NURSING ETHICS - · PDF filemodule will examine ethics that are specific to nursing. Ethics, Values, And Morals

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NURSING ETHICS

Dana Bartlett, RN, BSN, MSN, MA

Dana Bartlett is a professional nurse and

author. His clinical experience includes 16

years of ICU and ER experience and over 20

years of as a poison control center

information specialist. Dana has published

numerous CE and journal articles, written

NCLEX material and textbook chapters, and

done editing and reviewing for publishers

such as Elsevier, Lippincott, and Thieme. He has written widely on the subject of toxicology

and was recently named a contributing editor, toxicology section, for Critical Care Nurse

journal. He is currently employed at the Connecticut Poison Control Center and is actively

involved in lecturing and mentoring nurses, emergency medical residents and pharmacy

students.

Abstract

The American Nurses Association (ANA) Code of Ethics for Nurses contains

nine provisions developed for nurses to guide them in everyday nursing

practice, helping nurses carry out their responsibilities and the ethical

obligations when caring for patients. Making ethical decisions is an essential

part of nursing practice. It involves specific values, attitudes, and conduct

that nursing as a profession carry forward to benefit patients, the profession

of nursing, and society as a whole. Nursing ethics according to the ANA and

case examples of each ANA provision are discussed.


Continuing Nursing Education Course Planners

William A. Cook, PhD, Director, Douglas Lawrence, MA, Webmaster,

Susan DePasquale, MSN, FPMHNP-BC, Lead Nurse Planner

Policy Statement

This activity has been planned and implemented in accordance with the

policies of NurseCe4Less.com and the continuing nursing education

requirements of the American Nurses Credentialing Center's Commission on

Accreditation for registered nurses. It is the policy of NurseCe4Less.com to

ensure objectivity, transparency, and best practice in clinical education for all

continuing nursing education (CNE) activities.

Continuing Education Credit Designation

This educational activity is credited for 2.5 hours. Nurses may only claim

credit commensurate with the credit awarded for completion of this course

activity.

Statement of Learning Need

Ethical decision-making is a necessary part of nursing practice. The

professional practice of nursing is always changing and evolving to address

the complex needs of society and of healthcare. Nurses need to be educated

on ethical decision-making in healthcare to stay abreast of issues and to be

actively involved as professionals in the dialogue of ethics.


Course Purpose

To provide nursing professionals with knowledge of the American Nursing

Association’s (ANA) code of ethics and practical applications of the code in

clinical situations.

Target Audience

Advanced Practice Registered Nurses and Registered Nurses

(Interdisciplinary Health Team Members, including Vocational Nurses and

Medical Assistants may obtain a Certificate of Completion)

Course Author & Planning Team Conflict of Interest Disclosures

Dana Bartlett, RN, BSN, MSN, MA, William S. Cook, PhD,

Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC –

all have no disclosures

Acknowledgement of Commercial Support

There is no commercial support for this course.

Activity Review Information

Reviewed by Susan DePasquale, MSN, FPMHNP-BC

Release Date: 1/1/2016 Termination Date: 9/19/2018

Please take time to complete a self-assessment of knowledge, on

page 4, sample questions before reading the article.

Opportunity to complete a self-assessment of knowledge learned

will be provided at the end of the course.


1. Ethics are defined as

a. behaviors/attitudes that a group considers desirable or harmful.

b. personal feelings about right and wrong.

c. beliefs that categorize attitudes and behaviors as good or bad.

d. a system of morality.

2. Which of the following is a specific provision of the ANA code of ethics?

a. Nurses should not profit unreasonably from their work.

b. The nurse’s primary commitment is to the patient.

c. A nurse should collaborate with other healthcare professionals.

d. Nurses not interfere with a patient’s decision to refuse treatments.

3. True or false: The ANA code of ethics is considered equivalent to laws.

a. True.

b. False.

4. The ANA code of ethics states that nurses have responsibility for nursing

practice.

a. This provision is used to assign legal responsibility for nursing actions.

b. This provision is intended to differentiate nurses from physicians.

c. This provision reinforces that nurses are independent professionals.

d. This provision clearly outlines what nurses can and cannot do.

5. Ethical decisions

a. frequently require collaboration with other healthcare professionals.

b. are seldom complicated or difficult.

c. seldom require collaboration with other healthcare professionals.

d. should never involve the patient; the nurse is the professional.


Introduction

The relationship between a nurse and patient is one of trust, responsibility,

and caring. The healthcare environment is a professional workplace where

nurses interact not only with patients but also with their co-workers and

others. Because of this, the profession of nursing is inextricably linked with

ethics. Ethics, in its simplest terms, means doing what is right.

Doing what is right is part of the daily functions of the nurse. While ethics is

part of every profession, each one has its specific ethical concerns. This

module will examine ethics that are specific to nursing.

