The Nursing Code of Ethics: Its Value, Its History

^md

Beth Epstein, PhD, RN

Martha Turner PhD, RN-BC

Abstract

To practice competently and with integrity, today's nurses must have in place several key elements that
guide the profession, such as an accreditation process for education, a rigorous system for licensure and
certification, and a relevant code of ethics. The American Nurses Association has guided and supported
nursing practice through creation and implementation of a nationally accepted Code of Ethics for Nurses with
Interpretive Statements. This article will discuss ethics in society, professions, and nursing and illustrate
how a professional code of ethics can guide nursing practice in a variety of settings. We also offer a brief
history of the Code of Ethics, discuss the modern Code of Ethics, and describe the importance of periodic
revision, including the inclusive and thorough process used to develop the 2015 Code and a summary of
recent changes. Finally, the article provides implications for practicing nurses to assure that this document is
a dynamic, useful resource in a variety of healthcare settings.

Citation: Epstein, B., Turner, M., (May 31, 2015) "The Nursing Code of Ethics: Its Value, Its History" OJIN:
The Online Journal of Issues in Nursing Vol. 20, No. 2, Manuscript 4.

DOI: 10.3912/OJIN.Vol20No02Man04

Key words: Ethics, code of ethics, nursing, profession

To practice competently and with integrity, today's nurses must have in place several key elements that guide the

profession... Professional nursing is defined as “the protection, promotion, and optimization of health

and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of
human response, and advocacy in the care of individuals, families, communities, and populations” (ANA,
2010, p. 10). To practice competently and with integrity, today's nurses must have in place several key
elements that guide the profession, such as an accreditation process for education, a rigorous system for
certification and licensure, and a relevant code of ethics. The American Nurses Association (ANA) has guided
and supported nursing practice through policy development and action; establishment of the scope and
standards of nursing practice; and implementation of a nationally accepted Code of Ethics for Nurses with
Interpretive Statements (hereafter referred to as the Code; ANA, 2015b). This article will discuss ethics in
the context of society, professions, and nursing and illustrate how a professional code of ethics, specifically
the Code, can guide nursing practice in a variety of settings. We also offer a brief history of the Code of
Ethics, discuss the modern Code of Ethics and describe the importance of periodic revision, including the
inclusive and thorough process used to develop the 2015 Code and a summary of recent changes. Finally,
the article provides implications for practicing nurses to assure that the Code is a dynamic, useful resource
in a variety of healthcare settings.

Ethics in Society, Professions, and Nursing

Ethics of Society

The agreement to live by rules may be externally imposed by laws and leaders or internally imposed by the

common morality. The field of ethics addresses how we ought to treat each other, how we ought to act,

what we ought to do, and why. We manage ethical issues every day as members of society, as members of
families, and as members of a profession. To live in society, for example, we are obligated to not kill or hurt
one another or to take from others what is not ours. These rules are not just in our own best interest (not to
be killed, for instance), but they promote the flourishing of our society. We would likely have great difficulty
living productive lives if we constantly worried about our homes being ransacked or our lives being in
danger. The agreement to live by rules may be externally imposed by laws and leaders or internally imposed
by the common morality.

In the 1600s, British philosopher Thomas Hobbes (1651/1950) posited that, if left solely to ourselves, we
would be at constant war, “every man against every man (p. 103).” To counteract this for our own survival,
notes Hobbes, we require strong leadership and an accepted social contract to guide conduct (Hobbes,
1651/1950). Several leading contemporary bioethicists assert that as vulnerable human beings, we have
realized the need to abide by a common set of moral rules, the common morality, which allow us to live and
flourish without constant worry of destruction (Beauchamp & Childress, 2009; Gert, 2004). These are not
necessarily imposed upon us, as through strong leadership, but are internally driven moral rules.
Regardless, our abilities to live peacefully and productively and to identify our obligations to one another in
our own society and across cultures are informed by ethics.

Ethics of Professions

To consider ethical issues, some level of guidance about how to do so should be in place. Similarly, the choice to

pursue a career in nursing, medicine, business, law, or other professions involves incorporating the
obligations and virtues of that smaller “society.” These obligations and virtues are added to our already
assumed obligations as members of the larger society. For health professionals in particular, Purtilo writes,
“citizens in general are not morally required to help another in need. You are. Citizens are not morally
required to keep in confidence information they hear about another. You are. Citizens are not morally
required to be nonjudgmental about another’s character. You are…” (Purtilo, 2005, p. 11). As professionals,
we agree to identify those ethical issues that tend to arise within our chosen profession. To consider ethical
issues, some level of guidance about how to do so should be in place. For many professions, this is done
with a code of ethics. Examples include the Code of Medical Ethics, social workers’ Code of Ethics, and
the Code of Ethics for Nurses with Interpretive Statements (AMA, 2014-2015; ANA, 2015b; National
Association of Social Workers [NASW], 2008). These documents guide practice decisions and set a standard
of practice behavior expected of every member of a given profession.

