code of ethics nursing essay

What is the Nursing Code of Ethics?

History of the nursing code of ethics.

• 4 Ethical Principles in Nursing

Nursing Code of Ethics Interpretive Statements

Making ethical decisions as a nurse, how nurses use the nursing code of ethics.

According to the American Nurses Association (ANA) , the nursing code of ethics is a guide for “carrying out nursing responsibilities in a manner consistent with quality in nursing care and the ethical obligations of the profession.”

Ethics, in general, are the moral principles that dictate how a person will conduct themselves. Ethical values are essential for ALL healthcare workers, but ethical principles in nursing are particularly important given their role as caregivers.

There are 4 main principles that are part of the nursing code of ethics. They are:

• Autonomy in Nursing
• Beneficence in Nursing
• Non-maleficence

These principles are ideally what every nurse should be aware of in their daily nursing practice. While ethical principles are sometimes confusing and often taught briefly during undergraduate nursing -- they should be constants in nursing practice in order to provide the best, safest, and most humane care to all patients.

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Interestingly, the nursing code of ethics is suggested to have been founded in 1893 and named the “Nightingale Pledge” after Florence Nightingale , the founder of modern nursing. As a modification of the Hippocratic Oath, taken by medical doctors, the Nightingale Pledge has been recited by nursing students at graduations with little changes since inception. 

The formal code of ethics was developed in the 1950s by the American Nurses Association (ANA) and has undergone numerous modifications since. The most significant recent change was in 2015 when 9 interpretative statements or provisions were added to the code of ethics to help guide nursing practice in a more definitive way. 

Many states include the ANA’s nursing code of ethics in their practice statements. Even though the code of ethics is primarily ethics-related, it also has legal implications. Given the importance of the code to the nursing profession, revisions continue on a regular basis.

4 Ethical Principles in Nursing 

1. autonomy .

Autonomy is recognizing each individual patient’s right to self-determination and decision-making. As patient advocates, it is imperative that nurses ensure that patients receive all medical information, education, and options in order to choose the option that is best for them. This includes all potential risks, benefits, and complications to make well-informed decisions. 

Once the patient has all the relevant information, the medical and nursing team can make a plan of care in compliance with the medical wishes of the patient. 

It is important that nurses support the patient in their medical wishes and ensure that the medical team is remembering those wishes. Sometimes, nurses will need to continue to advocate for a patient despite the wishes being verbalized because the medical team might not agree with those wishes.

Many factors may influence a patient's acceptance or refusal of medical treatment, such as culture, age, gender, sexual orientation, general health, and social support system.

2. Beneficence

Beneficence in nursing is acting for the good and welfare of others and including such attributes as kindness and charity. The American Nurses Association defines this as “actions guided by compassion.”

Justice is that there should be an element of fairness in all medical and nursing decisions and care. Nurses must care for all patients with the same level of fairness despite the individual's financial abilities, race, religion, gender, and/or sexual orientation. 

An example of this is when working at a free flu clinic or diabetes screening clinic. These are open to all individuals in the community regardless of the previously mentioned factors.

4. Nonmaleficence 

Nonmaleficence is to do no harm. This is the most well-known of the main principles of nursing ethics. More specifically, it is selecting interventions and care that will cause the least amount of harm to achieve a beneficial outcome

The principle of nonmaleficence ensures the safety of the patient and community in all care delivery. Nurses are also responsible for reporting treatment options that are causing significant harm to a patient, which may include suicidal or homicidal ideations. 

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Revised in 2015 to include 9 provisions, the ANA’s nursing code of ethics now includes interpretative statements that can provide more specific guidance for nursing practice.

9 Provisions of the Nursing Code of Ethics 

Currently, the nurse’s code of ethics contains 9 main provisions:

• The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person.
• The nurse’s primary commitment is to the patient, whether an individual, family, group, community, or population.
• The nurse promotes, advocates for, and protects the rights, health, and safety of the patient.
• The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to provide optimal patient care.
• 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.
• 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.
• 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.
• The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities.
• The profession of nursing, collectively through its professional organization, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy.

The aforementioned nine provisions were implemented to help guide nurses in ethical decision-making throughout their practice. 

Unfortunately, nurses are often unable to make complex ethical decisions based solely on the four principles and nine provisions. In these instances, it is important to consult the ethics committee before making any major decisions. Often, other resources are needed when making major ethical decisions.

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Knowing the nursing code of ethics is essential for nurses because it will help guide everyday practice and navigate the daily complexities of the healthcare profession. Nurses often use the four major ethical principles throughout a shift, even if not fully aware of them. 

This may include,

• Providing pain medication to a post-operative hip replacement
• Holding the hand of a dying patient who is alone
• Advocating for the patient that wants to end chemotherapy and enter hospice care

Nursing is consistently regarded as the most honest and ethical profession and practicing with the nursing code of ethics is essential to ensuring that patients and their families receive the care they have come to know and expect. Utilizing the ethical codes of justice, nonmaleficence, autonomy, and beneficence on a daily basis allows nurses to provide the safest and most compassionate care for their patients. 

What are the five codes of ethics in nursing? 

• The 5 nursing ethic codes are: nonmaleficence, beneficence, autonomy, justice, and privacy/confidentiality. 

What is the Professional Code of Ethics for Nurses?

• The Professional Code of Ethics for Nurses is the guiding outline for how nurses should behave ethically within their profession and how they should decide to act if they encounter barriers that prevent them from fulfilling their professional obligations. 

Why is the code of ethics important in nursing? 

• It can guide nurses’ professional behavior, provide a framework for decision-making when faced with challenges, and provide support and help prevent moral distress. 

What is the code of ethics in healthcare? 

• There is not one board ethical code for every healthcare professional, although it has been proposed. Instead, each branch of healthcare, from quality control to medical directors to physicians to nursing, has its own ethical codes. 

What is scholarly ethics in nursing? 

Kathleen Gaines (nee Colduvell) is a nationally published writer turned Pediatric ICU nurse from Philadelphia with over 13 years of ICU experience. She has an extensive ICU background having formerly worked in the CICU and NICU at several major hospitals in the Philadelphia region. After earning her MSN in Education from Loyola University of New Orleans, she currently also teaches for several prominent Universities making sure the next generation is ready for the bedside. As a certified breastfeeding counselor and trauma certified nurse, she is always ready for the next nursing challenge.

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• OJIN Homepage
• Table of Contents
• Volume 20 - 2015
• Number 2: May 2015
• Nursing Code of Ethics: Its Value, Its History

The Nursing Code of Ethics: Its Value, Its History

Beth Epstein, PhD, RN is an Associate Professor of Nursing at the University of Virginia (UVA) School of Nursing and is also a member of the faculty of the Center for Bioethics and Humanities at the UVA School of Medicine in Charlottesville, VA. She attended the University of Rochester in Rochester, NY for her BS in Biochemistry and then UVA for her MS in Pharmacology, BSN, and PhD in Nursing. Beth teaches ethics in the School of Nursing and lectures in the Center for Bioethics and Humanities. She is an active member of the UVA Health System Ethics Consult Service and Ethics Committee, and currently directs the Moral Distress Consult Service.

Martha Turner PhD RN-BC is the Assistant Director of the American Nurses Association Center for Ethics and Human Rights (2006-present). She attended the University of Minnesota in Minneapolis, MN for a BS and PhD in nursing, Loma Linda University in Loma Linda, CA for an MS in nursing and Ball State University in Muncie, IN for an MA in counseling psychology. Martha retired in January 2006 from Active Duty with the Air Force after 30 years. She was a flight nurse and achieved the rank of Colonel. Dr. Turner was the Consultant for Healthcare Ethics to the Air Force Surgeon General from 1998 until 2006. Her responsibilities included representing the DoD as an ex-officio member of the Secretary's (HHS) Advisory Committee for Genetics, Health and Society, reviewing policies related to many aspects of healthcare and developing ethics programs and ethics expertise throughout the Air Force Medical Service. She was a member of the Minnesota Nurses Association ethics committee from 1997-2002 and the Ethics Advisory Council of the Oncology Nurse Society from 1994-1996. Most recently (2010-2014) she staffed the revision of the ANA Code of Ethics for Nurses with Interpretive Statements as content editor, revision coordinator and co-lead writer.

To practice competently and with integrity, today's nurses must have in place several key elements that guide the profession, such as an accreditation process for education, a rigorous system for licensure and certification, and a relevant code of ethics. The American Nurses Association has guided and supported nursing practice through creation and implementation of a nationally accepted Code of Ethics for Nurses with Interpretive Statements . This article will discuss ethics in society, professions, and nursing and illustrate how a professional code of ethics can guide nursing practice in a variety of settings. We also offer a brief history of the Code of Ethics , discuss the modern Code of Ethics , and describe the importance of periodic revision, including the inclusive and thorough process used to develop the 2015 Code and a summary of recent changes. Finally, the article provides implications for practicing nurses to assure that this document is a dynamic, useful resource in a variety of healthcare settings.

Key words: Ethics, code of ethics, nursing, profession

To practice competently and with integrity, today's nurses must have in place several key elements that guide the profession...  Professional nursing is defined as “the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations” ( ANA, 2010, p. 10 ). To practice competently and with integrity, today's nurses must have in place several key elements that guide the profession, such as an accreditation process for education, a rigorous system for certification and licensure, and a relevant code of ethics. The American Nurses Association (ANA) has guided and supported nursing practice through policy development and action; establishment of the scope and standards of nursing practice; and implementation of a nationally accepted Code of Ethics for Nurses with Interpretive Statements (hereafter referred to as the Code; ANA, 2015b ). This article will discuss ethics in the context of society, professions, and nursing and illustrate how a professional code of ethics, specifically the Code, can guide nursing practice in a variety of settings. We also offer a brief history of the Code of Ethics, discuss the modern Code of Ethics and describe the importance of periodic revision, including the inclusive and thorough process used to develop the 2015 Code and a summary of recent changes. Finally, the article provides implications for practicing nurses to assure that the Code is a dynamic, useful resource in a variety of healthcare settings.

Ethics in Society, Professions, and Nursing

Ethics of Society

The agreement to live by rules may be externally imposed by laws and leaders or internally imposed by the common morality.  The field of ethics addresses how we ought to treat each other, how we ought to act, what we ought to do, and why. We manage ethical issues every day as members of society, as members of families, and as members of a profession. To live in society, for example, we are obligated to not kill or hurt one another or to take from others what is not ours. These rules are not just in our own best interest (not to be killed, for instance), but they promote the flourishing of our society. We would likely have great difficulty living productive lives if we constantly worried about our homes being ransacked or our lives being in danger. The agreement to live by rules may be externally imposed by laws and leaders or internally imposed by the common morality.

