American nurses association florence nightingale pledge

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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History of this Commitment

The Nightingale Pledge, which is patterned after medicine's Hippocratic oath, is generally accepted as the first nursing code of ethics. While it contains a pledge that the nurse devote herself to the welfare of those committed to her care, it does not explicitly mention compassion and respect for human dignity. Similarly, the earliest code drafted by the American Nurses Association in 1926 mentions only devotion. A Tentative Code, published in The American Journal of Nursing in 1940 but never adopted, contains the following statements:

The nurse should carry out professional commitments and activities with meticulous care, with a generous measure of performance, and with fidelity toward those whom she serves. Honesty, understanding, gentleness, and patience should characterize all of the acts of the nurse. A sense of the fitness of things is particularly important (ANA, 1940; p. 978).

The nurse has a basic concern for people as human beings, confidence in the fundamental power of personality for good, respect for religious beliefs of others, and a philosophy which will sustain and inspire others as well as herself (ANA, 1940; p. 980).

In the 1950 Code for Professional Nurses, a substantive revision of A Tentative Code, we find for the first time:

Need for nursing service is universal. Professional nursing service is therefore unrestricted by considerations of nationality, race, creed or color (ANA, 1950; p. 110).

This statement became the first provision of the 1968 Code for Professional Nurses:

The nurse provides services with respect for the dignity of man, unrestricted by considerations of nationality, race, creed, color or status (ANA, 1968).

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In 1976, the Code added the following important content to this provision:

The nurse provides services with respect for human dignity and the uniqueness of the client unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems (emphasis added) (ANA, 1976; p. 3).

In addition to signaling the uniqueness of each recipient of nursing care (then newly termed “the client”), the 1976 Code also recognized that things other than nationality, race, creed, color, and status can result in unacceptable differences in treatment. This provision remained the same in the 1985 Code. In the 2001 revision, the scope was broadened to include “all professional relationships” so that “respect” is now broadened to include “inherent dignity (a critical modifier), worth, and uniqueness.” A significant addition was the phrase “practices with compassion and respect.” The addition of the virtue compassion was related to the serious scholarship currently being done by nurse ethicists in virtue theory and care ethics. Also noteworthy was the replacement of the term client with “every individual,” so that the Code now states that:

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 (emphasis added) (ANA, 2001).

It is important to recognize that the drafters of the Code of Ethics for Nurses have continued to identify respect for persons as a core ethical principal, including respect for autonomy in this principle (Interpretive Statement 1.4, Right to Self-determination). Although The Belmont Report (National Commission for Behavioral Research, 1979) identified respect for persons, beneficence and justice as the three basic ethical principles, Beauchamp and Childress in their Principles of Biomedical Ethics, now in its fifth edition (2001), popularized four principles of biomedical ethics: autonomy, beneficence, nonmaleficence, and justice.

As bioethics in the United States evolved, autonomy replaced respect for persons in most lists of core principles. While the emphasis on autonomy was understandable in a country struggling to correct the abuses of paternalistic medicine, its narrower focus ignores bigger challenges related to inherent dignity and worth. Strikingly absent from popularized versions of the principles of bioethics is responsiveness to human vulnerability. The Code of Ethics recognizes the many factors that result in injustices in health care and holds nurses to a high standard of compassion and respect for all—especially those most vulnerable. As recent national studies continue to prove, great disparities in health outcomes in the United States continue—making Provision 1 an ideal not yet realized (AHRQ, 2006).

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Nurse ethicist Barbara Jacobs recommends respect for, or the restoration of, human dignity, as a common central phenomenon to unite and reflect nursing theory and practice (Jacobs, 2001). Consilience, a way to unify the knowledge that is needed to support this phenomenon, is suggested as one example of a possible approach toward a philosophy of nursing that embraces multiple forms and sources of knowledge in all-encompassing morality that ultimately ennobles the lives of all human beings in covenantal relationships with nurses both in theory and in practice.

Thinking Beyond This Provision

Most nurses will tell you that they entered nursing to “help others,” and few at first will admit to being biased or discriminatory in their professional relations. Honest reflection, however, results in most of us realizing that we respond to patients and other professional caregivers differently based on numerous factors, not the least of which are race and ethnicity, age, financial status, position/title, body size, health, and other personal attributes. We probably all think of those with whom we interact professionally as falling into one of three categories: people for whom we'd do anything—even at great personal cost; people whom we give their due; and people we serve grudgingly, if at all. It is to be hoped that few nurses can identify individuals with whom they interact professionally who fall into a fourth category: people they aim to harm by disrespectful behavior or worse.