Ethics, Values, And Morals

This module will discuss the ANA’s code of ethics and the nine provisions of

that code. In order to provide a background for that discussion, ethics,

morals, and values will be defined and explained.

Ethics

Ethics involves specific behaviors and attitudes that a group of people or a

society considers to be beneficial and desirable, as well as attitudes and

behaviors that are considered bad and harmful. Ethics could also be

considered as principles of conduct. Additionally, ethics are social in nature.

Some of the aspects of ethics in healthcare are listed in Table 1, which relate

to privacy, confidentially, beneficence, nonmaleficence, human dignity,

informed consent, and autonomy.


Table 1: Ethics In Healthcare

Privacy - Seclusion from the presence of others

Confidentially - Spoken, written or acted on in privacy

Beneficence - Doing good, performing acts of kindness

Nonmaleficence - Doing no harm

Human Dignity - Respect for the intrinsic worth of humans

Informed Consent - Right and responsibility to freely and voluntarily

consent or refuse treatment or a procedure, and being given enough

information to do so.

Autonomy - Ability of an individual to maintain control over her/his

life and health.

Values

Values are beliefs about attitudes and behaviors, and values categorize

attitudes and behaviors as good or bad. Although we can offer explanations

and rationales for our values, a value cannot truly be explained or defended;

it can only be believed in or not, adhered to or ignored. Despite that, there

are many values that are shared by essentially everyone and almost

universally accepted to be good or bad.

Morals

Morals are closely connected to values, but the term moral is used to

describe a person’s values. Someone who has what is considered to be good

values and whose behavior reflects those values is said to be a moral person

and to be someone who acts morally.


Ethics then can be seen as values in action, and ethics are generated by the

values of a group or a society or what that group or society believes is good

or bad. Ethics is a set of rules for what society should and should not do and

values are the underpinnings for specific ethics.

Morality refers to how closely an individual or a group adheres to a set of

ethics. A simple example can be used to connect these concepts. It is illegal

to physically harm another person except for the purpose of self-defense or

protecting someone else.

Causing physical harm is illegal because we value each individual’s health

and safety and believe that causing injury or pain to another person is

wrong. Someone who commits a battery will be judged to have behaved

immorally and perhaps unethically, as well. The specific value determines

what is good or bad behavior.

Ethics, Law, Religion, And Conscience

Ethics are not law and laws are not ethics. Laws may be derived from ethics.

Unlike ethics laws are binding and must be recognized by every member of a

society. There can be ethical disputes, which remain simply disputes; but,

breaking a law is quite different.

ETHICS → VALUES → MORALITY


Violation of a law is associated with a specific punishment; whereas, to

violate an ethical standard may or may not be punishable. Importantly,

ethics are not religion. Ethics are certainly part of religion, but religion is

personal acceptance and belief in a system that has associated ethics,

values, and morals. Ethics are not individual feelings of what is right or

wrong. Ethics are not the conscience. Conscience belongs to an individual.

Ethics are shared and social.

The Nursing Profession And Ethics

A concern with ethics has always been a part of the nursing profession.

Florence Nightingale developed a pledge in the 1800s, and it is the basis for

much of the current code of ethics. Nightingale’s pledge states:

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

knowingly administer any harmful

drug. I will do all in my power to

maintain and 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 calling.

With loyalty will I endeavor to aid the physician, in his work, and

devote myself to the welfare of those committed to my care.


In 2001, the ANA developed a code of ethics and it is considered the gold

standard for nursing ethical practice. This code has been modified over the

years but the nine provisions of the code (which are described below) have

remained essentially the same, as have its major themes of beneficence,

remaining loyal to the profession, performing beneficial services, and

maintaining honesty to yourself and the patients.

The nine provisions of the ANA code are described in an abbreviated form in

Table 2. (A provision is defined as a condition or a requirement. The full text

is available as a read-only document or for purchase on the ANA website at

http://www.nursingworld.org/MainMenuCategories/EthicsStandards/CodeofEthicsforNurses.a

spx).

The ANA ethical code outlines the values of the profession. These values are

not limited to the nurse-patient relationship but the code describes what

nurses should understand about their ethical responsibilities to patients, and

to co-workers and others. It also informs others what is expected of nurses.

Nurses who follow the ANA code of ethics will provide quality care, promote

the profession of nursing, and increase their degree of professionalism.

In Table 2, below, the reader is guided through each statement in the ANA

code of ethics that addresses nursing practice, commitment to the patient,

advocacy, duty to self and to others, and the nurses overall professional

interactions with others and collective participation to promote the

profession and wellbeing of patients.

http://www.nursingworld.org/MainMenuCategories/EthicsStandards/CodeofEthicsforNurses.aspx

http://www.nursingworld.org/MainMenuCategories/EthicsStandards/CodeofEthicsforNurses.aspx


Table 2: American Nursing Association Code Of Ethics

1. The nurse practices with compassion and respect for the inherent dignity

and worth of each person.

