The work for this paper entails interviewing TWO different categories of advanced practice nurses (APNs).
February 15, 2020
Field Activity Paper Ethics
February 15, 2020

Code of Ethics for Nurses with Interpretive Statements

ANA CODE OF ETHICS

APPENDIX
B

Preface

The Code of Ethics for Nurses with Interpretive Statements
(the Code) establishes the ethical standard for the profession and
provides a guide for nurses to use in ethical analysis and
decision-making. The Code is nonnegotiable in any setting. It may be
revised or amended only by formal processes established by the American
Nurses Association (ANA). The Code arises from the long, distinguished,
and enduring moral tradition of modem nursing in the United States. It
is foundational to nursing theory, practice, and praxis in its
expression of the values, virtues, and obligations that shape, guide,
and inform nursing as a profession.

Nursing encompasses the protection, promotion, and restoration of
health and well-being; the prevention of illness and injury; and the
alleviation of suffering, in the care of individuals, families, groups,
communities, and populations. All of this is reflected, in part, in
nursing’s persisting commitment both to the welfare of the sick,
injured, and vulnerable in society and to social justice. Nurses act to
change those aspects of social structures that detract from health and
well-being.

Individuals who become nurses, as well as the professional
organizations that represent them, are expected not only to adhere to
the values, moral norms, and ideals or the profession but also to
embrace them as a part of what it means to be a nurse. The ethical
tradition of nursing is self-reflective, enduring, and distinctive. A
code of ethics for the nursing profession makes explicit the primary
obligations, values, and ideals of the profession. In fact, it informs
every aspect of the nurse’s life.

The Code of Ethics for Nurses with Interpretive Statements serves the following purposes:

•  It is a succinct statement of the ethical values, obligations,
duties, and professional ideals of nurses individually and collectively.

Source: American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. Silver Spring, MD: Author.

•  It is the profession’s non-negotiable ethical standard.

•  It is an expression of nursing’s own understanding of its commitment to society.

Statements that describe activities and attributes of nurses in this
code of ethics and its interpretive statements are to be understood as
normative or prescriptive statements expressing expectations of ethical
behavior. The Code also expresses the ethical ideals of the
nursing profession and is, thus, both normative and aspirational.
Although this Code articulates the ethical obligations of all nurses, it
does not predetermine how those obligations must be met. In some
instances nurses meet those obligations individually; in other instances
a nurse will support other nurses in their execution of those
obligations; at other times those obligations can only and will only be
met collectively. ANA’s Code of Ethics for Nurses with Interpretive Statements
addresses individual as well as collective nursing intentions and
actions; it requires each nurse to demonstrate ethical competence in
professional life.

Society recognizes that nurses serve those seeking health as well as
those responding to illness. Nurses educate students, staff, and others
in healthcare facilities. They also educate within communities,
organizations, and broader populations. The term practice refers
to the actions of the nurse in any role or setting, whether paid or as a
volunteer, including direct care provider, advanced practice registered
nurse, care coordinator, educator, administrator, researcher, policy
developer, or other forms of nursing practice. Thus, the values and
obligations expressed in this edition of the Code apply to nurses in all
roles, in all forms of practice, and in all settings.

ANA’s Code of Ethics for Nurses with Interpretive Statements
is a dynamic document. As nursing and its social context change, the
Code must also change. The Code consists of two components: the
provisions and the accompanying interpretive statements. The provisions
themselves are broad and noncontextual statements of the obligations of
nurses. The interpretive statements provide additional, more specific,
guidance in the application of this obligation to current nursing
practice. Consequently, the interpretive statements are subject to more
frequent revision than are the provisions—approximately every
decade—while the provisions may endure for much longer without
substantive revision.

Additional ethical guidance and details can be found in the position
and policy statements of the ANA or its constituent member associations
and affiliate organizations that address clinical, research,
administrative, educational, public policy, or global and environmental
health issues.

The origins of the Code of Ethics for Nurses with Interpretive Statements
reach back to the late 1800s in the foundation of ANA, the early ethics
literature of modem nursing, and the first nursing code of ethics,
which was formally adopted by ANA in 1950. In the 65 years since the
adoption of that first professional ethics code, nursing has developed
as its art, science, and practice have evolved, as society itself has
changed, and as awareness of the nature and determinants of global
health has grown. The Code of Ethics for Nurses with Interpretive Statements is a reflection of the proud ethical heritage of nursing and a guide for all nurses now and into the future.