To the extent that we admit to some degree of difference in our ways of relating to others, Provision 1 presents us with a challenging ideal:

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 (emphasis added).

Provision 1 is not claiming that every nurse needs to have “warm and fuzzy” feelings for all encountered professionally—that would be unrealistic. Certain patients, members of their families, and even other healthcare professionals, will fill us with frustration, anger, sometimes even disgust and revulsion, but the Code mandates that we have a professional obligation to move beyond these feelings and, at the very least, to recognize the humanity of others and respond with compassion and respect. At times, this can be a heroic effort and may even require the support of the professional caregiving team.

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It is helpful for nurses to be reflective concerning the fundamental assumptions about people they bring to practice. Reflect on the following statements and check those with which you agree. Compare your list with that of a colleague and explore any differences. Talk about the consequences of the assumptions you hold for yourself, your patients, your colleagues, and the public at large. Which of your assumptions are consistent with Provision 1 of the Code of Ethics? How should colleagues respond to individuals with convictions that violate Provision 1 of the Code of Ethics?

Every human being, merely by virtue of being human, merits my equal and full respect.

The more vulnerable people are because of illness, frailty, or other marginalizing factors, the more they command my compassion and respect.

The more vulnerable people are because of illness, frailty, or other marginalizing factors, the less they command my compassion and respect.

I agree that I need to be compassionate and respectful to those innocently affected by disease, injury, or frailty—so long as self-abusive behaviors did not cause the disease or infirmity

People need to earn my respect.

It is only human and ethically justifiable to respect people differently.

Interpretive Statement 1.4, the right to self-determination, mandates that nurses be knowledgeable about the moral and legal rights of all patients to be self-determining. Many critics of contemporary health care bemoan the failure of all healthcare professionals, including nurses, to promote patients' authentic autonomy. Respect for autonomy in many cases is now reduced to not interfering with a patient's expressed choices. This is a far cry from what nurse ethicist Sally Gadow initially described as existential advocacy:

The ideal which existential advocacy expresses is…that individuals be assisted by nursing to authentically exercise their freedom of self-determination. [A]uthentic… [means] a way of reaching decisions…truly one's own—decisions that express all…one believes important about oneself and the world. … (Gadow, 1980; p. 85).

How many nurses today know their patients well enough to facilitate authentic autonomy? And how many nurses value existential advocacy such that they are willing to fight for institutional cultures that demand nothing less.

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Applying the Provision: Rethinking Professional Relationships and What has Historically Been Termed “The Therapeutic Use of Self”

In every human encounter, we convey one of three messages: (1) Go away, my world would be better without you; (2) You are an object, a task to be done, you mean nothing to me; or (3) You are a person of worth, I care about you. The more vulnerable people are, the more we can become their world of meaning. Since disease, injury, and illness can separate people from affirming experiences that enhance their sense of worth (family relationships, work, other achievements), how we present ourselves as health professionals to individuals needing care truly matters. A quick moment of reflection will help you to identify individuals in your own life whom you perceive as being either therapeutic or toxic presences. How do you think your patients and colleagues would evaluate your presence? What do you leave in your wake: affirmation, peace, joy, warmth, support, the experience of being cared about as well cared for? In healthcare settings, it is critical for nurses to relate to patients as a healing presence. Two stories follow to illustrate this point.

A friend of mine named Laurie, who has cancer, wrote to me after a visit to an infusion therapy center:

The nurse came into my room and touched me on the forearm. It wasn't a furtive nurse searching for a vein thing. It wasn't “I'm a nurse, you're a patient, too bad” thing. It was “I'm a human being, you're a human being, how are you?” thing. And that one touch rendered tolerable everything else she had to do that morning.

Powerfully illustrated in this example are the profound consequences of human touch and compassionate, respectful presence. Contrast this illustration with the next.

Another friend diagnosed with advanced ovarian cancer spent two long, hard years dying. She was president of our college, had a PhD in biology, was from Worcester, Massachusetts, and had that delightful New England sense of reserve and privacy. She was one of the most gentle, loving human beings I have ever had the blessing to know. She had intestinal obstructions and was in and out of the hospital constantly. I remember spending hours simply sitting behind her to lend physical support as she retched over an emesis basin. She instructed me to tell my students the following:

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When I first got sick, it didn't matter how people treated me because I knew who I was. But now that I've grown weaker I become whomever people make me. If a nurse walks into my room and moves me like meat, I become meat!

It made me want to cry that I or a member of my profession had the capacity to take a Lillian and transform her to a slab of meat by virtue of how I gazed, what I said or failed to say, or how I touched. This is the power that is ours. At the end of the shift, have people been left better or worse for having experienced us?

Reflect on the following case studies in light of Provision 1 of the Code of Ethics.

