Describe the topics or theme of the assigned reading. What are the major points, questions, objections to discuss with the class? Identify Blooms Taxonomy Cognitive

Guide to the Code of Ethics for Nurses with Interpretive Statements Development, Interpretation, and Application, 2nd Edition by Marsha D.M. Fowler, PhD, MDiv, MS, RN, FAAN

An essential resource for nursing classrooms, in-service training, workshops

and conferences, self-study, and wherever nursing professionals use ANA’s

Code of Ethics for Nurses with Interpretive Statements in their daily practice.

Each chapter of this comprehensively revised text is devoted to a single Code

provision, including:

n Key ethical concepts

n Theories and models of ethical decision-making

n Interpretative statement ‘s contribution to interpreting and applying the provision, with examples and illustrative cases, based on real situations, to facilitate study and discussion

n Bibliographic Web links to key national and international documents

For convenience of reference, the primary text of ANA’s 2015 Code of Ethics

for Nurses with Interpretive Statements is included as an appendix. This

book will challenge each nurse to achieve deeper professional and personal

understanding, and provide a foundation for professional pride.

From the classroom to professional practice, nurses in all roles or settings

will find Guide to the Code of Ethics for Nurses with Interpretive Statements

a powerful tool for learning how to examine, and apply in their practice, the

values, duties, ideals, and commitments of their living ethical tradition. Guide to the Code of Ethics for N

urses w ith Interpretive Statem

ents: D evelopm

ent, Interpretation, and A pplication, 2nd Edition

M arsha D

.M . Fow

ler

8515 Georgia Avenue, Suite 400, Silver Spring, MD 20910-3492

1-800-274-4ANA (4262) www.Nursingworld.org

ePDF ISBN: 978-1-55810-604-9 First published in March 2015.

For more information or to order multiple copies, go to www.Nursesbooks.org, call 1-800-637-0323 or scan the QR code.

Guide to the Code of Ethics for Nurses with Interpretive Statements

by Marsha D. M. Fowler, PhD, MDiv, MS, RN, FAAN

Development, Interpretation, and Application

Second Edition

The American Nurses Association is the only full-service professional organization representing the interests of the nation’s 3.1 million registered nurses through its constituent/state nurses associations and its organizational affiliates. The ANA advances the nursing profession by fostering high standards of nursing practice, promoting the rights of nurses in the workplace, projecting a positive and realistic view of nursing, and by lobbying the Congress and regulatory agencies on health care issues affecting nurses and the public.

American Nurses Association 8515 Georgia Avenue, Suite 400 Silver Spring, MD 20910-3492 1-800-274-4ANA http://www.Nursingworld.org

Published by Nursesbooks.org The Publishing Program of ANA http://www.Nursesbooks.org

Copyright ©2015 American Nurses Association. All rights reserved. Reproduction or transmission in any form is not permitted without written permission of the American Nurses Association (ANA). This publication may not be translated without written permission of ANA. For inquiries, or to report unauthorized use, email [email protected]

Cataloging-in-Publication Data on file with the Library of Congress

ePDF ISBN: 978-1-55810-604-9

First published in March 2015.

Dedication • Guide to the Code of Ethics for Nurses with Interpretive Statements, 2nd Ed. • i

To my family Donald, Katherine,

Robert, Allison, Ætley, Laura

Raven, Tucker, Wolfgang, Hero

Y Gwir yn erbyn y Byd, A oes Heddwch? Calon wrth Galon, A oes Heddwch?

Gwaedd uwch Adwaedd, A oes Heddwch?

The Truth against the World: is there Peace? Heart to Heart, is there Peace?

Shout above resounding Shout, is there Peace?”

