By Heather Stringer
Each of the country’s 3.1 million RNs may make dozens of decisions about patient care every day. Making those decisions with ethical considerations in mind is increasingly challenging in the modern healthcare environment where technology and patient care are evolving at a rapid pace. In January, the American Nurses Association rolled out a revised version of the Code of Ethics — which had not been updated since 2001 — after an 18-month revision process. Nurse leaders involved in the revision process hope the newer version will both guide and support nurses as they face decisions that touch upon everything from end-of-life care to involvement with social media.
“The authors of the code wanted simpler, stronger language that would speak to everyone, and that is refreshing,” said Carol Taylor, MSN, PhD, RN, a senior research scholar at the Kennedy Institute of Ethics at Georgetown University in Washington D.C. “Thousands of nurses gave input on this document, and a lot of care went into making it responsive. I think all nurses owe it to themselves to read this carefully and see how it speaks to the ethical challenges in everyday practice.”
Updates to the original code
The beginnings of the code date back to 1896 when the Nightingale Pledge, patterned after the Hippocratic Oath, was accepted as the first nursing code of ethics. Today’s version includes nine provisions followed by interpretive statements that explain how each provision can be applied to contemporary nursing. The code has been updated about once every decade, but the 2015 revision was the first time in 25 years that both the nine provisions and subsequent interpretive statements were thoroughly revised, according to the ANA.
Nearly 4,000 nurses submitted feedback during two public comment periods. One common response from RNs included concerns about how the code addresses moral dilemmas, such as risks to patient safety as a result of short staffing, said Margaret Hegge, MS, EdD, RN, FAAN, a nursing professor at South Dakota State University in Brookings and chair of the revision steering committee for the code. In response, it now includes stronger language in section 5.4, which covers “preservation of integrity.”
“This section was one of the areas that most needed updating in the context of so many forces that fail to put the interest of the patient first,” Taylor said. “If nurses are committed to the patient, then they find themselves in these conflicts. This revision does a lot more to help them.”
For example, the revised version states “when nurses are placed in circumstances that exceed moral limits … they must express to the appropriate authority their conscientious objection to participating in these situations.” In the previous version, the verb was “may express.”
“If short staffing puts the nurse in jeopardy of providing unsafe care, the nurse could conscientiously object to providing care without more help,” Hegge said.
This stronger language in the Code of Ethics also could support caregivers such as the U.S. Navy nurse who refused to force-feed prisoners on a hunger strike at Guantánamo Bay last July, Taylor said. The code would allow nurses in this type of situation to refuse to participate on moral grounds by expressing their conscientious objection, she said.
The updated code also calls nurse executives to respond to these objections and seek changes in work environments that are morally objectionable. For example, a nurse executive might create a nursing governance council to openly discuss issues causing moral distress in the workplace and how policies could be changed, Hegge said.
Navigating care for the dying patient
End-of-life care, Hegge said, is another issue that surfaced frequently during the public comment period. “Nurses feel caught in the middle between patients, families and physicians,” she said. “According to section 1.4 [of the Code of Ethics], patients have the right to refuse treatment, and nurses should support patients in that refusal, but nurses may not participate in ending a life.”
In states where physician-assisted suicide is legal, nurses cannot administer any medication that will end a life, Hegge said. When it comes to lethal injection for death row inmates, nurses should refuse to insert the IV, and even the act of training someone else to do this task could make them complicit, she said.
Vigilance in the age of social media
The updated code also includes new verbiage in section 3.1 related to a nurse’s obligation to maintain patient confidentiality in the work setting and off-duty in all venues, including social media and other communication. Nurses are urged to maintain vigilance regarding postings, images, recordings or commentary. “None of the specific social media tools are mentioned in the code because this has to last 10 to 15 years and things will become outdated, but nurses should be very cautious,” Hegge said. “I’ve heard of cases where nurses are pulled in to say that a family needs money on sites like CaringBridge, and this would go against the code.”
The bigger picture
Although there are revisions throughout the updated code, most changes are in the interpretive statements for provisions 7, 8 and 9, Hegge said. “Now we have a mandate to work together nationally and globally to address social determinants of health, such as violence, poverty, homelessness and abuse,” Hegge said. “Nurses need to see beyond the individual patient in the bed and look to outside factors that are causing the illness. One way nurses could apply this would be involving themselves in professional organizations that can create policies addressing these issues.”
Even though these may seem like lofty expectations, nurse leaders involved in the revision hope the updated code will generate conversations within the nursing community that can eventually lead to change. To recognize the importance of ethical practice, the ANA has designated 2015 as the Year of Ethics, which includes activities such as a webinar that was held in January and an ethics symposium that will be held in June. The ANA also has designated its 2015 National Nurses Week theme to be “Ethical Practice. Quality Care,” in keeping with its Year of Ethics outreach initiative.
This month, the association will release “Guide to the Code of Ethics For Nurses: Development, Interpretation, and Application, 2nd Edition,” by Marsha D. M. Fowler, MS, PhD, RN, FAAN, a resource for nursing classrooms, inservice training, and wherever nursing professionals use the Code of Ethics.
The topic of ethics also was at the center of a summit held in August at Johns Hopkins University, where 50 nursing leaders gathered to discuss the ethical issues facing the profession. In November, the leaders involved in the summit released the “Blueprint for 21st Century Nursing Ethics,” which includes recommendations to nurses in four areas: clinical practice, education, nursing research and policy.
“We felt that the Robert Wood Johnson Future of Nursing Report in 2010 was largely silent about the ethical foundation of nursing, and this was a significant gap,” said Cynda Hylton Rushton, PhD, RN, FAAN, a professor of clinical ethics at Johns Hopkins School of Nursing and Berman Institute of Ethics, Baltimore, and lead organizer of the summit. “Many times people think of ethics as the add-on, but we should be using the Code of Ethics as a yardstick for the design of nursing practice in the future.”
Most trusted for a reason
The blueprint and revised Code of Ethics are an integral part of why nursing has been rated the top profession for honesty and ethical standards for the 13th consecutive year, said Indiana University Health nurse ethicist Lucia Wocial, PhD, RN, a member of the code revision steering committee.
“If we are the most trusted profession, people expect us to be beneficent, to go out of our way to do the right thing,” Wocial said. “On any given day, nurses face countless ethical dilemmas, and it is not always easy to identify what is the right or good thing in these situations. The code is important because it has to guide what we do. We have to use it as a foundation for our values and build that into our identities as nurses.” •
Recommendations in blueprint include:
Clinical Practice: Create tools and guidelines for achieving ethical work environments, evaluate their use in practice and make the results easily accessible.
Education: Develop recommendations for preparing faculty to teach ethics effectively.
Nursing Research: Develop metrics that enable ethics research projects to identify common outcomes, including improvements in the quality of care, clinical outcomes, costs and impacts on staff and the work environment.
Policy: Develop measurement criteria and an evaluation component that could be used to assess workplace culture and moral distress.
Heather Stringer is a freelance writer.
To comment, email [email protected]