Ethics and Nursing

Nurse involvement in biomedical ethics. Nurses typically encounter ethical issues in three realm of
biomedical ethics including the broad, overarching, health-related problems that impact policy or society as
a whole; dilemmas that arise within organizations; and those that affect patient populations or individual
patients. Nurse researchers, policy makers, educators, consultants, administrators, ethicists, advanced
practice nurses, and clinical nurses all encounter biomedically-related ethical problems every day (Moon,
Taylor, McDonald, Hughes & Carrese, 2009; Ulrich et al., 2010).
On a policy or societal level, broad questions are asked. Examples of such queries may include discussion
about whether access to healthcare is a right or a privilege; how to protect research participants from harm;
the most fair method for resource distribution during an Ebola crisis; or the inappropriateness of punitive
measures against pregnant women who use drugs and alcohol. Nurses are involved in these questions as
clinicians, researchers, policy makers, ethicists, and educators. They may participate in preparation of
position statements and guidance documents from federal and national organizations such as
the Presidential Commission for the Study of Bioethical Issues, the American Nurses Association, or
the American Association of Critical Care Nurses (AACN), to name a few (Presidential Commission,
2015; ANA, 2015a, AACN, 2015).

...the organization and the nurse’s central place within it... are often a cause of nurses’ ethical dilemmas. At the

organizational level, many ethically challenging questions arise for nurses. In the 1980s, Chambliss
conducted a sociological study of hospital nurses to better understand the kinds of ethical issues that arose
(Chambliss, 1996). He embedded himself in a hospital setting and soon found that it was the organization
and the nurse’s central place within it—the multiple loyalties, hierarchies of power, the tendency within
systems to be slow to change and to impede individual practice—that was often a cause of nurses’ ethical
dilemmas.

More recent literature about organizational ethics and culture has explored the hospital ethical climate and
the culture of quality and safety, as well as shifts in financial concerns that influence professional practice
(Austin, 2007; Engelhard, 2014; Institute of Medicine [IOM], 2001; Mills, 2014; Peter, Macfarlane, &
O’Brien-Pallas, 2004). In their analysis of the moral habitability of the nursing work environment, Peter et
al. (2004) found evidence of oppressive environments, moral suffering, and unclear, overwhelming role
expectations. They also found, however, that nurses tended to identify paths of resistance and influence,
such as finding strength in numbers and being assertive in order to achieve their goals. Other studies have
evaluated relationships between ethical climate and job satisfaction, ethics stress (stressors related to
ethical dilemmas within the healthcare setting), and moral distress (situations where the “right” action is
known but cannot be carried out). Researchers have found that poor ethical climates were correlated with
higher levels of moral distress, poorer job satisfaction, and increased likelihood of intent to leave a position
(Hamric & Blackhall, 2001; Whitehead, Herbertson, Hamric, Epstein & Fisher, 2015; Pauly, Varcoe, Storch &
Newton, 2009; Ulrich et al., 2007). Thus, it is clear that the organizational ethics aspects of healthcare are
important factors for nurses.

An effective ethical code for nursing practice must provide guidance on managing ethical problems that arise at the

societal level, the organizational level, and the clinical level. On a clinical level, ethical questions arise every

day. In a study of the ethical issues encountered by nurses, Ulrich et al. (2010) found that more than 60%
of nurses identified patient’s rights, autonomy, and informed consent as frequent or daily problems. Other
common issues included advanced care planning, surrogate decision making, end-of-life decision making,
and breeches of confidentiality (Ulrich et al., 2007). Pavlish, Brown-Saltzman, Hersh, Shirk & Rounkle
(2011) explored the ethical issues, actions and regrets of nurses and found that unnecessary pain and
suffering, difficult decision making, and inattention to patient autonomy were problematic. Nurses acted in
several ways to address these problems, such as communicating and speaking up, advocating and
collaborating, being present and empathetic, and being informed (Pavlish et al., 2011).

The utility of the Code. An effective ethical code for nursing practice must provide guidance on managing
ethical problems that arise at the societal level, the organizational level, and the clinical level. The following
fictional case, adapted from White and Zibelman (2005) illustrates a bedside nurse’s dilemma that has both
clinical, patient-level aspects and organizational aspects. This scenario demonstrates the benefit of the Code
as a useful tool for evaluation and action.

Mr. Logan is a 48 year old who has struggled with an opioid addiction for the past 5 years. Recently, he was
playing basketball with friends when he slipped on the court, fell, and broke his arm badly. After his arm
was repaired surgically, the physician orders acetaminophen, 650 milligrams by mouth or normal saline, 1
cc, IM, prn for pain. The nurse asks the physician about this, concerned about Mr. Logan’s pain control post-
operatively. The physician says, “I’m not going to add insult to injury. Tell Mr. Logan you’re giving him
medication for his pain. Hopefully he’ll get a placebo effect.” Meanwhile, Mr. Logan is in excruciating pain.
The nurse gives him the acetaminophen and several injections of the “pain medicine” with no effect. Mr.
Logan says, “What are you giving me? It isn’t working!” What should the nurse do now?

The immediate questions that arise in this dilemma are, ‘should the nurse deceive Mr. Logan?’ ‘is this an
appropriate use of placebo?’, ‘how should Mr. Logan participate in his own pain management plan?’, and
‘how should the nurse advocate for the patient?’ To answer these questions, the Code and other resources
provide guidance.