Gorsedd Beirdd Ynys Prydain Liturgy of the Bardic Ceremony of the

Unsheathing of the Grand Sword

Dedication

Contents

Contents • Guide to the Code of Ethics for Nurses with Interpretive Statements, 2nd Ed. • iii

Acknowledgments v

Author’s Preface. Review and Renewal: The Half-Life of a Code vii

Preface 2015. Nursing’s 2015 Code of Ethics xi Anne J. Davis, PhD, DS, MS, RN, FAAN

Preface 2008. The Initiating Edition of Guide to the Code xiii Anne J. Davis, PhD, DS, MS, RN, FAAN

Foreword XV Patricia Benner, PhD, RN, FAAN

Introduction. Provisions, Decisions, and Cases: XXIV Getting to What is Right and Good

The Nursing Process, Models of Ethical Decision-Making, and Using the Cases xx Suggested Questions for Case Discussions xx Concluding Remarks xxvi

Provision 1. Affirming Health through Relationships of Dignity and Respect 1 Introduction 1 1.1 Respect for Human Dignity 7 1.2 Relationships with Patients 10 1.3 The Nature of Health 13 1.4 The Right to Self-Determination 15 1.5 Relationships with Colleagues and Others 18

Provision 2. The Patient as Nursing’s Foundational Commitment 25 Introduction 25 2.1 Primacy of the Patient’s Interests 26 2.2 Conflict of Interest for Nurses 32 2.3 Collaboration 33 2.4 Professional Boundaries 35

Provision 3. Advocacy’s Geography 41 Introduction 41 3.1 Protection of the Rights of Privacy and Confidentiality 41 3.2 Protection of Human Participants in Research 46

iv • Guide to the Code of Ethics for Nurses with Interpretive Statements, 2nd Ed. • Contents

3.3 Performance Standards and Review Mechanisms 50 3.4 Professional Responsibility in Promoting a Culture of Safety 50 3.5 Protection of Patient Health and Safety by Action on

Questionable Practice 51 3.6 Patient Protection and Impaired Practice 53

Provision 4. The Expectations of Expertise 59 Introduction 59 4.1 Authority, Accountability, and Responsibility 62 4.2 Accountability for Nursing Judgments, Decisions, and Actions 64 4.3 Responsibility for Nursing Judgments, Decisions, and Actions 65 4.4 Assignment and Delegation of Nursing Activities or Tasks 68

Provision 5. The Nurse as Person of Dignity and Worth 73 Introduction 73 5.1 Duties to Self and Others 78 5.2 Promotion of Personal Health, Safety, and Well-Being 79 5.3 Preservation of Wholeness of Character 81 5.4 Preservation of Integrity 85 5.5 Maintenance of Competence and Continuation of Professional Growth 88 5.6 Continuation of Personal Growth 90

Provision 6. The Moral Milieu of Nursing Practice 95 Introduction 95 6.1 The Environment and Moral Virtue 102 6.2 The Environment and Ethical Obligation 104 6.3 Responsibility for the Healthcare Environment 105

Provision 7. Diverse Contributions to the Profession 113 Introduction 113 7.1 Contributions through Research and Scholarly Inquiry 115 7.2 Contributions through Developing, Maintaining, and Implementing

Professional Practice Standards 122 7.3 Contributions through Nursing and Health Policy Development 122

Provision 8. Collaboration to Reach for Greater Ends 129 Introduction 129 8.1 Health Is a Universal Right 131 8.2 Collaboration for Health, Human Rights, and Health Diplomacy 132 8.3 Obligation to Advance Health and Human Rights and Reduce Disparities 137 8.4 Collaboration for Human Rights in Complex, Extreme, or Extraordinary

Practice Settings 140

Provision 9. Social Justice: Reaching Out to a World in Need of Nursing 151 Introduction 151 9.1 Articulation and Assertion of Values 155 9.2 Integrity of the Profession 155 9.3 Integrating Social Justice 159 9.4 Social Justice in Nursing and Health Policy 160

Appendix A. Code of Ethics for Nurses with Interpretive Statements (2015) 171

Index 211

Acknowledgments

Acknowledgements • Guide to the Code of Ethics for Nurses with Interpretive Statements, 2nd Ed. • v

No book is the work of one person. Even single-author works owe a debt of gratitude to all those who went before them, as well as those who helped along the way. This book is indebted to the nurses who, from the inception of modern nursing to the present, have devoted themselves both to nursing and to its ethical tradition and have sought to build that tradition. Florence Nightingale, Isabel Robb, Charlotte Aikens, Charlotte Talley, Sara Parsons, Rose Helené Vaughn, Patricia Goodall, and Lystra Gretter are some of the names that any student of nursing ethics history will come to know. It is upon the remarkable foundation that their work laid that nursing ethics continues to develop.