Case Example 1

Jean Thatcher is a morbidly obese, 47-year-old, single, white attorney with multiple sclerosis. She is frequently admitted to your hospital for complications related to her multiple sclerosis and obesity. Since she quickly “exhausts” the patience and best efforts of the staff, she is “rotated” among several units all of whom know her well and loathe her inpatient stays on their unit. The staff's best efforts to educate her about appropriate self-care and preventive practices have fallen on deaf ears. She refuses to cooperate when her support is elicited for bathing, position changes, and the like. Her one visitor, her mother, believes that the staff discriminates again her daughter and complains frequently to management. Both the patient and her mother frequently threaten to sue the hospital for neglect and discrimination. Jean admits that she is refusing to eat or help with bathing and positioning. She said she has “had enough” and wants to give up. Most of the staff have already “given up” and ask “why we should we try to help Jean when she has been clear about not wanting our help?” Today, one nurse was overheard saying, “I'm not going to sprain my back trying to get her to move when she refuses to cooperate. She can lie in her filth for all I care.” The nurse manager calls a meeting to explore how the team can best respond to the challenges of caring for Ms. Thatcher. In what practical ways does Provision 1 of the Code of Ethics influence the standard of care for Ms. Thatcher and similar patients? Is Ms. Thatcher's wish to “give up” an autonomous act of self-determination that should be supported by her nurses?

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Case Example 2

Mr. Rivera staggers into the emergency room at 2:00 a.m. complaining of belly pain. He speaks Spanish only. Well known to the ER staff, Mr. Rivera is homeless and has a history of alcoholism and violence. He has been blacklisted at several of the local shelters for homeless men. The night is cold and there is freezing rain. The resident called to examine Mr. Rivera does not “work-up” the complaint of “belly pain,” instead saying that, once again, Mr. Rivera only wants a warm bed for the night, a bath, something to eat and meds to make him “feel good.” The E.R. nurse manager instructs a nursing student to “clean up” Mr. Rivera when the day shift arrives. The nursing student finds him combative when aroused and asks for help only to be told to “do the best she can.” His stools are dark and she suspects blood in the stool, but is told only to babysit the patient until he is discharged. In what practical ways does Provision 1 of the Code of Ethics for Nurses influence the standard of care for Mr. Rivera and similar patients? Does Mr. Rivera's previous history justify the lack of care he is receiving this admission? Is it justified to expect the nursing student to meet his needs unaided? How should the student's clinical instructor respond to the student when she complains about the staff's lack of compassion, professionalism, and aid?

Case Example 3

You are the director of nursing in a large nursing home. Your units are staffed primarily with licensed practical nurses and nursing assistants. Recently several nursing assistants have come to you complaining about unequal treatment in assignments and privileges. You know that there are some racial tensions among the staff, which is predominantly persons of African American and Hispanic identity, and suspect that these may be contributing to the conflict. While the nursing home allegedly has a “zero tolerance” policy for discrimination, you know that this is not always the case. What guidance does Provision 1 of the Code of Ethics offer to promote respectful professional relationships among the staff and residents?

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References

All online references were accessed in December 2007.

Agency for Healthcare Research and Quality (AHRQ). 2006. National Healthcare Disparities Report. 2006. Rockville, MD: AHRQ. http://www.ahrq.gov/qual/nhdr06/nhdr06.htm.

American Nurses Association. 1926. A Suggested Code: A code of ethics presented for the consideration of the American Nurses' Association. American Journal of Nursing 26(8): 599-601.

American Nurses Association. 1940. A Tentative Code for the nursing profession. American Journal of Nursing 40(9): 977-80.

American Nurses Association. 1950. Code for professional nurses. ANA House of Delegates Proceedings, Vol. 1; New York: ANA.

American Nurses Association. 1968. Code for professional nurses, Revised. ANA House of Delegates Proceedings, Vol. 1; New York: ANA.

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

American Nurses Association. 1985. Code for Nurses with Interpretive Statements, Revised. Washington, DC: American Nurses Publishing.

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

Beauchamp, T.L. and J.F. Childress. 2001. Principles of Biomedical Ethics, 5th ed. New York: Oxford University Press.

Cooper, L.A., and N.R. Powe. 2004. Disparities in Patient Experiences, Health Care Processes, and Outcomes: The Role of Patient-Provider Racial, Ethnic, and Language Concordance. New York: The Commonwealth Fund.

Gadow, S. 1980. Existential advocacy: Philosophical dimensions of nursing practice. In Nursing Images and Ideals, S. Spicker and S. Gadow, eds. NY: Springer Publishing Company.

