Obligation to Promote Health and to Provide Optimal Care.

4.1 Authority, Accountability, and Responsibility

The scope of nursing practice is continuously evolving. The nurse is responsible for the quality of nursing care that a patient receives and is accountable for their own practice. Nurses must exercise sound judgment when accepting responsibilities, seeking out consultation, and assigning activities to others within the nursing team. Nursing practice includes direct nursing care, care as ordered by a physician or advanced practice nurse, coordination of care, evaluation of interventions, etc. Both the APRN issuing the order and the nurse accepting the order are responsible for the sound judgments made and are accountable for the actions taken. Additionally, the professional nurse must always comply with and adhere to state nurse practice acts, regulations, standards of care, and the ANA’s Code of Ethics for Nurses with Interpretive Statements.

4.2 Accountability for Nursing Judgments, Decisions, and Actions

Nurses follow a code of ethical conduct that includes moral principles and adhere to the scope and standards of nursing practice. Every nurse is individually accountable for their own decisions made and actions taken. Systems and technologies that aide in clinical practice should not replace the nurse’s skill and knowledge. Hence, nurses are responsible for their own practice in nursing, even in instances of technology or system failure.

4.3 Responsibility for Nursing Judgments, Decisions, and Actions

Nurses are responsible for assessing their own competence and can accept or reject specific role demands and assignments based on their knowledge and experience, as well as their assessment for risk to patient safety. When the needs of the patient are beyond the competence of a nurse, the nurse has an obligation to consult and collaborate with more qualified nurses and healthcare professionals.

Each nurse has an individual responsibility to implement the standards of professional practice and cannot engage in practices prohibited by law, or delegate activities to other members of the nurse team who are prohibited by their state nurse practice acts.

4.4 Assignment and Delegation of Nursing Activities or Tasks

Nurses are responsible for the delegation of select nursing interventions and must make a reasonable effort to assess competence when delegating a nursing activity that is consistent with state practice acts. Nurses are also responsible for monitoring the activities delegated and evaluating the outcomes of the care provided by other healthcare workers to whom the nurse has delegated the task. A nurse may not willfully delegate a task to any member of the nursing team when that person is not prepared or qualified.

Provision 4 Case Study Example

Judy Song is a new graduate RN who has just been hired to the Labor and Delivery unit. Judy has just arrived to work to start her first shift after orientation and proctorship. During her first rounds of assessments, Judy notices that one of her newborns has what she believes to be a heart murmur. Judy has never actually heard a murmur on a newborn before but does believe that the heartbeat that she auscultated sounds abnormal. She is unsure who she should consult with about the possible murmur. Judy does not want to look incompetent in front of her new peers and is also unsure if she should notify the physician; she is fearful that her assessment may be incorrect. Instead of consulting with a more seasoned nurse or notify the physician, Judy continues her shift duties and moves on to the next patient. During the next round of physical assessments, the mother of the newborn with the possible heart murmur inquires about the rapid heartbeat of the newborn. Judy informs the new mother that a newborn’s heartbeat is much more rapid than an adult. Because of the mother’s inquiry, Judy uses the opportunity to notify the physician about the new mother’s concerns, and about the suspected heart murmur. Did Judy’s decision making exemplify competence when caring for the newborn?

Provision 4 Case Study Example Response

Judy’s decision making did not exemplify competence when caring for the newborn. Judy was unsure if she auscultated a heart murmur in the newborn, and instead of seeking consultation or guidance from a more experienced nurse or physician, she chose to ignore her assessments findings. Judy clearly did not adhere to the ANA Code of Ethics with Interpretive statements provision 4.3 Responsibility for Nursing Judgments, Decisions, and Action which states that “Nurses are responsible for assessing their own competence and can accept or reject specific role demands and assignments based on their knowledge and experience, as well as their assessment for risk to patient safety. When the needs of the patient are beyond the competence of a nurse, the nurse has an obligation to consult and collaborate with more qualified nurses and healthcare professionals.”