Introduction

In any work that serves the whole of the profession, choices of
terminology must be made that are intelligible to the whole community,
are as inclusive as possible, and yet remain as concise as possible. For
the profession of nursing, the first such choice is the term patient versus client. The term patient has ancient roots in suffering;
for millennia the term has also connoted one who undergoes medical
treatment. Yet, not all who are recipients of nursing care are either
suffering or receiving medical treatment The root of client
implies one who listens, leans upon, or follows another. It connotes a
more advisory relationship, often associated with consultation or
business.

Thus, nursing serves both patients and clients. Additionally, the
patients and clients can be individuals, families, communities, or
populations. Recently, following a consumerist movement in the United
States, some have preferred consumer to either patient or client. In this revision of the American Nurses Association’s (ANA’s) Code of Ethics for Nurses with Interpretive Statements (the Code), as in the past revision, ANA decided to retain the more common, recognized, and historic term patient as representative of the category of all who are recipients of nursing care. Thus, the term patient refers to clients or consumers of health care as well as to individuals or groups.

A decision was also made about the words ethical and moral. Both are neutral and categorical. That is—similar to physical, financial, or historical—they refer to a category, a type of reflection, or a behavior. They do not connote a rightness or goodness of that behavior.

Within the field of ethics, a technical distinction is made between ethics and morality. Morality
is used to refer to what would be called personal values, character, or
conduct of individuals or groups within communities and societies. Ethics
refers to the formal study of that morality from a wide range of
perspectives including semantic, logical, analytic, epistemological, and
normative. Thus, ethics is a branch of philosophy or theology in which
one reflects on morality. For this reason, the study of ethics is often
called moral philosophy or moral theology. Fundamentally,
ethics is a theoretical and reflective domain of human knowledge that
addresses issues and questions about morality in human choices, actions,
character, and ends.

As a field of study, ethics is often divided into metaethics, normative ethics, and applied ethics. Metaethics
is the domain that studies the nature of ethics and moral reasoning. It
would ask questions such as “Is there always an element of
self-interest in moral behavior?”and “Why be good?” Normative ethics addresses the questions of the ought, the four fundamental terms of which are right and wrong, good and evil. That is, normative ethics addresses what is right and wrong in human action (what we ought to do); what is good and evil in human character (what we ought to be); and good or evil in the ends that we ought to seek.

Applied ethics wrestles with questions of right, wrong, good, and
evil in a specific realm of human action, such as nursing, business, or
law. It would ask questions such as “Is it ever morally right to
deceive a research subject?”or “What is a ‘good nurse’ in a moral
sense?” or “Are health, dignity, and well-being intrinsic or
instrumental ends that nursing seeks?”All of these aspects of ethics are
found in the nursing literature. However, the fundamental concern of a
code of ethics for nursing is to provide normative, applied moral
guidance for nurses in terms of what they ought to do, be, and seek.

Some terms used in ethics are ancient such as virtue and evil, yet they remain in common use today within the field of ethics. Other terms, such as ethics and morality,
are often—even among professional ethicists—used imprecisely or
interchangeably because they are commonly understood or because common
linguistic use prevails. For example, one might speak of a person as
lacking a “moral compass” or as having “low morals.” Another example is
the broader public use of the term ethical. Ethics is a category
that refers to ethical or nonethical behavior: either a behavior is
relevant to the category of ethics, or it is not. Here, the term unethical has no meaning, although it is commonly used in lectures and discussions—even by professional ethicists—to mean morally blameworthy, that is, wrong. The terms should and must are often substituted for the more precise normative ethical term ought. Ought indicates a moral imperative. Must expresses an obligation, duty, necessity, or compulsion, although not an intrinsically moral one. Likewise, should expresses an obligation or expediency that is not necessarily a moral imperative.