Jacobs, B. 2001. Respect for human dignity: A central phenomenon to philosophically unite nursing theory and practice through consilience of knowledge. Advances in Nursing Science 24(1): 17-35.

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Kaiser Health Disparities Report: A Weekly Look at Race, Ethnicity and Health. http://www.kaisernetwork.org/Daily_reports/rep_disparities.cfm

National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. 1979. The Belmont Report: Ethical Principles and Guidelines for the Protection of Human Subjects of Research. Washington, DC: U. S. Government Printing Office.

Smedley, B.D., A.Y. Stith, and A.R. Nelson, Eds. 2002. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academies Press.

Provision Two

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

Anne J. Davis, PhD, DS, MS, RN, FAAN, and Professor Emerita, taught at the University of California for 34 years. Beginning in 1962, Dr. Davis's career focused on international work with appointments in Israel, India, Nigeria, Ghana, Kenya, Japan, Korea, China, and Taiwan. These rich experiences led to the development of her overriding interest in cultural diversity and nursing ethics. She is a graduate of Emory University in Atlanta (BS, Nursing), Boston University (MS, Psychiatry), and University of California, Berkeley (PhD, Higher Education). Dr. Davis has been the recipient of numerous awards, including an honorary Doctor of Science from Emory University and election as a Fellow in the American Academy of Nursing.

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

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History of this Commitment

From the beginning of professional nursing in the 1870s in the United States, after the Civil War when nurses served in military hospitals, nursing care was limited only to those sick or injured individuals who were usually cared for in homes through “private duty nursing.” The nurse was customarily employed by the family, through a “registry,” at the request of a physician. Often the physician would request a specific nurse for one of “his patients.” In this relationship, there were four potentially competing ethical loyalties: patient, registry, physician, self.

Later, both patient care and nursing moved into hospitals. Nurses continued to be employed as private duty nurses, even within hospitals, until World War II, after which nurses predominantly became employees of the hospital rather than the patient or patient's family. Now the nurse faced loyalties to an institution instead of a registry, a physician whom the nurse may or may not have known, the patient, and self. In the days of registries and, subsequently, in hospitals, nurses could be blackballed, sometimes solely at the request of a physician, sometimes for reasons unrelated to practice. This heightened to need for nurses to be “loyal” to the physician. It has only been in recent years that a physician could not march into a nursing administration office and demand the firing of a particular nurse. Such power placed nurses in a terrible position—not only did the nurse have to “obey” and not oppose a physician, but the nurse also had to “please” the physician with a proper attitude of deference. Loyalty to the patient could be jeopardized where nurses believed their livelihood to be at stake. In addition, nurses were expected to serve, sometimes without remuneration, placing yet another strain on the nurse's loyalty to the patient. And yet, nursing, in its literature and its practice consistently articulated a primary commitment to the patient. After the 1950s, health care, or more specifically, illness care, has become far more complex than in the days of the inception of modern nursing in the United States in the 1870s. Nursing has moved out of diploma programs and into colleges and universities, and uniform mandatory registration and licensure has been instituted across the nation.

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Both medicine and nursing have developed specialties and subspecialties, so the patients (and the nurses) now deal with a battalion of physicians in each case. Third party payors have entered into the mix, including both insurance companies and government agencies. Unionization and collective bargaining on behalf of nurses has increased. Accrediting bodies, both for institutions and for professions, have also become a part of the system. Many formerly independent hospitals have either gone out of business or coalesced into multihospitals and multiagency megacompanies. Restrictions may now be placed on care for economic rather than clinical reasons. And, importantly, there has been a rise in technological interventions available and both rising costs and access to care has become a problem for many. Increasingly, “competition” between ethical “loyalties” for nurses have become ever more robust and complex. In addition, though illness care remains the focus of the “healthcare system,” there is an awareness of the importance of preventive care.

Preventive care was not greatly valued until an understanding of disease etiology came about in the 1870s and 1980s when Robert Koch and Louie Pasteur worked out the germ theory. Florence Nightingale, who was at Scutari and the Crimea in 1854, had no scientific knowledge of the germ theory, nor did she support the idea later, yet she was among the first to value prevention and to see the benefit of keeping people out of hospitals, which were often defined then as death houses. Before she became the famous “Lady with the Lamp,” she had become convinced that improved public health measures were the royal road to making Britain a healthier nation, and became known in London social circles for her panoramic expertise in this field. Her much read Notes on Nursing (Nightingale, 1860) and her reorganization of the military health system reflected this knowledge and her value of disease prevention. Her vision enlarged the definition of the patient role and redefined the nursing role.