In Mr. Logan’s case, the defining question is, does deceiving the patient provide any benefit or prevent any

risk? The action to question this physician order suggests that nurse believes that deceiving the

patient is wrong. Provision 1 of the Code states that the nurse is obligated to act with compassion and to
respect the dignity and autonomy of each patient (ANA, 2015b). Lying to the patient, watching him suffer,
and not involving him in his plan of care achieve neither goal. Additionally, Provision 5 addresses preserving
one’s own dignity and 5.4 more specifically notes the threat to one’s integrity that is done by deceiving
patients and withholding information (ANA, 2015b). However, in this case, there is an inkling of doubt
because of the possibility of a placebo effect. That is, the saline injection may induce some analgesic effect
even though it is not a pain medication. Also, there is some concern that while an opioid may provide short-
term benefit, it could cause harm in the longer term by causing re-addiction. In Mr. Logan’s case, the
defining question is, does deceiving the patient provide any benefit or prevent any risk?

After review of the Code and a search of the literature, Mr. Logan’s nurse understands more fully that deceiving

him is wrong... Investigating the risks and benefits of placebo use and pain management in patients

with histories of substance abuse will be helpful to answer this question. The American Medical Association
Code of Medical Ethics prohibits use of placebo except when the patient is fully informed (AMA, 2007).
However, placebo use continues even after years of advocacy against this practice. Thus it is not surprising
that there are healthcare providers still willing to use placebos, including the physician in Mr. Logan’s case
(Arnstein, Broglio, Wuhrman & Kean, 2011; Fassler, Meissner, Schneider, & Linde, 2010). A recent position
statement by the American Society for Pain Management Nursing supports a pain management regimen
including careful monitoring and agreement with a fully-informed patient (Oliver et al., 2012). After review
of the Code and a search of the literature, Mr. Logan’s nurse understands more fully that deceiving him is
wrong because it is disrespectful of the patient, diminishes his autonomy, and threatens the nurse’s own
integrity. Using a placebo to treat Mr. Logan’s pain without his consent is inappropriate for the same reasons
and is not in keeping with current guidelines for pain management.

The question now becomes, how should the nurse best advocate for this patient? Whether or not to
advocate is not in doubt (Provision 3), but just how to do that is a bit more difficult. This dilemma is also an
organizational issue as the nurse does not have authority to single-handedly change the prescription.
Clearly, advocating will involve collaboration with a hesitant physician. The Code can provide some
guidance, but some weighing and balancing of the different provisions is necessary. In response to Mr.
Logan’s question, “What are you giving me?” the nurse could inform him that the physician has prescribed
saline in the hopes that he would have a placebo effect. This would alleviate the concern about deception
and withholding information (Provision 5.4). Conversely, this may undermine Mr. Logan’s trust in the
physician as well as the nurse (Provision 1.2: Relationships with patients). In addition, it may threaten the
collegial relationship between the nurse and physician (Provision 2.3 and 8 address interprofessional
collaboration), a relationship that will continue long after Mr. Logan has been discharged. Provision 6 also
addresses maintaining an ethical work environment in order to support quality of care. Another alternative
for the nurse is to collaborate with the physician first, bringing to light the concerns about patient deception
and the evidence of inappropriate placebo use. This alternative action will hopefully have several benefits,
such as increasing the likelihood of a more effective treatment plan, maintaining patient trust in the
healthcare team, and supporting a professional and collegial doctor-nurse relationship. The potential
benefits of approaching the physician first suggest that this is the more sound, justifiable solution to the
dilemma.

The Code can provide direction for multiple levels of direct and indirect care. Ethical issues in clinical nursing

often involve not only dilemmas at the bedside, but also dilemmas at the organizational level, such as
navigating a complex system to protect a patient or provide quality care or identifying ways to collaborate
with colleagues to maintain strong working relationships and trust. The Code (ANA, 2015b) can provide
direction for multiple levels of direct and indirect care. The Code applies to other areas of nursing practice as
well, such as nursing education, research, and policy making. Advancing the profession through research
and policy by attending to informed consent, advocacy, and accountability of practice are examples of other
professional areas of practice with potential ethical dilemmas that make the provisions of the Code a
relevant nursing resource.

A Brief History of the Code of Ethics

...for many years, nurses had no formalized code of ethics and used Gretter’s Nightingale Pledge, akin to medicine’s

Hippocratic Oath, to guide their practice. The first formal code of ethics for nurses was adopted in 1950

(Fowler, 1997). However, a need for ethical guidance was recognized soon after modern nursing began to
formalize in the mid-1800s. Although in 1896, one of the initial goals of the newly established American
Nurses Association was to write a code of ethics, urgent issues such as nurse registration, the welfare of
nurses, and accreditation processes for nursing schools took precedence (Fowler, 1997). Thus, for many
years, nurses had no formalized code of ethics and used Gretter’s Nightingale Pledge, akin to medicine’s
Hippocratic Oath, to guide their practice (ANA, n.d.).