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 Duties to Self and Others

A nurse has the same moral duties to oneself that he/she has to others. These duties include preservation of integrity and character, promotion of health and safety, maintenance of competency, and continuation of personal and professional growth.

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

Nurses have a duty to take care of their own health and safety. Nurses should model health maintenance and promotion measures that they teach, such as maintain a healthy diet, exercise, get enough rest, and attend to spiritual or religious needs. These activities and work must be held in balance to maintain a nurse’s own health and well-being.

5.3 Preservation of Wholeness of Character

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 between the nurse and anyone with relevant interests. As moral agents, nurses are an important part of the community and have an obligation to express moral perspectives, especially when such perspectives are important to a situation. When a nurse is asked for an opinion, he/she is generally free to express an informed opinion if they maintain appropriate moral and professional boundaries and preserve the free will of the patient. Nurses can assist patients in reaching informed decisions if coercion, manipulation, and influence is avoided.

5.4 Preservation of Integrity

Nurses must be treated with respect and should never tolerate abuse. In any healthcare environment, nurses can face threats to their integrity such as requests to deceive patients, to withhold information, or to falsify records. Expectations that nurses will make decisions that are inconsistent with the nurse’s ideals or are in direct violation of the Ethics for Nurses with Interpretive statements may occur. Nurses have a right to act according to their own personal and professional values and accept compromise only if it preserves the nurse’s moral integrity and does not jeopardize the well-being of others. When a decision is morally objectionable to the nurse, the nurse is justified in refusing to participate on moral grounds. Conscience-based refusals to participate on moral grounds exclude personal preference, convenience, prejudice, or bias.

5.5 Maintenance of Competence and Continuation of Professional Growth

Nurses must maintain competence and strive for excellence in their nursing practice. Competence affects not only the quality of care that is rendered, but also one’s self-esteem, self-respect, and the meaningfulness of work. Nurses are responsible for developing criteria for practice evaluation, and to achieve the highest standards, nurses must routinely evaluate their own performance and participate in peer review for professional growth. Professional growth requires the nurse’s commitment to lifelong learning through continuing education, self-study, specialty certification, and advanced degree achievement.

5.6 Continuation of Personal Growth

Personal and professional growth reciprocate and interact. Activities that broaden a nurse‘s understanding of themselves and the world affects his/her understanding of patients. Nurses are encouraged to continue life-long learning, read and engage in personal study, and participate in civic and advocacy activities.

Provision 5 Case Study Example

Michael Davidson has been working in ICU for the last 5 years. Michael is interested in earning the CCRN certificate. After studying for 1 month, Michael took the test and successfully passed. He is excited for three reasons; he can now be nationally recognized as having the specialty certificate, he believes that the certificate acknowledges his level of competence in nursing, and his employer offers compensation for having the CCRN certificate. Did Michael exhibit personal growth according to the ANA Code of Ethics with Interpretive Statements?

Provision 5 Case Study Example Response

Yes, according to provision 5.5 Maintenance of Competence and Continuation of Professional Growth, Michael’s passing of the CCRN exam exemplified his competence in nursing practice. According to the code of ethics, “Nurses must maintain competence and strive for excellence in their nursing practice. Competence affects not only the quality of care that is rendered, but also one’s self-esteem, self-respect, and the meaningfulness of work…. Professional growth requires the nurse’s commitment to lifelong learning through continuing education, self-study, specialty certification, and advanced degree achievement.”

Provision 6

The Nurse, Through Individual and Collective Effort, Establishes, Maintains, and Improves the Ethical Environment of the Work Setting and Conditions of Employment That Are Conducive to Safe, Quality Health Care.

 6.1 The Environment and Moral Virtue        

Virtues are attributes of moral character, such as knowledge, skill, compassion, wisdom, patience, and honesty, that allow nurses to meet their own moral obligations and do what is right.  These attributes describe a morally “good nurse.” For virtues to develop, they must be supported by a moral milieu that enables them to flourish. Nurses must create, maintain, and contribute to morally sound environments that allow them to be virtuous. Such a moral milieu fosters mutual caring, communication, generosity, dignity, kindness, and respect, and applies to all nurses, colleagues, and patients.

