In just 217 words, the American Nurses Association explains its guiding values for the profession, known as The Code of Ethics for Nurses with Interpretive Statements, a document that has existed for more over 70 years. Within the Code of Ethics is a list of nine provisions, which are part of a 64-page online document in which the ANA summarizes the obligations, duties, and aspirations of millions of nurses across the country. The organization highlights the importance of ethics in nursing on its website, calling the code, "the profession's non-negotiable ethical standard." "The Code of Ethics helps nurses by giving them structure as to how to own their accountability and their responsibilities within their nursing practice and help make those decisions based on what would be providing the most optimal care for the patient," said Emily Emma, DNP, RN-BC, NEA-BC, the director for Magnet and professional practice at Stony Brook (N.Y.) University Hospital. Emma said the code is discussed in nursing school, while the NCLEX-RN national licensure exam also includes questions about ethics.
"Having ethical principles in nursing really guides the nurse to make the best, most moral decision on behalf of themselves as practitioners and for the patients," she said.
How It All Started The importance of ethics in nursing led the ANA to adopt its first formal Code of Ethics in 1950, according to the Online Journal of Issues in Nursing (OJIN). Ten years later, the Code for Professional Nurses included 17 provisions, which was later edited to 10 in 1968. According to OJIN, the code has gone through regular updates and was revised in 2015, when ANA launched "The Year of Ethics" in an effort to raise awareness of nursing ethics in the profession. "One thing it does is support the general professionalization of nursing," said Eric Vogelstein, PhD, MA, an associate professor and bioethicist at the Duquesne University School of Nursing and Department of Philosophy. "It's probably one thing that separates a profession from a job or a career. Nursing is a profession, so they need to have that standard aspect of professionalization in place." Having a long history of ethical guidelines sets nursing apart. "Nursing has a particular emphasis on ethics," Vogelstein said. "As we know, nursing is consistently rated as the most trusted profession (by the annual Gallup poll of honesty and ethics). One thing that contributes to that is it has a robust relationship with ethics, and the Code of Ethics serves the public in that capacity just as much as it does the nursing profession itself." What's In the Nursing Code of Ethics? In a 2015 presentation, the ANA explained that the first three provisions of the nursing Code of Ethics address direct patient care and describe the most fundamental values and commitments of the nurse. The provisions include:
- Provision 1: The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person.
- Provision 2: The nurse's primary commitment is to the patient, whether an individual, family, group, community, or population.
- Provision 3: The nurse promotes, advocates for, and protects the rights, health, and safety of the patient.
With provisions 4-6, the ANA explains the boundaries and duties of loyalty for nurses. The provisions include:
- Provision 4: The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to promote health and provide optimal care.
- Provision 5: 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.
- Provision 6: 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 focus of the final three provisions, according to the ANA, address commitments beyond individual patient encounters.
- Provision 7: 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.
- Provision 8: The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities.
- Provision 9: The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy.
In addition to the nine provisions, nurses can draw guidance from four ethical principles -- respect for autonomy, nonmaleficence, beneficence, and justice -- that optimize patient care and outcomes. Respecting autonomy speaks to patients having the ability to make their own decisions, while nonmaleficence is best described as "do no harm." Beneficence in nursing equates to actions guided by compassion, and justice in nursing means treating patients fair and impartially. Together, the Code of Ethics and the four ethical principles offer nurses a way to navigate difficult ethical decisions. "It provides guidelines of what to do in a situation or dilemma in which the nurse needs clarity," Emma said. But ethical decisions often don't have easy answers. "You can't just look up the answer to a complicated ethical dilemma in the code and they say, 'Oh, that's what I should do,'" Vogelstein said. "You have to apply the principles. There's a lot of reasoning behind these cases. That's why healthcare ethics is a robust area of scholarly inquiry and why I teach whole classes on it. The code isn't going to resolve the case, but it will get me started." Using the Code Putting the code to use in nursing practice isn't just reserved for extreme cases. "There are ethical questions in the everyday, as well," Vogelstein said. According to a study in the Journal of Advanced Nursing, among the most common ethical issues for nurses are:
- Protecting patients' rights
- Autonomy and informed consent to treatment
- Breaches of patient confidentiality or right to privacy
- Advanced care planning
- Surrogate decision-making
- End-of-life and beginning-of-life decisions
- Genetic testing and counseling
- Organ donation and transplantation
- Resource allocation
- Staffing patterns that negatively affect work
At Stony Brook, Emma said, "A majority of the ethical dilemmas/ethics consult cases called by nurses are for goals of care for a patient. This can be management of a patient's pain level or discussing a code status with the patient, family, and interprofessional teams after a poor prognosis. Because the nurse provides continuity of care with a patient, it is important for the nurse to feel empowered and advocate for their patient. The ethics consult provides support to the nurse." In his graduate school nursing classes, Vogelstein said his students often exhibit just how much thought and reasoning go into an ethical dilemma. "I have several assignments that ask them to describe an ethical issue that has come up in their practice," he said. "You can tell they are just clamoring to get this out. Some of them write two or three times as much as the assignment calls for." Decisions, Decisions, Decisions When an ethical decision arises, where can nurses turn? Some immediately get a supervisor involved, according to Vogelstein. For Emma's colleagues at Stony Brook, they can call an ethics consult 24/7 with a member of the facility's regulatory affairs department. "They will assemble an institutional ethics committee that is made up of nursing staff as well as other interprofessional team members to help offer guidance," she said. Ethics consults and committees are often commonplace at healthcare facilities across the country. These services, however, often go underutilized, according to Vogelstein. Some nurses "only call when things get to a more difficult place," he said. "It would be beneficial to call on [for an ethics consultation] before it gets there. Later on, it's more difficult to resolve." For more information, read the digital edition, "How to Navigate Nursing Ethics". 