In the early 1900s, Isabel Hampton Robb’s text, Nursing's Ethics for Hospital and Private Use described the
obligations of the nurse to the patient, physician, institution, self, and profession and the creativity needed
to find solutions to problems and provide good nursing care (Robb, 1926). In 1926, the ANA published a
“suggested” code which provided the first outline of ethical behavior for nurses (ANA, 1926). The provisions
were framed in terms of the various relationships between the nurse and patient; the nurse and medicine;
and nurses and their profession. For example, the relation of the nurse to the patient involved “bringing all
of the knowledge, skill, and devotion” to the work (ANA, 1926, p. 600).
 The first formal Code for Professional Nurses was adopted in 1950 and was edited slightly before being revised in

1960. At the same time as the suggested code, ethics was on the minds of nurse faculty and

administrators in terms of training and educating nursing students and practicing nurses (Crawford,
1926; Ethical Problems, 1926; Ethical Problems, 1933; Fowler, 1997). Their work highlights the thinking of
the time, that is, that character was a significant factor in determining right action. Ms. Beulah Crawford’s
article, How and What to Teach in Nursing Ethics stated, “…in the end, it is the character of the nurse which
makes her; if she has the right principles she will not go far wrong in the minor matters” (Crawford, 1926,
p. 211) and included nursing etiquette or rules of conduct in the hospital setting. The article provided
direction about which aspects of character and living help a nurse “steer her craft safely on the stormy seas”
(p. 212), such as accepting authority, being adaptable to difficult situations, being industrious, and using
“judgment in the use of the tongue” (p. 212).

A “Tentative Code” in 1940 (ANA, 1940) described nursing as a profession and outlined many provisions
similar to those in the 1926 suggested code, including framing the provisions in terms of relationships to
patient, colleagues, and profession. The first formal Code for Professional Nurses was adopted in 1950 and
was edited slightly before being revised in 1960 (Fowler, 1997). The 1960 Code for Professional Nurses
outlined 17 provisions beginning with the “fundamental responsibility…to conserve life, to alleviate suffering,
and to promote health” and extending to accountability for practice and conduct, participation in research
and “action on matters of legislation affecting nurses” (ANA, 1960, p. 1287) .

...the Code has been revised over time to introduce obligations to advance the profession and build and maintain a

healthy work environment. The 1968 revision of the Code included several significant changes (ANA,

1968). First, prior to this revision, the provisions were simply listed with little, if any, interpretation. The
new code provided brief interpretations which helped the nurse see how the provision might be applied.
Second, the provisions were reduced from 17 to a more manageable 10. Finally, there was a fundamental
shift in language in the 1968 revision. The obligations of the nurse changed from generalized responsibilities
to “conserve life, alleviate suffering and promote health” (ANA, 1960, p 1287) to a deeper, more duty-based
obligation to “respect the dignity of man, unrestricted by considerations of nationality, race, creed, color, or
status” and to “safeguard the individual’s right to privacy” (ANA, 1968, p. 2582). With changes in the level
of practice independence; advances in technology; societal changes; and expansion of nursing practice into
advanced practice roles, research, education, health policy, and administration, the Code has been revised
over time to introduce obligations to advance the profession and build and maintain a healthy work
environment (ANA, 1976; ANA, 1985; ANA, 2001; ANA, 2015b).

The Modern Code of Ethics

As in the past, the current Code of Ethics with Interpretive Statements forms a central foundation for our profession

to guide nurses in their decisions and conduct. As in the past, the current Code of Ethics with Interpretive

Statements (ANA, 2015b) forms a central foundation for our profession to guide nurses in their decisions
and conduct. It establishes an ethical standard that is non-negotiable in all roles and in all settings. The
Code is written by nurses to express their understanding of their professional commitment to society. It
describes the profession’s values, obligations, duties, and professional ideals. The provisions and interpretive
statements reflect broad expectations without articulating exact activities or behaviors. The 2015 Code
“addresses individual as well as collective nursing intentions and actions; it requires each nurse to
demonstrate ethical competence in professional life” (ANA, 2015b, p. vii). Nurse practice acts in many states
incorporate the Code of Ethics. Even though the Code is primarily ethics-related, it also has legal
implications. Given the importance of the Code to the profession on so many levels, revisions continue on a
regular basis.

The Process for Revising the Code

[The Code] is a living document that informs and is informed by advances in healthcare... As society changes, so

must the Code (ANA, 2015b). It is a living document that informs and is informed by advances in healthcare
such as genomics, technology, new roles for nurses and changes in healthcare delivery. The nine provisions
address the general, enduring obligations of nurses and rarely require major revision. However, the
interpretive statements are more specific and address current topics and issues. Since healthcare-related
problems rapidly unfold in our society, the interpretive statements must be reviewed and revised every 10
to 12 years. Review of the 2001 Code (ANA, 2001) revealed several areas requiring updates in language and
content. An overview of this process below illustrates the intentional considerations inherent to the revision,
the opportunities for nurse participation at all levels, and the impact that nurses have toward the final
product.

The use of technology made this recent revision process more effective and efficient than in previous times.
For example, the pre-internet revision of the 1985 Code (ANA, 1985) took seven years, had many onsite
committee meetings, and handled over 15,000 written responses following a solicitation for feedback,
editorial comments, and suggestions. In the revision of the 2001 Code (ANA, 2001), greater use of
technology resulted in a single onsite meeting. Much work was accomplished using conference calls, email,
and other electronic platforms (e.g., screen sharing software) over a 4-year period from initial review to
publication. Table 1 provides a timeline of the most recent Code revision process. Nurses participating in
the revision process took advantage of technology for online committee meetings and discussions and online
public comment periods to solicit feedback from nurses across the country. Previously, public comment was
solicited by mailing multiple copies of the draft manuscript to the state nurses’ associations and other
associations, which were then edited and returned to the ANA.