Once modern public health systems were established in the United Kingdom and the United States, the roles and functions of nurses expanded to include not only the sick, but the well; and not only individuals, but groups of people; with emphasis on cleanliness, vaccination, and prenatal and well-baby care. Though the nurse's role had expanded, the professional and ethical emphasis continued to be on the “patient,” who might now be a family unit, a group, a community, or an individual.

In her book, Nursing Ethics, the American nurse Isabel Hampton Robb wrote:

I want to emphasize the fact that the nursing for all patients—rich or poor, in the hospital or in their own houses—is in the main identical… From the very outset

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let her [the nurse] determine that she will be no respecter of persons, but will treat all her patients with impartiality. While in the hospital, the nurse should always make it her rule to think of every patient—even the poorest and most unattractive—not as a mere case, interesting only from a scientific standpoint, but as an individual sick human being, whose wishes, fancies and peculiarities call for all the consideration possible at her hands. (Robb, 1900; pp. 213-14)

These words demonstrate the central place of all patients, with unique and individual attributes, in nursing and nursing ethics.

In each ANA Code since the first one in 1950, the patient, whether individual, family, group, or community, has been at the center of the nursing profession's ethics. That is still the case today, but life in general, nursing practice in particular, and the structure of the healthcare system, have become far more complex and the new ANA Code reflects these changes.

Thinking Behind This Provision

Though it has been the case that, throughout modern nursing in the United States, nurses have been morally obligated to put the patient first, the previous versions of the Code commingled this obligation with others. The Task Force for the Revision of the Code felt strongly that the primacy of the patient was of sufficient importance, historicity, and priority that it necessitated an emphatic and unequivocal statement in the provisions. Thus, the previous Provision 2 was bumped to third place and the duty to the patient placed second.

Historically, nurses had ethical obligations that placed emphasis on attending to the patients' needs, and yet the context of nursing was not necessarily supportive of this obligation. Today, the nurse's ethical obligation to the patient, first, is even more complex to negotiate. Our present day ethics has moved from a fairly recent physician-oriented, paternalistic model in which physicians, using the ethical principle of nonmaleficence or “do no harm,” knew what was “best for the patient.” As nursing expanded its educational offerings, developed specialized practice areas, escalated its research, and even developed forms of independent practice, nurses generally moved into the realm of independent nursing functions while retaining the so-called dependent functions of carrying out medical orders. In recognizing its own right to participate in decision making and formulate plans of patient care, nursing moved to ethics that recognized patient's rights, including the right to know and discuss their health status and make healthcare decisions. Simultaneously, nurses began coming to a greater awareness of “nursing rights,” particularly as they related to the delivery of high-quality health care. This changed ethics

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model functions in the midst of increased clinical complexities that include economic constraints and managed care environments. This does not mean that nurses see patients (or themselves) as sidelined by events and priorities, but it does mean that nurses must learn to deal with economic pressures that may compete with moral values or with patients' rights. The patients and their rights must remain central. At the same time, ethical obligation to the patient is primary, but it is not the sole ethical obligation.

In this latest edition of the Code, Provision 5 has been added with the potential of creating additional ethical conflicts between the needs and rights of the patient and the nurse as it describes a nurse's duty to self. The function of duties to self is not some sort of entitlement; it is care for the self in such as way as to enable nurses to fulfill other moral duties. At times, nurses have, wrongly, placed their own needs before those of the patient in situations as simple as failing to confront a physician colleague who is indifferent or worse to the needs of the patient. Such situations, and others like it, that present the nurse with possible conflicting obligations raise several questions. First, does the nurse's primary obligation always mean a focus on the patient, as has historically been the case, even to the harm of the nurse? A “no” answer to this would require a strong ethical argument to support it. There may be an exception to this primary commitment, but a nurse would have to think long and hard about the ethical reason to act on this exception. Importantly, even in situations of conflicting moral claims, where the nurse must act in a morally self-regarding manner, the nurse must never abandon the patient. This means that if one nurse cannot, on ethical grounds, engage in some treatment, activity, or procedure, then another nurse or caregiver must be found who does not object to such involvement.

Nurses have multiple ethical obligations, sometimes competing, sometimes conflicting, including those to the patient, the organization or institution in which they work, other healthcare professionals, and the nursing profession. Today, as nursing becomes increasingly entrepreneurial, a nurse's own “business priorities” could conceivably come into conflict with the needs of the patient. Sometimes the nurse must decide to whom she or he owes a primary obligation (Davis et al, 1997). The Code says the primary obligation is to the patient. Nursing work always occurs in some social structure and this fact can make it difficult always to put the patient first in a nurse's ethical obligations. When nurses focus on what they think will be the consequences of an ethical act, sometimes they may need courage (a virtue) in order to act. They also need to draw support from the nursing community within which they work. In order to make this provision of the Code have full meaning, nursing leaders in all care giving settings will need to create environments in which candid, reflective, and open ethical discussions can take place.