In the present there are many colleagues whose commitment to nursing ethics is enduring, rigorous, scholarly, and always ultimately directed toward the recipients of nursing care, while also with a heart for nurses themselves. A number of persons are deserving of special acknowledgement in the preparation of this work. In particular, Col. Martha Turner, PhD, RN-BC, USAF NC (Ret.) who read and critiqued the manuscript with great knowledge, insight, and wisdom, and who responded to all my annoying late night queries with alacrity. I also acknowledge the invaluable assistance of Denise Gehring, MS (LIS), MA who used her magical librarian skill to scour the globe for obscure articles that were needed to support the research for this volume. I firmly believe, and have written elsewhere, that a good librarian is the right arm of a researcher. There have been many over the years who have been faithful nursing colleagues and friends of inflorescent dignity (see Chapter 1) who also possessed just the right balance of humor, imagination, curiosity, scholarship, and eccentricity: Anne Davis, Verena Tschudin, Patricia Benner, Marilyn Flood, Sonya Grypma, Marianne Hattar, Barb Pesut, Sheryl Reimer-Kirkham, Rick Sawatzky, and Beth Johnston Taylor. Co-conspirators though they may have been over the years, the blame for any “dodgy bits” in this manuscript belong solely to me and not to

them. Thanks also to Eric Wurzbacher, editor extraordinaire at ANA, who was intrepid in his efforts to bring this work ever so rapidly to print.

Finally, to my dear family, friends, personal trainer, dogs, hens, bicycle, and garden, which were sorely neglected during this process, I apologize and promise to mend my ways.

Marsha Fowler Thanksgiving Day 2014

vi • Guide to the Code of Ethics for Nurses with Interpretive Statements, 2nd Ed. • Acknowledgements

Author’s Preface • Guide to the Code of Ethics for Nurses with Interpretive Statements, 2nd Ed. • vii

A code of nursing ethics cannot be static, neither can it be unstable. It must be enduring and rooted in the core of nursing identity, but must also be responsive to the growth, development, and context of practice. Thus, approximately every decade a profession’s code of ethics must be reviewed for datedness, fit with practice, and inclusion of emerging concerns and directions. However, the central importance of this code of ethics requires that its periodic revision be undertaken with great care and with attention to the voices from all of nursing’s specialties and settings. Thus the 2001 ANA Code of Ethics for Nurses with Interpretive Statements (the Code) underwent a four-year process of revision that led to the renewed Code of Ethics for Nurses with Interpretive Statements, 2015. The process began in 2010 and concluded in August 2014 after which it was approved by the Ethics Advisory Board and the Board of Directors of the ANA for formal adoption.

From October 2010 to March 2011, the Ethics Advisory Board (EAB) reviewed the 2001 Code, recommended that it undergo a review process, and submitted this request to both the ANA President and CEO. The request was approved. A workgroup to review the Code was formed with the following charge:

You will not edit the Code provisions or Interpretive Statements but will seek input by preparing a request for public comment to determine need for clarification, change, or addition. Recommendations will be to a) allow current Code of Ethics for Nurses to stand or b) form a committee to draft edits based on comments and review.1

The Code Review Workgroup reviewed the Code itself and, via NursingWorld (NursingWorld.org), conducted an online public survey of nurses and interested persons who also reviewed the Code and suggested revisions. The Workgroup analyzed approximately 2,800 suggestions for revision that were made on the survey and via other communications. The Code Review Workgroup then recommended to the EAB that the Code be

Author’s Preface. Review & Renewal: The Half-Life of a Code

viii • Guide to the Code of Ethics for Nurses with Interpretive Statements, 2nd Ed. • Author’s Preface

revised and that the EAB communicate this recommendation to the ANA President and CEO.

The recommendation and request were received and subsequently a 15-member steering committee for the revision of the Code was formed with the following charge:

To complete a revision of the Code of Ethics for Nurses based upon the recommendations of the Code of Ethics Review Workgroup recommendations to retain what is possible of the 2001 Code, make changes to the content of interpretive statements to improve organization, streamline the wording, expand to be inclusive of new/ current concepts, and update the vocabulary.2

The steering committee met monthly by conference call between September 2013 and April 2014 to draft a revision that incorporated public comment. That draft was posted for public comment between May and June 2014. Approximately 1,500 comments and suggestions were received on the draft. In a meeting in Silver Spring, Maryland, the steering committee evaluated the suggestions and prepared a final draft for submission to the EAB for their vote of approval and with a recommendation that it be sent on to the Board of Directors for approval. The EAB received the final draft and approved it in October 2014. It was then forwarded to the ANA Board of Directors who approved it for adoption on November 12, 2014.

