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Issues Update

American Journal of Nursing - July, 2000 - Volume 100, Issue 7

A New Code of Ethics for Nurses
Combining an unchanged mission with the challenges of contemporary nursing

By the ANA’s Code of Ethics Project Task Force

The ANA’s Code for Nurses has served as a statement of our professional goals and values and has provided guidance for conduct since 1950. The ANA’s Code, which includes 11 provisions and interpretive statements, has been periodically revised and is currently undergoing its fourth alteration, headed by the ANA’s Code of Ethics Project Task Force. The code should reflect the issues facing nursing in modern times as well as our unchanging mission to provide quality care.

The most recent update was in 1985. Although this version embodies nursing’s core values, the document no longer provides timely guidance for practice. Thus, the Code of Ethics Project Task Force has suggested that the document be updated to better reflect the current health care environment. Following are the revisions proposed, and the rationale for these changes.

Nursing’s goals and values

The first provision of the 1985 document declares the nurse’s respect for the dignity, worth, and uniqueness of each patient. Yet this addresses only the relationship between nurses and patients. Instead, the task force believes that the nurse’s respect should extend to all individuals, including colleagues, employees, and students.

“This principle is fundamental to practice. The provision should be broadened to include all persons the nurse encounters in professional relationships,” explained Ohio Nurses Association member Barbara Daly, PhD, RN, chairperson of the ANA’s Code of Ethics Project Task Force.

Compassion is often cited by survey respondents as the quality most integral to nursing care. Yet the 1985 Code for Nurses is curiously silent on this subject. Therefore, the task force proposes adding a statement on compassion to this provision.

Protecting patients

The code’s second and third provisions highlight the need for protection, targeting two areas of special concern: loss of privacy and threats stemming from the incompetent, unethical, or illegal practice of others.

When these provisions were added to the code, preserving patient confidentiality was crucial—nursing predominantly took place in the home, where nurses had access to private family information. But threats to patient welfare are now more varied, as medical records may be available online and transferred to third-party payers. Therefore, nursing’s new roles, such as promoting health and advocating patient rights, must be reflected in the code.

“Economic conditions, conflicts of interest, the unwarranted and unwanted use of technology, and the use of incentives to promote research goals present threats to patients,” said ANA California member Marsha Fowler, PhD, MDiv, MS, RN, FAAN, a member of the Code of Ethics Project Task Force. “The code should address the duty to protect in terms of all patient rights rather than emphasizing one, such as confidentiality, which would wrongly imply that it has greater weight than other rights. In addition, the need to balance conflicting rights such as confidentiality and the public good or harm to others is best done through an interpretive statement.”

These provisions have established the foundation of patient advocacy. This can take many forms, such as when a staff nurse insists that a physician talks to a patient before surgery regarding his concerns (which he only voiced to the nurse), or when a clinical nurse specialist lobbies for a less restrictive ICU visitation policy that allows families to be more active in supporting a critically ill patient.

The 1985 code uses the term “safeguarding” in regard to patient protection. But this doesn’t capture the current breadth of nurses’ expanded advocacy and health promotion activities. Similarly, the code has addressed patient protection from threats posed by the actions of individuals; yet patients now face greater threats from the managed care environment than from individuals. For example, the current code offers little guidance for the nurse manager’s role in assuring adequate staffing levels. The revised code will address these issues, providing information that can be used to meet the challenges of today’s health care environment.

Ensuring competence and taking responsibility

Provisions 4, 5, and 6 emphasize individual responsibility, accountability, and competence. Provision 4 states that nurses assume responsibility and accountability for their individual nursing judgments and actions. Provision 5 addresses the need to maintain professional competence. Provision 6 focuses on accepting responsibilities, consulting and collaborating when there are different levels of competence, and determining the responsibility and accountability associated with delegating patient care functions.

But the provisions created in 1985 don’t clearly delineate the scope of these responsibilities. Members of the task force repeatedly identified a considerable overlap in these provisions and their interpretive statements, and they’ve suggested condensing the three provisions into two. They also noted several concepts not adequately addressed in the last code update and made several suggestions for strengthening the language of the provision and broadening its application. For example, because of the increased use of unlicensed assistive personnel and changes in patterns of delegation, a more thorough discussion of responsibility and accountability is required. Further, delegation issues are not limited to assistive staff: nurse managers delegate activities to other nurses, and nurse educators delegate patient care activities to students.

“Nurses must maintain competence,” asserted Fowler. “However, the moral basis for this patient duty resides in nurses’ duties to themselves: continuing personal learning, seeking professional growth, and preserving integrity. Assuring that their work promotes the values of human worth, dignity, and well-being and addresses factors that impede moral practice is not just a responsibility of professional nurses, it’s a duty they owe to their patients and to themselves.”

