The Code of Ethics for Nurses With Interpretative Statements was developed to guide nurses in ethical decision making and analysis. ? Nurses are expected to

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Jill Winland-Brown, EdD, FNP-BC, DPNAP, is Professor Emeritus, Christine E. Lynn College of Nursing, Florida Atlantic University, and member of American Nurses Association Ethics and Human Rights Advisory Board.

Vicki D. Lachman, PhD, APRN, MBE, FAAN, is President, V.L. Associates, a consulting and coaching firm, Avalon, NJ, and Sarasota, FL. She is Chair, American Nurses Association Ethics and Human Rights Advisory Board, and serves on a hospital ethics committee.

Elizabeth O’Connor Swanson, DNP, MPH, APRN-BC, is Assistant Professor of Nursing, Mary Black School of Nursing, University of South Carolina Upstate; Nurse Practitioner/Clinical Nurse Specialist, South Carolina Department of Juvenile Justice; and member of the American Nurses Association Ethics and Human Rights Advisory Board.

The New ‘Code of Ethics for Nurses With Interpretive Statements’ (2015): Practical Clinical Application, Part I

F or the 13th year in a row, Gallup poll results indi- cate Americans rate nursing as the most honest profession and nurses as having the highest ethi-

cal standards (Gallup, 2014). In addition, the American Nurses Association (ANA) identified the focus of 2015 National Nurses Week as “Ethical Practice, Quality Care” as part of its effort for 2015 to be named “The Year of Ethics.” The new Code of Ethics for Nurses with Interpretive Statements (ANA, 2015) (Code) was released in January after a 4-year review process involving input from sever- al thousand RNs (OnCourse Learning Corporation, 2015). The second edition of the Guide to the Code of Ethics for Nurses with Interpretative Statements: Development, Interpretation, and Application (Fowler, 2015) was released in April.

This two-part series will explore the new Code and its use in every day clinical practice with a case situation for each article. Part I will introduce the Code, discuss the glossary, and use a nursing case situation to explore the first four provisions. The second part of the series will continue discussion of the last five provisions.

The Code (ANA, 2015) articulates the ethical obliga- tions of all registered nurses. The nine provisions iden- tify the responsibilities of nurses, while the interpretive statements provide guidance in their application. The introduction to the Code explains why certain terms were chosen, such as patient versus client, as well as the use of moral and ethical word choices. This introduc- tion also gives an overview of some terms, and includes links to foundational and supplemental documents on

the ANA ethics web page. Because many terms in nurs- ing ethics are used imprecisely and interchangeably with possible misconceptions, this edition of the Code includes a glossary of 49 terms, such as compassion fatigue, moral distress, and social media (ANA, 2015, pp. 35-45).

The first three provisions explain the most basic val- ues and commitments of the nurse, all of which might be helpful in exploring the following nursing case situ- ation. These provisions address the nurse’s duties to respect the patient, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems. The fourth provision discuss- es the nurse’s accountability in practice.

The following nursing case situation is used to illus- trate some of the Code violations:

Keisha and Kyle are two RNs on the night shift. They have been out of school for sever- al years and are trying to move to the day shift to normalize their lives. They have got- ten very close through their years in nursing school together; he was one of her major supports as she re-entered nursing after an addiction to oxycodone due to a shoulder injury. Kyle understands Keisha has some biases against major surgical interventions for palliation and engaging patients in Phase 1 clinical trials.

Tonight, they are caring for Mrs. Williams, a 44-year-old married woman with four chil- dren ages 3-20. She was admitted with an intestinal obstruction and is scheduled for surgery tomorrow. After some imaging stud- ies, the physician suspects a massive tumor that will likely require removal for palliative purposes only. He believes the cancer has spread to all surrounding organs and lymph nodes. However, nothing is certain until sur- gery.

Leaving the unit in the morning, Keisha and Kyle are talking about the case when Mrs. Williams’s 20-year-old daughter Wendy gets on the elevator. Wendy recognizes the

Ethics, Law, and Policy

Jill Winland-Brown Vicki D. Lachman

Elizabeth O’Connor Swanson

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nurses from her mother’s unit. She overhears them saying “What a shame with such a massive tumor and with four children at home!” Although Wendy assumes they are talking about her mother, she thought her mother only had a minor intestinal obstruc- tion. She does not know what to do as her mother is going to surgery very soon.

