Code of Ethics for Nurses

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Definition
A code of ethics is a guide for an individual or group to follow in making decisions
regarding ethical issues.

Description
In the broadest sense, ethics are the principles that guide an individual, group, or
profession in conduct. Although nurses do make independent decisions regarding patient
care, they are still responsible to the profession as a whole in how those decisions are
made. From the earliest concept of nursing, the proper behavior and conduct of a nurse
was closely scrutinized. Florence Nightingale wrote of specific issues of conduct and
moral behavior. The Nightingale pledge that was composed in 1893 by nursing instructor
Lystra Gretter includes the vow "to abstain from whatever is deleterious and mischievous
and will not take or knowingly administer any harmful drug."

Over the last 100 years, nursing has evolved into a very complex professional field.
Nurses are now faced with life and death decisions, sometimes on an hourly basis.
Medical care has advanced to the point that new technology with its potential benefit or
harm to a patient changes constantly. Although the private conduct of a nurse is no longer
controlled by the employer, the effects of that lifestyle on the nurse's ability to think and
respond to patients while on duty falls under the code of ethics.

Viewpoints
The study of ethics is actually a branch of philosphy. The word ethics is derived from the
Greek term ethos which means customs, habitual usage, conduct, and character. The
study of ethics has led to the identification of basic concepts including rights, autonomy,
beneficence, nonmaleficence, justice, and fidelity. Understanding these concepts assists
the nurse with making decisions during difficult situations.

Rights

Webster defines a right as "something to which one has a just claim or the power or
priviledge to which one is justly entitled." Patient rights have evolved to the point that
federal legislation has been passed in the United States to protect a patient's individual
rights. A Patient's Bill of Rights was initially developed by the American Hospital
Association in 1973 and revised in1992. All hospitals are now required by law to inform
patients of these rights upon admission to the hospital.

Autonomy

Autonomy comes from the latin auto meaning "self" and nomy which means "control."
Individuals must be given the rights to assist in their own decision making. This ethical
concept has led to the need for informed consent. Sometimes patients' religious or
cultural beliefs lead them to make decisions regarding their own care that may seem
controversial or even dangerous. However, the concept of autonomy gives them the right
to make those decisions unless they are mentally impaired.

Beneficence and nonmaleficence

Beneficence means to do good, not harm, to other people. Nonmaleficence is the concept
of preventing intentional harm. Both of these ethical concepts relate directly to patient
care. In the American Nurses Association Code for Nurses, there is a specific charge to
protect patients by specifying that nurses should report unsafe, illegal, or unethical
practices by any person. Nurses are often faced with making decisions about extending
life with technology, which might not be in the best interest of the patient. Often the
concept of weighing potential benefit to the patient against potential harm is used in
making these difficult decisions, along with the patient's own stated wishes.

Justice

The word justice is closely tied with the legal system. However, the word refers to the
obligation to be fair to all people. In 2001, healthcare economics have hospitals and other
providers stretching their resources to their limits. Economic decisions about healthcare
resources have to be made based on the number of patients who would benefit. The
potential of rationing care to the frail elderly, poor, and disabled creates an ethical
dilemma that is sure to become even more complicated in the future.

Fidelity

Fidelity refers to the concept of keeping a commitment. Although the word is more
closely used to describe a marital relationship, fidelity is the concept of accountability.
What is the nurse's responsibility to his or her patient, employer, society, or government?
Privacy and confidentiality are concepts that could be challenged under the concept of
fidelity. If a nurse is aware of another healthcare giver who is impaired, but the
circumstances are private or confidential, how is the conflict resolved?

Professional implications
As a general rule, nurses are employed by a hospital, clinic, or private practice. Decisions
that are made about patient care are not totally independent. Every decision creates a
ripple effect and touches someone else in the health care field. One of the purposes of a
code of ethics is to help nurses keep perspective and a balanced view regarding decisions.
One way to study a code of ethics is to look at a case study.