In the 1600s, British philosopher Thomas Hobbes ( 1651/1950 ) posited that, if left solely to ourselves, we would be at constant war, “every man against every man (p. 103).” To counteract this for our own survival, notes Hobbes, we require strong leadership and an accepted social contract to guide conduct ( Hobbes, 1651/1950 ). Several leading contemporary bioethicists assert that as vulnerable human beings, we have realized the need to abide by a common set of moral rules, the common morality, which allow us to live and flourish without constant worry of destruction ( Beauchamp & Childress, 2009 ; Gert, 2004 ). These are not necessarily imposed upon us, as through strong leadership, but are internally driven moral rules. Regardless, our abilities to live peacefully and productively and to identify our obligations to one another in our own society and across cultures are informed by ethics.

Ethics of Professions

To consider ethical issues, some level of guidance about how to do so should be in place.  Similarly, the choice to pursue a career in nursing, medicine, business, law, or other professions involves incorporating the obligations and virtues of that smaller “society.”  These obligations and virtues are added to our already assumed obligations as members of the larger society. For health professionals in particular, Purtilo writes, “citizens in general are not morally required to help another in need. You are. Citizens are not morally required to keep in confidence information they hear about another. You are. Citizens are not morally required to be nonjudgmental about another’s character. You are…” ( Purtilo, 2005, p. 11 ). As professionals, we agree to identify those ethical issues that tend to arise within our chosen profession. To consider ethical issues, some level of guidance about how to do so should be in place. For many professions, this is done with a code of ethics. Examples include the Code of Medical Ethics , social workers’ Code of Ethics , and the Code of Ethics for Nurses with Interpretive Statements ( AMA, 2014-2015 ; ANA, 2015b ; National Association of Social Workers [NASW], 2008 ). These documents guide practice decisions and set a standard of practice behavior expected of every member of a given profession.

Ethics and Nursing

Nurse involvement in biomedical ethics. Nurses typically encounter ethical issues in three realm of biomedical ethics including the broad, overarching, health-related problems that impact policy or society as a whole; dilemmas that arise within organizations; and those that affect patient populations or individual patients. Nurse researchers, policy makers, educators, consultants, administrators, ethicists, advanced practice nurses, and clinical nurses all encounter biomedically-related ethical problems every day ( Moon, Taylor, McDonald, Hughes & Carrese, 2009 ; Ulrich et al., 2010 ).

On a policy or societal level, broad questions are asked. Examples of such queries may include discussion about whether access to healthcare is a right or a privilege; how to protect research participants from harm; the most fair method for resource distribution during an Ebola crisis; or the inappropriateness of punitive measures against pregnant women who use drugs and alcohol. Nurses are involved in these questions as clinicians, researchers, policy makers, ethicists, and educators. They may participate in preparation of position statements and guidance documents from federal and national organizations such as the Presidential Commission for the Study of Bioethical Issues , the American Nurses Association , or the American Association of Critical Care Nurses (AACN), to name a few ( Presidential Commission, 2015 ; ANA, 2015a , AACN, 2015 ).

...the organization and the nurse’s central place within it... are often a cause of nurses’ ethical dilemmas.  At the organizational level, many ethically challenging questions arise for nurses. In the 1980s, Chambliss conducted a sociological study of hospital nurses to better understand the kinds of ethical issues that arose ( Chambliss, 1996 ). He embedded himself in a hospital setting and soon found that it was the organization and the nurse’s central place within it—the multiple loyalties, hierarchies of power, the tendency within systems to be slow to change and to impede individual practice—that was often a cause of nurses’ ethical dilemmas.

More recent literature about organizational ethics and culture has explored the hospital ethical climate and the culture of quality and safety, as well as shifts in financial concerns that influence professional practice ( Austin, 2007 ; Engelhard, 2014 ; Institute of Medicine [IOM], 2001 ; Mills, 2014 ; Peter, Macfarlane, & O’Brien-Pallas, 2004 ). In their analysis of the moral habitability of the nursing work environment, Peter et al. ( 2004 ) found evidence of oppressive environments, moral suffering, and unclear, overwhelming role expectations. They also found, however, that nurses tended to identify paths of resistance and influence, such as finding strength in numbers and being assertive in order to achieve their goals. Other studies have evaluated relationships between ethical climate and job satisfaction, ethics stress (stressors related to ethical dilemmas within the healthcare setting), and moral distress (situations where the “right” action is known but cannot be carried out). Researchers have found that poor ethical climates were correlated with higher levels of moral distress, poorer job satisfaction, and increased likelihood of intent to leave a position ( Hamric & Blackhall, 2001 ; Whitehead, Herbertson, Hamric, Epstein & Fisher, 2015 ; Pauly, Varcoe, Storch & Newton, 2009 ; Ulrich et al., 2007 ). Thus, it is clear that the organizational ethics aspects of healthcare are important factors for nurses.

An effective ethical code for nursing practice must provide guidance on managing ethical problems that arise at the societal level, the organizational level, and the clinical level.  On a clinical level, ethical questions arise every day. In a study of the ethical issues encountered by nurses, Ulrich et al. ( 2010 ) found that more than 60% of nurses identified patient’s rights, autonomy, and informed consent as frequent or daily problems. Other common issues included advanced care planning, surrogate decision making, end-of-life decision making, and breeches of confidentiality ( Ulrich et al., 2007 ). Pavlish, Brown-Saltzman, Hersh, Shirk & Rounkle ( 2011 ) explored the ethical issues, actions and regrets of nurses and found that unnecessary pain and suffering, difficult decision making, and inattention to patient autonomy were problematic. Nurses acted in several ways to address these problems, such as communicating and speaking up, advocating and collaborating, being present and empathetic, and being informed ( Pavlish et al., 2011 ).

The utility of the Code . An effective ethical code for nursing practice must provide guidance on managing ethical problems that arise at the societal level, the organizational level, and the clinical level. The following fictional case, adapted from White and Zibelman ( 2005 ) illustrates a bedside nurse’s dilemma that has both clinical, patient-level aspects and organizational aspects. This scenario demonstrates the benefit of the Code as a useful tool for evaluation and action.

Mr. Logan is a 48 year old who has struggled with an opioid addiction for the past 5 years. Recently, he was playing basketball with friends when he slipped on the court, fell, and broke his arm badly. After his arm was repaired surgically, the physician orders acetaminophen, 650 milligrams by mouth or normal saline, 1 cc, IM, prn for pain. The nurse asks the physician about this, concerned about Mr. Logan’s pain control post-operatively. The physician says, “I’m not going to add insult to injury. Tell Mr. Logan you’re giving him medication for his pain. Hopefully he’ll get a placebo effect.” Meanwhile, Mr. Logan is in excruciating pain. The nurse gives him the acetaminophen and several injections of the “pain medicine” with no effect. Mr. Logan says, “What are you giving me? It isn’t working!” What should the nurse do now?

The immediate questions that arise in this dilemma are, ‘should the nurse deceive Mr. Logan?’ ‘is this an appropriate use of placebo?’, ‘how should Mr. Logan participate in his own pain management plan?’, and ‘how should the nurse advocate for the patient?’  To answer these questions, the Code and other resources provide guidance.

In Mr. Logan’s case, the defining question is, does deceiving the patient provide any benefit or prevent any risk?  The action to question this physician order suggests that nurse believes that deceiving the patient is wrong. Provision 1 of the Code states that the nurse is obligated to act with compassion and to respect the dignity and autonomy of each patient ( ANA, 2015b ). Lying to the patient, watching him suffer, and not involving him in his plan of care achieve neither goal. Additionally, Provision 5 addresses preserving one’s own dignity and 5.4 more specifically notes the threat to one’s integrity that is done by deceiving patients and withholding information ( ANA, 2015b ). However, in this case, there is an inkling of doubt because of the possibility of a placebo effect. That is, the saline injection may induce some analgesic effect even though it is not a pain medication. Also, there is some concern that while an opioid may provide short-term benefit, it could cause harm in the longer term by causing re-addiction. In Mr. Logan’s case, the defining question is, does deceiving the patient provide any benefit or prevent any risk?

After review of the Code and a search of the literature, Mr. Logan’s nurse understands more fully that deceiving him is wrong...  Investigating the risks and benefits of placebo use and pain management in patients with histories of substance abuse will be helpful to answer this question. The American Medical Association Code of Medical Ethics prohibits use of placebo except when the patient is fully informed ( AMA, 2007 ). However, placebo use continues even after years of advocacy against this practice. Thus it is not surprising that there are healthcare providers still willing to use placebos, including the physician in Mr. Logan’s case ( Arnstein, Broglio, Wuhrman & Kean, 2011 ; Fassler, Meissner, Schneider, & Linde, 2010 ). A recent position statement by the American Society for Pain Management Nursing supports a pain management regimen including careful monitoring and agreement with a fully-informed patient ( Oliver et al., 2012 ). After review of the Code and a search of the literature, Mr. Logan’s nurse understands more fully that deceiving him is wrong because it is disrespectful of the patient, diminishes his autonomy, and threatens the nurse’s own integrity. Using a placebo to treat Mr. Logan’s pain without his consent is inappropriate for the same reasons and is not in keeping with current guidelines for pain management.

The question now becomes, how should the nurse best advocate for this patient? Whether or not to advocate is not in doubt (Provision 3), but just how to do that is a bit more difficult. This dilemma is also an organizational issue as the nurse does not have authority to single-handedly change the prescription. Clearly, advocating will involve collaboration with a hesitant physician. The Code can provide some guidance, but some weighing and balancing of the different provisions is necessary. In response to Mr. Logan’s question, “What are you giving me?” the nurse could inform him that the physician has prescribed saline in the hopes that he would have a placebo effect. This would alleviate the concern about deception and withholding information (Provision 5.4). Conversely, this may undermine Mr. Logan’s trust in the physician as well as the nurse (Provision 1.2: Relationships with patients). In addition, it may threaten the collegial relationship between the nurse and physician (Provision 2.3 and 8 address interprofessional collaboration), a relationship that will continue long after Mr. Logan has been discharged. Provision 6 also addresses maintaining an ethical work environment in order to support quality of care. Another alternative for the nurse is to collaborate with the physician first, bringing to light the concerns about patient deception and the evidence of inappropriate placebo use. This alternative action will hopefully have several benefits, such as increasing the likelihood of a more effective treatment plan, maintaining patient trust in the healthcare team, and supporting a professional and collegial doctor-nurse relationship. The potential benefits of approaching the physician first suggest that this is the more sound, justifiable solution to the dilemma.

The Code can provide direction for multiple levels of direct and indirect care.  Ethical issues in clinical nursing often involve not only dilemmas at the bedside, but also dilemmas at the organizational level, such as navigating a complex system to protect a patient or provide quality care or identifying ways to collaborate with colleagues to maintain strong working relationships and trust.  The Code ( ANA, 2015b ) can provide direction for multiple levels of direct and indirect care. The Code applies to other areas of nursing practice as well, such as nursing education, research, and policy making. Advancing the profession through research and policy by attending to informed consent, advocacy, and accountability of practice are examples of other professional areas of practice with potential ethical dilemmas that make the provisions of the Code a relevant nursing resource.