Hence, while the revision of the code will reaffirm the themes of responsibility, accountability, and competence, it needs to more fully describe the scope and basis of these duties.

Ensuring continued learning

Provisions 7 and 8 address the profession’s efforts to continue to develop its body of knowledge and improve nursing standards. These two provisions stem from the recognition of the distinctive body of knowledge upon which practice standards are based and the belief that individual nurses have a responsibility to contribute to ongoing scholarly inquiry and the continued development of practice standards. Therefore, the task force suggested combining the provisions, to better organize and focus the discussion of these responsibilities. The code will list various ways nurses can meet these responsibilities, including participating in research, applying research findings, and implementing and evaluating standards of care.

The new provision would signify that all nurses have a role in advancing the profession in order to improve patient care. And it would assert that nursing action is needed in health policy (leaders in the nursing field have frequently suggested that policy initiatives are the most effective way to promote change in health care).

Workplace rights and protections

Provision 9 recognizes the influence of employment conditions on the delivery of high-quality nursing care. Based on feedback from nurses, the ANA task force is currently discussing the need for and appropriateness of an explicit discussion of collective bargaining in the code.

“Our goal is to establish a firmer foundation on which the nurse can address employment conditions,” said Daly. “ ‘Collective action’ can serve as an umbrella term encompassing a variety of appropriate steps. Placing this term in the provision reaffirms the importance of promoting ethically sound practice in the work environment.”

In day-to-day practice, nurses are responsible for contributing to an ethically sound environment through interaction with colleagues, support of peers, and identification of issues that should be addressed. The definition of advocacy clearly includes contribution to environments that support ethical practice, through qualities such as compassion. Depending on how they are used, organizational structure, job descriptions, compensation systems, disciplinary procedures, and access to grievance mechanisms and ethics committees all contribute to an environment that can either foster or obviate ethical practice.

The tools of workplace advocacy include individual actions, working within organizational chains-of-command, use of collective action such as collective bargaining and, ultimately, choosing not to be employed by facilities that routinely commit serious violations of human rights (such as failing to seek informed consent) or repeatedly require nurses to compromise their integrity.

The following provisions appeared in the 1985 code but will be removed from the updated version. Aspects of these provisions have been modified and included in other parts of the revised code.

Advancing nursing action and social advocacy

Provision 10 in the present code specifies the nurse’s duty to protect the public from misinformation and misrepresentation and to maintain the integrity of nursing. Yet, the 1985 code only discusses misinformation and misrepresentation in terms of product safety, advertising, marketing, and recommendations. Maintaining the integrity of nursing is interpreted in the code as an honorable use of the title RN and avoidance of conflicts of interest that result in personal gain. These issues, and that of advertising, should be examined within the context of advocacy, both of the individual patient and the public.

Issues of protocol about the use of titles and academic degrees are not germane to the ethics code, per se. Financial gain from a conflict of interest deserves a fuller discussion that encompasses systemic conflicts.

Provision 11 highlights multidisciplinary collaboration to ensure public access to care. But it doesn’t encompass broader health concerns such as hunger, pollution, and poverty. It also doesn’t address contemporary concerns for public health education, cultural sensitivity, and the development of healthy lifestyles. This provision does call for individual nurse participation in institutional and political decision making to ensure a just distribution of health care resources. Yet nurses may wield a stronger influence by acting collectively through professional associations.

“The profession itself, as represented by associations and their members, has a responsibility to articulate core nursing values to society in an effort to bring about the social change necessary to enhance health,” said Fowler. “And the profession is responsible for self-evaluation, in order to foster change within the profession and its organizations and to maintain its integrity.”

Preparing for the future

A critical part of safeguarding the integrity of the profession is maintaining the code. The present code focuses on the responsibilities of nurses but doesn’t fully address their duties. The viability of the code depends on incorporating the constant values of the nursing profession and adapting to the new complexities of today’s health care environment.

“The ideals and principles embodied in the provisions of the 1985 code are as valuable today as they were when this version was drafted,” Daly said. “Nevertheless, if our code is to fulfill the purposes for which it was created, we must continue to assess its expression and applicability to the issues that confront nurses today.”

The revisions discussed in this article are to the Code for Nurses; with Interpretive Statements, 1985; the provisions  of this code can be viewed at online.

Suggestions regarding these revisions should be sent to:

The Code of Ethics Project Task Force
ANA Center for Ethics and Human Rights
600 Maryland Avenue, SW, Suite 100W
Washington, DC 20024;

To purchase a complete copy of the 1985 code, call (800) 638-0373 or go to www.nursesbooks.org.

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