2. The nurse’s primary commitment is to the patient.

3. The nurse advocates for, protects, and promotes the health of patients.

4. The nurse has accountability, authority, and responsibility for nursing

practice, and makes decisions and takes actions to provide care.

5. The nurse has the same duty to self as to others, promoting health, personal

and professional development, safety and health.

6. By individual and collective action the nurse establishes, maintains, and

improves the ethical environment of the work setting.

7. The nurse advances the profession through policy development, research

and scholarly inquiry.

8. The nurse collaborates with other health professionals and the public to

protect human rights, and to promote health diplomacy and reduce health

disparities.

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.

Practical Applications Of The Provisions Of The ANA Code Of Ethics

This section will re-examine several of the nine provisions of the ANA code of

ethics and place each one in the context of a clinical concern, question, or

situation. The following section will discuss possible answers or solutions to

the examples that have been presented.

The provisions of the ethical code are clear and unambiguous. For example,

the first provision states in part that the nurse practices with respect for the

inherent dignity of the patient, and the third provision states that a nurse


should advocate for the health of patients. Concern for the dignity and

health of others and working to maintain and preserve someone’s dignity

and health are seen as good; these qualities and behaviors are valued.

Although the provisions of the ethical code are quite plain and not

complicated, applying them and using them is not always straightforward.

Consider the following points.

An ethical code is applied in situations in which all the data and facts

may not immediately be available and/or in situations that are in flux.

It is simple to say that nurses should protect a patient’s health but

health and health needs are different for each person and are

frequently changing.

The terms of an ethical code may be defined and interpreted

differently by each individual. For example, what do the terms

“advance” and “promote” mean in a given situation? How can advance

and promote be measured? And who decides what these terms mean

in a specific circumstance? Should the patient’s or the healthcare

professional’s definitions of health and healthcare be used?

Cultures change, societies change, and the expectations patients have

of healthcare systems and healthcare professionals change. An ethical

code defines what is considered to be good or bad, and nurses hold to

these values while caring for patients in environments that are

constantly evolving.

At this point the theme should be clear: the provisions of the ANA code of

ethics provide direction but not instructions. In addition, the nine provisions

can be interpreted in different ways. Applying the provisions in practical,


day-to-day situations requires flexibility and professional judgment and

using these provisions requires input from patients and collaboration with

other healthcare professionals. Ethics do not and cannot provide solutions or

answers for specific problems or situations. They can only serve as a guide

for ethical and moral conduct.

Provision Number 1: The Nurse Practices with Compassion and

Respect for the Inherent Dignity and Worth of Each Person

Compassion is awareness of the

suffering of others and a desire to

alleviate suffering. Respect is defined

as recognition of the worth or value

of someone or something. These are

concepts we all understand and they

are two of the primary values of the

ANA code of ethics, but who defines

suffering? What is acceptable in

terms of alleviating suffering and

what is excessive or intrusive? What

is compassionate behavior?

The definitions and concepts are simple. Application of them is not and

knowing what to do in any particular patient-nurse interaction or patient

care situation can be challenging. Answers are not always simple or

straightforward.


Example #1: How can a nurse manage a situation in which he or she

suspects a patient is requesting an opioid analgesic less for the purpose of

pain relief than for euphoria?

Management of pain is a nursing responsibility and it certainly involves

compassion and a desire to alleviate suffering. But patients’ expectations of

how nurses should be involved in pain management can vary significantly. In

simpler terms they expect nurses to care about their pain, but caring has a

different meaning for each person.

Patients and caregivers may also have distinctly different ideas of what is an

acceptable level of pain and what is reasonable in terms of pain relief. In

addition, healthcare providers need to maintain some emotional distance in

order to give competent care so balancing objectivity and compassion is

difficult.

Dignity is considered to be the quality or state of being worthy of honor or

respect. The ANA code stresses that dignity is intrinsic to all people, and it

emphasizes that each person has an inherent worth. We all have value and

inherent worth simply by being human and so each person should be treated

with dignity. Everyone is deserving of this basic consideration, regardless of

the situation or our feelings. The nurse should not be influenced by the

person’s social status, health conditions, economic status, or personal

attributes. Every patient and co-worker should be treated equally. Nurses

may still dislike a patient or a colleague but expressing these feelings should

not be done in any way that interferes with patient care.

People who are hospitalized are exposed to many threats to their dignity;

i.e., lack of privacy, lack of modesty, and loss of autonomy and control. In


addition, there are many possible interpretations of honor, respect, and

inherent worth, and these are all influenced by factors such as age, cultural

or ethnic background, sexual orientation, and religious belief.

Example #2: Someone suffers a traumatic brain injury and it is determined

that the patient has suffered brain death.

The spouse feels that the best way to honor the patient’s dignity and

inherent worth is to stop all medical interventions and let the patient die.