Table 1: Timeline of the Revision Process for the 2015 Code

Assessment of Need for Revision
October 2010 Initial discussion of process for Code review
June 2012 Code Review Working Group appointed
February 2013 through Online survey comment period and analysis of survey findings
April 2013
May 2013 Recommendation from the Ethics Advisory Board that the Code be revised
approved by ANA President
Revision Process
September 2013 Code Steering Committee established to draft the revision
May 2014 through June Draft revision posted for public comment; suggestions evaluated
2014
November 2014 Approved by ANA Board of Directors for publication

The process for the most recent revision began with an initial review by the ANA Ethics Advisory board of
the current Code provisions and interpretive statements, the International Council of Nurses (ICN) code
(ICN, 2012), and the codes of other health professions such as pharmacy, occupational therapy, social work,
medicine, physical therapy, and public health. This extensive review helped to determine the need for
revision. The Code Review Working Group was appointed to collect public comment regarding the need for
revision.

A qualitative content analysis (Miles & Huberman, 1994; Patton, 2002) of the 2783 public comment
responses was conducted. The summary report of this analysis included recommendations to revise the
2001 Code (ANA, 2001) for the following reasons:

Time and Relevance

 Thirteen years had passed since the previous Code revision. New issues had important
ethical implications to address in the Code. These included the widespread use of social
media and resultant threats to privacy; use of emerging technologies throughout
healthcare; growing importance of inter-professional collaboration; a stronger and more
direct consideration of social justice as a core value; and an inclusion of global health
responsibilities of the profession.

Clarity

 Comments on the first seven provisions and interpretive statements were not sufficiently
compelling to warrant a substantive revision. However, comments on the remaining
provisions (8 and 9) did press for revision for different reasons. Unlike other provisions,
Provision 8 had changed in a way that it had lost its original meaning and thus had a dual
focus that needed to be unified and sharpened. Provision 9 was different in that it was
both new and unique in the history of the Code when approved in 2001. Now that it had
become an accepted part of the Code it, too, needed to be sharpened.
 The preface and afterword required revision for clarity to help the reader by providing a
framework for the Code.

Access to Resources

 Links were recommended to provide access to various ANA position statements; Scopes
and Standards of Practice; and the Social Policy Statement (ANA, 2010) to facilitate
navigation through all the major resources of the ANA as well as links to external
resources that support or elaborate on content in the Code.

Nursing Roles and Advocacy

 Recommendations were made to specifically address the role of nurse executives in the
Code, to ensure a climate for ethical practice and civility and create a healthier practice
environment for nurses, and to address the roles and responsibilities of APRNs.
 The nurses’ role in leadership, advocacy, and collective action for social justice should be
highlighted to underscore the urgent need to address determinants of health.
 The nurses’ voice in social and health policy should be strengthened to add to the unified
efforts on behalf of all in the profession.

After recommendations were accepted, the ANA website, NursingWorld, posted a call with an invitation to
participate in the revision. More than 400 nurses volunteered; from these 15 were selected to serve on the
Code Steering Committee (SC). Between September 2013 and April 2014, a draft revision was prepared.
Throughout the process of writing and editing, a Code scholar with several publications on the nursing Code
of Ethics (Fowler, 1985; 1992; 1997; 2010; & 2015) and participation experience in the 2001 code revision
simultaneously reviewed and edited the drafts. In May 2014, the edited draft was posted for public
comment. By early June, nearly 1,000 individuals had posted suggestions for changes, clarifications,
additions, or deletions. Each suggestion was evaluated using the analysis processes described above,
preserving the essential and eliminating the incidental. Further revisions were made based on this additional
analysis. A final version of the 2015 Code was approved by the ANA Board of Directors in November 2014
and was published on NursingWorld in January 2015.

Changes in the 2015 Code of Ethics for Nurses

The revision process led to several significant changes in the 2015 Code of Ethics. The revision process led to

several significant changes in the 2015 Code of Ethics (ANA, 2015b). Overall, the document’s language has
been updated. For example, terms such as “technology,” “social media,” “genetics,” “incivility in the
workplace,” “pain and suffering,” and “evidence informed practice” have been added. Other broad changes
include increased emphasis on nursing leadership; renewed emphasis on the inclusion of nurses in all roles
and in all settings; and strengthening of the nurse’s voice in social and health policy and of the nurse’s role
in global health. The preface was revised to strengthen the purpose of the Code, the ethical framework, and
the context. A new introduction now clarifies terms such as “patient,” “client,” and “consumer,” “moral,”
“ethical,” and the differences between “must,” “ought,” and “should.” A glossary of terms was added and a
list of online resources and other support documents will be posted on the ANA website.