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How do nurses think about an ethical problem to arrive at some conclusion that they believe to be the ethically right action? Ethical decision making requires knowledge and refection including knowledge of clinical practice, institutional policies and procedures, the field of ethics, the Code of Ethics for Nurses, and an understanding of the self and one's own values. While the patient remains at the center of this thinking, other people need to be considered, including the same self-consideration on the part of the nurse.

Applying the Provision: The Nurse-Patient Relationship

The nurse-patient relationship creates the basic unit in which much of nursing practice and ethics occurs. A nurse's ethical sensitivity is the first requirement in the application of this provision that places the patient at its center. Sometimes, nurses define a problem as a clinical one without seeing the ethical aspects in it. If the ethical issues that exist are missed, then that part of the situation is not attended to by the nurse. If the nurse is clinically competent, but ethically insensitive or oblivious, then this provision will not have a part in the decision making and actions that are needed to deal with the whole patient situation. If nurses are sensitive to the ethical issues or concerns involved in a given situation, the next step is them to pay attention to their own reactions to this situation. This reaction informs the nurse that something is wrong or missing ethically. This sensitivity and intuitive reaction comes from our values and socialization as children into adulthood. This informal, basic ethics education is further developed in nursing school where students are taught and socialized into the values and ethics of nursing. Sometimes, these values are deep enough that we may not be aware of them until they arise in a specific situation. It is at this point that one needs to examine both the situation and the reaction that one has had to it more closely.

To examine the ethics of the situation, one needs some way of viewing the ethical issues. This calls for knowledge of the clinical situation, the people involved, and the patient's values and wishes. Nurses can use ethical principles, such as respect for patient autonomy, nonmaleficence (the noninfliction of harm), beneficence (or doing good), justice, truth telling, and promise keeping (Beauchamp and Childress, 2001). To use these principles, one needs some understanding of what each of these principles mean and how they interact. This requires basic ethics education. For example, the ethical principle “respect for autonomy” is very important, but it is not absolute. This means that, in some limited and carefully thought-out situations, patient autonomy can be overridden in the service of another, more stringent, ethical principle, to do no harm. In using the ethical principle “do no

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harm” to override a patient's autonomous choice, health professionals need to be very clear that it is the patient who is being kept from harm and not the caregiving staff. Additionally, it is so much “easier” simply to tell people what they should do than to explain their clinical situation to them and have them participate in the decision making process. This is true whether the patient is an individual, family, group, or community.

But creating easy situations for healthcare professionals is not what ethics is about. Nurses use ethical principles such as “respect for autonomy,” “do not harm,” and “doing good” as they engage in ethical reflection and deliberation. They also use aspects of “caring ethics” that is developing as an alternative ethical theory. These aspects are: attentiveness, responsibility, competence, and responsiveness.

Ethical problems often relate to the tensions between responsibilities, as well as the multiple commitments of people who live or work in a network of relationships. It becomes necessary to interpret the different view points of all those involved with an ethical problem. It is also necessary to understand that our own values, obligations, loyalties, and ideals arise from multiple sources, as do those of others. In situations with people from cultures that differ from that of the nurse, value and obligation structures that come into play can be further complicated. Values underlie our ethical analyses, choices, and actions. Not all values are shared; thus, different people may choose or act in ways that would not be the choices or actions of the nurse What may seem strange to one person may be perfectly reasonable to another, given that person's world view, culture, and values (Davis, 2003).

When nurses deal with a group or community as the patient, notions of justice may come into play. Where resources are limited or managed, the principle of distributive justice is particularly important. Distributive justice refers to the sharing of burdens and benefits in the allocation of resources, sometimes, but not always, under conditions of scarcity or rationing. Customarily terms such as “fair,” “equitable,” “just,” and “fitting” are used with regard to “justice” in the distribution of resources. The nurse needs to think through how to be fair in any issue of resource allocation, including the nurse's skill and attention or time.

In thinking through ethically problematic situations, the nurse will need to answer some questions. What, if any anything, should I do to be ethical in this situation? Why?

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Thinking about these basic questions may help in this process:

What do I know about this patient situation?

What do I know about the patients' values and moral preferences?

What assumptions am I making that need more data to clarify?

What are my own feelings (and values) about the situation and how might they be influencing how I view and respond to this situation?

Are my own values in conflict with those of the patient?

What else do I need to know about this case and where can I obtain this information?

What can I never know about this case?

Given my primary obligation to the patient, what should I do to be ethical?