6.2 The Environment and Ethical Obligation

Nurses must create a culture of excellence and maintain environments that support each other in the fulfillment of their ethical obligations. Many factors contribute to a healthcare environment that can either cause barriers or promote ethical practice, such as disciplinary procedures, ethics committees, grievance mechanisms that prevent reprisal, and health and safety initiatives. Environments that exhibit fair, equitable, and just treatment of all reflect the values of the nursing profession and nurture excellent nursing practice.

6.3 Responsibility for the Healthcare Environment

Nurses must always be treated fairly and be allowed to be involved in decisions related to their practice and working conditions. Nurses are responsible for contributing to a moral environment that expects respectful interactions among colleagues and peers, and openly identifies difficult issues, including professional development of staff in ethical problem solving. With the use of the profession’s standards of practice and the Code of Ethics for Nurses with Interpretive Statements, nurses should address concerns about their healthcare work environment through appropriate channels and/or regulatory or accrediting bodies. After unsuccessful efforts to bring about change, nurses have a duty to resign from a healthcare facility, agency, or institution where there is a sustained pattern of violation of patient’s rights, where a nurse is required to compromise his/her standards of practice or integrity, or where the administration is unresponsive to the nurse’s concerns. The needs of patients cannot be used to obligate nurses to remain in a morally unacceptable work environment, because remaining in such an environment risks the nurse becoming complicit in ethically unacceptable practices, leading to adverse personal and professional consequences.

Provision 6 Case Study Example

James Mickelson is an Oncology nurse new to the night shift. James is just finishing his last round of assessments on his patients prior to the change of shift handoff reports. While checking the infusion rates of his medications, James realizes that he administered antibiotics to the wrong patient. The infusion is 3/4’s complete, and James immediately stops and removes the antibiotics from the wrong patient. James considers notifying his supervisor but is worried that he will receive reprimand for his mistake. After careful contemplation, James decides to inform the patient and his supervisor of his mistake. The patient was grateful that he was honest enough to report the error, and his supervisor used James medication error as an anonymous training tool for the ‘5 rights’ when administering medications to patients. Did James follow the code of ethics with interpretive statements according to the ANA?

Provision 6 Cast Study Example Response

Yes, James followed the Code of Ethics with Interpretive Statements according to the ANA, namely provision 6.2 The Environment and Ethical Obligation. This provision recognizes that “Many factors contribute to a healthcare environment that can either cause barriers or promote ethical practice, such as disciplinary procedures, ethics committees, grievance mechanisms that prevent reprisal, and health and safety initiatives. Environments that exhibit fair, equitable, and just treatment of all reflect the values of the nursing profession and nurture excellent nursing practice.” Instead of James being reprimanded for his mistake, it was used as an anonymous teaching tool to increase knowledge and training of nurses in the ‘5 rights of medication administration’.

Provision 7

The Nurse, in All Roles and Settings, Advances the Profession Through Research and Scholarly Inquiry, Professional Standards Development, and the Generation of Both Nursing and Health Policy.

7.1 Contributions through Research and Scholarly Inquiry

Nursing knowledge contributes to the sciences and humanities through scholarly inquiry, clinical and educational innovation, and interprofessional collaboration. Nurses must participate in the advancement of the profession through knowledge development, application, and evaluation of practice. Knowledge development relies chiefly on research and scholarly inquiry. Nurses engage in scholarly inquiry to increase knowledge that advances the theory and practice of the nursing discipline. Nurse research conduction conforms to national and international ethical standards including review by an Institutional Review Board prior to initiation, and tests existing knowledge and generates new evidence-based nursing knowledge. Nurse researchers take care to ensure that research is soundly constructed, significant, and conforms with ethical standards. Dissemination of the research findings, regardless of results, is fundamental to ongoing disciplinary discourse and knowledge. Nurses must remain committed to patients and research participants during their participation in research and throughout the continuum of care, as the right to autonomy must be honored and respected.