The Code Provisions have been reworded to be more concise and better articulate their intent, although the
general structure remains the same as the 2001 Code (ANA, 2001). For example, the first three provisions
still describe the most fundamental values and commitments of the nurse; the next three address
boundaries of duty and loyalty, and the last three address aspects of duties beyond individual patient
encounters. Finally, there were significant changes to the interpretive statements, where content has been
updated to improve relevance to modern day practice, reorganized for consistency with the wording in the
provisions, and revised to reduce redundancy.

Summary: Implications for Practice

The Code is an important document that can provide effective guidance as the nurse negotiates the complexities

inherent to many situations. This article has suggested several implications for nursing practice including

consideration of the everyday nature of ethical concerns in nursing at multiple levels, the usefulness of the
Code (ANA, 2015b) as a guide, and the importance of an inclusive and thorough process for revising the
Code. Each day, situations arise for nurses that require both decision and action, and may include ethical
dilemmas. Examples of those most common include errors and near misses, delegation, end-of-life care, use
of technology and fatigue. Managing these challenges well contributes to safe, compassionate, quality care.
The Code (ANA, 2015b) is an important document that can provide effective guidance as the nurse
negotiates the complexities inherent to many situations.

Nurses and other healthcare professionals are not expected to be able to resolve complex ethical problems
alone, using only a code of ethics. Often, other resources are needed to grasp the full complexity of an
ethical dilemma. Selected potentially helpful online resources are listed in Table 2. Today’s professional
nurses are engaged in ethical thinking and ethical challenges in a wide variety of settings. The following
recommendations can be helpful at any level of practice:

 Research hospital policies and legal information related to the concern under review.
  Consider an ethics consult service. It often requires a team of individuals to fully understand and
resolve difficult ethical problems. However, professional codes of ethics provide support and
direction about behavior(s).
 Consider the three levels of ethical engagement when reviewing a dilemma, specifically the broad,
societal level of biomedical ethics where questions affecting health and healthcare are generated
(e.g., stem cell research, healthcare for undocumented immigrants); the organizational level (e.g.,
hospital system obligations to its employees, hierarchical structures, bed allocation); and the
clinical level (e.g., withdrawal of aggressive treatment, surrogate decision making).
 Participate in the ongoing revision of the nursing Code. This article provided an outline of the
modern process for Code revision. Nurses in every role and every setting were invited to, and did,
participate in the process. When the next call is made, take time to offer your suggestions to
ensure the Code continues to remain a relevant resource for practice.

Table 2. Online Resources

2015 ANA Code of Ethics for Nurses with  Provisions and interpretation
Interpretive Statements
www.nursingworld.org/principles  Of relevance are the principles for delegation,
nurse staffing, collaborative relationships, social
networking, delegation
ANA Nursespace  Forum for discussion on specific topics, blog,
professional issues
ANA Position Statements on Ethics and Human  Statements on ethical nursing practice (e.g., non-
Rights punitive treatment for pregnant women, nursing
care and DNR, restraint use)
International Council of Nurses  Federation of over 100 nursing associations
 Addresses nursing care, health policy, and
nursing education globally
Online Journal of Health Ethics  Multidisciplinary journal providing a forum for
health-related ethics issues
Presidential Commission for the Study of Bioethical Appointed commission to address ethical issues
Issues of national significance (e.g., stem cell research,
Ebola)

Today’s Code (ANA, 2015b) is a result of the ANA’s long-standing commitment to support nurses in their
daily life and practice. The process for the 2015 Code revisions used technology to a great advantage. This
provided an avenue for a highly participatory process to receive input from all nurses in every type of
practice and allow working groups to collaborate efficiently and effectively with a minimum of travel.
Recognizing that nursing practice extends from horizon to horizon—from the bedside to the classroom, from
the executive suite to the laboratory bench—the 2015 Code continues to provide all nurses with a firm
foundation for ethical practice

Authors

Beth Epstein, PhD, RN

Email: [email protected]

Beth Epstein, PhD, RN is an Associate Professor of Nursing at the University of Virginia (UVA) School of
Nursing and is also a member of the faculty of the Center for Bioethics and Humanities at the UVA School of
Medicine in Charlottesville, VA. She attended the University of Rochester in Rochester, NY for her BS in
Biochemistry and then UVA for her MS in Pharmacology, BSN, and PhD in Nursing. Beth teaches ethics in the
School of Nursing and lectures in the Center for Bioethics and Humanities. She is an active member of the
UVA Health System Ethics Consult Service and Ethics Committee, and currently directs the Moral Distress
Consult Service.
Martha Turner, PhD, RN-BC
Email: [email protected]

Martha Turner PhD RN-BC is the Assistant Director of the American Nurses Association Center for Ethics and
Human Rights (2006-present). She attended the University of Minnesota in Minneapolis, MN for a BS and
PhD in nursing, Loma Linda University in Loma Linda, CA for an MS in nursing and Ball State University in
Muncie, IN for an MA in counseling psychology. Martha retired in January 2006 from Active Duty with the Air
Force after 30 years. She was a flight nurse and achieved the rank of Colonel. Dr. Turner was the Consultant
for Healthcare Ethics to the Air Force Surgeon General from 1998 until 2006. Her responsibilities included
representing the DoD as an ex-officio member of the Secretary's (HHS) Advisory Committee for Genetics,
Health and Society, reviewing policies related to many aspects of healthcare and developing ethics programs
and ethics expertise throughout the Air Force Medical Service. She was a member of the Minnesota Nurses
Association ethics committee from 1997-2002 and the Ethics Advisory Council of the Oncology Nurse Society
from 1994-1996. Most recently (2010-2014) she staffed the revision of the ANA Code of Ethics for Nurses
with Interpretive Statements as content editor, revision coordinator and co-lead writer.