The English language continues to evolve, and the once firm and clearly understood distinctions between may and can; will and shall; and ought, should, and must
have faded in daily language and have come to be used interchangeably
in both speech or writing, except in rare instances in which the nuance
is essential to an argument. To aid the reader in understanding the
terms used, this revision of ANA’s Code of Ethics for Nurses with Interpretive Statements will, for the first time, include a glossary of terms that are found within the Code.

This revision also includes another innovation: links to foundational
and supplemental documents. The links to this material are available on
ANA’s Ethics webpage. These documents are limited to works judged by
the Steering Committee as having both timely and timeless value.
Nursing’s ethics holds many values and obligations in common with
international nursing and health communities. For example, the Millennium Development Goals of the United Nations, the World Medical Association’s Declaration of Helsinki about research involving human subjects, and the International Council of Nurses’ Code of Ethics for Nurses are documents that are both historically and contemporaneously important to U.S. nurses and nursing’s ethics.

The afterword from the 2001 Code has been included and updated to
reflect the 2010–2014 revision process. This Introduction, another new
component of this revision, was added to provide a general orientation
to the terminology and the structure of this document.

The nine provisions of the 2001 Code have been retained with some
minor revisions that amplify their inclusivity of nursing’s roles,
settings, and concerns. Together, the nine provisions contain an
intrinsic relational motif: nurse-to-patient, nurse-to-nurse,
nurse-to-self, nurse-to-others, nurse-to-profession, nurse-to-society,
and nursing-to-society, relations that are both national and global. The
first three provisions describe the most fundamental values and
commitments of the nurse; the next three address boundaries of duty and
loyalty; the final three address aspects of duties beyond individual
patient encounters. This revision also retains, for each provision,
interpretive statements that provide more specific guidance for
practice, are responsive to the contemporary context of nursing, and
recognize the larger scope of nursing’s concern in relation to health.

It was the intent of the Steering Committee to revise the Code in
response to the complexities of modern nursing, to simplify and more
clearly articulate the content, to anticipate advances in health care,
and to incorporate aids that would make it richer, more accessible, and
easier to use.

—Steering Committee for the Revision of the
Code of Ethics for Nurses with Interpretive Statements, September 2014

Provision 1

The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person.

   1.1 Respect for Human Dignity

A fundamental principle that underlies all nursing practice is
respect for the inherent dignity, worth, unique attributes, and human
rights of all individuals. The need for and right to health care is
universal, transcending all individual differences. Nurses consider the
needs and respect the values of each person in every professional
relationship and setting; they provide leadership in the development and
implementation of changes in public and health policies that support
this duty.

   1.2 Relationships with Patients

Nurses establish relationships of trust and provide nursing services
according to need, setting aside any bias or prejudice. Factors such as
culture, value systems, religious or spiritual beliefs, lifestyle,
social support system, sexual orientation or gender expression, and
primary language are to be considered when planning individual, family
and population-centered care. Such considerations must promote health
and wellness, address problems, and respect patients’ or clients’
decisions. Respect for patient decisions does not require that the nurse
agree with or support all patient choices. When patient choices are
risky or self-destructive, nurses have an obligation to address the
behavior and to offer opportunities and resources to modify the behavior
or to eradicate the risk.

   1.3 The Nature of Health

Nurses respect the dignity and rights of all human beings regardless
of the factors contributing to the person’s health status. The worth of a
person is not affected by illness, ability, socioeconomic status,
functional status, or proximity to death. The nursing process is shaped
by unique patient preferences, needs, values, and choices. Respect is
extended to all who require and receive nursing care in the promotion of
health, prevention of illness and injury, restoration of health,
alleviation of pain and suffering, or provision of supportive care.

Optimal nursing care enables the patient to live with as much
physical, emotional, social, and religious or spiritual well-being as
possible and reflects the patient’s own values. Supportive care is
particularly important at the end of life in order to prevent and
alleviate the cascade of symptoms and suffering that are commonly
associated with dying. Support is extended to the family and to
significant others and is directed toward meeting needs comprehensively
across the continuum of care.

Nurses are leaders who actively participate in assuring the
responsible and appropriate use of interventions in order to optimize
the health and well-being of those in their care. This includes acting
to minimize unwarranted, unwanted, or unnecessary medical treatment and
patient suffering. Such treatment must be avoided, and conversations
about advance care plans throughout multiple clinical encounters helps
to make this possible. Nurses are leaders who collaborate in altering
systemic structures that have a negative influence on individual and
community health.

