1. © 2015 American Nurses Association

2. © 2015 American Nurses Association
Purpose and Evolution of the Code and Provisions 1-3, Nurses and Patients
Slide Deck 1
© 2015 American Nurses Association

3. Provisions 1-3, Nurses and Patients
What do we mean by nurses and patients?
Provisions 1-3 address direct patient care and describe the most fundamental values and commitments of the nurse.

4. Scope of Nursing Ethics
Unless separately referenced, all content comes from ANA’s Code of Ethics for Nurses with Interpretive Statements, 2015 (“the Code”) OR Fowler, M. D.M. (2015). Guide to the code of ethics for nurses: Development, application, and interpretation (2nd Ed.). Silver Spring, MD: American Nurses Association. *All images are public domain under the Creative Commons license and were retrieved from The question mark icon throughout indicates a discussion point or question to engage in dialogue.

5. What Is Ethics?
A specialized area of philosophy dating back to ancient Greece and earlier
Concepts of Hippocrates still inform today’s ethical issues.
A systematic study of what is right and good measured against principles, virtues and core values of a profession.

6. Scope of Nursing Ethics
Deals with:
Character (what sort of person one ought to be)
Conduct (how one should act)
Deals with duties and obligations of nurses to:
Patients
Other health professionals
The profession
The wider public
Global humanity

7. Why Ethics in Nursing? Because nurses… Serve vulnerable persons
Promise to protect patients
Impact patient well-being
Depend on public trust
Have a moral relationship with patients that gives rise to ethical obligations

8. Personal Values and Nursing
Morality comprises personal values, character and conduct.
Those entering nursing bring moral values stemming from:
Religion, culture, family, education, life experience
Embedded moral values are a starting point for ethical behavior and personal integrity.
As nursing core values are learned and practiced, they are integrated with personal values to create a nursing moral identity.

9. Branches of Ethics METAETHICS Theoretical thinking about morality
NORMATIVE ETHICS
What is right/wrong, good/evil individual or collective choices
APPLIED ETHICS
Right/wrong, good/evil of actions in a specific profession or discipline

10. What Is an Ethical Code?
An ethical code is an identifying feature of a profession to:
Facilitate professional self-regulation and accountability
Describe obligations of client-professional and colleague-to-colleague relationships
Serve as a guide for analysis, decision and action

11. ANA’s Code of Ethics for Nurses with Interpretive Statements (“the Code”)
Conveys shared ethical values, obligations, duties and ideals of nurses individually and collectively
Provides an implied contract with the public
Informs society of the moral values and ideals by which it functions
Informs new professionals of the expected moral behaviors
Guides the profession in self-regulation
Provides a framework for ethical decision-making
Is unapologetic, aspirational and nonnegotiable

12. Legacy of the Code
Commitment to service is the most precious ideal of the nursing profession.
The Code supports ideals of nursing’s service.
The Code guides all nurses in living out the values and ideals of the profession.
The Code is a living, ongoing legacy of core values from Florence Nightingale in 1850 to 2015 and beyond.

13. Evolution of the Code 1893: “Nightingale Pledge”
1926: Suggested Code in the American Journal of Nursing (AJN)
1940: Tentative Code, AJN
1950: The Code adopted by ANA
1956, 1960, 1968, 1976, 1985, 2001: Revisions of the Code
2015: Major revision of the Code

14. Maturation of the Code
The Code was first adopted in 1950; it was periodically updated to reflect the changing context and practice of nursing.
Early versions stressed
Nurse’s obligation to carry out physician’s orders
Rules of conduct, moral character, hygiene
Duty with skill and moral perfection
Later versions stressed
Principles, especially respect for patient autonomy
Nurse’s obligation to the patient, including protection from incompetent, unethical or illegal practice

15. Structure of the Code Preface Introduction
Provisions 1-3 with Interpretive Statements: Nurses and Patients
Provisions 4-6 with Interpretive Statements: Boundaries of Duties and Loyalty
Provisions 7-9 with Interpretive Statements: Commitments Beyond Individual Patient Encounters
Afterword
Glossary
Time line: The Evolution of Nursing’s Code of Ethics
Note: The Interpretive Statements for each provision provide more specific guidance for practice, are responsive to the contemporary context of nursing, and recognize the larger scope of nursing’s concern in relation to health.