References

American Association of Critical Care Nurses. (2015). Standards. Retrieved

from www.aacn.org/WD/Practice/Content/standards.content?menu=Practice&lastmenu

American Medical Association. (2014-2015). Code of medical ethics. Retrived from www.ama-
assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics.page

American Medical Association. (2007). Code of medical ethics, opinion 8.083: Placebo use in clincal practice.
Retrieved from www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-
ethics/opinion8083.page.

American Nurses Association. (1926). A suggested code. American Journal of Nursing 26(8): 599-601.

American Nurses Association. (1940). A tentative code. American Journal of Nursing 40(9): 977-980

American Nurses Association. (1960). The code for professional nurses. American Journal of Nursing 60(9):
1287.

American Nurses Association. (1968). Code for nurses. American Journal of Nursing 68(12): 2581-2585.

American Nurses Association. (1976). Code for nurses. ANA Publishing: Kansas City, MO.

American Nurses Association. (1985). Code for nurses with interpretive statements. ANA Publishing:
Washington, DC.

American Nurses Association. (2001). Code of ethics with interpretive statements. ANA Publishing: Silver
Spring, MD.

American Nurses Association. (2010). Nursing’s social policy statement: The essence of the profession. ANA
Publishing: Silver Spring, MD.

American Nurses Association. (2015a). American Nurses Association position statements on ethics and
human rights. Retrieved from www.nursingworld.org/MainMenuCategories/EthicsStandards/Ethics-Position-
Statements
American Nurses Association. (2015b). Code of ethics for nurses with interpretive statements. Silver Spring,
MD: Nursesbooks.org Retrieved
from www.nursingworld.org/MainMenuCategories/EthicsStandards/CodeofEthicsforNurses/Code-of-Ethics-
For-Nurses.html

American Nurses Association. (n.d.). Nightingale pledge. Retrieved

from: www.nursingworld.org/FunctionalMenuCategories/AboutANA/WhereWeComeFrom/FlorenceNightingale
Pledge.aspx

Arnstein, P., Broglio, K., Wuhrman, E. & Kean, M.B. (2011). Use of placebos in pain management. Pain
Management Nursing, 12(4): 225-229.

Austin, W. (2007). The ethics of everyday practice: Healthcare environments as moral

communities. Advances in Nursing Science, 30(1): 81-88.

Beauchamp, T.L. & Childress, J.F. (2009). Principles of biomedical ethics, 6th ed. New York: Oxford
University Press.

Chambliss, D. F. (1996). Beyond caring: Hospitals, nurses, and the social organization of ethics. Chicago:
University of Chicago Press.

Crawford, B, (1926). How and what to teach in nursing ethics. American Journal of Nursing, 26(3), 211-215.

Engelhard, C.L. (2014). Healthcare ethics and a changing healthcare system. In G.L. Filerman, A.E. Mills, &
P.M. Schyve (eds). Managerial ethics in healthcare: A new perspective. Chicago: Health Administration
Press/Association of University Programs in Health Administration.

Ethical problems. (1926). American Journal of Nursing, 26(8), 643

Ethical problems. (1933). American Journal of Nursing, 33(3), 266

Fassler, M., Meissner, K., Schneider, A., Linde, K. (2010). Frequency and circumstances of placebo use in
clinical practice: A systematic review of empirical studies. BMC Medicine, 8:15. doi:10.1186/1741-7015-8-
15

Fowler, M. (1985). The evolution of the code for nurses. The California Nurse, 81(5): 5.

Fowler, M. (1992). Evolution of the code. In Ethical dilemmas in contemporary nursing practice (G.B. White,
Ed). ANA: Washington, DC.

Fowler, M. (1997). Nursing’s ethics. In A.J.Davis, M.A. Aroskar, J.Liaschenko, T.S.Drought (Eds).: Ethical
dilemmas and nursing practice. 4th Ed. Stamford, CT: Appleton & Lange.

Fowler, M. (ed.) (2010). Guide to the Code of Ethics for Nurses: Interpretation and Application. Silver
Spring, MD: American Nurses Association Publishing.

Fowler, M (2015). Guide to the Code of Ethics for Nurses: Development, Interpretation and Application (2nd
ed). Silver Spring, MD: ANA.

Gert, B. (2004). Common morality: Deciding what to do. New York: Oxford University Press.
Hamric, A.B. & Blackhall, L.J. (2007). Nurse-physician perspectives on the care of dying patients in intensive
care units: Collaboration, moral distress, and ethical climate. Critical Care Medicine 35: 422-429.

Hobbes, T. 1588-1679 (1950). Leviathan. New York: Dutton. (Original work published in 1651)

International Council of Nurses. (2012). The ICN code of ethics for nurses. Geneva, Switzerland: Author.
Retrieved from www.icn.ch/images/stories/documents/about/icncode_english.pdf

Institute of Medicine, Committee on Quality of Health Care in America (2001). Crossing the quality chasm: A
new health system for the 21st century. Washington, DC: National Academy Press.