The patient’s siblings feel that allowing the patient to die is the ultimate

measure of disrespect and would be equivalent to murder and many people

would agree.

Provision Number 2: The Nurse’s Primary Commitment is to the

Patient

This provision needs little explanation as the impetus and motivation for a

career in nursing is caring for patients. But clearly identifying what the

words “commitment to the patient” means in a given situation can be

difficult.

Example #3: A patient’s family has voiced doubts to the nurse and to the

patient about the efficacy of a particular therapy their relative is receiving;

they feel that the treatment may be dangerous and they want it stopped.

The patient’s family has not told the prescribing physician about their

feelings. The patient has not expressed any such concerns, but the nurse

notices when interacting with the prescribing physician that the patient

seems hesitant and unsure.


The patient has the mental acuity to ask for and understand information,

and is very close to his family. It is clear to the nurse and the other nursing

team members that the physician’s recommendations are safe and in the

patient’s best interest, and refusing this treatment would be harmful to the

patient. The primary commitment of the nurse is to the patient but how is

this best expressed in this situation?

Provision Number 3: The Nurse Advocates for, Protects, and

Promotes the Health of Patients.

There are many ways that nurses may advocate for a patient’s health. They

do so most often in situations in which the patient needs advice and

counseling from a professional. Protecting a patient’s health means having a

vigilant interest in patient welfare and safety and taking proactive steps to

maintain them, and promoting a patient’s health involves actively

encouraging and supporting anything that preserves and improves health. All

of these values are focused on health, but each individual has a personal

definition of health and that definition changes.

Example #4: The nurse is caring for a 73-year-old female who has

congestive heart failure (CHF). Her disease has been well-controlled and her

symptoms minimal through the use of a diuretic and an ACE inhibitor, but in

the past several months she has been increasingly short of breath.

The patient’s physician advises the patient to lose weight, exercise, make

some changes in diet, and prescribes a nitrate and an angiotensin-receptor

blocker. This treatment plan is not unusual and will almost certainly be

effective. But the patient is very reluctant to comply with the physician’s

recommendations; she states that she “feels fine.”


Should the nurse encourage the patient to accept these changes and, if so,

how vigorous should this encouragement be? What is the ethical solution for

these patient care situations?

Example # 1: How can a nurse manage a situation in which she suspects a

patient is requesting an opioid analgesic less for the purpose of pain relief

than for euphoria?

Nurses are ethically bound to treat patients with compassion and respect.

But nurses should also protect and promote patient health, and, for nurses

to inappropriately administer controlled substances would not be promoting

or protecting health. The great majority of patients who request a strong

analgesic do so because they are having pain, but abuse of, and unhealthy

dependence on opioids, are not uncommon. It is also possible that abuse,

unhealthy dependence, and pain can co-exist.

This is a difficult scenario and the answer requires asking questions,

knowledge, and collaboration. Is it likely the patient is having pain? Does

she/he have a history of opioid abuse or dependence? Would it be clinically

safe to administer an opioid analgesic at the time of the request? Are there

alternatives that would provide analgesia and would be acceptable to the

patient? And, if the patient is seeking euphoria and has an unhealthy

dependence on opioids, would giving or denying the patient this dose be

especially harmful or beneficial? Talking with the patient, speaking with the

patient’s physician, consulting with other nurses, or seeking advice from a

substance abuse counselor or addictions specialist can help to obtain

answers to these questions.


Example # 2: Someone suffers a traumatic brain injury and it is determined

that the patient has suffered brain death.

The spouse feels that the best way to honor the patient’s dignity and

inherent worth is to stop all medical interventions and let the patient die.

The patient’s parents feel that allowing their daughter to die is the ultimate

measure of disrespect and would be equivalent to murder and many people

would agree.

This example illustrates an ethical issue that has gathered much attention

and at times has involved the U.S. Supreme Court and a sitting president. In

1990, 27-year-old Teri Schiavo had a cardiac arrest. She was successfully

resuscitated but suffered irreversible hypoxic brain damage. She was

diagnosed as being in a permanent vegetative state with no hope for

recovery. Her husband wanted all interventions stopped, including hydration

and nutrition, claiming that Teri would not have wanted to continue to live in

this condition. Teri’s parents vehemently disagreed. After 15 years and a

protracted court battle Schiavo’s spouse prevailed and she was allowed to

die.

There is no right or wrong answer to this situation, there are only conflicting

values and the solution was found in the law. End-of-life issues are not black

and white, but many shades of gray. It often comes down to working with

the patient to determine how her/his care should proceed at the end of life.

Even had Teri Schiavo been conscious and able to decide for herself that she

did not want to live there are many people who feel that life should always

be preserved.