A Brief History of the Code of Ethics

...for many years, nurses had no formalized code of ethics and used Gretter’s Nightingale Pledge, akin to medicine’s Hippocratic Oath, to guide their practice.  The first formal code of ethics for nurses was adopted in 1950 ( Fowler, 1997 ). However, a need for ethical guidance was recognized soon after modern nursing began to formalize in the mid-1800s. Although in 1896, one of the initial goals of the newly established American Nurses Association was to write a code of ethics, urgent issues such as nurse registration, the welfare of nurses, and accreditation processes for nursing schools took precedence ( Fowler, 1997 ). Thus, for many years, nurses had no formalized code of ethics and used Gretter’s Nightingale Pledge, akin to medicine’s Hippocratic Oath, to guide their practice ( ANA, n.d. ).

In the early 1900s, Isabel Hampton Robb’s text, Nursing's Ethics for Hospital and Private Use described the obligations of the nurse to the patient, physician, institution, self, and profession and the creativity needed to find solutions to problems and provide good nursing care (Robb, 1926). In 1926, the ANA published a “suggested” code which provided the first outline of ethical behavior for nurses ( ANA, 1926 ). The provisions were framed in terms of the various relationships between the nurse and patient; the nurse and medicine; and nurses and their profession.  For example, the relation of the nurse to the patient involved “bringing all of the knowledge, skill, and devotion” to the work ( ANA, 1926, p. 600 ).

The first formal Code for Professional Nurses was adopted in 1950 and was edited slightly before being revised in 1960.  At the same time as the suggested code, ethics was on the minds of nurse faculty and administrators in terms of training and educating nursing students and practicing nurses ( Crawford, 1926 ; Ethical Problems, 1926 ; Ethical Problems, 1933 ; Fowler, 1997 ). Their work highlights the thinking of the time, that is, that character was a significant factor in determining right action. Ms. Beulah Crawford’s article, How and What to Teach in Nursing Ethics stated, “…in the end, it is the character of the nurse which makes her; if she has the right principles she will not go far wrong in the minor matters” ( Crawford, 1926, p. 211 ) and included nursing etiquette or rules of conduct in the hospital setting. The article provided direction about which aspects of character and living help a nurse “steer her craft safely on the stormy seas” (p. 212), such as accepting authority, being adaptable to difficult situations, being industrious, and using “judgment in the use of the tongue” (p. 212).

A “Tentative Code” in 1940 ( ANA, 1940 ) described nursing as a profession and outlined many provisions similar to those in the 1926 suggested code, including framing the provisions in terms of relationships to patient, colleagues, and profession. The first formal Code for Professional Nurses was adopted in 1950 and was edited slightly before being revised in 1960 ( Fowler, 1997 ). The 1960 Code for Professional Nurses outlined 17 provisions beginning with the “fundamental responsibility…to conserve life, to alleviate suffering, and to promote health” and extending to accountability for practice and conduct, participation in research and “action on matters of legislation affecting nurses” ( ANA, 1960, p. 1287 ) .

...the Code has been revised over time to introduce obligations to advance the profession and build and maintain a healthy work environment.  The 1968 revision of the Code included several significant changes ( ANA, 1968 ). First, prior to this revision, the provisions were simply listed with little, if any, interpretation. The new code provided brief interpretations which helped the nurse see how the provision might be applied. Second, the provisions were reduced from 17 to a more manageable 10. Finally, there was a fundamental shift in language in the 1968 revision. The obligations of the nurse changed from generalized responsibilities to “conserve life, alleviate suffering and promote health” ( ANA, 1960, p 1287 ) to a deeper, more duty-based obligation to “respect the dignity of man, unrestricted by considerations of nationality, race, creed, color, or status” and to “safeguard the individual’s right to privacy” ( ANA, 1968, p. 2582 ). With changes in the level of practice independence; advances in technology; societal changes; and expansion of nursing practice into advanced practice roles, research, education, health policy, and administration, the Code has been revised over time to introduce obligations to advance the profession and build and maintain a healthy work environment ( ANA, 1976 ; ANA, 1985 ; ANA, 2001 ; ANA, 2015b ).

The Modern Code of Ethics

As in the past, the current Code of Ethics with Interpretive Statements forms a central foundation for our profession to guide nurses in their decisions and conduct.  As in the past, the current Code of Ethics with Interpretive Statements ( ANA, 2015b ) forms a central foundation for our profession to guide nurses in their decisions and conduct. It establishes an ethical standard that is non-negotiable in all roles and in all settings. The Code is written by nurses to express their understanding of their professional commitment to society. It describes the profession’s values, obligations, duties, and professional ideals. The provisions and interpretive statements reflect broad expectations without articulating exact activities or behaviors. The 2015 Code “addresses individual as well as collective nursing intentions and actions; it requires each nurse to demonstrate ethical competence in professional life” ( ANA, 2015b, p. vii ). Nurse practice acts in many states incorporate the Code of Ethics. Even though the Code is primarily ethics-related, it also has legal implications. Given the importance of the Code to the profession on so many levels, revisions continue on a regular basis.

The Process for Revising the Code

[The Code] is a living document that informs and is informed by advances in healthcare...  As society changes, so must the Code ( ANA, 2015b ). It is a living document that informs and is informed by advances in healthcare such as genomics, technology, new roles for nurses and changes in healthcare delivery. The nine provisions address the general, enduring obligations of nurses and rarely require major revision. However, the interpretive statements are more specific and address current topics and issues. Since healthcare-related problems rapidly unfold in our society, the interpretive statements must be reviewed and revised every 10 to 12 years. Review of the 2001 Code ( ANA, 2001 ) revealed several areas requiring updates in language and content. An overview of this process below illustrates the intentional considerations inherent to the revision, the opportunities for nurse participation at all levels, and the impact that nurses have toward the final product.

The use of technology made this recent revision process more effective and efficient than in previous times. For example, the pre-internet revision of the 1985 Code ( ANA, 1985 ) took seven years, had many onsite committee meetings, and handled over 15,000 written responses following a solicitation for feedback, editorial comments, and suggestions. In the revision of the 2001 Code ( ANA, 2001 ), greater use of technology resulted in a single onsite meeting. Much work was accomplished using conference calls, email, and other electronic platforms (e.g., screen sharing software) over a 4-year period from initial review to publication. Table 1 provides a timeline of the most recent Code revision process. Nurses participating in the revision process took advantage of technology for online committee meetings and discussions and online public comment periods to solicit feedback from nurses across the country. Previously, public comment was solicited by mailing multiple copies of the draft manuscript to the state nurses’ associations and other associations, which were then edited and returned to the ANA.

The process for the most recent revision began with an initial review by the ANA Ethics Advisory board of the current Code provisions and interpretive statements, the International Council of Nurses (ICN) code ( ICN, 2012 ), and the codes of other health professions such as pharmacy, occupational therapy, social work, medicine, physical therapy, and public health. This extensive review helped to determine the need for revision. The Code Review Working Group was appointed to collect public comment regarding the need for revision.

A qualitative content analysis ( Miles & Huberman, 1994 ; Patton, 2002 ) of the 2783 public comment responses was conducted. The summary report of this analysis included recommendations to revise the 2001 Code ( ANA, 2001 ) for the following reasons:

Time and Relevance

• Thirteen years had passed since the previous Code revision. New issues had important ethical implications to address in the Code. These included the widespread use of social media and resultant threats to privacy; use of emerging technologies throughout healthcare; growing importance of inter-professional collaboration; a stronger and more direct consideration of social justice as a core value; and an inclusion of global health responsibilities of the profession.
• Comments on the first seven provisions and interpretive statements were not sufficiently compelling to warrant a substantive revision.  However, comments on the remaining provisions (8 and 9) did press for revision for different reasons. Unlike other provisions, Provision 8 had changed in a way that it had lost its original meaning and thus had a dual focus that needed to be unified and sharpened. Provision 9 was different in that it was both new and unique in the history of the Code when approved in 2001. Now that it had become an accepted part of the Code it, too, needed to be sharpened.
• The preface and afterword required revision for clarity to help the reader by providing a framework for the Code.

Access to Resources

• Links were recommended to provide access to various ANA position statements; Scopes and Standards of Practice; and the Social Policy Statement ( ANA, 2010 ) to facilitate navigation through all the major resources of the ANA as well as links to external resources that support or elaborate on content in the Code.

Nursing Roles and Advocacy

• Recommendations were made to specifically address the role of nurse executives in the Code, to ensure a climate for ethical practice and civility and create a healthier practice environment for nurses, and to address the roles and responsibilities of APRNs.
• The nurses’ role in leadership, advocacy, and collective action for social justice should be highlighted to underscore the urgent need to address determinants of health.
• The nurses’ voice in social and health policy should be strengthened to add to the unified efforts on behalf of all in the profession.

After recommendations were accepted, the ANA website, NursingWorld, posted a call with an invitation to participate in the revision. More than 400 nurses volunteered; from these 15 were selected to serve on the Code Steering Committee (SC). Between September 2013 and April 2014, a draft revision was prepared. Throughout the process of writing and editing, a Code scholar with several publications on the nursing Code of Ethics ( Fowler, 1985 ; 1992 ; 1997 ; 2010 ; & 2015 ) and participation experience in the 2001 code revision simultaneously reviewed and edited the drafts. In May 2014, the edited draft was posted for public comment. By early June, nearly 1,000 individuals had posted suggestions for changes, clarifications, additions, or deletions. Each suggestion was evaluated using the analysis processes described above, preserving the essential and eliminating the incidental. Further revisions were made based on this additional analysis. A final version of the 2015 Code was approved by the ANA Board of Directors in November 2014 and was published on NursingWorld in January 2015.

Changes in the 2015 Code of Ethics for Nurses

The revision process led to several significant changes in the 2015 Code of Ethics.  The revision process led to several significant changes in the 2015 Code of Ethics ( ANA, 2015b ). Overall, the document’s language has been updated. For example, terms such as “technology,” “social media,” “genetics,” “incivility in the workplace,” “pain and suffering,” and “evidence informed practice” have been added. Other broad changes include increased emphasis on nursing leadership; renewed emphasis on the inclusion of nurses in all roles and in all settings; and strengthening of the nurse’s voice in social and health policy and of the nurse’s role in global health. The preface was revised to strengthen the purpose of the Code, the ethical framework, and the context. A new introduction now clarifies terms such as “patient,” “client,” and “consumer,” “moral,” “ethical,” and the differences between “must,” “ought,” and “should.” A glossary of terms was added and a list of online resources and other support documents will be posted on the ANA website.

The Code Provisions have been reworded to be more concise and better articulate their intent, although the general structure remains the same as the 2001 Code ( ANA, 2001 ). For example, the first three provisions still describe the most fundamental values and commitments of the nurse; the next three address boundaries of duty and loyalty, and the last three address aspects of duties beyond individual patient encounters. Finally, there were significant changes to the interpretive statements, where content has been updated to improve relevance to modern day practice, reorganized for consistency with the wording in the provisions, and revised to reduce redundancy.