   1.4 The Right to Self-Determination

Respect for human dignity requires the recognition of specific
patient rights, in particular, the right to self-determination. Patients
have the moral and legal right to determine what will be done with and
to their own person; to be given accurate, complete, and understandable
information in a manner that facilitates an informed decision; and to be
assisted with weighing the benefits, burdens, and available options in
their treatment, including the choice of no treatment. They also have
the right to accept, refuse, or terminate treatment without deceit,
undue influence, duress, coercion, or prejudice, and to be given
necessary support throughout the decision-making and treatment process.
Such support includes the opportunity to make decisions with family and
significant others and to obtain advice from expert, knowledgeable
nurses, and other health professionals.

Nurses have an obligation to be familiar with and to understand the
moral and legal rights of patients. Nurses preserve, protect, and
support those rights by assessing the patient’s understanding of the
information presented and explaining the implications of all potential
decisions. When the patient lacks capacity to make a decision, a
formally designated surrogate should be consulted. The role of the
surrogate is to make decisions as the patient would, based upon the
patient’s previously expressed wishes and known values. In the absence
of an appropriate surrogate decision-maker, decisions should be made in
the best interests of the patient, considering the patient’s personal
values to the extent that they are known.

Nurses include patients or surrogate decision-makers in discussions,
provide referrals to other resources as indicated, identify options, and
address problems in the decision-making process. Support of patient
autonomy also includes respect for the patient’s method of
decision-making and recognition that different cultures have different
beliefs and understandings of health, autonomy, privacy and
confidentiality, and relationships, as well as varied practices of
decision-making. Nurses should, for example, affirm and respect patient
values and decision-making processes that are culturally hierarchical or
communal.

The importance of carefully considered decisions regarding
resuscitation status, withholding and withdrawing life-sustaining
therapies, foregoing nutrition and hydration, palliative care, and
advance directives is widely recognized. Nurses assist patients as
necessary with these decisions. Nurses should promote advance care
planning conversations and must be knowledgeable about the benefits and
limitations of various advance directive documents. The nurse should
provide interventions to relieve pain and other symptoms in the dying
patient consistent with palliative care practice standards and may not
act with the sole intent to end life. Nurses have invaluable experience,
knowledge, and insight into effective and compassionate care at the end
of life and should actively engage in related research, scholarship,
education, practice, and policy development.

Individuals are interdependent members of their communities. Nurses
recognize situations in which the right to self-determination may be
outweighed or limited by the rights, health, and welfare of others,
particularly in public health. The limitation of individual rights must
always be considered a serious departure from the standard of care,
justified only when there are no less-restrictive means available to
preserve the rights of others, meet the demands of law, and protect the
public’s health.

   1.5 Relationships with Colleagues and Others

Respect for persons extends to all individuals with whom the nurse
interacts. Nurses maintain professional, respectful, and caring
relationships with colleagues and are committed to fair treatment,
transparency, integrity-preserving compromise, and the best resolution
of conflicts. Nurses function in many roles and settings, including
direct care provider, care coordinator, administrator, educator, policy
maker, researcher, and consultant.

The nurse creates an ethical environment and culture of civility and
kindness, treating colleagues, coworkers, employees, students, and
others with dignity and respect. This standard of conduct includes an
affirmative duty to act to prevent harm. Disregard for the effects of
one’s actions on others, bullying, harassment, intimidation,
manipulation, threats, or violence are always morally unacceptable
behaviors. Nurses value the distinctive contribution of individuals or
groups as they seek to achieve safe, quality patient outcomes in all
settings. Additionally, they collaborate to meet the shared goals of
providing compassionate, transparent, and effective health services.

Provision 2

The nurse’s primary commitment is to the patient, whether an individual, family, group, community, or population.

   2.1 Primacy of the Patient’s Interests

The nurse’s primary commitment is to the recipients of nursing and
healthcare services—patient or client—whether individuals, families,
groups, communities, or populations. Each plan of care must reflect the
fundamental commitment of nursing to the uniqueness, worth, and dignity
of the patient. Nurses provide patients with opportunities to
participate in planning and implementing care and support that are
acceptable to the patient. Honest discussions about available resources,
treatment options, and capacity for self-care are essential. Addressing
patient interests requires recognition of the patient’s place within
the family and other relationships. When the patient’s wishes are in
conflict with those of others, nurses help to resolve the conflict Where
conflict persists, the nurse’s commitment remains to the identified
patient.