Ethically no nurse can act in a way with the sole intention of ending

someone’s life. Many times nurses perform activities such as administering

pain medication to a terminally ill patient that may speed up the dying

process. But the right to choose what treatment to accept or refuse, even if

that choice might result in what some people would consider an unnatural

death, is one of the foundations of our healthcare system. Respecting a

patient’s autonomy is a basis for the ANA code of ethics. In a situation

similar to that of Teri Schiavo, the nurse who feels he/she cannot be a part

of actions that would allow someone to die should not participate in that

patient’s care. Influencing anyone who agrees or opposes would be

unethical. Participating in the decision for or against removing life support

would be unethical.

Example # 3: A patient’s family has voiced doubts to the nurse and to the

patient about the efficacy of a particular therapy their relative is receiving.

They feel that the treatment may be dangerous and they want it stopped.

The patient’s family has not told the prescribing medical provider about their

feelings. The patient has not expressed any such concerns, but the nurse

notices that when interacting with the prescribing physician there is notable

hesitancy and the patient appears unsettled. The patient has the mental

acuity to ask for and understand information, and he is very close to his

family. It is clear to the nurse and the other nurses on the team that the

physician’s recommendations are safe and in the patient’s best interest and

that refusing this treatment would be harmful. The primary commitment of

the nurse is to the patient, but how is this commitment best expressed in

this situation?


It would be sensible and ethical for the nurse to discuss the situation with

the patient and the family and to encourage them to have a group meeting

with the physician. Additionally, the nurse should determine the level of

knowledge of the family members and the patient, and to ask them if it

would be acceptable for the nurse to notify the physician about what is

happening. If the patient and family refuse, this places the nurse in a

difficult situation. The nurse is committed to the patient’s health and welfare

and to making sure that everyone involved in the patient’s care is well-

informed, which could be viewed as commitment to the patient.

Yet, the nurse must also respect the patient’s autonomy. At that point the

only ethical course of action is to be sure that the patient and the family

have all the facts they need to make an informed decision and to ensure

they understand the risks and benefits of accepting or rejecting this

treatment. If the decision to refuse treatment would pose an imminent and

serious threat to the patient’s safety, it would probably be ethical to inform

the patient’s physician, regardless of their wishes. If this is not the case, the

decision to do this would be much more difficult.

Example #4: The nurse is caring for a 73-year-old female who has

congestive heart failure (CHF). Her disease has been well controlled and her

symptoms minimal through the use of a diuretic and an ACE inhibitor, but in

the past several months she has been increasingly short of breath.

The patient’s physician advises the patient to lose weight, exercise, make

some changes in diet, and wants the patient to begin taking a nitrate and an

angiotensin-receptor blocker. This treatment plan is not unusual and will

certainly be effective yet the patient is very reluctant to comply with the

physician’s recommendations. She states that she feels fine.


The physician’s recommendations will improve the patient’s health. Provision

number 3 of the ANA code of ethics states that the nurse advocates,

protects, and promotes the health of patients. Patients are often reluctant to

accept new therapies and make lifestyle changes, but the nurse has

personally observed how the signs and symptoms of CHF can be improved

and quality of life improved with the treatment’s the physician is prescribing.

The nurse also knows that many people need time to adjust to a change in

their medical regimens. Given these facts, the obvious conclusion would be

that the nurse should strongly encourage the patient to comply.

However, provision number 1 requires nurses to respect the dignity of

patients. Autonomy in matters of health is a part of dignity, and patients

have the right to choose which treatments they want and to refuse

treatments that they do not want. Also, health is more than vital signs and

improvement of symptoms. In this situation the ethical course of action

would involve conversation and education. The patient should be consulted

to find out why she is reluctant to accept these changes. Her knowledge of

what these therapies and lifestyle interventions entail, i.e., benefits, risks,

and level of commitment, should be determined. It may be appropriate to

consult with dieticians, a physical therapist, a pharmacist, and perhaps the

patient’s family. In short, the nurse needs to know why the patient feels the

way she does, and the nurse should make sure that the patient has

everything she needs to make an informed decision.

Nurses need to understand their patients’ values and allow them to

participate in goal setting. Practical steps for nurses to take to implement

this provision include:

Having a care plan meeting to discuss goals of the patient.

Act as a patient advocate.


Develop a strong collaborative relationship between nurse and medical

provider. Nurses who have a strong relationship with attending

providers have more influence on their ability to act as an advocate for

patients. Developing a good collaborative relationship requires that the

nurse is a good communicator and is trustworthy, knowledgeable and

respectful.

Maintain patient confidentiality. Nurses have a responsibly to their

patient to protect their privacy and safeguard information.

Be aware of conflicts of interest.

Other Provisions Of The ANA Code Of Ethics

Provision number 4 states that the nurse has accountability, authority, and

responsibility for nursing practice. This provision stresses that nurses are

independent professionals and responsible for their actions and decisions.

Provision number 5 states that the

nurse has a duty to take care of

her/himself. The nurse should

maintain integrity, maintain

professional growth, remain safe,

and monitor his/her own

competence. This provision asks the

nurse to detect any problems from

within and determine the best

course of action to remedy them.