Summary: Implications for Practice

The Code is an important document that can provide effective guidance as the nurse negotiates the complexities inherent to many situations.  This article has suggested several implications for nursing practice including consideration of the everyday nature of ethical concerns in nursing at multiple levels, the usefulness of the Code ( ANA, 2015b ) as a guide, and the importance of an inclusive and thorough process for revising the Code. Each day, situations arise for nurses that require both decision and action, and may include ethical dilemmas. Examples of those most common include errors and near misses, delegation, end-of-life care, use of technology and fatigue. Managing these challenges well contributes to safe, compassionate, quality care. The Code ( ANA, 2015b ) is an important document that can provide effective guidance as the nurse negotiates the complexities inherent to many situations.

Nurses and other healthcare professionals are not expected to be able to resolve complex ethical problems alone, using only a code of ethics. Often, other resources are needed to grasp the full complexity of an ethical dilemma. Selected potentially helpful online resources are listed in Table 2 . Today’s professional nurses are engaged in ethical thinking and ethical challenges in a wide variety of settings. The following recommendations can be helpful at any level of practice:

• Research hospital policies and legal information related to the concern under review.
• Consider an ethics consult service. It often requires a team of individuals to fully understand and resolve difficult ethical problems. However, professional codes of ethics provide support and direction about behavior(s).
• Consider the three levels of ethical engagement when reviewing a dilemma, specifically the broad, societal level of biomedical ethics where questions affecting health and healthcare are generated (e.g., stem cell research, healthcare for undocumented immigrants); the organizational level (e.g., hospital system obligations to its employees, hierarchical structures, bed allocation); and the clinical level (e.g., withdrawal of aggressive treatment, surrogate decision making).
• Participate in the ongoing revision of the nursing Code. This article provided an outline of the modern process for Code revision. Nurses in every role and every setting were invited to, and did, participate in the process. When the next call is made, take time to offer your suggestions to ensure the Code continues to remain a relevant resource for practice.

Today’s Code ( ANA, 2015b ) is a result of the ANA’s long-standing commitment to support nurses in their daily life and practice. The process for the 2015 Code revisions used technology to a great advantage. This provided an avenue for a highly participatory process to receive input from all nurses in every type of practice and allow working groups to collaborate efficiently and effectively with a minimum of travel. Recognizing that nursing practice extends from horizon to horizon—from the bedside to the classroom, from the executive suite to the laboratory bench—the 2015 Code continues to provide all nurses with a firm foundation for ethical practice

Beth Epstein, PhD, RN Email: [email protected]

Martha Turner, PhD, RN-BC Email: [email protected]

© 2015 OJIN: The Online Journal of Issues in Nursing Article published May 31, 2015

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Fowler, M. (1985). The evolution of the code for nurses. The California Nurse, 81(5): 5.

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May 31, 2015

DOI : 10.3912/OJIN.Vol20No02Man04

https://doi.org/10.3912/OJIN.Vol20No02Man04

Citation: Epstein, B., Turner, M., (May 31, 2015) "The Nursing Code of Ethics: Its Value, Its History" OJIN: The Online Journal of Issues in Nursing Vol. 20, No. 2, Manuscript 4.

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The Code of Ethics in Nursing

Nursing, like other professionals, has set up values, ethical principles, and standards to which they aspire to act and can be judged. Ethical behavior results from nurses’ commitment to acting ethically. Ethical codes are adopted so that professionals differentiate right and wrong and know their expectations. They can apply understanding in their decisions. A code of ethics will guide nurses in conducting their functions honestly and with integrity. The Code of ethics encompasses the best professional practice in nursing. Contravening the Code of ethics in nursing results in professional disciplinary actions, which may even mean termination. According to American Nurses Association, standards of practice for registered nurses are responsibilities they are supposed to perform. The execution of these responsibilities is supposed to be done competently. In collaboration with standards of nursing practice, ethical practices bring out the nursing professional identity.

Importance of Code of Ethics

Nurses have been ranked the most ethical profession in the United States every year, besides one since 1999. Most years, nurses are way ahead of all other disciplines by point count. Due to ethical codes that arise from systematic guidelines, nurses have been shaped to a desired ethical behavior. Ethics in nursing offers a framework that helps them ensure the safety and well-being of patients and other healthcare providers. ANA’s Code of Ethics for Nurses with Interpretive Statements is the nationally accepted guide called The Code. The Code of ethics establishes the ethical standards in the nursing profession and guides in ethical analysis and decision-making (ANA, 2015).

In the healthcare setup, ethical values are paramount to every healthcare provider. Nurses, however, require ethical principles since they are patient caregivers. There are four main ethical principles in nursing: autonomy, justice, beneficence, and non-maleficence. These are daily nursing practices that nurses should be aware of to ensure safe, best, and most humane care to all patients. Most states in the US have included the ANA’s Code of ethics in their practice statement not only to be ethics related but also to provide legal implications. Continued revision is done regularly due to the importance of the Code to the nursing profession.

Nursing principles of ethics make them patients advocates. As patient advocates, nurses ensure every patient has the right to self-determination and decision-making. Patient education, medical information, and an explanation of available treatment options are done. Patients are then allowed to make an informed choice after explaining all potential risks, complications, and benefits. Ethical factors influencing patient acceptance of treatment, like age, culture, gender, social support, and sexual orientation, should be carefully thought through (Landis et al, 2020).

Ethically nurses should act for the good welfare of the patient. According to ANA, nurses should be kind and charitable. It is a nursing attribute to be compassionate. Fairness is paramount in all nursing and medical decisions. All patients should receive the same level of care despite individual financial status, social status, race, religion, gender, and sexual orientation. Nurses are ethically bound not to harm any patient. Patient harm may come; as a result, intervention and care or lack of it. Nurses are ethically bound to choose interventions and care that cause the least harm to the patient or the community and report treatment options that cause harm.

ANA Standards of Practice for RN Licensure

American Nursing Association has developed standards of nursing practice to ensure excellent nursing practices. A registered nurse should perform their functions responsibly and competently. The nursing care process involves assessment, diagnosis, outcome identification, planning, implementation, follow-up, and evaluation which is the basis of standards of practice. Registered nurses collect essential patient information. Comprehensive analysis of data collected on assessment is vital to ensure all patient needs are met and he is served in a dignified manner. Analysis determines the diagnosis and possible problems and challenges that might arise. From this, potential outcomes are identified, and the plan is individualized. The identified care plan is implemented through strategies to help attain expected results. Implementation of the care plan is supposed to be holistic, systematic, effective, timely, and patient-centered by ensuring its multidisciplinary team. Performance should be evidence-based, equitable, and efficient manner. After implementing patient care, the registered nurse should evaluate patient care continuously using the set outcome expectations. For nurses to achieve the level of the competencies mentioned above, they must complete a postsecondary training program to licensure to practice. They are also required to complete an associate degree in nursing from an accredited nursing institution to register for NCLEX-RN

The Code of ethics in nursing addresses the core values expected by a nurse as they perform their functions. The nursing profession’s Code of conduct creates the nursing professional identity. The Code of Ethics outlines four ethical principles that nurses should employ in patient care and management. These principles guide nurses in their decision-making. They are autonomy, recognizing patients’ rights and self-determination; beneficence; acting for the good and welfare of the patient; justice; fairness, and nonmaleficence, focusing on not harming the patient (Duquesne University, 2020). The codes of ethics help shape the quality of patient care by being non-negotiable. Standards of care emphasize every nurse’s expectations regarding competence and professionalism (Landis et al, 2020. The basis of the standard of care is the nursing care process. Patient care should be safe, efficient, timely, and patient-centered. Through continued individual and collective efforts by the nurse, advances in the standards of care are made through safe, quality, and conducive healthcare. Advances through scholarly inquiry, professional development, and health policy development help improve standards of practice.

Landis, T. T., Severtsen, B. M., Shaw, M. R., & Holliday, C. E. (2020, July). Professional identity and hospital‐based registered nurses: A phenomenological study. In Nursing forum (Vol. 55, No. 3, pp. 389-394). https://doi.org/10.1111/nuf.12440

American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. https://www.nursingworld.org/coe-view-only

Duquesne University: School of Nursing (2020). Ethical principles in nursing: Tips for nurse leaders in promoting ethical practice. https://onlinenursing.duq.edu/blog/ethical- principles-in-nursing/

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The Importance of Ethics in Nursing

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Nurses perform hundreds of critical, health-related tasks every day. In some cases, the decisions they must make test their professional and personal morality. The nursing code of ethics helps caregivers consider patient needs from several viewpoints and maintain a safe recovery environment. Ethical guidelines remind caregivers to treat all people equitably and individually, while protecting the privacy rights of patients in ways that may not seem overtly obvious. These recommendations also call on caregivers to advocate and seek justice for those in their care, and to take full responsibility for their work as nurses.

RNs looking to advance their careers should explore the benefits of a  Bachelor of Science in Nursing  (RN-BSN) program.

What Are Ethics in Nursing?

Professional nurses sometimes experience situations in the workplace that challenge their personal and professional ethics. Morally courageous healthcare professionals, however,  find a way to make ethical decisions even if they are alone in their beliefs. Nurses who exercise this ability strive to behave according to the nursing code of ethics, regardless of negative personal outcomes that may arise. These outcomes may include a tainted reputation, personal embarrassment, angst, ostracism by peers, employer or peer backlash, and career ramifications.

Moral practitioners create a safe, non-judgmental caregiving environment. When unforeseen danger occurs, nurses take action to protect patients and themselves. They also express empathy through words and actions, while forming strong connections with their patients. These relationships foster a dialogue that helps healthcare professionals find personalized and effective care solutions.

Nurses need to practice professional humility and flexible thinking. The nursing code of ethics encourages healthcare professionals to incorporate these moral guidelines into their personal lives as well. According to the American Nurses Association (ANA), nursing ethics cover several common areas.

• End-of-life issues
• Moral courage, moral distress, and moral resilience

Cultural Competency in Nursing

An important area of ethics in nursing is cultural awareness. Nurses are increasingly seeing patients from different cultures, with different languages and different beliefs. Those patients rely on nurses to make culturally appropriate ethical decisions regarding their care. That is, nurses should try to understand how social and cultural differences influence a patient’s healthcare-related beliefs, attitudes, and actions.

The code of ethics can help nurses remember that each patient has a unique background and unique needs. In addition, nurses can improve their cultural competency by communicating openly, withholding judgment, normalizing cultural differences, and examining their own biases.

Having a keen sense of cultural awareness can serve caregivers well, especially when they are faced with dilemmas regarding care for patients from diverse backgrounds. Ultimately, cultural competency helps nurses serve individual and community interests by working toward the best possible health-related outcomes.

Examples of Ethics in Nursing

Key examples of ethics in nursing cover a variety of areas.

Confidentiality

Under HIPAA, nurses cannot disclose sensitive information about their patients. In addition, the nursing code of ethics emphasizes the importance of keeping the details of patient cases confidential. This guideline goes beyond making sure that unauthorized persons do not gain access to private records. The code encourages caregivers to discuss cases only when others are not present or are unable to hear their dialogue. This applies especially in the care setting, where nearby staff or patrons may overhear clinical discussions.

