Legal and Ethical Conduct

Discussion: Legal and Ethical Conduct

As emphasized in this week’s media presentation, all nurses need to be familiar with the laws and regulations that govern their practice: their state’s Nurse Practice Act, ANA’s Nursing: Scope and Standards of Practice, specialty group standards of practice, etc. In addition, basic ethical principles guide nurses’ decision-making process every day. ANA’s Code of Ethics and ANA’s Social Policy Statement are two important documents that outline nurses’ ethical responsibilities to their patients, themselves, and their profession. This said, there is a dilemma: The laws are not always compatible with the ethical positions nurses sometimes take. This week’s Discussion focuses on such a dilemma.

Legal and Ethical Conduct
Legal and Ethical Conduct

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Review this week’s Learning Resources, focusing on the information in the media presentation about the relationship between the law and ethics.

Consider the ethical responsibility of nurses in ensuring patient autonomy, beneficence, non-malfeasance, and justice.

Read the following scenario:

Lena is a community health care nurse who works exclusively with HIV-positive and AIDS patients. As a part of her job, she evaluates new cases and reviews confidential information about these patients. In the course of one of these reviews, Lena learns that her sister’s boyfriend has tested HIV positive. Lena would like to protect her sister from harm and begins to consider how her sister can find out about her boyfriend’s health status.

Consult at least two resources to help you establish Lena’s legal and ethical position. These resources might include your state’s Nurse Practice Act, the ANA’s Code of Ethics, ANA’s Nursing: Scope and Standards of Practice, and internal or external standards of care.

Consider what action you would take if you were Lena and why. 

Determine whether the law and the ANA’s standards support or conflict with that action.

Post a description of the actions you would take in this situation, and why. Justify these actions by referencing appropriate laws, ethical standards, and professional guidelines.

                                            Required Readings

Milstead,  J. A. (2019). Health policy and politics: A nurse’s guide (6th ed.).  Burlington, MA: Jones and Bartlett Publishers.

Chapter 4, “Government Response: Regulation” (pp. 56-81) 

This chapter explains the major concepts of the regulation of health professionals, with emphasis on advanced practice nurses (APN) and the process of licensure and credentialing.

ANA’s Foundation of Nursing Package – (Access this resource from the Walden Library databases through your NURS 6050 Course Readings List)

Guide to the Code of Ethics: Interpretation and Application

This guide details the history, purpose and theory, application, and case studies of this must-have Code of Ethics.

Nursing Social Policy Statement

The Nursing Social Policy Statement provides an understanding of the social framework and obligations of the nursing profession.

Nursing: Scope & Standards of Practice

This book contains several national standards of practice that can be used to inform the decision-making process, development, implementation, and evaluation of several functions and aspects of advanced practice nursing.

Guide to the Code of Ethics for Nurses: Interpretation and Application

Preface

A code of ethics stands as a central and necessary mark of a profession. It functions as a general guide for the profession’s members and as a social contract with the public that it serves. The group that would eventually become the American Nurses Association first discussed a code of ethics in 1896. When the ANA code of ethics was first developed, it was used as a model by nursing organizations elsewhere in the world, so it had considerable influence both in this country and internationally. As American nursing education and practice advanced over the years since then, and we developed a deeper understanding and appreciation of ourselves as professionals, the code has been updated on several occasions to reflect these changes. However, the core value of service to others has remained consistent throughout. One major change that can be found is the re-conceptualization of the patient. Formerly limited to an individual person usually in the hospital, now the concept of the patient includes individuals, their families, and the communities in which they reside. Another change of great significance, detailed in the fifth provision of the code, reminds us that nurses owe the same duties to self as to others. Such duties include professional growth, maintenance of competence, preservation of wholeness of character, and personal integrity. Just as the health system and professional organizations need to attend to the rights of patients, they also must support nurses and help them to take the actions necessary to fulfill these duties.