7.2 Contributions through Developing, Maintaining, and Implementing Professional Practice Standards

The nursing profession identifies its own scope of practice as informed, specified, directed by state and federal law and regulations, and by the ANA’s Code of Ethics for Nurses with Interpretive Statements. Professional autonomy and self-regulation are necessary for instituting nursing standards and for assuring quality care. Nursing practice standards must be developed and grounded in nursing’s ethical commitments and developing body of knowledge and reflect nursing’s responsibility to society. 

7.3 Contributions through Nursing and Health Policy Development

Nurses must serve, mentor, and lead on institutional or agency policy committees within the practice setting. Nurses must also function as advocates or appointed representatives in civic activities related to health care through local, regional, state, national, or global initiatives and promote evidence-based practice and to support the nursing profession through ethical integrity and professionalism, and advance effective, ethical healthcare policies, environments, and a balance of patient-nurse interests.

Provision 7 Case Study Example

Lisa Stokes has a PH.D. in nursing and has conducted a vast amount of research on the geriatric population. Recently, she was asked to be a mentor for nursing research that focused on geriatric autonomy when accessing the healthcare system. Lisa has some ethical concerns about the research topic, such as if some participants experience inaccessibility to healthcare, how will the inaccessibility not cause a deterrent to health treatment and potentially result in exacerbations of untreated health conditions?  Also, how was the topic approved by the Institutional Review Board (IRB)? After careful contemplation, Lisa decides not to participate in the research as a mentor. Lisa’s decision is based on two thoughts; the questionable IRB approval, and how the participants who experience inaccessibility to healthcare are provided treatments to prevent exacerbation of illnesses. Was Lisa correct in her decision not to participate in the research?

Provision 7 Case Study Review Response

Yes, Lisa’s decision not to participate in the research is correct. According to the ANA Code of Ethics with Interpretive Statements 7.1 Contributions through Research and Scholarly Inquiry “Nurses engage in scholarly inquiry to increase knowledge that advances the theory and practice of the nursing discipline. Nurse research conduction conforms to national and international ethical standards including review by an Institutional Review Board prior to initiation, and tests existing knowledge and generates new evidence-based nursing knowledge. Nurse researchers take care to ensure that research is soundly constructed, significant, and conforms to ethical standards. Dissemination of the research findings, regardless of results, is fundamental to ongoing disciplinary discourse and knowledge. Nurses must remain committed to patients and research participants during their participation in research and throughout the continuum of care, as the right to autonomy must be honored and respected.” Lisa was correct to question the ethics of the research topic. She was also correct to question the IRB approval for the research. As an advanced practice nurse, Lisa’s commitment is always to the patient (participant) throughout the conduction of research to ensure that autonomy is respected.

Provision 8

The Nurse Collaborates with Other Health Professionals and the Public to Protect Human Rights, Promote Health Diplomacy, and Reduce Health Disparities.

8.1 Health Is a Universal Right

Health is a universal human right, and the World Health Organization states “…the highest attainable standard of health is a fundamental right of every human being.” The right to health has economic, social, political, and cultural dimensions. It includes access to health care, emergency and trauma care, basic sanitation, education, treatment, and control of prevailing health problems, immunizations, injury prevention, and reproductive health care. Health is a universal human right, and therefore, the need for nurses is universal. The affirmation of health as a fundamental, universal human right is held in common with the International Council of Nurses, United Nations, and many human rights treaties.

8.2 Collaboration for Health, Human Rights, and Health Diplomacy

All nurses must commit to advancing health, safety, and welfare. This commitment reflects the nurse’s intent to achieve and maintain health so that individuals and communities can live with dignity. Ethics, nursing, and human rights converge as a formidable instrument for social health diplomacy and justice that can be increased through collaboration with other healthcare professionals. Nurses must also understand that poverty, inequality, and social marginalization contribute to the deterioration of health. Nurses must address the social determinants of health, which include poverty, access to clean water and clean air, sanitation, hunger, human rights, and healthcare disparities. Nurses must lead collaborative partnerships to create effective public health legislation, projects, policies, and programs that promote health, prevent illness, and alleviate suffering.