Case Example 1

The 87-year-old patient has end-stage lung cancer and is nearing the terminal phase, though not yet considered “terminally ill” for the purposes of admission to hospice. He tells the nurse that he is tired and does not want any more treatment, but he does want to be “kept comfortable.” He indicates that he is tired of trying to fight the cancer and feels that his present life has no quality. Also, he says, “I have lived a good, long life and I am ready to go.” His adult children have had a conference with the physician and said they want everything done for their father. The physician tends to go along with these adult children. What does the nurse need to know about this clinical situation? What are the values and obligations at stake in this case? What values or obligations should be affirmed and why? How might that be done?

Case Example 2

The 32-year-old patient is in persistent vegetative state and has been for some years. The patient's outdated advance directive is confusing on the issue of food and fluid, though clear about not wanting to be on a ventilator if she were in a

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coma. Her husband wants the feeding tube removed, but is unable to say that it would have been the patient's wish. He says that it is his decision for her. Her two adult siblings and parents reject this as a possibility because, they say, “human life is sacred” and that their daughter believed this. They say their daughter is alive and should receive nursing care, including feeding. The healthcare team does not know what to do ethically and fear being sued by either the husband, siblings, or the parents. What do you need to know about this clinical situation? What are the values and obligations at stake in this case? What values or obligations should be affirmed and why? How might that be done?

Case Example 3

The national nursing shortage problem has arrived at the local hospital and the Vice President for Nursing is having difficulties staffing all units adequately, even though two units have been closed altogether. She can either spread the nurses around the hospital and keep all the remaining units open with fewer nurses on each unit than is really safe, or she can close some additional units and place those nurses on other units to have an adequate nursing staff. This choice would be safer for admitted patients, but other patients could not be admitted due to closed units. In order to reason through this problem of resource allocation, the nurse administrator must rely on the ethical principles of justice, nonmaleficence, and beneficence. This VP for Nursing must consider the welfare of the institution, the nursing staff, and the patients. How would you assess this situation morally. In your ethical analysis, what would be acceptable options? What would not be acceptable? How might the Code for Nurses inform the VP's decision? What choice of action might promote the most good while creating the least harm?

Case Example 4

This year there is a severe shortage of influenza vaccine. The policy from the Central Health Department is to restrict this vaccine only to pregnant women and people who are 60 years of age or older until such time as additional vaccine might become available. The potential availability of additional vaccine in the coming weeks is uncertain. The nurse himself is worried about exposure to the flu from the clinic population as he is at higher risk of exposure than the general

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population. Due to the nursing shortage, he is the only “shot nurse” for this extremely busy vaccination clinic. His is 35. He is considering giving himself the vaccine, or asking a colleague to do it. If you were that nurse, how would you reason, ethically, about taking the vaccine yourself? What arguments would you make for and against taking the vaccine? What do you believe to be the strongest argument? How might the Code assist you in making a decision?

Summary

The patient—individual, family, group, community—stands at the center of nursing's ethics. There are several ways for nurses to reason through ethical problems to reach an ethical solution. First, nurses need to be aware that each situation is an ethical problem and then they need to obtain as much information as possible about the clinical facts as well as ascertaining the values and wishes of the patient or the patient's surrogate in order to think the problem through. There is a body of knowledge, nursing ethics, that they can use for this decision making process. Two nursing ethics approaches were briefly mentioned above—principle based ethics and caring ethics (Davis et al, 2006).

The patient, broadly defined, will remain at the center of nursing ethics; however, nurses will continue to face ethical problems that they need to think through carefully using their Code of Ethics for Nurses and other sources of knowledge.

References

Beauchamp, T., and J. Childress. 2001. Principles of Biomedical Ethics. 5th ed. New York: Oxford University Press.

Davis, A.J. 2003. International Nursing Ethics: Context and Concerns. In Approaches to Ethics, V. Tschudin, ed., pp. 95-104. London: Butterworth-Heinemann.

Davis, A.J., M.A. Aroskar, J. Liaschenko, and T. Drought. 1997. Ethical Dilemmas and Nursing Practice. 4th ed. Stamford, CT: Appleton & Lange.

Davis, A.J., V. Tschudin, and L. deRaeve, eds. 2006. Essentials of Teaching and Learning Nursing Ethics: Perspectives and Methods. London: Elsevier.

Nightingale, F. 1860. Notes on Nursing: What It Is and What It Is Not. London: Harrison & Sons.

Robb, I.H. 1900. Nursing Ethics: For Hospitals and Private Use, pp. 213-214. Cleveland: E.C. Koeckert, Publisher.