You will need to read this Code carefully and repeatedly to reflect on these nine provisions for what they mean in your daily life as a nurse. Ethics and ethical codes are not just nice ideas that some distant committee dreamed up. Rather, they are what give voice to who we as professional nurses are at our very core. This Code reflects our fundamental values and ideals as individual nurses and as a member of a professional group.

When the ANA House of Delegates first unanimously accepted the Code for Professional Nurses in 1950, years of consideration had been given to the development of this code, consideration that continues to this day. The ANA modified the Code in 1956, 1960, 1968, 1976, 1985, and 2001 so that it could continue to guide nurses in increasingly more complex roles and functions. These revisions reflect not only the changing roles and functions of nurses and their relationships

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with colleagues, but also and more importantly, the commitment of professional nursing to maintaining one of its most important and vital document that continues to inform nurses, other health professionals, and the general public of nursing’s central values. These values underpin this Code of Ethics. Read it often and use it wisely.

And finally, join me in thanking the latest ANA task force for their excellent work in revising our Code.

Anne J. Davis PhD, DS, MS, RN, FAAN

Professor Emerita, University of California, San Francisco

Professor, Nagano College of Nursing, Japan

Former Chair, ANA Ethics Committee

Introduction

The Code Of Ethics For Nurses: Something Old And Something New

The American Nurses Association’s (ANA) Code of Ethics for Nurses with Interpretive Statements (ANA, 2001) was never intended to be carved in stone for all eternity. Rather, it was meant to be a document that has naturally evolved and developed in accord with the changing social context of nursing, and with the progress and aspirations of the profession. However, despite the changes over time in the Code’s expression, interpretation, and application, the central ethical values, duties and commitments of nursing have remained stable. The Code of Ethics for Nurses is the profession’s public expression of those values, duties, and commitments. An understanding of the conventional history of this document and its various revisions over time is prerequisite to understanding the current Code of Ethics for Nurses.

The first generally accepted code of ethics for nursing in the United States was written in 1893 by Lystra Gretter, principal of the Farrand Training School for Nurses, in Detroit, in the form of a pledge patterned after medicine’s Hippocratic Oath. Gretter felt that Florence Nightingale embodied the highest ideals of nursing and, consequently, named the first version of the Code the “Florence Nightingale Pledge.” The Nightingale Pledge was generally accepted in this country in its original version, and was usually administered at school of nursing graduation exercises, even after ANA adopted its first official code of ethics in 1950. The Nightingale Pledge reads as follows:

I solemnly pledge myself before God and in the presence of this assembly: To pass my life in purity and to practice my profession faithfully. I will abstain from whatever is deleterious and mischievous, and will not take or knowingly administer any harmful drug. I will do all in my power to elevate the standard of my profession, and will hold in confidence all personal matters committed to my keeping, and all family affairs coming to my knowledge in the practice of my profession. With loyalty will I endeavor to aid the physician in his work and devote myself to the welfare of those committed to my care (Gretter, 1910).

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The original Nightingale Pledge has served as the basis for numerous Hollywood portrayals of nurses, and it continues to be administered at nursing school graduations to this day. In 1896, three years after the appearance of the Nightingale Pledge, the delegates and representatives of the Nurses’ Associated Alumnae of the United States and Canada (renamed the American Nurses Association in the early 1900s) met at the Manhattan Beach Hotel in New York to establish their constitution and articles of incorporation. The first purpose of the group was “to establish and maintain a code of ethics” (Minutes, 1896). However, despite the recognized significance of a code of ethics for the profession, 54 years were to lapse before a Code was officially adopted.

In 1926, A Suggested Code was provisionally adopted by ANA and published in the American Journal of Nursing (AJN) [ANA, Committee on Ethics, 1926]. Critical comments were sought from the AJN readership. The first proposed Code was written in the flowery narrative style characteristic of the late 1800s and early 1900s. Although somewhat idealized, it was a solid document, admirably unwavering and professionally astute in its statement of the values of the profession at the time. However, despite its rhetorical elegance, it did not enumerate specific principles at a more practical level as the membership had hoped, and so the Suggested Code was not adopted.