Provision 1 The nurse practices with compassion and respect for

the inherent dignity, worth, and unique attributes of every person.

This provision is more concise than the previous Provision 1, but encompasses the same concepts. Five interpretive statements are similar to the previous edi- tion, but the language is updated to articulate the con- tent more clearly. The first two statements address nurs- es’ fundamental ethical obligations for patient respect and development of trust between nurse and patient.

The first interpretive statement addresses “respect for human dignity.” Keisha and Kyle seemed to have com- passion for their patient, but they did not respect her right to confidentiality. The second interpretive state- ment identifies “relationships with patients” and the importance of trust. While Keisha and Kyle may have developed a relationship with Mrs. Williams, they vio- lated the trust by discussing her health situation in a public place. It is not clear if Mrs. Williams was aware of her diagnosis or the physician’s surgical plans. As this interpretative statement indicates, nurses do not need to agree with patient choices, but they are required to set aside any bias or prejudice (e.g., Keisha’s bias con- cerning palliative care surgeries).

The third interpretive statement for Provision 1 con- cerns the “nature of health.” To promote Mrs. Williams’s health fully, the nurses should have encour- aged an honest dialogue between the patient and sur- geon. She has the right to know what the surgeon is anticipating. Also, this statement addresses the need for support for the family and significant others, including the patient’s daughter Wendy.

The fourth interpretive statement focuses on “the right to self-determination.” Mrs. Williams has the capacity to understand her diagnosis and participate in the decision for her surgery. From the case situation, the husband should be included in discussion and Mrs. Williams may like her daughter Wendy to be involved in the decision-making process as well. As this state- ment indicates, “patients have a moral and legal right to determine what will be done with and to their person” (p. 2). The physician, patient, and family need to know the diagnosis and prognosis in order to make an informed decision for surgery. If the surgery is only for palliation, then the patient and family need to engage in an advance care planning conversation with the physician. The nurse’s obligation is to assure the patient has accurate, complete, and understandable informa- tion on which to base her decision.

The last interpretive statement for Provision 1 involves the nurse’s “relationships with colleagues and others.” Keisha and Kyle failed to demonstrate respect for persons when they had their conversation, which included identifying information about the patient, in a public place. Nurses have a responsibility to create an ethical environment, including an affirmative duty to prevent harm. Their violation of confidentiality could cause significant harm to the needed trust as Mrs. Williams and her family struggle to make the best deci- sion for her. Additionally, this interaction in the eleva- tor initiated a great deal of distress for Wendy.

Provision 2 The nurse’s primary commitment is to the patient,

whether an individual, family, group, community, or population.

This provision has retained the previous four inter- pretive statements, with added clarity in the explana- tions. It focuses on the nurse’s obligation to assure the primacy of the patient’s interests regardless of conflicts that arise between clinicians or patient and family.

The first interpretive statement is for the “primacy of the patient’s interests.” Keisha’s and Kyle’s primary com- mitment is to Mrs. Williams and her family. They need to provide opportunities for Mrs. Williams and her fam- ily to participate in her care, including honest discus- sions about available resources and treatment options. Wendy’s reactions seem to indicate she is unaware of her mother’s prognosis or the purpose of the surgery.

The second interpretive statement involves the “con- flict of interest for nurses.” This nursing case situation illustrates several possible conflicts: between physician and nurses, physician and patient, physician and family members, and nurses and family members. Nurses pro- mote Mrs. Williams’s best interests when they speak up and raise questions about her understanding of her prognosis, thus supporting interprofessional collabora- tion with physicians. Nurses must address conflicting expectations from patients, families, and physicians, as well as conflicts arising between their own professional and personal values.

The third interpretive statement relates to “collabora- tion.” “Nurses are responsible for articulating, represent- ing, and preserving the scope of nursing practice, and the unique contributions of nursing to patient care” (p. 6). This collaboration “requires mutual trust, recogni- tion, respect, transparency, shared decision-making and open communication among all who share concern and responsibility for health outcomes” (p. 6). If nurses are reluctant to open a dialogue with the physician con- cerning a patient’s possible lack of understanding of diagnosis and/or prognosis, other professionals can be used: other health care colleagues, leaders, and the hos- pital ethics committee. With collaboration, the desired outcome is always a demonstrated commitment to the patient.