The goal of this provision is to

promote self-respect and

professional growth.


Nurses need to maintain a balance between life and work. It is an ethical

responsibility to maintain personal competence and to recognize areas of

personal knowledge and performance that need improvement. It is also the

individual’s responsibility to keep up with advances in the field. Activities to

improve professional competence include: taking continuing education

courses, talking to more experienced employees, asking employers for more

training, attending seminars, taking self-study courses, getting more

certifications, being involved in research, and returning to school.

Provision number 6 requires the nurse to establish, maintain, and improve

the ethical environment of the work setting. Caring for patients is the

primary commitment of a nurse, but the best efforts of an individual to

provide good care will not be successful if the workplace environment is sub-

optimal. Establishing, maintaining, and improving the workplace

environment must be done on an individual and a collective basis. Staff

nurses should be encouraged to point out workplace issues that interfere

with delivery of care. Nurses who work in administration have a primary role

to assure that the healthcare environment provides good quality healthcare.

If the organization cannot or will not improve the healthcare environment

and care, the ethical course of action may require the nurse to seek other

employment.

Provision number 7 addresses the need for individual responsibility for the

profession. It recognizes that healthcare and healthcare needs are not static

and nurses should attempt to advance the profession by contributions to

education, research, and policy development.

Provision number 8 identifies one of the essential components of nursing

care, collaboration. Nurses do not and cannot operate in isolation and they


cannot take care of every healthcare need. In addition, finding ethical

solutions to patient care issues often requires consultation with other

healthcare professionals.

Provision number 9 is closely associated with provision number 4, which

states that the nurse has accountability, authority, and responsibility for

nursing practice. Provision number 9 states that nurses have a role in

making sure that nursing values are articulated and that the integrity of the

profession is maintained. Nurses are independent professionals and provision

number 9 of the ANA code of ethics recognizes that maintaining this

independence requires the nursing profession to ensure its standards and

ethics are upheld. The nursing profession must also actively promote these

values.

The Process Of Making Ethical Decisions

Using nursing ethics and acting ethically in day-to-day practice can be

complicated. There is no substitute for experience, but the learning curve of

making proper ethical decisions can be shortened and made easier by

considering it as a process. The steps listed below are an example: this

process can be modified as needed.

Ethical Decision Making

Step 1: Is this an ethical issue? Ethics are specific behaviors and attitudes

that a group of people or a society considers to be beneficial or harmful. The

primary ethics of nursing could be considered commitment to the patient

and taking action to benefit his/her health, but those ethics can be broadly

defined. Make sure the issue is one that involves the provisions of the

nursing code of ethics.


Step 2: Define the issue. This step of any problem solving process is often

overlooked but it is vital.

Step 3: Gather information. If needed consult with other nurses or

healthcare professionals. Ethical decisions often require collaboration.

Step 4: Review previous ethical issues that are similar. What worked, what

didn’t, and why?

Step 5: Make a plan. A useful adjunct to this step is explanation. Imagine

explaining a plan of action to someone. Would it be defined and clear? Would

other nurses consider the stated reasons for the plan ethical? Is the plan

practical and are there well-defined ways in which its success or failure can

be measured? Are the steps of the plan and the outcomes measurable? If

the answer is ‘no’ to any of these questions, then the plan should be

reformulated.

Step 6: Evaluate the success of the plan.

Using the Process of Ethical Decision Making

In example #3, described above, a patient’s family has voiced doubts to the

nurse and to the patient about the efficacy of a particular therapy the patient

is receiving; the family feels that the treatment may be dangerous and want

it stopped. They have not told the prescribing physician about their feelings.

The patient has not expressed any such concerns, but the nurse notices that

when interacting with the prescribing physician that the patient seems

hesitant and unsure. The patient has the mental acuity to ask for and

understand information, and he is very close to his family. It is clear to the

nurse and to the other nurses of the team that the physician’s


recommendations are safe and in the patient’s best interest and that

refusing this treatment would be harmful. If the decision to refuse treatment

would pose an imminent and serious threat to the patient’s safety, it would

be ethical to inform the patient’s physician. If this is not the case, the

decision to do this would be much more difficult.

The primary commitment of the nurse is to the patient but how is this

commitment best expressed in this situation?

Step 1: Is this an ethical issue? Yes; the primary commitment of the nurse is

to the patient and the nurse should promote and protect a patient’s health.

Step 2: Define the issue. The issues here are patient safety, patient dignity,

and patient autonomy.

Step 3: Gather information. The nurse should speak to the patient and to

the family members. This can be done circumspectly and in a way that is

non-intrusive. Other nurses should be consulted as well.

Step 4: Review previous ethical issues that are similar.