8.3 Obligation to Advance Health and Human Rights and Reduce Disparities

Advances in genetics, technology, and environmental science require robust responses from nurses for creative solutions and innovative approaches that are respectful of human rights, ethical, and equitable in reducing health disparities. Nurses must collaborate with other healthcare professionals to change structures and processes that unjustly affect individuals and communities. Inequalities and disparities increase the incidence of illness, trauma, and premature death. Nurses educate the public, advocate for informed choice; identify circumstances and conditions that contribute to illness, injury, and disease, emphasize healthy lifestyles; and participate in institutional and legislative efforts to protect and promote health, and address barriers to health. Nurses must recognize that health care is given to culturally diverse populations and should collaborate to create a moral milieu that is sensitive to diverse cultural practices and values.

8.4 Collaboration for Human Rights in Complex, Extreme, or Extraordinary Practice Settings

Nurses must be mindful of conflicting values or obligations and must bring attention to human rights violations in all settings. Genocide, poverty, rape as an instrument of war, abuse, human trafficking, hate crimes, the oppression and exploitation of migrant workers, are of grave concern to nurses. The nursing profession must respond when violations are encountered. Likewise, human rights may be jeopardized in political turmoil, pandemics, regional conflicts, or environmental catastrophes. Nurses must always stress human rights protections with special attention to preserving the human rights of vulnerable populations such as the elderly, the poor, the homeless, the mentally ill women, children, and socially stigmatized groups. Because inaction risks unintended consequences for human rights, nurses must carefully assess intentions, weigh all possible options, and formulate clear moral justifications for their actions. Nurses may subordinate human rights concerns to other considerations only in extreme emergencies and under exceptional conditions. In this instance a utilitarian framework should guide decisions with special emphasis on protection of the public, being transparent, and fairness of stewardship of resources.

Provision 8 Case Study Example

Ming Hua is a 7-year-old who is being discharged from the emergency room. Ming was originally brought to the emergency room by her mother who speaks little English. Ming’s mother brought Ming to the emergency room after Ming experienced one week of nausea, vomiting, and severe abdominal pain. During the triage assessment, Ming experienced a syncopal episode. She was immediately rushed back to the emergency department where she was found to be in sustained ventricular tachycardia. Ming was given IV fluids, and the physician told Ming’s mother that she would have to go to the nearest county hospital for continued treatment. Instead of arranging for transport to the county facility, the physician wrote out paperwork for leaving the hospital against medical advice (AMA) and handed the paperwork to the nurse. The nurse began providing the instructions for discharge to Ming’s mother without an interpreter, and Ming’s mother signed the paperwork for leaving the hospital against medical advice. According to the ANA Code of Ethics with Interpretive statements, what part of Provision 8 did the nurse not follow?

Provision 8 Case Study Example Review

The nurse did not follow 8.1 Health Is a Universal Rightwhich states in part “The right to health has economic, social, political, and cultural dimensions. It includes access to health care, emergency and trauma care, basic sanitation, education, treatment, and control of prevailing health problems, immunizations, injury prevention, and reproductive health care. Health is a universal human right, and therefore, the need for nurses is universal.”  8.2 Collaboration for Health, Human Rights, and Health Diplomacy also states in part that “Ethics, nursing, and human rights converge as a formidable instrument for social health diplomacy and justice that can be increased through collaboration with other healthcare professionals. Nurses must also understand that poverty, inequality, and social marginalization contribute to the deterioration of health.” The nurse should have advocated for Ming to ensure that she received proper care for her diagnosis and appropriate transfer to another hospital. The nurse also should have requested for a language interpreter and requested that the physician change the form from against medical advice to discharge, as the mother never requested to leave without treatment. By not advocating for Ming and having the mother sign paperwork without an interpreter, the nurse violated Ming’s right to access to emergency care and use of language services for her mother.