Accountability

Nursing professionals take responsibility for their actions. They are honest and exercise strong moral practices in the workplace. Ethical nurses never attempt to provide services beyond their proficiency and do all they can to keep their patients safe.

Valuing Individual Patients

Caregivers educate themselves about the individuals and communities they serve, and encourage their peers to be equally proactive in following this same standard. Additionally, nurses treat everyone with respect and maintain appropriate professional boundaries at all times.

Wholistic Treatment

Responsible nurses do everything in their power to promote a wholistic care approach, taking into account patients’ physical, mental, and spiritual well-being. They network with other healthcare professionals to meet and apply this goal as universally as possible. They also work to mitigate threats to responsible wholistic care, such as public health initiatives that misalign with community health needs.

Advocating for Patients

Nurses must dedicate themselves as patient advocates, ensuring every patient’s unique needs and preferences are incorporated into their care. The Nursing code of ethics sets forth the principle that people have the right to decide how they want treatment and to be informed about that treatment in a manner that meets their preferences. It is important, however, that patients be mentally fit to make those types of decisions. If they are not, nurses must help them with the decision-making process.

Promoting Equality

The nursing code of ethics promotes fair treatment toward all individuals and denounce discrimination for any reason. This includes making sure they distribute limited healthcare resources based on need. By exercising fair treatment, caregivers create trusting relationships with their clients.

Pursue a Nursing Career

The history of nursing education at AdventHealth University Online stretches back to 1908, providing students with a strong foundation of academic excellence. Today, that education is marked by cutting-edge courses taught by experienced faculty who are dedicated to helping individuals pursue an online Bachelor of Science in Nursing (RN-BSN) degree .

If you are passionate about caregiving, and want to exemplify the importance of ethics in nursing in your career, consider earning an  online Bachelor of Science in Nursing  (RN-BSN) degree from AdventHealth University Online.

Recommended Readings

Advocating for Nurses With Disabilities

Leadership Styles in Nursing: Seven Effective Approaches

What Is Humanitarian Nursing?

American Nurses Association, “Ethics and Human Rights”

American Nurses Association, “Ethics Topics and Articles”

American Nurses Association, “Nursing Advocacy”

American Nurses Association, “View the Code of Ethics for Nurses”

BMC Nursing , “Increasing Cultural Awareness: Qualitative Study of Nurses’ Perceptions About Cultural Competence Training”

Quality Interactions, “Cultural Awareness in Healthcare: A Checklist”

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Nursing Code of Ethics Report

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Introduction

Goals of the nursing code of ethics, ethical principles, reference list.

Nursing practice is guided by a set of code of ethics which constitutes an essential part of the profession. For a long time now, nursing practice has integrated the concern for the welfare of patients and the vulnerable population as well as for social justice. From a functional perspective, nurses work towards the normalization of those elements that detract from health. Not only are the nursing career prospects obliged to abide by the moral and ethical standard of nursing profession, but also to embrace them as a critical aspect of the health care profession.

• To serves as concise reminder of the ethical duties and commitment of all the persons who choose the nursing career.
• To outline the nursing profession’s invariable ethical standards.
• To highlight the professional’s own awareness of its obligation to the community.

In the code of ethics, the term practice has been used to signify the various functions of the nurse in whatever position he or she assumes, such as immediate patient care provider, policy developer, researcher, administrator, educator among other. Therefore, the principles and commitment outlined in this code of ethics fits all the nursing positions and context (Lubkin & Larsen, 2006).

The nurses in all the aforementioned positions and context, performs with respect and compassion for the innate distinctness, worth, and dignity of each person, without any regard for his or her social or financial status, personal characteristics, or the nature of the health issue. Thus the ethical obligations of nursing practice can be summarized under the following principles (Lubkin & Larsen, 2006):

• Respect for human dignity: – represents a fundamental principle that drives the general nursing practice. This pertains to regard for human rights, self-esteem, and value of all people, including the client, colleagues, physician, and the general public. Nurses have been taught to take into consideration the demands and morals of every person in all professional liaisons (Lubkin & Larsen, 2006).
• Interaction with patients: – the nurse must develop a relationship in their provision of nursing services, taking into account respect for human requirements and standards, with no bias. Nurses, while planning a patient’s health care, must take into account an individual’s lifestyle, religious orientation, and value system. This consideration reflects the respects for the patient personality, as opposed to condoning or agreement with specific individual preferences.
• The characteristics of health condition: – the nurse expresses respect for privileges, dignity, and worth of each human being regardless of the characteristics of the health condition. This principle upholds that the approach fo any patient’s provision should not be influenced by the nature of the disease or injury, propensity for death, or functional potential. This perception extends to those who need the services of the nurse for improving health, prognosis, normalization of health, relief of suffering, as well as provision of compassionate care to the terminally ill individuals.
• The right to freewill: – regard for human dignity concerns the identification of certain patient’s privileges, especially, the right of freewill. Freewill or autonomy forms the philosophical basis with regard of informed consent in all medical care contexts. Patients are morally and lawfully entitled to involvement in the determination of the process that will be followed including; (a) right to accurate, comprehensive, and understandable instructions in a way that allows an informed decision; (b) to be helped with evaluating the benefits, challenges, and alternatives in their management, as well as the option of no treatment; (c) to allow, refuse, or cease treatment devoid of falsehood, undue persuasion or penalty; and (d) to be afforded considerable support in the entire decision-making and management procedure. The patient should be allowed to consult with family and other crucial persons in regard of decision making under the support and guidance of competent nurses and other health specialists. Noteworthy, patient should be allowed to participate in determining their health care extent possible and willing to participate.
• Association with peers and others: – respect for persons applies to every individual with the work context of the nurse. The nurse upholds a compassionate and caring attitude when interacting with peer and others with dedication to unbiased treatment of patient, to conflict resolution, and to integrity-preserving conciliation. This concept should be observed in all the possible nursing positions, such as direct care provider, consultant, educator, researcher, and administrator. This standards of conduct disqualify any biased action, any harassment or intimidating behavior, or disregard for the repercussion of own conduct on other people. The nurse acknowledges the unique role of different person or teams, and collaborates to achieve the common objective of availing quality health care services.

All nurses are responsible for creating, sustaining, and contributing to a practice environment that upholds nurses in observing their ethical obligations. A practice background typically involves physical attributes, including the working condition, and inscribed policies and protocols outlining the prospects for nurses, and less tangible attributes like informal peer standards.

Organizational framework, function description, safety and health strategies, grievance procedure, penalty procedures, compensation system, and ethics committee, collectively contribute to the working context that impedes or enhance professional accomplishment and ethical practice.

Settings within which staff are afforded unbiased hearing of grievances, are facilitated based on the level of care, and are fairly handled to allow the accomplishment of the principles of the nursing profession that are in alignment with a proper nursing practice (Oermann & Henrich, 2005).

The ethical code focuses largely on health care practice, although level of practice is dependent on availability of resources. Because of this relation, an ethical code concurrent to the nursing code of ethic should be designed, so that nurses are in a position meet their ethical obligations.

American Nurses Association. (2001). Code of Ethics for Nurses with Interpretive Statements. New York: The American Nurses Association Inc.

Lubkin, I. M., & Larsen, P. D. (2006). Chronic illness: impact and interventions. London: Sage.

Oermann, M. H., & Heinrich, K. T. (2005). Annual review of nursing education: strategies for teaching. Stamford, Mass: Cengage Learning.

• Data Normalization and Its Main Advantages
• Free Will and Determinism: Discussion
• An Overview on Application of Data Normalization
• “On Moral Medicine: Theological Perspective in Medical Ethics” by Stephen Lammers and Allen Verhey
• The Problem of Assistance in Self-Deliverance
• Commercialization of Organ Transplants
• Pros and Cons of the Commercialization of Organ Transplants
• The Importance of Consent in Research
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IvyPanda. (2019, May 3). Nursing Code of Ethics. https://ivypanda.com/essays/nursing-code-of-ethics-report/

"Nursing Code of Ethics." IvyPanda , 3 May 2019, ivypanda.com/essays/nursing-code-of-ethics-report/.

IvyPanda . (2019) 'Nursing Code of Ethics'. 3 May.

IvyPanda . 2019. "Nursing Code of Ethics." May 3, 2019. https://ivypanda.com/essays/nursing-code-of-ethics-report/.

1. IvyPanda . "Nursing Code of Ethics." May 3, 2019. https://ivypanda.com/essays/nursing-code-of-ethics-report/.

Bibliography

IvyPanda . "Nursing Code of Ethics." May 3, 2019. https://ivypanda.com/essays/nursing-code-of-ethics-report/.

Ethics Topics and Articles

For nurses to fulfill their ethical obligations to patients, it is vital to have access to a wide range of information and to keep up-to-date with advances in ethical practices. These articles and links offer context for nurses on difficult issues and best-practice recommendations.

Bioethics/Biodefense

American society of bioethics and humanities (asbh).

Serves as a resource for anyone interested in bioethics and humanities by providing a group of further on-line resources and links to aid in finding other related information through the Internet. www.asbh.org

National Reference Center for Bioethics Literature

Offers extensive searches in Bioethics. www.bioethics.georgetown.edu

Nursing2015 - Issues in Nursing

A Nurse’s Obligations to Patients with Ebola

End of Life Issues

American Association of Colleges of Nursing (AACN) End-of-Life Nursing Consortium (ELNEC) - Information on a national education program to improve end-of-life (EOL) care by nurses.  www.aacnnursing.org/ELNEC

Euthanasia Research and Guidance Organization (ERGO) Compendium of information and news on "right-to-die" issues, plus a glossary of terms.  www.finalexit.org

The Patients Rights Council The Patients Rights Council is committed to the principle that you have the right to know all the facts about the critical issues of life, death, and assisted suicide. Few issues are as important as the compassionate treatment and care for those who are most vulnerable. www.patientsrightscouncil.org

Not Dead Yet Disability rights organization that strongly opposes the legalization of assisted suicide. Site contains articles, legal briefs, links, and more.  http://notdeadyetnewscommentary.blogspot.com/

Compassion & Choices The leading nonprofit organization committed to helping everyone have the best death possible. We offer free consultation, planning resources, referrals and guidance, and across the nation we work to protect and expand options at the end of life.  https://www.compassionandchoices.org/

University of Toronto Joint Centre for Bioethics Information and background materials on end-of-life care.  http://jcb.utoronto.ca/ .

