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Understanding Ethical Practice in Nursing: Part One

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What Role Should Ethics Play in Nursing?

Nurses play an integral role in the advocacy of the patients and families in which they serve. Whether it be advocating for more aggressive treatment to meet their patient’s needs, or escalating perceived ethical challenges in nursing practice to the ethics committee, nurses are trusted to do what’s best for their patients. In order for nurses to do what is considered to be ‘best’ their patients, we must first understand the basics of ethics as it applies to nursing.

In this three-part series, we will discuss

  • The Nursing Code of Ethics
  • Ethical challenges in Nursing
  • Collaborative solutions to improve upon ethical challenges
  • Innovative ways to improve ethical practice in healthcare
  • How to identify barriers to providing ethical care
  • and Nurse-driven quality improvement initiatives
In part one of this three-part series, let’s review the nursing code of ethics and explore some common ethical challenges in nursing:


Florence Nightingale believed that a nurse’s ethical duty was first and foremost to care for the patient. This belief underpins every discussion of ethics in nursing to date. As health care becomes increasingly complex and the variety of circumstances nurses face becomes more challenging, considerable elaboration on ethical principles is required. There are four core concepts which are essential to professional nursing practice. They are – respect for patient autonomy, and the duty to act with beneficence, nonmaleficence and justice.
The American Nurses Association (ANA) adopted its first formal code of ethics in 1950. Over the years, many of the specifics have evolved and been clarified, yet the essentials remain. (The International Council of Nurses (ICN) also has had a Code of Ethics for Nurses since 1953.) The Code has since been through two thoughtful and lengthy revision processes, which included seeking input from nursing leaders and staff nurses alike, and developing examples of how the new Code could be used in specific clinical situations. The most recent revised document, known as the Code of Ethics for Nurses With Interpretive Statements, gained final organizational approval in January 2015.
READ THIS: 12 Characteristics that describe Nurses (And What They’re Not)
According to ANA, the Code “is foundational to nursing theory, practice, and praxis in its expression of the values, virtues, and obligations that shape, guide, and inform nursing as a profession,” and it serves the following purposes:

  • It is a succinct statement of the ethical values, obligations, duties, and professional ideals of nurses individually and collectively.
  • It is the profession’s non-negotiable ethical standard.
  • It is an expression of nursing’s own understanding of its commitment to society.


The ANA Code of Ethics has nine provisions that encompasses the role of the professional nurse in its entirety. The nine provisions include:

Provision 1

The nurse in all professional relationships, practices compassion and respect for the dignity, worth and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems. This provision includes subconcepts that include:

  • Respect for human dignity
  • Relationships to patients
  • The nature of health problems
  • The right to self-determination
  • Relationships with colleagues and others

Provision 2

The nurse’s primary commitment is to the patient, whether an individual, family, group or community. This provision includes subconcepts that include:

  • Primacy of the patient’s interests
  • Conflict of interest for nurses
  • Collaboration
  • Professional boundaries

Provision 3

The nurse promotes, advocates for, and strives to protect the health, safety, and rights of patient. This provision includes subconcepts that include:

  • Right to privacy
  • Right to confidentiality
  • Protection of participants in research
  • Standards and review mechanisms
  • Acting on questionable practice
  • Addressing impaired practice

Provision 4

The nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurse’s obligation to provide optimal patient care. This provision includes subconcepts that include:

  • Acceptance of accountability and responsibility
  • Accountability for nursing judgment and action
  • Responsibility for nursing judgment and action
  • Delegation of nursing activities

Provision 5

The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth. This provision includes subconcepts that include:

  • Moral self-respect
  • Professional growth and maintenance of competence
  • Wholeness of character
  • Preservation of integrity

Provision 6

The nurse participates in establishing, maintaining, and improving healthcare environments and conditions of employment conducive to the provision of quality healthcare and consistent with the values of the profession through individual and collective action. This provision includes subconcepts that include:

  • Influence of the environment on moral virtues and values
  • Influence of the environment on ethical obligations
  • Responsibility for the healthcare environment

