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How the Code of Ethics for Nurses Should be Applied

When the American Nurses Association (ANA) established its first formal Code of Ethics for Nurses in 1950, it did more than its stated goal of establishing an ethics-based framework for issues such as nurse registration, nurse well-being and nurse accreditation.

It also created a path for resolution of conflicts between ethical behavior and unethical demands. An extreme example of this kind of conflict was experienced by Salt Lake City, Utah, nurse Alex Wubbels in July 2017.

Wubbels was the charge nurse on duty who refused to provide a patient blood sample that a police phlebotomist demanded in the wake of a fatal car accident. The patient, who was not a suspect in the accident, was comatose.

Wubbels cited hospital policy when she refused to allow the blood to be drawn from the unconscious patient. The police officer, acting with support from his lieutenant, eventually lost patience and physically restrained Wubbels, who yelled for help and protested as the officer handcuffed her and dragged her to his patrol car.

When video of the incident became public a few months later, the officer and his lieutenant were placed on administrative leave. The officer eventually was fired, and Wubbels reached a $500,000 settlement with Salt Lake City and the university that runs the hospital. Wubbels told reporters that she intended to us some of the settlement money to help increase awareness about workplace violence against nurses.

Wubbels’ steadfast action in the face of an ethical conflict with a police officer was applauded by the ANA and other nursing advocates – as well as in official statements by the hospital and local elected officials. In addition to attempting to comply with hospital policy, she had made sure to remain in compliance with a recent U.S. Supreme Court ruling that blood draws from drivers require probable cause and a warrant.

Underlying Wubbels’ actions and the hospital policy was the Code of Ethics for Nurses, and the ANA’s public statement about the conflict emphasized the role Wubbels played in protecting the rights of her patient. The statement from ANA President Pam Cipriano read, in part: “Nurse Wubbels did everything right. It is imperative that law enforcement and nursing professionals respect each other and resolve conflicts through dialogue and due process.”

Fortunately, experiences this dramatic are relatively rare for nurses. Far more common are less-obvious, more-subtle ethical challenges.

One of the first codified sets of ethics for nurses was written by Isabel Hampton Robb in the early 1900s: Nursing’s Ethics for Hospital and Private Use. It described ways nurses could meet the obligations of their patients, physicians, the institution where they worked, themselves as individuals and the nursing profession as a whole.

It was developed as a framework for relationships nurses were (and still are) required to nurture to ensure good nursing care. The relationships explored included:

  • Nurses and patients
  • Nurses and doctors
  • Nurses and medicine
  • Nurses and the nursing profession
  • Nurses and the hospital or clinic

Later, as the 1950 Code of Ethics underwent revisions based on evolving modern interpretations of ethical standards, the ANA established the following purpose statement for its Code of Ethics for Nurses (from the introduction of the 2015 ANA publication, Code of Ethics for Nurses with Interpretive Statements):

“… the fundamental concern of the 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.”

The most recent edition of the Code of Ethics for Nurses, published in 2015, includes nine provisions:

Provision 1 – The nurse practices with compassion and respect for the inherent dignity, worth and unique attributes of every person.

Provision 2 – The nurse’s primary commitment is to the patient, whether an individual, family, group, community or population.

Provision 3 – The nurse promotes, advocates for and protects the rights, health and safety of the patient.

Provision 4 – The nurse has authority, accountability and responsibility for nursing practice; makes decision; and takes action consistent with the obligation to promote health and to provide optimal care.

Provision 5 – The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence and continue personal and professional growth.

Provision 6 – The nurse, through individual and collective effort, establishes, maintains and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality healthcare.

Provision 7 – The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy.

Provision 8 – The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy and reduce health disparities.

Provision 9 – The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession and integrate principles of social justice into nursing and health policy.

As an example, Wubbels lived up to no fewer than four of the provisions as she protected the patient’s dignity (provision 1), made the patient her primary commitment (provision 2) and advocated for the patient’s right not to have blood drawn while unconscious and unable to consent (provision 3).

She especially lived up to provision 4 by taking action consistent with her obligation to provide optimal care.

Students at Jacksonville University’s Keigwin School of Nursing receive comprehensive instruction in the ethics of nursing, particularly as it relates to organizational leadership. The Keigwin School of Nursing mission statement reflects a commitment to the highest ethical standards for medical education:

“(The) Jacksonville University Keigwin School of Nursing is committed to the success of each student as a self-assured, clinically competent, caring professional nurse who practices in an evolving, complex healthcare environment, provides leadership to promote health among culturally diverse people and promotes the advancement of nursing knowledge through evidence-based practice and life-long nursing.”

Nursing education and nursing ethics are inextricably linked. Today’s nurses are confronted with age-old and relatively new ethical and moral dilemmas, such as:

  • Euthanasia and assisted suicide
  • Therapeutic use of marijuana
  • End-of-life care
  • Privacy and confidentiality
  • The use of capital punishment
  • Bioethics
  • Stem cell treatment and research
  • And many more

Ultimately, the Code of Ethics for Nurses is intended as a set of guidelines to strengthen the nursing profession and help individual nurses navigate ethically ambiguous medical issues. It has evolved considerably to meet modern requirements, and it will no doubt continue to evolve as the nursing profession responds to the shifting needs of the population.

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