J. L. presents herself to the emergency room with lower right abdominal pain. J. L. is a
17-year-old white female and is accompanied by her mother. J. L.'s mother is a nurse and
works in another department of the hospital. The mother signed all of J. L.'s admission
paperwork and received the Patient Bill of Rights. Although J. L.'s pain does not seem
severe enough for appendicitis, she does have a history of fever for 24 hours and her
temperature in the hospital is 100.8°F (38°C). An ultrasound that did not show
appendicitis had been done earlier in the day. She was told to report to emergency room
if the fever rose. After J. L. reports her symptoms to both a nurse and a physician
assistant, she is examined briefly by emergency department physician. The staff assumes
that J. L.'s mother wants to stay in the room and does not seek the patient's permission.
As a part of her history, J.L. informs them she is not sexually active and is on the second
day of her menstrual cycle. The mother can tell by the tone of questioning that the staff
does not believe J.L. is still a virgin. After a two-hour delay, including having to repeat
the urinalysis because of a lost specimen, the emergency physician decides a pelvic
exam needs to be done. The pelvic exam is traumatic for the patient, despite her mother's
best efforts to calm her. J. L. is told in a condescending tone that the exam hurts because
of her failure to relax. Following the exam, the physician tells J. L. and mother that her
blood count is normal, the urinalysis was inconclusive because of menstrual blood, and
the patient was uncooperative in giving a catheterized specimen.

J. L. and her mother were informed a pregnancy test was done, because the staff have
experienced "immaculate conceptions" in their department. The only time that J. L. and
her mother had contact with an RN during this time was when she was initially triaged
and when the discharge instructions were handed to her mother. J. L. and her mother
were sent home with instructions. Her pain subsided without treatment.

Although this case study is not one of life and death decision making, there were
numerous violations of the patient's rights and of the nursing code of ethics. The patient's
right to privacy was violated. It is questionable whether the patient (J. L.) ever saw the
Patient's Bill of

Rights, since it was given to her mother. J. L. was sexually inactive and a virgin, so the
question of nonmaleficence is raised by the traumatic pelvic exam. The question of
abandonment is also raised due to lack of nursing attention. If J. L. had asked her mother
to leave during the exams, could confidentiality have been breached by the mother the
next day by checking the hospital computer for reports? The answer to all of the above
questions is yes; areas of nursing code of ethics could have been broken. No one died, but
there must be constant reeducation of staff regarding the importance of these issues.

In an attempt to keep the concept of ethical care in the forefront of nurses, physicians,
and other healthcare worker's minds, hospitals have ethics committees or even an ethicist
on staff. Special educational seminars may be offered or actual case studies reviewed.
Some hospitals have protocols for requesting an ethics consult at the bedside. These type
of consults are usually seen in ICU or trauma situations where ceasing life support is
being discussed.

A new area of potential ethical dilemma was discussed in the July 2, 1999, Online
Journal of Issues in Nursing. Silva and Ludwick discussed the pros and cons of interstate
practice laws. As new laws are passed that allow more fluid movement of nurses between
states, new issues of ethical behavior may arise. The initial reaction of most people in the
health care field is that a nurse practices the same way everywhere, but there are subtle
differences in the laws between states. For example, there are different definitions of
minors and when minors can be emancipated to make their own decisions. Are there
differences in state laws regarding patients with impaired decision-making capabilities?
What if the nurse is not aware of the subtle differences in each state's law?

Communication technology such as the Internet is also complicating ethical issues. Do

web sites that encourage patients to describe symptoms to on-line nurses expose too great
a risk? What backup mechanisms are in place if a patient talking to a triage nurse gets
disconnected or loses consciousness? How can there be assurances of confidentiality in a
telenursing setting? Silva and Ludwick encouraged their readers to "be proactive and
stimulate critical thinking about ethics and interstate practice."

A nursing code of ethics cannot remain a stagnant document. As new issues arise in
nursing and healthcare practice, they must be addressed and possibly included in a formal
statement. The American Nurses Association (ANA) Code for Nurses with Interpretive
Statements was approved in 1985 and was still being used in mid-2001. A task force met
in 1996 and began the process of reviewing and revising the code. A draft of the new
code is anticipated to be approved and released in 2001. The new code is more
comprehensive than the 1985 code. It is the responsibility of all professional nurses to be
aware of the Code for Nurses and any changes that may be made in the future. It is also
the responsibility of each individual nurse to practice ethical care on a daily basis.

KEY TERMS

Beneficence—The obligation to do good, not harm, to other people.

Ethics—A specific area of study of morality, which concentrates on conduct and human
values.

Maleficence—The act of intentionally doing harm or evil. Nonmaleficence is the

principle of purposefully not doing harm.

Resources
BOOKS

Ellis, Janice R. and Celia L. Hartley. Nursing In Today's World: Challenges, Issues and
Trends, 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins Publishing, 2001.

PERIODICALS

Silva, Mary C. and Ruth Ludwick. "Interstate Nursing Practice and Regulation: Ethical
Issues for the 21st Century." Online Journal of Issues in Nursing July 1999.
<http://www.nursingworld.org/ojin>.