16. Emphasis of the Code
All nurses, all roles with various scopes of practice and settings
Relationship with other caregivers, including unlicensed personnel
Increasing diversity of patients and nurses
Wholeness of character: Nursing as a lifetime endeavor; core values and dispositions pervading all aspects of life

17. Revision Considerations
Not lightning rod for controversial, divisive public debate
Not political
Timeless language, no buzzwords that outdate
Succinct, clear, and understandable to students and new nurses
Useful to all nurses in all roles and settings

18. Nursing Is Value Laden
Caring for those suffering in the most vulnerable moments of life:
Finding meaning
Bearing witness
Facilitating healing
Being present
Expressing caring

19. Ethical Theories Nursing draws from many ethical theories, including:
Kantian Normalism
Utilitarianism
Virtue Ethics
Ethic of Caring
The Code functions at mid-range
Any of these theories can be used “behind” the Code

20. Provision 1 The nurse practices with compassion and respect for the
inherent dignity, worth and unique attributes of every
person.
Interpretive Statements
1.1 Respect for Human Dignity
1.2 Relationships With Patients
1.3 The Nature of Health
1.4 The Right to Self-Determination
1.5 Relationships With Colleagues and Others

21. 1.1 Respect for Human Dignity
Patient dignity is the foundation of nursing ethics.
Dignity is inherent, not “earned.”
A patient never loses dignity, e.g., when comatose, delirious, frail, or in an altered state.
A nurse must approach every patient with respect for dignity, regardless of personal attributes, health state, or any other situational or patient variable.
Source: Ferrell, B.R., & Coyle, N. (2008). The nature of suffering and the goals of nursing. New York, NY: Oxford University Press.

22. How would you react?
If you had to care for a hospitalized terrorist who injured himself while bombing your hometown…how does the Code guide you?

23. 1.2 Relationships With Patients
Trust
Honoring patient choices, even when risky
How would you react?
If a patient is self-harming by cutting to soothe anxiety, is this an autonomous choice? Should you stop the patient?
How does the Code guide you?

24. 1.3 The Nature of Health
Care shaped by patient preferences, needs, values, choices
Evidence provides the science of options; patient particulars help choose the options
How would you react?
Can you refuse to care for an Ebola patient to avoid risking your own health?
How does the Code guide you?

25. 1.4 The Right to Self-Determination
Patients have a right to decide for themselves.
The patient, and decisions made by the patient, are to be respected regardless of personal attributes of the patient, conflicting values, or circumstances.

26. Informed Consent for Treatment
Elements of informed consent:
Capacity to decide
Pertinent, understandable information
Voluntary decision
Assent if a minor
Advance directives:
Living will, five wishes, DPAHC
If declared by court “incompetent” to decide:
Incompetence is a legal/court decision
Power of attorney or next of kin
Substituted judgment
Best interest standard
Legal Information Institute. 38 CFR Informed consent and advance care planning.
Battard Menendez, J. (Dec. 2013). Informed consent: Essential legal and ethical principles for nurses. JONA's Healthcare Law, Ethics, and Regulation, 15(4), 140–144.
Retrieved from
Schrems, B.M. (2014). Informed consent, vulnerability and the risks of group specific attribution. Nursing Ethics, 21(7), 829–843.
Incompetence can only be declared by a court (not by physicians)—i.e., is a legal term.

27. Who Is the Patient? Individual Family Group Community Population
Resident in LTC
Consumer in mental health
Client
Recipient of care
Family
Group
Community
Population

28. Who Is the Final Decision-Maker?
Respect for autonomy
The patient, if competent
If family disagrees with the patient…
Are family goals realistic? How do you know?
What about futile treatment recommended by doctor?
If family members disagree among themselves, who arbitrates?
If family makes decision that conflicts with physician’s orders, who arbitrates?