In 1940, A Suggested Code was replaced by A Tentative Code, also published in AJN (ANA, Committee on Ethics, 1940). This 1940 version of the Code incorporated verbatim some sections from the Suggested Code. Both codes were organized around the theme of categories of relationships, such as nurse-to-profession or nurse-to-patient. The emphasis of the 1940 Code, however; demonstrated a more overt concern for the status and public recognition of nursing as a profession. As with the 1926 Suggested Code, comments were sought from AJN readers.

Subsequent debate, inquiries, and expressions of concern formed the basis for an entirely rewritten version in 1949. The revised Tentative Code was submitted to ANA members, professional groups, schools of nursing, and healthcare agencies for comment. In addition, input was solicited through the use of a questionnaire mailed to groups and individuals, resulting in 4,759 responses (Flanagan, 1976). The Code for Professional Nurses was unanimously accepted by the ANA House of Delegates in 1950 (ANA, 1950). At last, the profession had an official code of ethics! The style of the 1950 Code differed dramatically from that of the two previous, unadopted versions. It consisted of a brief preamble and 17 succinct, enumerated provisions. This Code relinquished the overt use of professional relationships as its organizing framework.

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It did, however, incorporate many elements of relationships within its provisions. Following adoption of the 1950 Code, debates were held and comments were periodically sought from AJN readers. Responses from readers and others formed the basis for a minor emendation to the Code, made in 1956. A 1950 provision, which proscribed advertising, was revised at this time. This provision originally read:

Professional nurses do not permit their names to be used in connection with testimonials in the advertisement of products. (ANA, 1950).

The provision was revised to read:

Professional nurses assist in disseminating scientific knowledge through any form of public announcement not intended to endorse or promote a commercial product or service. Professional nurses or groups of nurses who advertise professional services do so in conformity with the standards of the nursing profession.

Apart from that small change, the first major revision of the 1950 Code was developed in 1960 (ANA, 1960).

Between 1950 and 1960, attention shifted from concern for the content of the Code to concern about its enforcement in the practice setting. Subsequent changes in the ANA bylaws incorporated provisions relating to the obligations of association members to uphold the Code. Thus, in 1964, the ANA Committee on Ethics developed the Suggested Guidelines for Handling Alleged Violations of the Code for Professional Nurses (ANA, 1964).

The next major revision of the Code was formally adopted in 1968. This revision dropped the term “professional” from the title to indicate that the Code applied to both technical and professional nurses. The 1968 revision also omitted the preamble of the 1960 Code, and condensed the number of provisions from 17 to 10 (ANA, 1968). Although the 1968 revision shortened the number of provisions, it still carried forward all the concerns of the 1960 Code, incorporating them either implicitly or explicitly. However, an important omission in the 1968 Code pertained to the personal ethics of the nurse. The 1968 Code was the first version to omit references to the “private ethics” of the nurse, and the demand that the nurse “adhere to standards of personal ethics which reflect credit upon the profession” (ANA, 1950). The personal sphere was no longer deemed to fall within the purview of professional scrutiny. Given the early focus of nursing educators and administrators on questions of the moral purity of the probationer, trainee, and graduate, this is both a significant and substantive change. Additionally, the 1968 Code was the first version that did not explicitly mention the physician; “members of other health professions” are mentioned, but the physician is not singled out

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(ANA, 1968). During the 1970s, significant changes in nursing and its social context made another revision to the Code necessary.