National Hospice Organization Founded in 1978, NHO is the oldest and largest nonprofit public benefit organization devoted to hospice care. Site features searchable database to locate hospices throughout the United States. https://www.nhpco.org/find-a-care-provider/

Hospice Foundation of America Supports the hospice concept through educational programs and grants; site includes online version of Journeys, a newsletter to help individuals deal with grief and loss.  www.hospicefoundation.org

Philadelphia Inquirer Series: Seeking a Good Death Five-article series addresses the rights of the dying and traces personal stories about end-of-life decision making. www.phillynews.com/packages/end_of_life

Choice in Dying Explanation of advance directives, with forms for every state available by downloading or mail order.  www.choices.org

Government Agencies

Medicare & Medicaid Agency Information, fact sheets, statistics and latest regulations, presented by the Health Care Financing Administration, federal agency that administers the programs. www.cms.gov

Social Security Online The official website of the Social Security Administration, providing information, forms, and resources.  www.ssa.gov

National Institute on Aging Lists and describes educational publications on medical and scientific aspects of aging, with ordering instructions.  www.nia.nih.gov

Health Care Ethics

The Center for Health Ethics and Law at the West Virginia University Health ethical issues for professionals and non-professionals.  http://wvethics.org/

Nuffield Council of Bioethics Addresses issues of ethical concern in medicine and biology.  http://nuffieldbioethics.org/

Centre for Applied Ethics, University of British Columbia The Centre is an independent unit in the Faculty of Graduate Studies. It is primarily an interdisciplinary research centre which studies a diverse range of topics, including health care practices, business and professional procedures, new information technologies and environmental issues.  www.ethics.ubc.ca

Kennedy Institute of Ethics, Georgetown University The Joseph P. and Rose F. Kennedy Institute of Ethics, is a teaching and research center offering ethical perspectives on major policy issues. It is the largest university based group of faculty members in the world devoted to research and teaching in biomedical ethics and other areas of applied ethics. The Institute also houses the most extensive library of ethics in the world, the National Reference Center for Bioethics Literature; produces BIOETHICSLINE ® , an online medical ethics database; and conducts regular seminars and courses in bioethics. http://kennedyinstitute.georgetown.edu/

The Hastings Center The Hastings Center is an independent, nonpartisan, and nonprofit bioethics research institute founded in 1969. The Center's mission is to address fundamental ethical issues in the areas of health, medicine, and the environment as they affect individuals, communities, and societies.  www.thehastingscenter.org/

The Presidential Commission for the Study of Bioethical Issues The Presidential Commission for the Study of Bioethical Issues (the Bioethics Commission) is an advisory panel of the nation’s leaders in medicine, science, ethics, religion, law, and engineering. The Bioethics Commission advises the President on bioethical issues arising from advances in biomedicine and related areas of science and technology. The Bioethics Commission seeks to identify and promote policies and practices that ensure scientific research, health care delivery, and technological innovation are conducted in a socially and ethically responsible manner.  www.bioethicsarchive.georgetown.edu/pcsbi/history.html

Human Trafficking

Office on Trafficking in Persons An Office of the Administration for Children & Families.  https://www.acf.hhs.gov/otip

National Human Trafficking Hotline ACF Programs and Services for Human Trafficking.

I nformation Memorandum on Human Trafficking Recognizing and Responding to Human Trafficking among American Indian, Alaska Native and Pacific Islander Communities.  https://www.acf.hhs.gov/sites/default/files/documents/otip/hhs_funded_ht_research_information_memo.pdf

HEAL Trafficking Health, Education, Advocacy, Linkage. Because Human Trafficking Is A Public Health Issue.  www.healtrafficking.org

American Nurse Today The costly business of human trafficking.

Human Trafficking Identifying Victims of Human Trafficking. Role of Health Provider in Identifying and Assessing Victims of Human Trafficking Educating Health Care Professionals on Human Trafficking (2014)

Resources: Common Health Issues Seen in Human Trafficking US Department of Health & Human Services, Administration of Children & Families. Campaign to rescue and restore human trafficking:  common health issues seen in human trafficking  victims fact sheet. July 2012. 

National Human Trafficking Resource Center Human trafficking is a form of modern-day slavery.  www.humantraffickinghotline.org

World Health Organization Human trafficking: understanding and addressing violence against women, 2013.

Human Trafficking An official position statement of the Association of Women’s Health, Obstetric and Neonatal Nurses .

Leading from the Middle for Ethical Climate and Safety

Edmonson, C. (2015). Strengthening moral courage among nurse leaders.  OJIN: The  Online Journal of Issues in Nursing. 20 ( 2). Retrieved from: OJIN

Fox, E., Crigger, B.J., Bottrell, M., Bauck, P. (2007).  Ethical Leadership: Fostering an Ethical  Environment and Culture.  Retrieved from  www.ethics.va.gov/Elprimer.pdf

Keselman, D. (2012). Ethical leadership.  Holistic Nursing Practice, 26  (5), 259-261.

Makaroff, K., Storch, J., Pauly, B., & Newton, L. (2014). Searching for ethical leadership in nursing . Nursing Ethics, 21  (6), 642-658.

Merrill, K. (2015). Leadership style and patient safety: Implications for nurse managers.  Journal of Nursing Administration, 45 (6), 319-324.

Pavlish, C., Brown-Saltzman, K., So, L., Heers, A. & Iorillo, N. (2015). Avenues of action in ethically complex situations: A critical incident study.  Journal of Nursing  Administration, 45  (6), 311-318.

Piper, L. (2011). The ethical leadership challenge: Creating a culture of patient and family-centered care in the hospital setting.  Health Care Manager, 30  (2), 125-132.

Robichaux, C., & Sauerland, J. (2012). Health care quality and ethics: Implications for practice and leadership.  Perioperative Nursing Clinics, 7  (3), 333-342.

Storch, J., Makaroff, K., Pauly, B., & Newton, L. (2013). Take me to my leader: The importance of ethical leadership among formal nurse leaders.  Nursing Ethics, 20  (2), 150-157.

Thompson, D., Hoffman, L., & Sereika, S. (2011). A relational leadership perspective on unit-level safety climate.  Journal of Nursing Administration, 41  (11), 479-487.

Moral Courage/Distress

Nurses practicing in today’s healthcare environment face increasingly complex ethical dilemmas. We encounter these dilemmas in situations where our ability to do the right thing is frequently hindered by conflicting values and beliefs of other healthcare providers. Some confront the ethical issues directly while others turn away. Upholding our commitment to patients requires significant moral courage. Moral courage helps us address ethical issues and take action when doing the right thing is not easy. Moral courage involves the willingness to speak out and do what is right in the face of forces that would lead us to act in some other way. Nurses who possess moral courage and advocate in the best interest of the patient may at times find themselves experiencing adverse outcomes. There is a need for all nurses in all roles across all settings to commit to working toward creating work environments that support moral courage. 

The Moral Distress Education Project "Core multidisciplinary experts on moral distress from across the country were interviewed in a documentary-style media project. This project is a self-guided web documentary."

Compassion Fatigue as a Threat to Ethical Practice: Identification, Personal, and Workplace Prevention/Management Strategies MEDSURG Nursing: July-August 2016

Exploring Moral Resilience Toward a Culture of Ethical Practice

Moral Resilience: Managing and Preventing Moral Distress and Moral Residue MEDSURG Nursing: March-April 2016

Moral Distress References

Moral Distress in Academia OJIN: The Online Journal of Issues in Nursing

Moral Courage and the Nurse Leader OJIN: The Online Journal of Issues in Nursing

Creating Workplace Environments that Support Moral Courage OJIN: The Online Journal of Issues in Nursing

Strategies Necessary for Moral Courage OJIN: The Online Journal of Issues in Nursing

Moral Courage in Healthcare: Acting Ethically Even in the Presence of Risk OJIN: Online Journal of Issues in Nursing

Understanding and Addressing Moral Distress OJIN: The Online Journal of Issues in Nursing

Using the AACN Framework to Alleviate Moral Distress OJIN: The Online Journal of Issues in Nursing

Moral Distress and Moral Courage in Everyday Nursing Practice OJIN: The Online Journal of Issues in Nursing

Moral Courage in Action: Case Studies MEDSURG Nursing: August 2007

Moral Courage: A Virtue in Need of Development? MEDSURG Nursing: April 2007

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Nursing Code of Ethics: The Ultimate Guide to Ethical Challenges

#i',$content, -1); --> table of contents a brief history of the nursing code of ethics code of ethics in nursing as basics of professional behavior the importance of studying the code of ethics for nurses main principles of the american nurses association code of ethics code of ethics nursing: 9 provisions a nurse must adhere to how can code of ethics for nursing help shape good nurses in conclusion all healthcare professionals must adhere to ethical standards. however, for nurses, keeping ethical principles is of paramount importance. according to statistics, nurses in a hospital spend about 60% of their time communicating with patients. this percentage is even higher in intensive care units in hospices and nursing homes. so, adhering to ethical standards is critical to doing a quality job. equally important is knowing how to deal with ethical dilemmas and solve related problems. the american nurses association (ana) has developed a nursing code of ethics. this is not just a set of rules but a support system that makes nurses’ jobs easier and their decisions more informed. it lays down the basic moral principles of healthcare. a brief history of the nursing code of ethics.

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Florence Nightingale, one of the most famous nurses in history, laid down the fundamental principles of the nursing code of ethics in the 19th century. She also established the groundwork for contemporary healthcare practices. Later, in the 50s of the 20th century, the American Nurses Association (ANA) unified these principles.

The Code of Ethics has undergone many revisions and additions. The last major revision passed in 2015, and a new one is scheduled for 2025. Changes are planned to adapt the regulation to modern challenges. However, the basics of the code of ethics, which include autonomy, beneficence, justice, and nonmaleficence, will remain unchanged.

Code of Ethics in Nursing as Basics of Professional Behavior

For more than 20 years, nursing has been the most moral profession in the United States, according to surveys. The code of ethics for nursing is one of the reasons for this high rating. This is the foundation of professional behavior, a set of principles and standards that define ethical obligations to clients, their families, colleagues, and society. The code should not be confused with job descriptions. The latter represents more technical and procedural work norms; the code, in turn, determines the general atmosphere of the working processes.

Many of the principles are self-evident norms of working behavior, and their observance simplifies the job and helps the patients feel safe. A person who feels cared for is better able to share their concerns and problems, which can be critical in determining successful treatment. Besides, it leads to better adherence to medical prescriptions after discharge, which has a beneficial effect on the number of remissions and results in the long term.

The Importance of Studying the Code of Ethics for Nurses

Competent and polite communication with clients is no less important than the ability to perform standard care procedures. In such a case, ethical awareness is just as much a part of professionalism. The code of ethics for nurses is an indispensable guide to becoming a good healthcare professional with well-developed communication skills. It is not just a course to take in nursing school but one of the fundamentals of quality care improvement.

The importance of code of ethics in nursing cannot be overemphasized. Knowing and successfully applying this code ensures a personalized approach to every patient and improving their outcomes. In addition, the study of nursing ethical considerations forms a common standard of behavior for all workers, which helps find answers to complex ethical issues. This enhances the standard of medical care and boosts trust in the field.

Main Principles of the American Nurses Association Code of Ethics

The American Nurses Association Code of Ethics defines the 4 main ethical principles when working with patients.