29. Compromised Autonomy Age: Infant, child Comatose
Developmentally disabled
Dementia, hypoxia, OBS, head injury
Cognitive impairment from drugs, alcohol
Setting constraints: prisoners, students, patients

30. Health Literacy
Self-determination depends on awareness of decisions to be made
Patient’s ability to comprehend treatment options may be impaired by:
Cognitive capacity
Literacy, language proficiency, or educational level
Visual or hearing impairment
Anxiety in presence of health professionals
Fear
Important to assess patient’s understanding of treatment options and implications
Glassman, P. (2014). Health literacy. National Network of Libraries of Medicine. Retrieved from

31. Balance
Protection
Over
Under
Paternalism
Negligence

32. At the End of the Day… Nurses must live with their own conscience
Adequate ethical justification for decisions and actions to sleep at night
Principles can only go so far
Clinical judgment is in the end situational, contextual and personal
Ethical decisions always entail ambiguity and uncertainty

33. Interpretive Statement 1.4
“Nurses may not act with intent to end life even though such actions may be motivated by compassion, respect for autonomy or quality of life considerations.”
Autonomy to accept, refuse, or terminate care:
Foregoing nutrition and hydration
Withholding or withdrawing life-sustaining treatment
Honoring advance directives
ANA Ethics Position Statements:
Position Papers developed by the Ethics Advisory Board and approved by the American Nurses Association:
American Nurses Association. (2011). Forgoing nutrition and hydration. Silver Spring, MD: Author.
American Nurses Association. (2012). Nursing care and do not resuscitate (DNR) and allow natural death decisions. Silver Spring, MD: Author.
American Nurses Association. (2013). Euthanasia, assisted suicide and aid in dying. Silver Spring, MD: Author.
American Nurses Association. (2011). Registered nurse roles and responsibilities in providing expert care and counseling at end of life. Silver Spring, MD: Author.

34. Doctrine of Double Effect
Nurse may administer medications with the intent of reducing symptoms of dying, even though the secondary impact may decrease respirations and perhaps hasten death
The nurse’s actions do not cause the death, the terminal illness causes the death
Doctrine of Double Effect. Stanford Encyclopedia of Philosophy. Retrieved from

35. 1.5 Relationships With Colleagues and Others
Interdisciplinary
All colleagues, including unlicensed personnel
Inter-professional
All licensed colleagues (medicine, pharmacy, social workers, dieticians, PT, OT, RT, etc.)
Trans-professional
Licensed colleagues working together on a team across fields of expertise
Institute of Medicine. (2013). Establishing transdisciplinary professionalism for improving health outcomes, workshop summary.
Retrieved from
Interprofessional Education Collaborative Expert Panel. (May 2011). Core competencies for interprofessional collaboration: Report of an expert panel. Washington D.C.: Interprofessional Education Collaborative.
Newhouse, R.P., & Spring, B. (Nov.-Dec. 2010). Interdisciplinary evidence-based practice: moving from silos to synergy. Nursing Outlook, 58(6), 309–317.
Ruddy, G., & Rhee, K.S. (2005). Transdisciplinary teams in primary care for the underserved: A literature review. Journal of Healthcare for the Poor and Underserved, 16(2), 248–256.

36. Create a Culture of Respect
Cultivate civility, collaboration, and collegiality to ensure:
Safe, quality patient care and outcomes
Compassionate, transparent, effective health services
A hospitable work environment

37. Provision 2
The nurse’s primary commitment is to the patient, whether an individual, family, group, community or population.
Interpretive Statements 2.1 Primacy of the Patient’s Interests
2.2 Conflict of Interest for Nurses
2.3 Collaboration
2.4 Professional Boundaries

38. 2.1 Primacy of the Patient’s Interests
Engagement, trust, intimacy, presence
Based on covenant relationship, existential encounter, response to vulnerability
Respond in the here and now
Attentiveness
Responsibility
Competence
Responsiveness
Ferrell, B.R., & Coyle, N. (2008). The nature of suffering and the goals of nursing. New York: Oxford University Press.
Tronto, Joan. (1993). Moral boundaries: a political argument for an Ethic of care. London: Routledge Publishing Company.