The final interpretive statement for this provision illustrates the importance of “professional boundaries.”

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Keisha and Kyle committed several boundary violations. “Nurse-patient and nurse-colleague relationships have as their foundation the promotion, protection, and restoration of health” (p. 7). The nurse-patient relation- ship needs to remain therapeutic and professional. Concerns arise in this situation about the casual way in which Keisha and Kyle engaged in an end-of-shift con- versation about a patient.

Provision 3 The nurse promotes, advocates for, and protects the

rights, health, and safety of the patient. The six interpretive statements within this provision

combine two from the previous Code (ANA, 2001) (pri- vacy and confidentiality) and add a new one: “profes- sional responsibility in promoting a culture of safety.” This provision focuses on the nurse’s obligation to pro- tect patients from harm.

The first interpretive statement for this provision addresses “protection of the rights of privacy and confi- dentiality.” This statement was most violated in the case situation. Keisha and Kyle should have known the importance of maintaining confidentiality and should not be discussing this case on the elevator. While they did not give any specifics related to the case, how many other patients on their unit are likely to have an intes- tinal problem and four children at home? This violates the fundamental trust between patient and nurse. “Patients rights are the primary factors in any decisions concerning personal information, whether from or about the patient” (p. 10).

The second interpretive statement centers on “pro- tection of human participants in research” and is similar to the third statement in the previous edition. This addresses the importance of informed consent and the fact participants may decline to participate or withdraw from any research. Nurses have the obligation to raise questions about the individual’s capacity to consent and honor the patient’s right to withdraw from research. If Mrs. Williams chooses to engage in a Phase 1 clinical trial, nurses may have to support her withdrawal.

The third interpretive statement, which focuses on “performance standards and review mechanisms,” is clearer and more concise than the previous edition. The statement addresses the need for nurses to continue their professional development to maintain their com- petence because nurses “are responsible and account- able for nursing practice and professional behaviors” (p. 11). Maintenance of confidentiality is considered a basic performance standard in nursing.

Interpretive statement four is entirely new: “profes- sional responsibility in promoting a culture of safety.” This statement addresses the importance of the nurse’s role in patient safety. The nurse is responsible for report- ing any errors or near misses to the appropriate author- ity, ensuring disclosure of the errors to patients, and establishing processes to investigate these errors to pre- vent recurrence. The nurse also must not remain silent in the event of an error. If a colleague would overhear

Ethics, Law, and Policy

Keisha’s and Kyle’s conversation, he or she would be required to address this violation with them. Not addressing their error could be seen as condoning their conversation.

The fifth statement in Provision 3 centers on the “protection of patient health and safety by acting on questionable practice.” This is similar to the previous edition, addressing the need to support nurses who become whistleblowers. As mentioned previously, the nurse overhearing Keisha and Kyle’s conversation has an obligation to confront them and organizational lead- ers have an obligation to protect the confronting nurse from any retaliation. “Reporting questionable practice, even when done appropriately, may present substantial risk to the nurse; however, such risk does not eliminate the obligation to address threats to patient safety” (p. 13).

The sixth and final interpretative statement focuses on “patient protection and impaired practice” and is similar to the previous version. The definition of impaired practice is broadened in this revision to include “mental or physical illness, fatigue, substance abuse, or personal circumstances” (p. 13). This state- ment not only addresses reporting the impaired nurse but also ensures the nurse receives assistance. This advo- cacy includes supporting the return of the individual to practice after recovery, as Kyle did for Keisha.

Provision 4 The nurse has authority, accountability, and

responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to pro- mote health and to provide optimal care.

Provision 4 has four interpretive statements empha- sizing responsibilities and obligations of the profession- al nurse to his or her patients. These statements remain essentially unchanged in this revised Code. Patients are seen as individuals, families, or populations. “Nursing practice includes independent direct nursing care activ- ities; care as ordered by an authorized healthcare provider, care coordination; evaluation of interventions and delegation of nursing interventions…” (p. 15).