Miles, M.B. & Huberman, A. M. (1994). Qualitative data analysis: An expanded sourcebook (2nd ed.).
Thousand Oaks, CA: Sage.

Mills, A.E. (2014). Ethics and the healthcare organization. In G.L. Filerman, A.E. Mills, & P.M. Schyve
(eds). Managerial ethics in healthcare: A new perspective. Chicago: Health Administration Press/Association
of University Programs in Health Administration.

Moon, M., Taylor, H.A., McDonald, E.L., Hughes, M.T. & Carrese, J.A. (2009). Everyday ethics issues in the
outpatient clinical practice of pediatric residents. Arch Pediatr Adolesc Med 163(9): 838-843.

National Association of Social Workers. (2008). Code of ethics of the National Association of Social Workers.
Retrieved from http://socialworkers.org/pubs/code/code.asp

Oliver, J., Coggins, C., Compton, P, Hagan, S., Matteliano, D., Stanton, M… Turner, H.N (2012). American
society for pain management nursing position statement: Pain management in patients with substance use
disorders. Pain Management Nursing 13(3): 169-183. doi:10.1016/j.pmn.2012.07.001

Pauly, B., Varcoe, C., Storch, J. & Newton, L. (2009). Registered nurses’ perceptions of moral distress and
ethical climate. Nursing Ethics, 16(5): 561-573.

Pavlish, C., Brown-Saltzman, K., Hersh, M., Shirk, M., & Rounkle, A-M. (2011). Nursing priorities, actions,
and regrets for ethical situations in clinical practice. Journal of Nursing Scholarship, 43(4): 385-295.
doi:10.1111/j.1547-5069.2011.01422.x.

Peter, E.H., Macfarlane, A.V. & O’Brien-Pallas, L.L. (2004). Analysis of the moral habitability of the nursing
work environment. Journal of Advanced Nursing, 47(4): 356-367.

Patton, M. Q. (2002). Qualitative research and evaluation methods (3rd ed.). Thousand Oaks, CA: Sage.

Presidential Commission. (2015). Presidential commission for the study of bioethical issues. Retrieved
from http://bioethics.gov/

Purtilo, R. (2005). Ethical dimensions in the health professions. 4th ed. Philadelphia: Elsevier Saunders.

Ulrich, C., O’Donnell, P, Taylor, C., Farrar, A., Danis, M. & Grady, C. (2007). Ethical climate, ethics stress,
and the job satisfaction of nurses and social workers in the United States. Social Science & Medicine, 65(8):
1708-1719.
Ulrich, C. M., Taylor, C., Soeken, K., O’Donnell, P., Farrar, A., Danis, M. & Grady, C. (2010). Everyday
ethics: Ethical issues and stress in nursing practice. Journal of Advanced Nursing 66(11): 2510-2519.
doi:10.1111/j.1365-2648.2010.05425.x.

White, B.C. & Zimbelman, J.C. (2005). Moral dilemmas in community health care: Cases and commentaries.
New York: Pearson/Longman.

Whitehead, P.B., Herbertson, R.K., Hamric, A.B., Epstein, E.G. & Fisher, J.M. (2015). Moral distress among
healthcare professionals: Report of an institution-wide survey. Journal of Nursing Scholarship, 47(2): 117-
125. doi:10.1111/jnu.12115

© 2015 OJIN: The Online Journal of Issues in Nursing

Article published May 31, 2015

Related Articles
 Nurses in the Know: The History and Future of Advance Directives
Blanca Miller, MSN, RN (September 6, 2017)

 Cornerstone Documents and Milestones: The Changing Landscape of Public Health

Nursing 1950 - 2015
Pamela A. Kulbok, DNSc, RN, APHN-BC; Joan Kub, PhD, RN, PHCNS-BC; Doris F. Glick, PhD, RN
(April 18, 2017)

 Cornerstone Documents, Milestones, and Policies: Shaping the Direction of Public Health
Nursing 1950-2015
Pamela A. Kulbok, DNSc, RN, APHN-BC; Joan Kub, PhD, RN, PHCNS-BC; Doris F. Glick, PhD, RN
(April 18, 2017)

 Historical Perspectives on an Expanded Role for Nursing

Arlene W. Keeling, PhD, RN, FAAN (May 31, 2015)

 Cornerstone Documents, Milestones, and Policies: Shaping the Direction of Public Health
Nursing 1890-1950
Joan Kub PhD, MA, PHCNS, BC, FAAN; Pamela A. Kulbok, DNSc, RN, PHCNS-BC, FAAN; Doris Glick
PhD, RN (May 31, 2015)

 Best Practices for Developing Specialty Nursing Scope and Standards of Practice
Deborah S. Finnell ; Elizabeth L. Thomas; Wendy M. Nehring; Kris McLoughlin; Carol J. Bickford
(May 31, 2015)

 Development and Implementation of Cornerstone Documents to Support Nursing Practice

in Cambodia
Richard Henker, PhD, RN, CRNA, FAAN; Manila Prak, RN, BSN; Virya Koy, RN, SNA, MNSc, MHPEd
(May 31, 2015)