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Suggested Reading

Benjamin, M.J., and J. Curtis. 1991. Ethics in Nursing, 3rd ed. New York: Oxford University Press.

Tuckett, A.G. 2004. Truth-telling in clinical practice and the arguments for and against: A review of the literature. Nursing Ethics 11(5): 500-13.

Volbrecht R.M. 2002. Nursing Ethics: Communities in Dialogue. Old Tappan, NJ: Prentice Hall.

Provision Three

John G. Twomey PhD, PNP

John G. Twomey, PhD, PNP, is an Associate Professor at the Graduate Program in Nursing at the MGH Institute of Health Professions in Boston, Massachusetts. Dr. Twomey's doctoral work was in bioethics. He teaches bioethics and research and serves on several human subjects research protection committees. He has completed two National Institute of Nursing Research-supported postdoctoral fellowships in genetics. A member of the International Society of Nurses in Genetics, he does research in the area of the ethics of genetic testing of children. He is the editor of the Ethics Column in the Society's quarterly newsletter.

The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.

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As a modern document, the 2001 Code of Ethics tends to be less directive than other professional codes. A review of the codes of ethics of other allied health professionals (for example, physical therapists and speech and language specialists) reveals that these professions tend be much more prescriptive in language about what is allowable or discouraged behaviors in their respective health professions. This can cause some questioning from nurses who believe that a code of ethics should be rather directive. The Code of Ethics Task Force deliberately created a code that focused on moral concepts that undergird the profession and did not attempt to make statements that would bind the individual nurse in all situations to a single course of action.

Even a deliberative document that states as its goal the provision of a moral framework must provide some specific behaviors for the members to consistently adhere to. In Provision 3, the reader will find language and some guidelines for the nurse who is working in any practice arena.

The Task Force recognized that, even in a document that was fairly revolutionary in its writing, it was necessary to bring forward concepts and language that the members of the profession would recognize from the last and previous Codes. More importantly, the authors had to honor many of the traditional moral beliefs and behaviors that nurses had been taught and were familiar with. So in this provision, concrete terms are used with updated nuances in the interpretive statements. Concepts such as protection of privacy and concern for subjects in healthcare research, as well as the professional values nurses have developed regarding dealing with impaired colleagues are taken from their separate places in the 1985 Code and grouped together here in Provision 3.1

To begin with, what are unifying concepts that help fit Provision 3 and its interpretive statements properly into the Code? First of all, the title of the Provision contains language that focuses the nurse's actions on encounters with patients. This Provision finalizes the process begun in Provisions 1 and 2, declaring to all

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that the ultimate moral duties of professional nurses involve working with people who need nursing care. The first three Provisions reiterate what nursing, through the American Nurses Association, has been stating for decades: When individuals need nursing care, only a professional registered nurse is educationally and morally capable of providing such care. This is a claim that can be traced directly back to Florence Nightingale and her successors, such Adelaide Nutting, Lavinia Dock, and others. Thus, our updated Code serves to link nurses practicing in the 21st century to our roots two centuries ago.2

But historical traditions need some substance that is recognized by the profession and its members if the legacy given to us is going to be meaningful in today's practice. The conceptual model that Provision 3 follows is one that nursing has embraced for many years. The phrase used in this provision “to protect” is deliberately chosen because of its recognized place in nursing practice. As the nursing profession matured in the second half of the 20th century, its members embraced the concept of protection as a core part of nursing. The Task Force wanted to be very particular in its use of terms around protection. Once assumed to be defined within the concept of advocacy, the concept of protection is expanded in Provision 3 to include all patients. This concept is extended to not just those with diminished health capacities, but to all who encounter the nurse and need assistance to protect their universal health needs, including but not limited to protection of information, need for education about health, and protection from those healthcare providers who are incompetent and/or impaired. So protection takes on a comprehensive definition within the Code.

Before moving on to a discussion of each interpretive statement, there must also be some mention of the ethical basis for the ideas in the provision, as well as the overall values reflected within the concept of protection. The 2001 Code uses a variety of ethical theories and concepts to reflect the diverse moral beliefs that American nurses bring to their practice. Despite this diversity, there are some unifying themes that will be described within this reader. Provision 3 reflects the bioethical theory based on the use of principles.3 This approach is probably the most widely used approach to bioethics among clinicians in the Western world and its specific primary principles are widely embraced in clinical practice and often by institutional bioethics committees as well. While the concept of protection fits well within the principle-based system, the reader must be clear about how a specific principle supports protection as it is described in the 2001 Code.

While many nurses would recognize the principle of nonmaleficence, which is often articulated as the duty of “the noninfliction of harm,” it would be incorrect to attribute this principle as the theoretical root of Provision 3. Instead, the ethical