The American Nurses Association (ANA) Code of Ethics is a foundational guide for nurses. It outlines the ethical principles underpinning nursing practice and provides a framework for making ethical decisions and upholding the integrity of the profession.
In January 2025, the ANA released a revised version of the Code of Ethics to reflect today's complex healthcare environment. Updates include a new provision focused on global health responsibilities, and language that addresses racism as a public health crisis, acknowledges intersectionality in care, and connects nurse well-being to the quality of patient care, according to a news release.
"The Code of Ethics helps nurses by giving them structure as to how to own their accountability and their responsibilities within their nursing practice and help make those decisions based on what would be providing the most optimal care for the patient," said Emily Emma, DNP, RN-BC, NEA-BC, the director for Magnet and professional practice at Stony Brook University Hospital in New York.
Emma said the code is discussed in nursing school, while the NCLEX-RN national licensure exam also includes questions about ethics.
"Having ethical principles in nursing really guides the nurse to make the best, most moral decision on behalf of themselves as practitioners and for the patients," she said.
How it all started
The importance of ethics in nursing led the ANA to adopt its first formal Code of Ethics in 1950, according to the Online Journal of Issues in Nursing (OJIN). Ten years later, the Code for Professional Nurses included 17 provisions, which were later edited to 10 in 1968.
According to OJIN, the code has gone through regular updates and revisions ever since.
"One thing it does is support the general professionalization of nursing," said Eric Vogelstein, PhD, MA, an associate professor and bioethicist at the Duquesne University School of Nursing and Department of Philosophy. "It's probably one thing that separates a profession from a job or a career. Nursing is a profession, so they need to have that standard aspect of professionalization in place."
Having a long history of ethical guidelines sets nursing apart. "Nursing has a particular emphasis on ethics," Vogelstein said. "As we know, nursing is consistently rated as the most trusted profession (by the annual Gallup poll of honesty and ethics). One thing that contributes to that is it has a robust relationship with ethics, and the Code of Ethics serves the public in that capacity just as much as it does the nursing profession itself."
What's in the nursing code of ethics?
The Code of Ethics outlines ten provisions that define the ethical responsibilities of every nurse. While the first nine have long provided the foundation for nursing ethics, the 2025 update introduced a tenth provision that reflects the profession’s broader global impact. Each provision addresses a different aspect of ethical nursing practice:
- Provision 1: The nurse practices with compassion and respect for every person's inherent dignity, worth, and unique attributes.
- 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 every patient's rights, health, and safety.
- Provision 4: The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to promote health and 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 health care.
- 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.
- Provision 10: The new provision affirms the scope of nursing ethics in a global context, emphasizing the profession's role in promoting human and environmental health worldwide. It underscores the importance of nurses' participation in global health initiatives, policy development, and health diplomacy. This provision recognizes that health challenges transcend national borders and that nurses have a responsibility to contribute to global health solutions.
Ethical decisions often don't have easy answers. "You can't just look up the answer to a complicated ethical dilemma in the code and they say, 'Oh, that's what I should do,'" Vogelstein said. "You have to apply the principles. There's a lot of reasoning behind these cases. That's why healthcare ethics is a robust area of scholarly inquiry and why I teach whole classes on it. The code isn't going to resolve the case, but it will get me started."
Using the code
Putting the code to use in nursing practice isn't just reserved for extreme cases. "There are ethical questions every day, as well," Vogelstein said. According to a study in the Journal of Advanced Nursing, among the most common ethical issues for nurses are:
- Protecting patients' rights
- Autonomy and informed consent to treatment
- Breaches of patient confidentiality or right to privacy
- Advanced care planning
- Surrogate decision-making
- End-of-life and beginning-of-life decisions
- Genetic testing and counseling
- Organ donation and transplantation
- Resource allocation
- Staffing patterns that negatively affect work
At Stony Brook, Emma said, "A majority of the ethical dilemmas/ethics consult cases called by nurses are for goals of care for a patient. This can be management of a patient's pain level or discussing a code status with the patient, family, and interprofessional teams after a poor prognosis. Because the nurse provides continuity of care with a patient, it is important for the nurse to feel empowered and advocate for their patient. The ethics consult provides support to the nurse."
In his graduate school nursing classes, Vogelstein said his students often exhibit how much thought and reasoning go into an ethical dilemma.
"I have several assignments that ask them to describe an ethical issue that has come up in their practice," he said. "You can tell they are just clamoring to get this out. Some of them write two or three times as much as the assignment calls for."
Seeking help
When an ethical decision arises, where can nurses turn? According to Vogelstein, some immediately involve a supervisor. Emma's colleagues at Stony Brook can call an ethics consultant 24/7 with a member of the facility's regulatory affairs department.
"They will assemble an institutional ethics committee that is made up of nursing staff as well as other interprofessional team members to help offer guidance," she said.
Ethics consults and committees are commonplace at healthcare facilities across the country. However, according to Vogelstein, these services are often underutilized. Some nurses "only call when things get to a more difficult place,” he said. "It would be beneficial to call [for an ethics consultation] before it gets there. Later on, it's more difficult to resolve."