In 1976, a new version of the Code was formally adopted. Among other changes, this version of the Code created a new emphasis on the responsibility of the patient to participate in his or her own care. The notions of nursing autonomy and the nurse-as-advocate were addressed as well. The 1976 Code also shifted to a predominant (though not consistent) use of the term client rather than patient, and a consistent use of nonsexist terminology (ANA, 1976). The 1985 revision of the Code retained the provisions of the 1976 version, yet included revised interpretive statements. In some cases, these new interpretive statements significantly clarified, redirected, or altered the sense of the original provisions. For instance, the 1976 interpretive statement for provision 11 declared that “quality health care is mandated as a right to all citizens” (ANA, 1976). The 1985 interpretive statement made citizenship irrelevant to any consideration of access to or distribution of nursing or health care services (ANA, 1985).

In 1995, a Task Force for the Revision of the Code for Nurses was convened to evaluate the need for a revision of the Code. The Task Force determined that not only did the interpretive statements need revision, but the Provisions themselves, unchanged for 23 years, also needed revision. The Task Force identified a number of concerns that needed to be addressed in a new revision. These included a need to expand the Code’s reflections of approaches to ethics that would include virtue and feminist, communitarian, and social ethics. The committee wished to see an enlarged concern for global health; for the conditions that produce disease, illness, and trauma; and for nurse participation in health policy. Economic constraints that could result in a workplace environment that posed a risk to patients or nurses needed increased attention. In addition, the Task Force wanted the Code to encompass all nurses, in all positions, in all venues, and the work of professional nursing associations. In some places, certain moral language needed clarification, such as “refusal to participate,” which needed to incorporate a discussion of “conscientious objection” as a moral ground for “refusal to participate.”

The Task Force was also concerned with reuniting “personal” and “professional” ethics and heightening recognition that the nurse has duties to self. The Task Force undertook this thorough revision of the Provisions as well as the interpretive statements with an acute awareness of the tradition of nursing ethics and a commitment to retaining our moral identity from the past and continuing to bring it into the present. This revision of the Code was faced with a different process of approval from previous Codes. In the reorganization of the structure of ANA, the new Code and its interpretive statements would go before the House of Delegates

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for approval. Previous codes required approval of the House for the provisions, but not for the interpretive statements.

The interpretive statements had previously been subject to revision and approval by the Committee on Ethics alone. However, in the reorganization, the Committee on Ethics was dissolved. The new revision of the Code’s provisions and interpretive statements was formally adopted by the ANA House of Delegates in 2001. The Code of Ethics for Nurses must of necessity undergo periodic revision in order to remain relevant. However, the Code is framed in such a way as to address categories of concern, rather than specific events or changes in the workplace. This is done to keep the Code “elastic” so that it need not be changed with every wind that blows. The Code might mention “natural disasters” and discuss a nurse’s responsibilities in such disasters, but it would not mention specific earthquakes, hurricanes, or tsunamis. The Code will address nursing “in clinical settings,” but will not mention specific settings such as intensive care units, retail nursing, or parish nursing. In that way, the Code would not need revision every time a new venue for nursing arose. The Code will address treatments or interventions generically, or categories of treatment such as “the administration of food and fluid,” but will no longer specify specific treatments lest the code need to be revised every time a new treatment is developed. In general, it is understood that the broader provisions of a Code will require revision substantially less frequently than will the more specific interpretive statements.

To date, these have been the successive revisions of the Code:

1893—Florence Nightingale Pledge (informal standard)

1926—A Suggested Code (unadopted)

1940—A Tentative Code (unadopted)

1950—Code for Professional Nurses

1956—Code for Professional Nurses, amended

1960—Code for Professional Nurses, revised

1968—Code for Professional Nurses, revised

1976—Code for Nurses with Interpretive Statements

1985—Code for Nurses with Interpretive Statements, revised

2001—Code of Ethics for Nurses with Interpretive Statements

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Though these versions of the Code vary in their articulation of the duties and values of the profession, they also contain important features that remain relatively unchanged. For instance, while nurses always were urged not to discriminate on the basis of creed, nationality, or race (ANA, Committee on Ethics, 1940), contemporary nursing has broadened that concern to disallow discrimination on the basis of any personal attribute, socioeconomic status, or nature of the health problem itself (ANA, 1976). The 1985 Code claims that “all national, ethnic, racial, religious, cultural, political, educational, economic, developmental, personality, role, and sexual differences” are unjust grounds for discriminating among those in need of care (ANA, 1985).

