Code of Ethics for Nurses

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

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

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

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

Rights

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

Autonomy

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

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

Justice

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

Fidelity

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

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

J. L. presents herself to the emergency room with lower right abdominal pain. J. L. is a 17-year-
old white female and is accompanied by her mother. J. L.'s mother is a nurse and works in
another department of the hospital. The mother signed all of J. L.'s admission paperwork and
received the Patient Bill of Rights. Although J. L.'s pain does not seem severe enough for
appendicitis, she does have a history of fever for 24 hours and her temperature in the hospital is
100.8°F (38°C). An ultrasound that did not show appendicitis had been done earlier in the day.
She was told to report to emergency room if the fever rose. After J. L. reports her symptoms to
both a nurse and a physician assistant, she is examined briefly by emergency department
physician. The staff assumes that J. L.'s mother wants to stay in the room and does not seek the
patient's permission. As a part of her history, J.L. informs them she is not sexually active and is
on the second day of her menstrual cycle. The mother can tell by the tone of questioning that the
staff does not believe J.L. is still a virgin. After a two-hour delay, including having to repeat the
urinalysis because of a lost specimen, the emergency physician decides a pelvic exam needs to
be done. The pelvic exam is traumatic for the patient, despite her mother's best efforts to calm
her. J. L. is told in a condescending tone that the exam hurts because of her failure to relax.
Following the exam, the physician tells J. L. and mother that her blood count is normal, the
urinalysis was inconclusive because of menstrual blood, and the patient was uncooperative in
giving a catheterized specimen.
J. L. and her mother were informed a pregnancy test was done, because the staff have
experienced "immaculate conceptions" in their department. The only time that J. L. and her
mother had contact with an RN during this time was when she was initially triaged and when the
discharge instructions were handed to her mother. J. L. and her mother were sent home with
instructions. Her pain subsided without treatment.

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

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

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

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

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

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