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 and Assertion of Values

Nurses are represented by their professional associations and organizations, and these groups give a united voice to the nursing profession. The nursing profession collectively has a responsibility to communicate and promote shared values both to the public and within the profession. It is essential that the profession engage in communication that supports critical self-analysis, ongoing self-reflection, and evaluation. The nursing profession’s associations and organizations communicate to the public the values that nursing considers key to the prevention of illness and injury, the promotion or restoration of health, the prevention of illness and injury, and the alleviation of pain and suffering. The nursing profession must reaffirm and strengthen nursing values and ideals through its professional associations and organizations the so that when those values are challenged, adherence is maintained.

9.2 Integrity of the Profession

The ethics and values of the nursing profession should be declared in all professional and organizational relationships. The nursing profession must continually emphasize the values of fairness, respect, and caring within the nursing communities to promote health in the population. A fundamental responsibility is to promote awareness and adherence to the codes of ethics for nurses, and practices and policies regarding access to nursing education, nurse migration and utilization, and workforce sustainability are required to achieve these goals. The nursing profession must engage in ongoing dialogue, and the covenant between the nursing profession and society is made explicit through the Code of Ethics for Nurses with Interpretive Statements, foundational documents.

9.3 Integrating Social Justice

It is the shared responsibility of professional nursing organizations to represent nurses and collectively shape health care and promulgate change for the improvement of health. Nurses must be vigilant recognizing the social determinants of health, and take action to influence leaders, legislators, and governmental agencies in all related health affairs. Nurses must also instill in the nursing student the professional responsibility to address unjust systems and structures and model the nursing profession’s commitment to social justice and health through experience 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 voices of U.S. nurses around the world. Professional nursing organizations must actively participate in the political process, that affect the public’s health and the nursing profession. Nurses must promote open communication that allows nurses to work together, 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 put their efforts and energies together. Human life and health are affected by the state of the world that surrounds us, and consistent with Florence Nightingale’s historic concerns for environmental influences on health, the nursing profession’s advocacy for social justice extends to assaults on ecojustice such as earth resources exploitation, environmental degradation, aridification, and ecosystem destruction, which disproportionately affects the health of the poor and ultimately affects the health of all humanity.

Provision 9 Case Study Example

Brandon Fisher has just been hired to work with the World Health Organization (WHO) as a public health nurse. His role in the new position will be to teach communities in India about HIV and AIDS prevention, transmission, and treatments. The new position is a lifelong dream of Brandon’s, and he believes that this would be a great opportunity to collaborate with other international healthcare organizations to promote health within the communities of India. What part of Provision 9 of the ANA Code of Ethics with Interpretive Statements is Brandon abiding by?

Provision 9 Cast Study Example Review

Brandon is abiding by provision 9.4 Social Justice in Nursing and Health Policy which states in part “The nursing profession must actively participate in solidarity with the global nursing community and health organizations to represent the voices of U.S. nurses around the world. Professional nursing organizations must actively participate in the political process, that affect the public’s health and the nursing profession. Nurses must promote open communication that allows nurses to work together, 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 put their efforts and energies together.” Through Brandon’s participation with the WHO, he will have the opportunity to work with other health organizations to reach a common goal of improving knowledge and prevention of HIV and AIDS.

International Council for Nurses: Code of Ethics for Nurses

Inherent in nursing is a respect for human rights, which includes cultural rights, the right to life and choice, to dignity and to be treated with respect. Nursing care is respectful and makes no considerations to age, race, creed, culture, disability or illness, gender, sexual orientation, nationality, politics, race. or social status.

The International Council for Nurses (ICN) adopted its first code of ethics in 1953.  The code of ethics has been revised multiple times; most recently in 2012, and since its creation in 1953 many nurses all over the world have adapted the ICN code of ethics. The four fundamental responsibilities of promoting health, preventing illness, restoring health, and alleviating suffering emanates from the role of nursing. The ICN code of ethics serves as an action-based standard of conduct related to four key elements: nurses and people, nurses and practice, nurses and the profession, and nurses and coworkers. Like the ANA code, the elements of the ICN code of ethics arise from a deontological, normative ethics framework for nurses to use as a guide for nursing conduct in practice, education, research, and leadership. The ICN code of ethics for nurses has four key elements that outline the standards of ethical conduct. They are as follows:

  1. Nurses and People
  • The nurse’s primary professional responsibility is to those who require nursing care.
  • In providing care, the nurse promotes an environment where human rights, values, customs and spiritual beliefs, family and community are respected.
  • The nurse ensures that the patient receives accurate, enough and timely information that is culturally appropriate to base consent for care and related treatment.
  • The nurse keeps confidence personal information private and uses judgement in sharing the information.
  • The nurse shares with society the responsibility for initiating and supporting action to meet the social and health needs of vulnerable populations.
  • The nurse is an advocate for equity and social justice in resource allocation, access to health care and other social and economic services.
  • The nurse demonstrates professional values such as compassion, trustworthiness, respectfulness, responsiveness, and integrity.

2. Nurses and Practice

  • The nurse has personal responsibility and accountability for nursing practice, and for maintaining competence through continued learning.
  • The nurse maintains a standard of personal health to ensure that care provided is not compromised.
  • The nurse uses judgement regarding competence when accepting and delegating responsibility.
  • At all times, the nurse will maintain standards of personal conduct that will reflect well on the profession and enhance its image and public confidence.
  • When providing care, the nurse will ensure that use of technology and scientific advances are compatible with the safety, dignity, and rights of people.
  • The nurse will strive to foster and maintain a practice culture promoting ethical behavior and open dialogue.

3. Nurses and the Profession

  • The nurse assumes the major role in determining and implementing acceptable standards of clinical nursing practice, management, research, and education.
  • The nurse is active in the development of research-based professional knowledge that supports evidence-based practice.
  • The nurse is active in developing and sustaining a core of professional values.
  • Acting through the professional organization, the nurse participates in creating a positive practice environment and maintaining safe, equitable social and economic working conditions in nursing.
  • In practice, the nurse works to sustain and protect the natural environment and is aware of its consequences on health.
  • The nurse contributes to an ethical organizational environment and challenges unethical practices and settings.

4. Nurses and Co-workers

  • The nurse sustains a collaborative and respectful relationship with co-workers within the healthcare system.
  • The nurse takes appropriate action to protect patients, families, and communities when their health is endangered by a co-worker or any other person.
  • The nurse takes appropriate action to support and guide co-workers to advance ethical conduct.

Discussion

Common threads exist between the nine provisions of the ANA code (2015) and the four elements of the ICN code (2012). The codes, which apply to all nurses in all settings and roles, are nonnegotiable ethical nursing standards with a focus on social values, people, relationships, and professional ideals. Both codes share values such as respect, privacy, equality, and advocacy. Nurses should protect the moral space in which patients receive care, and nurses should uphold the agreement with patients on an individual and collective basis. Protecting the moral space of patients requires nurses to provide compassionate care by endorsing the principles of autonomy, beneficence, nonmaleficence, and justice. Within the two codes of ethics, nursing responsibilities include promoting and restoring health and preventing illness, but a significant emphasis is alleviating suffering of patients who experience varying degrees of physical, psychological, and spiritual suffering.

Conclusion

The ANA outlined 9 nonnegotiable provisions through nonnormative ethics and deontology that serves as the basis for the nurse’s ethical decision making. The first 3 provisions focus on the nurse-patient relationship, the second 3 provisions focus on the accountability of practice toward others, oneself, and the work environment, and the last 3 provisions focus on duty to the profession, collaboration, and social justice. The Code requires the nurse to remain attentive and loyal to all patients that they care for and be watchful for ethical issues and conflicts of interest that can cause negative relationships with patients and decisions in care. Likewise, The International Council for Nurses (ICN) code of ethics arises from a deontological, normative ethics framework.  The ICN identifies four fundamental responsibilities of promoting health, preventing illness, restoring health, and alleviating suffering that emanates from the role of nursing. The ICN code of ethics also serves as an action-based standard of conduct related to four key elements: nurses and people, nurses and practice, nurses and the profession, and nurses and coworkers. However, one perceives the value of codes of ethics for nurses created by the ANA and ICN, they still serve as mandates for accountability in all roles of nursing and provide as valuable guides for nurses to utilize when faced with ethical dilemmas.

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