In 1950, the Code for Professional Nurses referred only to the provisions of that Code. At that time there were no interpretive statements, although a series of articles on the Code was subsequently published in the American Journal of Nursing. The 1960 Code consisted of 17 provisions that were accompanied by interpretive statements that were explanatory in nature. With reference to the 1950, 1960, and 1968 Codes, the title Code for Professional Nurses applied only to the provisions themselves. The 1976 revision of the Code was a turning point in two major ways. First, the number of provisions was significantly reduced. Second, the interpretive statements took on new force as they shifted from explanatory to interpretive, and the nature of the language changed from permissive to mandatory. From 1985 onward (2001, 2015), the interpretive statements become the definitive interpretation of the provisions with the force of standards. Thus, today, the Code of Ethics for Nurses with Interpretive Statements, including both provisions and interpretive statements, forms the non-negotiable moral standard for the profession.

The Code of Ethics for Nurses with Interpretive Statements is remarkable in its breadth and compass. It retains nursing’s historical and ethical values,

Author’s Preface • Guide to the Code of Ethics for Nurses with Interpretive Statements, 2nd Ed. • ix

obligations, ideals, and commitments, while extending them into the ever- growing art, science, and practice of nursing in 2015. As a foundational ethical standard of practice, the Code should also be a source of “pride of profession.”

Marsha D.M. Fowler, PhD, MDiv, MS, RN, FAAN Professor of Ethics Senior Fellow, Institute for Faith Integration Azusa Pacific University, Azusa, CA Assistant Pastor, New Hope Presbyterian Church, Pasadena, CA Member, ANA Committee on Ethics, 1985–87; Chairwoman, 1987–89 Member, project team for the evaluation of the 1985 Code for Nurses with Interpretive Statements, for revision, 1995 Member, Task Force for the Revision of the 1985 Code for Nurses with Interpretive Statements, 1996–2001 Member, ANA 2001 Code of Ethics for Nurses with Interpretive Statements Revision Workgroup, 2012–2013 Historian and Code Scholar, co-lead writer, ANA Steering Committee for the Revision of the 2001 Code of Ethics for Nurses with Interpretive Statements, 2013–2014

Preface • Guide to the Code of Ethics for Nurses with Interpretive Statements, 2nd Ed. • xi

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 ANA’s nursing 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, and we developed a deeper understanding and appreciation of ourselves as professionals, the ANA Code has been updated on several occasions to reflect these changes. However, the core value of service to others has remained consistent throughout. This second edition of the Guide to the Code of Ethics for Nurses provides material foundational to understanding the 2015 Code, its development, interpretation, and application.

One major change that can be found in the Code 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 reminds us that nurses owe the same duties to self as to others. Such duties include the promotion of personal health, safety, and well-being; preservation of wholeness of character and personal integrity, maintenance of competence, and continuation of professional, and personal growth. 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 Guide to the Code; it will assist you to carefully and repeatedly reflect on the 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

Preface 2015. Nursing’s 2015 Code of Ethics

xii • Guide to the Code of Ethics for Nurses with Interpretive Statements, 2nd Ed. • Preface

who we as professional nurses are at our very core. This Guide reflects upon the fundamental values and ideals of nurses as individuals and as members of a profession as found in the current Code of Ethics with Interpretive Statements (the Code).

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, 2001, and again in 2015 so that it could continue to guide nurses in increasingly more complex roles, functions, and settings. The Guide explains how these revisions reflect not only the changing roles and functions of nurses and their relationships with colleagues, but also, and more importantly, the commitment of professional nursing across the decades to maintaining one of its most important and vital documents that continues to inform nurses, other health professionals, and the general public of nursing’s central values.

This edition of the Guide includes explanations of a variety of ethical methods such as principles, ethics of care, virtue ethics. It gives historical and contextual development of each provision and provides extensive citations including links to key national and international documents. Additionally, this edition has developed foundational concepts such as human dignity, compassion, social justice, care, and human rights. Included also is an extensive discussion of social ethics, social justice, and nursing. This demonstrates the reciprocating interrelationships among nursing, ethics, and social forces. And finally, the Guide addresses the 2015 Code’s expanded focus on global nursing that has become more necessary in our interconnected world.