The 2001 Code is even more emphatic: “The need for health care is universal, transcending all individual differences. The nurse establishes relationships and delivers nursing services with respect for human needs and values, and without prejudice” (ANA, 2001). The primary ethical principle of justice remains a central concern; it is the expression of that principle that has developed over the successive revisions of the Code. Within the Code for Nurses, whatever the version, there is a deep and truly abiding concern for the social justice at every level; for the amelioration of the conditions that are the causes of disease, illness, and trauma; for the recognition of the worth and dignity of all with whom the nurse comes into contact; for the provision of high-quality nursing care in accord with the standards and ideals of the profession; and for just treatment of the nurse. These are consistent and historic concerns of the profession that have been reflected, more strongly at some times than at others, in the successive revisions of the Code. The “new Code” reflects the “old Code” in its continuity with nursing’s moral past; thus, the 2001 Code is a shiny, new, genuine antique.

The Code for Nurses reflects both constancy and change—constancy in the identification of the ethical virtues, values, ideals, and norms of the profession, and change in relation to both the interpretation of those virtues, values, ideals, and norms, and the growth of the profession itself. It is comforting to note that the moral duties and values of the profession were set in place long before the dizzying and sometimes chaotic forces of contemporary science and technology added to the burdens of clinical decision making. Though no easy task, ethical decision making in the nursing profession is not adrift—it is firmly anchored to the distinguished, distinctive, and definitive moral and ethical tradition of the

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nursing profession as represented in the Code of Ethics for Nurses. As you read each of the chapters that follow, you will see in them nursing’s moral past, present, and future.

Marsha D.M. Fowler

Professor of Ethics

Spirituality and Faith Integration and Senior Fellow

Institute for Faith Integration

Azusa Pacific University

Azusa, CA

Associate Pastor

First Congregational Church of Los Angeles

Los Angeles, California

References

American Nurses Association. 1950. ANA House of Delegates Proceedings, Vol. I. New York: ANA.

American Nurses Association. 1960. ANA House of Delegates Proceedings. New York: ANA.

American Nurses Association Committee on Ethics. 1964. Suggested Guidelines For Handling Alleged Violations of the Code for Professional Nurses. New York: ANA.

American Nurses Association. 1968. ANA House of Delegates Reports, 1966-1968. New York: ANA.

American Nurses Association. 1976. The Code for Nurses with Interpretive Statements. Kansas City, MO: ANA.

American Nurses Association. 1985. The Code for Nurses with Interpretive Statements, revised. Kansas City, MO: American Nurses Publishing.

American Nurses Association. 2001. The Code of Ethics for Nurses with Interpretive Statements. Washington, DC: Nursesbooks.org.

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American Nurses Association Committee on Ethics. 1926. A Suggested Code. American Journal of Nursing 26(8): 599-601.

American Nurses Association Committee on Ethics. 1940. A Tentative Code for the nursing profession. American Journal of Nursing 40(9): 977-980.

Flanagan, L. 1976. One Strong Voice. Kansas City, MO: ANA.

Gretter, L. 1910. Florence Nightingale Pledge: Autograph manuscript dated 1893. American Journal of Nursing 10(4): 271.

Provision One

Carol R. Taylor PhD, MSN, RN

Carol R. Taylor, PhD, MSN, RN, is a faculty member of the Georgetown University School of Nursing and Health Studies and Director of the Georgetown University Center for Clinical Bioethics. She is a graduate of Holy Family University (BSN), the Catholic University of America (MSN), and Georgetown University (PhD in philosophy with a concentration in bioethics). Bioethics has been a focus of her teaching and research since 1980 linked to her passion to “make health care work” for those who need it. Special interests include healthcare decision making and professional ethics.

The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems.

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