   2.2 Conflict of Interest for Nurses

Nurses may experience conflict arising from competing loyalties in
the workplace, including conflicting expectations from patients,
families, physicians, colleagues, healthcare organizations, and health
plans. Nurses must examine the conflicts arising between their own
personal and professional values, the values and interests of others who
are also responsible for patient care and healthcare decisions, and
perhaps even the values and interests of the patients themselves. Nurses
address such conflicts in ways that ensure patient safety and that
promote the patient’s best interests while preserving the professional
integrity of the nurse and supporting interprofessional collaboration.

Conflicts of interest may arise in any domain of nursing activity,
including direct care, administration, education, consultation, policy
development, and research. Nurses in all roles must identify and,
whenever possible, avoid conflicts of interest. Nurses who bill for
services and nurse executives with budgetary responsibilities must be
especially aware of the potential for conflicts of interest. Healthcare
financing and delivery systems may create conflict between economic
self-interest and professional integrity. Bonuses, sanctions, and
incentives tied to financial targets may present such conflict. Any
perceived or actual conflict of interest should be disclosed to all
relevant parties and, if indicated, nurses should withdraw, without
prejudice, from further participation.

   2.3 Collaboration

The complexity of health care requires collaborative effort that has
the strong support and active participation of all health professions.
Nurses should foster collaborative planning to provide safe,
high-quality, patient-centered health care. Nurses are responsible for
articulating, representing, and preserving the scope of nursing
practice, and the unique contributions of nursing to patient care. The
relationship between nursing and other health professions also needs to
be clearly articulated, represented, and preserved.

Collaboration intrinsically requires mutual trust, recognition,
respect, transparency, shared decision-making, and open communication
among all who share concern and responsibility for health outcomes.
Nurses ensure that all relevant persons, as moral agents, participate in
patient care decisions. Patients do not always know what questions to
ask or may be limited by a number of factors, including language or
health literacy. Nurses facilitate informed decision-making by assisting
patients to secure the information that they need to make choices
consistent with their own values.

Collaboration within nursing is essential to address the health of
patients and the public effectively. Although nurses who are engaged in
nonclinical roles (e.g., educators, administrators, policy-makers,
consultants, or researchers) are not primarily involved in direct
patient care, they collaborate to provide high-quality care through the
influence and direction of direct care providers. In this sense, nurses
in all roles are interdependent and share a responsibility for outcomes
in nursing care and for maintaining nursing’s primary commitment to the
patient.

   2.4 Professional Boundaries

The work of nursing is inherently personal. Within their professional
role, nurses recognize and maintain appropriate personal relationship
boundaries. Nurse–patient and nurse–colleague relationships have as
their foundation the promotion, protection, and restoration of health
and the alleviation of pain and suffering. Nurse–patient relationships
are therapeutic in nature but can also test the boundaries of
professionalism. Accepting gifts from patients is generally not
appropriate; factors to consider include the intent, the value, the
nature, and the timing of the gift, as well as the patient’s own
cultural norms. When a gift is offered, facility policy should be
followed. The intimate nature of nursing care and the involvement of
nurses in important and sometimes highly stressful life events may
contribute to the risk of boundary violations. Dating and sexually
intimate relationships with patients are always prohibited.

Boundary violations can also occur in professional colleague
relationships. In all communications and actions, nurses are responsible
for maintaining professional boundaries. They should seek the
assistance of peers or supervisors in managing or removing themselves
from difficult situations.

Provision 3

The nurse promotes, advocates for, and protects the rights, health, and safety of the patient.

   3.1 Protection of the Rights of Privacy and Confidentiality

The need for health care does not justify unwanted, unnecessary, or
unwarranted intrusion into a person’s life. Privacy is the right to
control access to, and disclosure or nondisclosure of, information
pertaining to oneself and to control the circumstances, timing, and
extent to which information may be disclosed.

 

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