Step 5: Make a plan. A sensible plan for (hopefully) solving this ethical issue

would have four components: 1) finding out why the family feels as they do;

2) finding out what the patient feels; 3) determine what the patient and the

family knows; and, 4) provide them with the information they need to make

an informed decision. These should be the goals of the plan.

The nurse should decide what she/he will say and how to say it before

meeting with the family members and the patient. Knowing the facts about


the risks and benefits of the therapy is critical. The nurse should be clear to

the family and patient about any concerns and to reassure them that she/he

is not trying to interfere with their relationship with the medical provider. If

the decision to refuse treatment would pose an imminent and serious threat

to the patient’s safety, it would be ethical to inform the patient’s provider

regardless of their wishes. If this is not the case, the decision to do this

would be much more difficult. Either way, the nurse must be sure that the

patient and his/her family understand the implications of refusing this

treatment.

Step 6: Evaluate the success of the plan. The plan can be evaluated by: 1)

getting feedback from the patient and the family that confirms the nurse’s

understanding of their feelings; and, 2) confirming that the patient and

family understand the information the nurse has provided.

Summary

The American Nurses Association code of ethics outlines the ethics of the

nursing profession and reflects its values. The code provides an ethical

framework, but applying the provisions of the code requires experience,

flexibility, and judgment. Situations that demand ethical decision-making are

common in the nursing profession. Using a standardized decision making

process in these situations can provide a better and more efficient outcome.

Steps nurses can take to improve ethical behavior include respecting the

human dignity of all people, and the privacy and confidentially of all patients.

Nurses need to be aware of situations that promote unethical behavior. This

may include a poor work environment, as overworked nurses are more likely

to compromise ethics to reduce personal stress. Nurses are required to


assume responsibility and accountability for all their actions. This includes

participation in continuing education to promote nursing competence.

Participation in research and other activities that promote nursing, as well as

in activities that enhance a good work environment are fundamental to

professionalism and to safe patient outcomes. This involves the nursing role

to develop professional relationships, demonstrate collegiality and promote

nursing growth through mentoring and supporting colleagues.

Please take time to help NurseCe4Less.com course planners evaluate the nursing knowledge needs met by completing the self-assessment

of Knowledge Questions after reading the article, and providing feedback in the online course evaluation.

Completing the study questions is optional and is NOT a course

requirement.


1) Ethics are defined as

behaviors/attitudes that a group considers desirable or harmful.

personal feelings about right and wrong.

beliefs that categorize attitudes and behaviors as good or bad.

a system of morality.

2) Values are defined as

personal feelings about right and wrong.

beliefs that categorize attitudes and behaviors and good or bad.

legally enforced morals.

behaviors/attitudes that group considers desirable or harmful.

3) Which of the following is a specific provision of the ANA code of ethics?

Nurses should not profit unreasonably from their work.

The nurse’s primary commitment is to the patient.

A nurse should collaborate with other healthcare professionals.

Nurses not interfere with a patient’s decision to refuse treatments.

4) Which of these could be considered a provision of the ANA code of

ethics?

A nurse is responsible only for the care that she/he provides.

Each nurse must provide competent and timely care.

A nurse should sympathize with his/her patients.

Nurses should practice with compassion and respect.

5) The ANA code of ethics is considered equivalent to laws.

True.

False.


6) According the ANA code of ethics nurses should

advocate for, protect, and promote patient health.

obtain advanced degrees, if possible.

never act independently; they are part of a team.

treat patients in a way that ignores age, gender, and sexual

orientation.

7) The ANA code of ethics states that nurses have responsibility for nursing

practice.

This provision is used to assign legal responsibility for nursing actions.

This provision is intended to differentiate nurses from physicians.

This provision reinforces that nurses are independent professionals.

This provision clearly outlines what nurses can and cannot do.

8) Ethics in nursing are limited to the actions of the individual nurse.

True.

False.

9) Ethical decisions

frequently require collaboration with other healthcare professionals.

are seldom complicated or difficult.

seldom require collaboration with other healthcare professionals.

should never involve the patient; the nurse is the professional.

10) According to the ANA code of ethics the nurse’s primary commitment

is to providing safe and accurate care.

is to act morally and with compassion.

is to the patient.

is to honesty and compassion in practice.


11) ______________is awareness of the suffering of others and a desire to

alleviate suffering.

Sympathy

Compassion

Respect

Empathy

12) _______________is defined as recognition of the worth or value of

someone or something.

Respect

Compassion

Autonomy

Empathy

13) Provision number 3 of the ANA code of ethics states that the nurse

advocates, protects, and promotes the health of patients

nurtures, educates, and advocates for patients

provides care, acts collaboratively and delivers safe care to patients

None of the above.

14) Ethically a nurse can act in a way with the sole intention of ending

someone’s life if the patient has a terminal illness and a living will to be

allowed to die.