• Autonomy in Nursing means people have the right to freedom of choice in treatment wherever possible. Nurses should respect patients’ views and support them in making informed decisions about their health.
• Beneficence in Nursing implies that nurses should do their best to improve patients’ health, morale, and quality of life, focusing their interests first rather than the specialist’s personal opinion.
• The Justice principle suggests that nurses should treat each person equally. They should give each patient the necessary attention and distribute their care fairly without preference or bias.
• The Non-maleficence principle of health care means that the nurse must ensure that the patient’s health and morale are not harmed. The cardinal rule of medicine should guide every action: “The main thing is not to harm.”

Adherence to these principles helps maintain the high quality of healthcare delivery and prevent wrong ethical decisions.

Code of Ethics Nursing: 9 Provisions a Nurse Must Adhere To

In addition to adhering to the 4 core principles of the ANA’s Code, it is important to be aware of what are the 9 Code of Ethics for Nurses. There are nine main provisions to follow for successful performance and professional development. Briefly, each of the provisions can be described as follows:

• A nurse must respect the dignity of every person and treat the individual with compassion.
• The nurse’s primary focus should be on the patient. The patient refers to a single person, family, or social group.
• The nurse should advocate and promote the patient’s right to quality health care.
• The nurse must provide care according to all regulations and capabilities to provide the best care.
• The nurse is accountable to patients and self by being an example of health promotion and professional growth.
• Through their efforts, the nurses shall promote an ethical environment and improve working conditions and healthcare.
• The nurse in any position shall promote the profession and enhance its public status.
• The nurse should cooperate with fellow healthcare and social professionals to enhance service quality and minimize health disparities.
• The nurses themselves and collectively, through their organization, should shape and develop nursing values and integrate them into the overall healthcare system.

Provision 9 of the regulation is worth mentioning separately, as it has a broad interpretation. In general, this provision of the Code of Ethics Nursing means that workers should organize groups and meet in committees. These meetings unite nurses to fight more effectively for social justice and improve national health policy in the country.

How Can Code of Ethics for Nursing Help Shape Good Nurses

Knowledge of theory, the ability to perform procedures, and the capability to meet people’s needs in care are the primary skills needed to becoming a nurse . Internships and lectures help hone specialized skills. Regarding patient communication and related soft skills, a significant part of being a nurse is having an excellent knowledge of the code of ethics in nursing and the ability to apply its principles to practice.

Knowing nursing ethics helps maintain high standards of the profession and moral principles in work. This increases trust and respect for the profession. A set of ethical rules is a reliable guide to navigating specialists in complex ethical dilemmas. These rules help resolve problems based on justice, fairness, and respect for human dignity. The study of ethical principles helps healthcare workers develop themselves. Through self-reflection and understanding of patients’ needs, the overall level of care delivery increases.

In Conclusion

The Nursing Code of Ethics, in its current form, has helped nurses worldwide maintain high ethical standards in patient care for over 70 years. This regulation has made the nursing profession one of the most respected in society. Learning the code of ethics is a crucial part of becoming every nurse. It is essential to realize this and not treat this manual as just another nursing training course. Knowing and following these rules will help you become better for yourself, your patients, and your community.

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• Iran J Public Health
• v.42(Supple1); 2013

The Code of Ethics for Nurses

1 Endocrinology and Metabolism Research Centre, Tehran University of Medical Sciences, Tehran, Iran

2 Medical Ethics and History of Medicine Research Centre, Tehran University of Medical Sciences, Tehran, Iran

A Parsapour

Ss bagher maddah.

3 University of Social Welfare and Rehabilitation Sciences, Tehran, Iran

MA Cheraghi

4 Faculty of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran

GH Mirzabeigi

5 Iranian Nursing Organization, Tehran, Iran

M Vahid Dastgerdi

6 Minister, Ministry of Health and Medical Education, Iran

7 Dept. of Gynecology & Obstetrics, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran

Nurses are ever-increasingly confronted with complex concerns in their practice. Codes of ethics are fundamental guidance for nursing as many other professions. Although there are authentic international codes of ethics for nurses, the national code would be the additional assistance provided for clinical nurses in their complex roles in care of patients, education, research and management of some parts of health care system in the country. A national code can provide nurses with culturally-adapted guidance and help them to make ethical decisions more closely to the Iranian-Islamic background. Given the general acknowledgement of the need, the National Code of Ethics for Nurses was compiled as a joint project (2009–2011). The Code was approved by the Health Policy Council of the Ministry of Health and Medical Education and communicated to all universities, healthcare centers, hospitals and research centers early in 2011. The focus of this article is on the course of action through which the Code was compiled, amended and approved. The main concepts of the code will be also presented here. No doubt, development of the codes should be considered as an ongoing process. This is an overall responsibility to keep the codes current, updated with the new progresses of science and emerging challenges, and pertinent to the nursing practice.

Introduction

Nurses are responsible to provide their clients/patients with the high-quality care. They are undoubtedly confronted with various ethical challenges in their professional practice, so they should be familiar with ethical codes of conduct and the essentials of ethical decision making.

The codes of ethics have been adopted for many professions in recent decades. In nursing, as one the most-trusted professions, the ethical codes have been also published by nearly every recognized professional group worldwide. The first international code of ethics for nurses was adopted by the International Council of Nurses (ICN) in 1953 ( 1 ). The two codes prepared by American Nurses Association (ANA) ( 2 ) and Canadian Nurse Association (CAN) ( 3 ) are the examples of national codes of ethics for nurses. The codes outline how the nurses should behave ethically as a profession, and how they should decide when encounter barriers preventing them from fulfilling their professional obligations. The codes can also support nurses in their practice and reduce their moral distress.

In Iran, studies have shown nurses’ weaknesses in the knowledge of ethics and its application in practice ( 4 , 5 ). In a qualitative study carried out by Negarandeh et al, the nurses identified “lack of code of ethics” as a barrier to patient advocacy in Iran ( 6 ). Sanjari et al, also, reviewed nursing codes of ethics and emphasized the necessity of compiling a national code of ethics for nurses in healthcare setting in 2008 ( 7 ). They suggested an adapted code considering cultural context and Islamic background of the country.

Considering the growing activities in the field of medical and healthcare ethics in Iran ( 8 , 9 ), and in order to address the needs and help to fulfill goals of health care system in the country, the National Code of Ethics for Nurses was prepared under supervision of the Ministry of Health and Medical Education (MOHME). It is expected that the Code will serve the interests and needs of the profession more efficiently, since it illustrate moral and professional obligations of nurses for prevention of diseases, promoting health in the society, communicating with colleagues, management of health care systems, and research activities.

The goal of this paper is to provide the nurses with the information about the National Code and help them to apply the provisions in their profession. The manuscript will introduce the main concepts of the recently published codes.

The project of “Compiling the National Code of Ethics for Nurses” was initiated by the Ethics Group of the Endocrinology and Metabolism Research Center (EMRC) of Tehran University of Medical Sciences (TUMS) in 2009.A working group composed of 3 nurses and one general practitioner prepared the first draft of the code through a study including the wide search of international and national codes of ethics for nurses in other countries. After compiling the draft, the project was continued as a joint project with Medical Ethics and History of Medicine Research Center (MEHRC) of TUMS and the Secretariat of High Council for Medical Ethics of Health Policy Council of MOHME.

At first, the preliminary draft was presented at special discussion secession at MEHRC and was challenged by professors, researchers and PhD and MPH students of TUMS. According to the discussions held, the draft was revised. Then, a Task Force that was appointed by the Secretariat of High Council for Medical Ethics of Health Policy Council of MOHME actively engaged in the process of reviewing and modification of the second draft of the code. The Task Force was composed of invited supervisors or head-nurses from main hospitals of TUMS, professors of Faculty of Nursing and Midwifery of TUMS, specialists in different fields of ethics, law, religion, and the representatives of Iranian Nursing Organization (INO), Medical Council of Islamic Republic of Iran, Office of Nursing Advisor to MOHME, Academy of Medical Sciences and Nursing Board of MOHME.

Owing to the sincere cooperation of all members of the Task Force, the final code was prepared after some discussion sessions. Then, it was proposed to the Health Policy Council of MOHME for evaluation and approval. The code as the National Code of Ethics for Nurses was delivered in the country in early 2011.

National Code of Ethics for Nurses

The Code is an entirely new document produced for nursing ethics in the country, which was published in Farsi ( 10 ). It is also available through the website of MOHME ( 11 ). The English version is enclosed here as annex1 . The target audience includes all nurses in the fields of nursing education, research, administrative, and clinical care, in the whole.

The National Code defines the values which are comprehensive and culturally-adapted. Then, it classify the ethical responsibilities as five main parts of “Nurses and People”, “Nurses and the Profession”, “Nurses and Practice”, “Nurses and Co-workers”, and “Nursing, Education and Research”, including 71 provisions in total.

The code sets out the required elements for ethical conduct and empowers nurses to make ethical decisions more perfectly as they perform as clinical nurses, researchers, administrators and policy-makers. It also reminds the nurses of the valuable state of their profession and what they should attempt to uphold as a nurse in providing direct care to clients/patients, teaching nursing students, performing research, and the supervision and management.

As a main general conceptual background of the National code, the patients are not considered as only people who receive the nursing care, and others including the patients’ family and healthy people in the society are considered in the plans and services. Another essence of the Code is that the individual dignity should be respected, regardless of who is receiving the care, or from which nationality, ethnicity, religion, culture, socio-economic class, gender, etc the patient/client is. Meanwhile, under the provisions of the National Code, nurses must recognize and respect cultural sensitivity in everyday practice, even in this era of globalization.

According the Code, the nurses should be sensitive to the ethical challenges and do their best to fulfill their moral duties. It also emphasizes the importance of informed consent, and addresses main ethical issues in everyday practice such as respect to privacy and confidentiality of patients/clients, relationship with colleagues, efficient performance of the professional duties, conflicts of interests, ethics in educational activities and protection of participants in research.

The Code also deals with the administrative duties of nurses. Moreover, it elucidates the concern of how the nurses should communicate with the hospital ethics committee for decision-making when are confronted with ethical cases.

Considering the experiences in compiling national ethical codes and guidelines ( 12 – 18 ), the National Code of Ethics for Nurses is developed as a guide for performing nursing responsibilities and the ethical obligations of the profession. Although there are authentic international codes of ethics for nurses, the national code would be the additional assistance provided for clinical nurses in their complex roles in care of patients, education, research and management of some parts of health care system in the country. Most nurses may be either too busy or exhausted to think about their behavior in practice. However, accountability through meeting the obligations is essential in nursing which is one the most-trusted professions in all societies.

Development of the codes should be considered as an ongoing process, so it is expected that nurses reflect their ideas when they deal with the shortcomings of the codes in their practice. The inputs will enable authorities to improve the code and pave the way for its effective implementation. The codes should be revised and updated in regular intervals considering reflections from nurses across the country. This is an overall responsibility to keep the codes current, updated with the new progresses of science and emerging challenges, and pertinent to the nursing practice.

Ethical considerations

Ethical issues (Including plagiarism, Informed Consent, misconduct, data fabrication and/or falsification, double publication and/or submission, redundancy, etc) have been completely observed by the authors.