We in the nursing profession can be proud of our values and this Code that reflects them. These values underpin the new revision of the Code of Ethics for Nurses with Interpretive Statements. This Guide will assist you to interpret and use that Code wisely.

And finally, join me in thanking the latest ANA task force for its excellent work in revising our Code.

Anne J. Davis, PhD, DS, MS, RN, FAAN American Academy of Nursing Living Legend, 2012 Professor Emerita, University of California, San Francisco Professor Emerita, Nagano College of Nursing, Japan

Former Chair, ANA Ethics Committee

Preface • Guide to the Code of Ethics for Nurses with Interpretive Statements, 2nd Ed. • xiii

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 whom it serves. The group that would eventually become the American Nurses Association first discussed a code of ethics in 1896. When the ANA nursing 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 family, and the community 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 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

Preface 2008. The Initiating Edition of Guide to the Code

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 with colleagues, but also and more importantly, the commitment of professional nursing to maintaining one of its most important and vital documents that continues to inform nurses, other health professionals, and the general public of nursing’s central values. These values underpin this Code. 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, RN, DSc (hon) Professor Emerita, University of California, San Francisco Professor, Nagano College of Nursing, Japan Former Chair, ANA Ethics Committee

xiv • Guide to the Code of Ethics for Nurses with Interpretive Statements, 2nd Ed. • Preface

Foreword • Guide to the Code of Ethics for Nurses with Interpretive Statements, 2nd Ed. • xv

Dr. Marsha Fowler has given both society and nursing a tour de force in this new second edition of the Guide to the Code of Ethics for Nurses (the Guide). This book is far more enlightening and transformative than its title “Guide” reveals. More than a mere guide, this book provides a breath-taking synthesis of the evolving identity and mission of nursing as a Civic Profession. i As a nurse and nurse ethicist, I read with awe and appreciation of the breadth, scope, and wisdom of the 2015 Guide to the newly adopted 2015 ANA Code of Ethics for Nurses with Interpretive Statements (the Code). I am gripped and inspired as I read this work’s responses to the sweeping societal changes in health care and to the nursing profession’s changes in identity and functions in the rapidly changing healthcare delivery systems.

Dr. Marsha Fowler respectfully seeks to understand our past ethical stances, and to encourage us to embrace past wisdom and aspirations as we gain new knowledge and responsibilities in our evolving role as Civic Professionals. By Civic Professionalism, I refer to the nursing profession’s civic (citizen) responsibility to contribute to a good society by taking seriously the obligations, skills, and virtues required to protect the rights of patients and clients, while seeking to limit risks and vulnerabilities of whole persons and entitled citizens.

This Guide makes evident the necessity of the new changes in our 2015 Code in order to improve the health of society and to improve healthcare delivery. Nurse readers are called to fully embrace the essential contributions of nurses and the nursing profession to create a better and healthier society as activist nurses, clinicians, scholars, and policy makers. The difficult challenges of ethical formation and comportment of nurses is taken up with insight, honesty, and intelligence. The 2015 Code embraces the ethical demands of respecting the wholeness of the person dwelling in a family and community. Health is emphasized as a universal right rather than as a commodity to be bought and sold in the marketplace with little concern for equitable distribution, quality, and access to health care. This stance is

Foreword

xvi • Guide to the Code of Ethics for Nurses with Interpretive Statements, 2nd Ed. • Foreword

evident in the new Code’s 2015 statement of nursing’s duties and aspirations as a profession:

Nursing encompasses the protection, promotion, and restoration of health and well-being, the prevention of illness and injury; and the alleviation of suffering, in the care of individuals, families, groups, communities, and populations. All of this is reflected, in part, in nursing’s persisting commitment both to the welfare of the sick, injured, and vulnerable in society and to social justice. Nurses act to change those aspects of social structures that detract from health and well-being.ii

The challenge of developing a nursing code of ethics that embraces the nursing profession’s concern with health promotion, illness prevention and care in all stages of injury and illness, and social justice is presented as nursing’s current, future, and past missions. The broad goals to increase distribution of healthcare resource

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