Emphasis of the first interpretative statement is on “authority, accountability, and responsibility.” Nurses have authority in every role, and are accountable and responsible for the quality of the care they provide and in meeting nurse practice acts, regulations, and the Code. Advanced practice registered nurses (APRNs) are included in Provision 4, specifically APRNs with pre- scribing privileges; the revised Code states both the ARPN who orders a treatment and the nurse who accepts the order are responsible for the judgments each makes and accountable for the actions each takes. The issuance of a prescriptive order by an APRN is not an act of delegation.

The second interpretative statement reviews “accountability for nursing judgments, decisions, and actions.” The revised Code recognizes technology that assists nurses in the clinical arena but identifies these

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systems and technologies are aids, rather than a substi- tute for the nurse’s skill and judgment. This statement reminds the professional nurse of two important issues in accountability. First, nurses are accountable for all decisions and actions in the course of practice. Second, system or technology failure does not relieve the nurse of practice accountability because these are seen as adjuncts to nursing knowledge and skill rather than replacements for them. Nurses are always accountable for their actions, decisions, and judgments, just as Keisha and Kyle are for their failure in judgment to honor patient confidentiality.

The third interpretative statement focuses on “responsibility for nursing judgments, decisions, and actions.” Keisha and Kyle exhibited poor nursing judg- ment by speaking about a patient in the elevator. This statement emphasizes the need to provide safeguards for patients, nurses, colleagues, and the environment, and nurses’ responsibility to “bring forward difficult issues related to patient care and/or institutional con- straints upon ethical practice for discussion and review” (p. 16). This revised Code places a duty on nurse execu- tives for safeguarding nurses’ access to organizational committees and institutional boards, as well as inclu- sion in decision-making processes that touch patient care ethics, quality, and safety. Nurses who participate on these committees and boards “are obligated to actively engage in, and contribute to, the decisions that are made” (p. 16). Inclusion of Keisha and/or Kyle on the hospital’s Ethics Committee may have sensitized them to the issues surrounding confidentiality.

Interpretative statement four addresses the “assign- ment and delegation of nursing activities or tasks.” The revised Code specifically indicates nurses may not dele- gate nursing process duties of assessment and evalua- tion, and “employer policies do not relieve the nurse of responsibility for making assignment or delegation deci- sions” (p. 17). This statement also focuses specifically on the importance of managers in facilitating appropriate assignment and delegation. In addition, this statement expands on the obligations of nurses functioning in educator or preceptor roles. As the revised Code states, “It is imperative that the knowledge and skill of the nurse or nursing student be sufficient to provide the assigned nursing care under appropriate supervision” (p. 17). There is nothing in this interpretative statement relevant to the case situation.

Conclusion When the Code (ANA, 2001) was written, few contrib-

utors could have envisioned the current health care envi- ronment. These revised provisions and interpretive state- ments were developed with an eye toward the future and a foot well-grounded in knowledge gained from the past. This updated version provides nurses with clarity on terms through a glossary, links to foundational docu- ments on the ANA website, and improved clarity through editing of the first four provisions. Through the

addition of interpretative statement 3.6, “protection of patient health and safety by acting on questionable prac- tice,” the importance of the role of the professional nurse in the patient safety is expressed.

REFERENCES American Nurses Association (ANA). (2001). Code of ethics for nurses

with interpretive statements. Silver Spring, MD: Author. American Nurses Association (ANA). (2015). Code of ethics for nurses

with interpretive statements. Silver Spring, MD: Author. Gallup. (2014). Americans rate nurses highest on honesty, ethical stan-

dards. Retrieved from http://www.gallup.com/poll/180260/ americans-rate-nurses-highest-honesty-ethical-standards.aspx

Fowler, M. (2015). Guide to the code of ethics for nurses with interpreta- tive statements: Development, interpretation, and application. Silver Spring, MD: American Nurses Association.

OnCourse Learning Corporation. (2015). The ANA’s “year of ethics” kicks off with the release of revised code of ethics. Retrieved from http://news.nurse.com/article/20150121/NATIONAL06/150121003 #.VRb80sYtGUk