True

False


15) Provision number 4 of the ANA states that the nurse has

legal and moral duty to provide ethical nursing

accountability, authority, and responsibility for nursing practice

professional knowledge and experience to deliver ethical care

a moral obligation to provide safe and affordable care

16) ____________________ developed a pledge in the 1800s, and it is the

basis for much of the current code of ethics

Hildegard Peplau

Betty Neuman

Florence Nightingale

Faye Abdellah

17) A well-known case that went before the U.S. Supreme Court in 1990

involved the right to end the life of 27-year-old _________________.

Teri Schiavo

Christie White

Alan Young

None of the above

18) Developing a good collaborative relationship requires that the nurse is a

good communicator

trustworthy/respectful

knowledgeable

all of the above


19) Violation of a law is associated with a specific punishment; whereas, to

violate an ethical standard may or may not be punishable.

True

False

20) The ANA code stresses that __________ (the quality or state of being

worthy of honor or respect) is intrinsic to all people, and that each person

has an inherent worth.

self-worth

dignity

autonomy

independence

Correct Answer Key:

1. Ethics are defined as

Correct Answer: behaviors/attitudes that a group considers desirable

or harmful.

2. Values are defined as

Correct Answer: beliefs that categorize attitudes and behaviors and

good or bad.

3. Which of the following is a specific provision of the ANA code of ethics?

Correct Answer: The nurse’s primary commitment is to the patient.

4. Which of these could be considered a provision of the ANA code of ethics?

Correct Answer: Nurses should practice with compassion and respect.


5. True or false: The ANA code of ethics is considered equivalent to laws.

Correct Answer: False.

6. According the ANA code of ethics nurses should

Correct Answer: advocate for, protect, and promote patient health.

7. The ANA code of ethics states that nurses have responsibility for nursing

practice.

Correct Answer: This provision reinforces that nurses are independent

professionals.

8. True or false: Ethics in nursing are limited to the actions of the individual

nurse.

Correct Answer: False.

9. Ethical decisions

Correct Answer: frequently require collaboration with other healthcare

professionals.

10. According to the ANA code of ethics the nurse’s primary commitment

Correct Answer: is to the patient.

11. ______________ is awareness of the suffering of others and a desire to

alleviate suffering.

Correct Answer: Compassion

12. _______________is defined as recognition of the worth or value of

someone or something.

Correct Answer: Respect


13. Provision number 3 of the ANA code of ethics states that the nurse

Correct Answer: advocates, protects, and promotes the health of

patients

14. True/False. Ethically a nurse can act in a way with the sole intention of

ending someone’s life if the patient has a terminal illness and a living will to

be allowed to die.

Correct Answer: False

15. Provision number 4 of the ANA states that the nurse has

Correct Answer: accountability, authority, and responsibility for

nursing practice

16. ____________________ developed a pledge in the 1800s, and it is the

basis for much of the current code of ethics.

Correct Answer: Florence Nightingale

17. A well-known case that went before the U.S. Supreme Court in 1990

involved the right to end the life of 27-year-old _________________.

Correct Answer: Teri Schiavo

18. Developing a good collaborative relationship requires that the nurse is a

Correct Answer: All of the above

19. True/False. Violation of a law is associated with a specific punishment;

whereas, to violate an ethical standard may or may not be punishable.

Correct Answer: True


20. The ANA code stresses that __________ (the quality or state of being

worthy of honor or respect) is intrinsic to all people, and that each person

has an inherent worth.

Correct Answer: dignity

References Section

The reference section of in-text citations include published works intended as

helpful material for further reading. Unpublished works and personal

communications are not included in this section, although may appear within

the study text.

1. American Nurses Association. Code of Ethics for Nurses with Interpretive

Statements. 2001. Retrieved December 9, 2009. Available from URL:

http://nursingworld.org/ethics/code/protected_nwcoe303.htm

2. Nightingale F. Nightingale Pledge. Code of ethics. Retrieved from: URL:

http://www.texashste.com/documents/curriculum/code_of_ethics.pdf

The information presented in this course is intended solely for the use of healthcare

professionals taking this course, for credit, from NurseCe4Less.com. The information is

designed to assist healthcare professionals, including nurses, in addressing issues

associated with healthcare.

The information provided in this course is general in nature, and is not designed to address

any specific situation. This publication in no way absolves facilities of their responsibility for

the appropriate orientation of healthcare professionals. Hospitals or other organizations

using this publication as a part of their own orientation processes should review the

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and employees from liability resulting from the use of this publication.

The contents of this publication may not be reproduced without written permission from

NurseCe4Less.com.

http://www.nursingworld.org/ethics/code/ethicscode150.htm

http://www.nursingworld.org/ethics/code/ethicscode150.htm

http://nursingworld.org/ethics/code/protected_nwcoe303.htm

http://www.texashste.com/documents/curriculum/code_of_ethics.pdf

Documents

NURSING ETHICS - · PDF filemodule will examine ethics that are specific to nursing. Ethics, Values, And Morals