Provision 7

The nurse participates in the advancement of the nursing profession through contributions to practice, education, administration and knowledge development. This provision includes subconcepts that include:

  • Advancing the profession through active involvement in nursing and in health care policy
  • Advancing the profession by developing, maintaining and implementing professional standards in clinical, administrative, and educational practice
  • Advancing the profession through knowledge development, dissemination, and application of practice

Provision 8

The nurse collaborates with other health professionals and the public in promoting community, national, and international efforts to meet health needs. This provision includes subconcepts that include:

  • Health needs and concerns
  • Responsibilities to the public

Provision 9

The profession of nursing, as represented by their associations and their members, is responsible for articulating nursing values, for maintaining the integrity of the profession and its practice, and for shaping social policy. This provision includes subconcepts that include:

  • Assertion of values
  • The profession carries out its collective responsibility through professional associations
  • Intraprofessional integrity
  • Social reform


When nurses encounter ethical dilemmas in situations in which they cannot do what they consider to be “the right thing,” they experience moral distress.
Let’s take a look as some examples of common ethical dilemmas in nursing practice:

  • Inadequate staffing ratios
  • Maintaining safety for self and patients
  • End of life care
  • Genetics and gene testing
  • Workplace bullying and lateral violence
  • Crippling healthcare costs
  • Unsupportive nursing administration

An example of maintaining safety for self and patients includes caring for those with mobility deficits, which may place them at risk for self-harm. Let’s consider that an alert and oriented elderly patient may want to walk without any nursing or nursing assistant supervision. The nurse knows that promoting independence is a therapeutic intervention, but the risk of patient injury due to falling may be great. The dilemma then becomes – how should the nurse balance the contrasting issues? Which is more important – patient independence or patient safety? Each nurse, patient, family, and healthcare team faces challenges such as this on a daily basis.
READ THIS: Professional Code Of Conduct For Nurses In Nigeria
Since nurses are caregivers on the front lines of health care, we are faced with ethical dilemmas at an increasing rate. Another example is that healthcare technology enables sick people to survive serious illnesses, however recent studies indicate that people who are surviving are not living high-quality lives. In fact, they are mostly bedridden, disabled, have have extensive comorbidities that make their day-to-day health care regimens incredibly complicated. This may place nurses in ethical dilemmas due to prolonging the suffering of individuals. Regardless of where nurses fall into ethical dilemmas, we have a role in implementing educational and clinical practices which address these individual issues as they arise.


Since nurses face increasing ethical dilemmas within the profession, nurse retention is suffering. Bullying and lateral violence in the workplace is one of the leading reasons why nurses leave the profession altogether. While nursing leadership and hospital administration continue to diminish the topic of bullying and lateral violence, nurses are leaving the profession in droves. In fact, approximately 60% of new nurses left their first job within six months due to bullying from their coworkers. When nurses are faced with unsupportive employers who do not invest in services to help their nursing staff navigate through ethical dilemmas, their moral distress may cause them to choose to leave their current place of employment with the hopes of finding a better fit.


Much like the effects of ethical dilemmas on nurse retention, patient outcomes are also at risk for negative impact. When nurses are distracted, torn, and struggling with moral distress due to unresolved ethical dilemmas, their focus shifts from patient-centeredness to that of self-preservation. When nurses face shifting priorities from that of the patient to themselves, patient outcomes will ultimately suffer. In a recent study, it was found that work-related moral distress may be associated with compromised health status among health professionals, reduced productivity, and inadequate safety during patient care.
As you can see, ethical challenges in nursing can cause a lot of distraction – which requires immediate resolution to promote optimal conditions for patient safety.
Stay tuned for part two of this three-part series, where we will go over collaborative solutions to enhance ethical practice in nursing and advocating for ethical patient care.
Best Wishes,


ANA. (2010, November 15). Code of Ethics with Interpretive Statements. Retrieved August 6, 2018, from https://www.princetonhcs.org/-/media/princeton/documentrepository/document
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