Acknowledgments

It is noteworthy that, this could not be accomplished without dedication and sincere contribution of university lecturers, researchers, and experts in the field. The collaborators (excluding the authors) and members of the Task Force are listed (in alphabetical order) as follows: Adibzade A, Ajali A, Alipor A Z, AzimiLolati H, Bararpour F, Biabangardi Z, DehghanNayeri N, Eesazadeh N, Ghadyani MH, Ghasemzadeh N, Ghorbanpour M, Hashemi F, Heidari A, Joudaki K, Joulaie S, Karimi M, Kashaninia Z, Kazemian M, Milanifar AR, Mobasher M, Namazi HR, NazariEshtehardi M, Parsayekta Z, Saber S, Sahebjam S, Salemi S, Shojaee AA, Soufizadeh M, Tafti F, VaskooeKh, YadavarNikravesh M.

The representatives of Health Policy council of MOHME, The Institution (Nahad) of Representative of the Supreme Leaderin TUMS, Medical Ethics and History of Medicine Research Center of TUMS, Iranian Nursing Organization, Medical Council of Islamic Republic of Iran, Office of Nursing Advisors to MOHME, Academy of Medical Sciences and also Nursing Board of Ministry of Health and Medical Education were among the members of the Task Force. The authors declare that there is no conflict of interest.

ANNEX 1. The Code of Ethics for Nurses in Islamic Republic of Iran

Nurses have the responsibility that within their career limit, make decisions and act based on their professional values. Values are intrinsically valuable concepts, and can be defined as the basis by which an individual or community selects the criterion of right or wrong. Taking into account the exalted position of nursing, professional values are determined by qualified associations and organization. In our country, the limits and boundaries of the actions, in many cases, are determined by Islam and our Constitution. As much as the ethical values are in compliance with religious principles, they are universal and transnational.

The most important principles that should be considered in nursing profession are:

• Respecting the patient/client and preserving human dignity
• Altruism and sympathy
• Devotion to professional obligations
• Accountability, responsibility and conscience
• Justice in services
• Commitment to honesty and loyalty
• Maintaining patient’s privacy, and commitment to confidentiality, and trust
• Continuous improvement of scientific and practical competence
• Promote the awareness of professional rules and ethical guidelines, and respecting them
• Mutual respect and appropriate communication with other health care providers
• Respecting autonomy of the patient/client
• Compassion and kindness

ETHICAL GUIDELINES

1. nurses and people.

The Nurse should:

• 1-1. Make effort for: improvement of community health, prevention of diseases, restoration of health and alleviation of pain and suffering of patients; and consider these as her/his main mission.
• 1-2. Offer the nursing care regardless of race, nationality, religion, culture, gender, age, socioeconomic status, political conditions, physical or mental illness, or any other factor; and strive to eliminate injustice and inequality in society.
• 1-3. Provide the nursing care to client/patient with respect to the human rights while considering; to the extent it is possible; values, socio-cultural traditions, and religious beliefs of patient/client.
• 1-4. Educate the community in term of health promotion and disease prevention and consider it as one of his/her most important responsibilities. Nursing care and standard teaching must be presented in a way to fit the culture, beliefs, values and individual’s needs.
• 1-5. Be sensitive to the challenges and ethical issues, in both community and workplace, that could undermine the sanctity of the nursing profession; and offer the appropriate solution when is necessary.
• 1-6. While cooperating and coordinating with other individuals, groups and social institutions, try to address social needs and resolve ethical issues raised in the area of health care.
• 1-7. Pay special attention to vulnerable groups and individuals such as children, elderly, people with physical disability, mental illness, and so on.
• 1-8. While have attention to the medical health at the local level, endeavor to achieve the health goals in national and international levels.
• 1-9. Perform his/her responsibilities, in crises and natural disasters such as war, earthquake, flood, and disease epidemic, while taking the necessary precautions.

2. Nurses and the Profession

• 2-1. Take into account ethical responsibilities, as well as the legal and professional liabilities, when implementing the nursing interventions and making the clinical decisions.
• 2-2. 2-Whitin the limits of his/her power and duties, attempt to provide a safe and healthy environment for the client / patient.
• 2-3. Maintain the safety of the client / patient by: being on time, efficient performance of the professional duties, and accurate and complete recording of the performed care.
• 2-4. Provide the best care to the client / patient; based on professional standards which is resulted from valid research and reliable evidence.
• 2-5. Carry out all the nursing interventions with respect to the client / patient and his/her family.
• 2-6. Do his/her maximum effort to conserve patient’s confidentiality and privacy, and respect autonomy, and obtain the informed consent.
• 2-7. Prevent the probable damage to the client / patient by detecting and reporting the professional errors of medical team.
• 2-8. In case of mistake in nursing interventions, explain honestly to the client / patient, and proceed with truthfulness and fairness in any circumstances.
• 2-9. Maintain and enhance his/her physical, mental, social, and spiritual abilities.
• 2-10. Keep his /her knowledge and skills up to date, in order to maintain the professional competence.
• 2-11. Have the capability and knowledge of effective and safe nursing care, without direct supervision, and be accountable for his/her actions.
• 2-12. Perform in a way that nobody could question his/her professional credibility and dignity.
• 2-13. Be cautious about misuse of his/her name and position for commercial advertising of products.
• 2-14. Avoid the acceptance of any gift or benefit from the client / patient or their relatives, which may cause any limitation either now or in the future.

3. Nurses and Practice

• 3-1. Introduce him /herself with name, title and his/her professional role to the client / patient.
• 3-2. Provide all the nursing interventions with respect to the client / patient and preserving their dignity.
• 3-3. Consider the client / patient’s demands regardless of their age, sex, race, economic status, lifestyle, culture, religion, political beliefs and physical abilities.
• 3-4. Perform the nursing care based on current knowledge and common sense.
• 3-5. Produce a gentle behavioral and verbal communication, in a way that with attracting the client/ patient trust, their needs and concerns could be understood.
• 3-6. Before performing any nursing interventions, obtain the patient or his/her legal guardian consent. In this regard, the nurse should provide sufficient information about nursing intervention for the patient, so that she/he could have the possibility of well-informed acceptance or rejection of the service.
• 3-7. When presenting or applying a new product in clinical practice, have a complete knowledge of its risks. Moreover, provide the client / patient with the necessary information about benefits and disadvantages of the product, hence they could have the possibility of informed choice.
• 3-8. Be aware that no one has the right to consent in place of a competent adult. In case of children, giving the consent is one of the legal guardian’s responsibilities.
• 3-9. In order to empower the client / patient, educate him/her and their family; in frame of care plan and discharge program.
• 3-10. As an exception, in case of an emergency, when the immediate therapeutic action is mandatory for saving the client / patient’s life, start the necessary intervention without patient’s consent.
• 3-11. Perform the appropriate intervention based on existing standards and patient’s higher interests; when obtaining the informed consent or realizing the patient’s wishes is not possible.
• 3-12. Apply the safety measures to be sure that nursing interventions are harmless, and when is necessary, consult this matter with other health team members.
• 3-13. Consider all the information given or obtained during the care process as the professional secrets, and do not reveal them without client / patient’s permission except in legally permissible cases.
• 3-14. Employ the medical information of client / patient only for health related purposes (treatment, research) and in patient’s interest. Inform the client / patient that part of his/ her medical record might be disclosed to other team members for medical consultation.
• 3-15. Using the medical information of the client / patient in research or education should be with their permission. Presentation of the result must be done without mentioning the name, address or any other information that could lead to identification of the patient.
• 3-16. Respect the patient privacy when performing any nursing intervention.
• 3-17. When performing the ideal service is unfeasible, continue the health care, in best of his /her ability, until establishment of a new health care program.
• 3-18. Provide the care for injured or patients in emergency situations, even outside the workplace.
• 3-19. In case of dissatisfaction of the client / patient or other problem, respect their right to change the charged nurse or other health care providers, and as much as possible, try to satisfy the client / patient in this matter.
• 3-20. In case of noticing a violation of standards of care, inform the authorities who have sufficient power for improvement of condition.
• 3-21. Report any objection or problem of patient to the ward supervisor.
• 3-22. Avoid any action, even in patient’s request, that requires ethical, legal or religious violation.
• 3-23. Assist the patients who spend the last days of their life for accepting the reality and to appropriately planning of their demands, including performing the religious practices or recording their wills.

4. Nurses and Co-workers

The Nurse should

• 4-1. Cooperate with medical team members, the client / patient and their family, for more efficient presentation of nursing interventions.
• 4-2. Contribute the client / patient or legal guardian in making decision about nursing interventions.
• 4-3. Share his/her professional knowledge and experience with other colleagues.
• 4-4. Establish a good relation based on mutual trust, with medical team.
• 4-5. Have a respectable conduct with other nurses, professors and students.
• 4-6. In case of any conflict of interest in the care of the client / patient, discuss it with senior colleagues and the principals, while giving the priority to preserving the clients / patients’ rights.
• 4-7. Establish a respectful professional relationship with co-workers in various levels, including the head nurse, supervisor, nursing director and department heads
• 4-8. Confronting any ethical challenge, consult the hospital ethics committee for decision-making.

Nursing Director should:

• 4-9. Act as a role model for other nurses in all aspects of professional carrier.
• 4-10. Put his/her maximum efforts into the transfer of legal and ethical information to other nurses.
• 4-11. Provide the necessary conditions for participation of nurses in continuous training program.
• 4-12. When required, consult ethicists, in order to resolve the ethical problems occur during nursing interventions.
• 4-13. According to the hierarchy, collaborated with other colleagues, act in line with client / patient’s interest.
• 4-14. With the aim of improving the service quality, do his/her maximum effort to maintain a good working environment and increase professional motivation.
• 4-15. Behave fairly in the process of evaluation and promotion of nurses while considering the professional standards and nursing ethics code.

5. Nursing, Education and Research

• 5-1. Nursing professors should employ their maximum efforts to update their scientific knowledge, and to promote ethical knowledge and conduct.
• 5-2. The relationship between professors and students in scientific, educational and research environments should be based on professional ethics and mutual respect.
• 5-3. Nursing professors should make effort to improve students’ knowledge and skills, and promote their ethical and professional performance.
• 5-4. Consider carefully and accurately the patient’s rights and ethical concerns, in cases of using the patients for educational purposes.
• 5-5. Medical services should not be affected if client /patient or their family do not wish to-cooperate in education of the students.
• 5-6. To improve the healthcare services, the quality of nursing training courses, existing guidelines and standards must be continually reviewed and revised.
• 5-7. Nurses, who are involved in research, must pass the specific training courses, have knowledge about the research regulations, and be familiar with national, general, and specific ethical guidelines and be pledged to these regulations.
• 5-8. Nurses should not use their professional positions to convince the client / patient to participate in the research project.
• 5-9. Refusal of participation in the research project by the patient or his/her family should not influence the delivery of the nursing interventions.
• 5-10. Clinical nurses should make effort to enhance the expertise and clinical capacities of nursing and midwifery students.

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