39. Anticipate Nuances Contextual variables shift
Decision-making never static or complete
Approach may be
Too broad/too narrow
Too hasty/too delayed
Too constrained/too flexible
Too conventional/too visionary
Too reductionist/too expansionist
Too technical/not caring enough

40. Conflict Resolution
When patient interests collide with those of others (family members, physician), the nurse’s primary commitment is to the patient.
A nurse helps resolve such conflicts, so patient wishes may be honored.

41. 2.2 Conflict of Interest for Nurses
If a nurse stands to gain personally from a clinical situation, a conflict of interest exists.
Disclosure of such a conflict to all involved is expected.
Professional integrity may be damaged if a nurse does not withdraw from a conflict of interest.
Crigger, N.J. (2009). Towards understanding the nature of conflict of interest and its application to the discipline of nursing. Nursing Philosophy, 10(4), 253–262.

42. “There comes a point in analysis of every ethical dilemma when people finally know what is right and what is wrong, regardless of analytical reasoning.” -George Annas, Law Professor
Annas, G. (2014). Religion and morality. Stanford Encyclopedia of Philosophy. Retrieved from

43. 2.3 Collaboration Trust, respect, transparency Voicing ethical opinion
Shared decision-making
“Community of moral discourse”
Equipping patients with the information, resources and courage to participate in mutual decision-making
Shared responsibility for outcomes
Interprofessional Education Collaborative Expert Panel. (May 2011). Core competencies for interprofessional collaboration: Report of an expert panel. Washington D.C.: Interprofessional Education Collaborative.

44. 2.4 Professional Boundaries
Intensely personal work with vulnerable patients may generate emotional attachments
Gifts generally not appropriate
Withdraw from problematic boundary situations with colleagues

45. Provision 3
The nurse promotes, advocates for, and protects the rights, health, and safety of the patient.
Interpretive Statements
3.1 Protection of the Rights of Privacy and Confidentiality
3.2 Protection of Human Participants in Research
3.3 Performance Standards and Review Mechanisms
3.4 Professional Responsibility in Promoting a Culture of Safety
3.5 Protection of Patient Health and Safety by Acting on Questionable Practice
3.6 Patient Protection and Impaired Practice

46. 3.1 Protection of the Rights of Privacy and Confidentiality
Policies and practices in an age of technology
HIPAA: Adhere to federal and state regulations
Facebook: Completely off limits for patient photos or identifying information
Caring Bridge: Patients decide, nurses should not engage
Electronic Health Records: Only shared with those directly involved in care

47. 3.2 Protection of Human Participants in Research
Institutional Review Board (IRB) approval of relevant research proposal
Voluntary participation of participants
No coercion, deceit
Informed consent documented
Right to withdraw at any point with no untoward consequences

48. Special Consideration for Vulnerable Subjects
Fetuses and human embryos
Pregnant women
Children and minors
Cognitively impaired persons
Prisoners
Traumatized and comatose patients
Terminally ill patients
Elderly/aged persons
Economically or educationally disadvantaged persons
Underserved populations
Institutional Review Board. IRB Guidebook, chapter VI. Special classes of subjects. Retrieved from

49. 3.3 Performance Standards and Review Mechanisms
Demonstrate ongoing knowledge, skills, dispositions and integrity for competence in practice
Assume accountability for current, quality nursing practice according to national, state, and institutional standards

50. 3.4 Professional Responsibility in Promoting a Culture of Safety
Avoid or reduce errors
Do not conceal errors
Correct or treat errors
Use chain of authority when reporting a problem
Provide timely responsive communication
Document

51. 3.5 Protection of Patient Health and Safety by Acting on Questionable Practice
If a nurse observes a violation of law, policy, or ethical standards that could jeopardize patient safety…
What guidance does the Code provide?
What ANA position papers provide additional guidance?
What other policies or procedures need to be followed?

52. 3.6 Patient Protection and Impaired Practice
When impaired practice is suspected, patient safety may be jeopardized
Identify colleagues whose practice may be impaired or who are placing patients at risk
Follow chain of authority with compassion and caring so remediation and recovery may follow
Access employee assistance program for help

53. What Will Guide Your Moral Compass?