Background on ANA Code for Nurses

Developing a code of ethics is an essential characteristic of a profession. Along with licensure, standards of care and certification, it is one of the means of professional self-regulation. A code of ethics indicates a profession's acceptance of the responsibility and trust with which it has been invested by society.

As early as 1893 nursing leaders saw the development of a code of ethics as a task of the professional organization. It was not until the 1926 American Nurses' Association Convention that the first Code of Ethics was adopted. Developed to create an awareness of ethical considerations, this early code dealt with personal behavior, the nurse's relationship with the physician as well as professiona1 behavior.

The American Nurses' Association periodically revises the code (the present Code was written in 1976). It serves to inform both nurses and the society we serve that we have professional expectations and requirements in ethical matters. Along with its interpretative statements the code serves as a framework to make ethical decisions.

Preamble

The Code for Nurses is based on belief about the nature of individuals, nursing, health and society. Recipients and providers of nursing services are viewed as individuals and groups who possess basic rights and responsibilities, and whose values and circumstances command respect at all times. Nursing encompasses the promotion and restoration of health' the prevention of illness. and the alleviation of suffering. The statements of the Code and their interpretation provide guidance for conduct and relationship in carrying out nursing responsibilities consistent with the ethical obligations of the profession and quality in nursing care.

1.1 Respect for Human Dignity
The fundamental principle of nursing practice is respect for the inherent dignity and worth of every client. Nurses are morally obligated to respect human existence and the individuality of all persons who are the recipients of nursing actions. Nurses therefore must take all reasonable means to protect and preserve human life when there is hope of recovery or reasonable hope of benefit from life-prolonging treatment.

Truth telling and the process of reaching informed choice underlie the exercise of self-determination, which is basic to respect for persons. Clients should be as fully involved as possible in the planning and implementation of their own health care. Clients have the moral right to determine what will be done with their own person; to be given accurate information, and all the information necessary for making informed judgments; to be assisted with weighing the benefits and bur dens of options in their treatment; to accept, refuse, or terminate treatment without coercion; and to be given necessary emotional support. Each nurse has an obligation to be knowledgeable about the moral and legal rights of all clients and to protect and support those rights. In situations in which the client lacks the capacity to make a decision, a surrogate decision-maker should be designated.

Individuals are interdependent members of the community. Taking into account both individual rights and the interdependence of persons in decision making, the nurse recognizes those situations in which individual rights to autonomy in health care may temporarily be overridden to preserve the life of the human community; for example, when a disaster demands triage or when an individual presents a direct danger to others. The many variables involved make it imperative that each case be considered with full awareness of the need to preserve the rights and responsibilities of clients and the demands of justice. The suspension of individual rights must always be considered a deviation to be tolerated as briefly as possible.

1.2 Status and Attributes of Clients
the need for health care is universal, transcending all national, ethnic, racial, religious, cultural, political, educational, economic, developmental, personality, role, and sexual differences. Nursing care is delivered without prejudicial behavior. Individual value systems and life-styles should be considered in the planning of health care with and for each client. Attributes of client's influence nursing practice to the extent that they represent factors the nurse must understand, consider, and respect in tailoring care to personal needs and in maintaining the individual's self-respect and dignity.

1.3 The Nature of Health Problems.
The nurse's respect for the worth and dignity of the individual human being applies, irrespective of the nature of the health problem. It is reflected in care given the person who is disabled as well as one without disability, the person with long-term illness as well as one with acute illness, the recovering patient as well as one in the last phase of life. This respect extends to all who require the services of the nurse for the promotion of health, the prevention of illness, the restoration of health, the alleviation of suffering, and the provision of supportive care of the dying. The nurse does not act deliberately to terminate the life of any person.

The nurse's concern for human dignity and for the provision of high quality nursing care is not limited by personal attitudes or beliefs. If ethically opposed to interventions in a particular case because of the procedures to be used, the nurse is justified in refusing to participate. Such refusal should be made known in advance and in time for other appropriate arrangements to be made for the client's nursing care. If the nurse becomes involved in such a case and the client's life is in jeopardy the nurse is obliged to provide for the client's safety, to avoid abandonment, and to withdraw only when assured that alternative sources of nursing care are available to the client.

The measures nurses take to care for the dying client and the client's family emphasize human contact. They enable the client to live with as much physical, emotional, and spiritual comfort as possible, and they maximize the values the client has treasured in life. Nursing care is directed toward the prevention and relief of the suffering commonly associated with the dying process. The nurse may provide interventions to relieve symptoms in the dying client even when the interventions entail substantial risks of hastening death.

1.4 The Setting for Health Care
The nurse adheres to the principle of nondiscriminatory, non-prejudicial care in every situation and endeavors to promote its acceptance by others. The setting shall not determine the nurse's readiness to respect clients and to render or obtain needed services.

2.1 The Client's Right to Privacy
The right to privacy is an inalienable human right. The client trusts the nurse to hold all information in confidence. This trust could be destroyed and the client's welfare jeopardized by injudicious disclosure of information provided in confidence. The duty of confidentiality, however, is not absolute when innocent parties are in direct jeopardy.

2.2 Protection of Information.
The rights, well being, and safety of the individual client should be the determining factors in arriving at any professional judgment concerning the disposition of confidential information received from the client relevant to his or her treatment. The standards of nursing practice and the nursing responsibility to provide high quality health services require that relevant data be shared with members of the health team. Only information pertinent to a client's treatment and welfare is disclosed, and it is disclosed only to those directly concerned with the client's care.

Information documenting the appropriateness, necessity, and quality of care required for the purposes of peer review, third-party payment, and other quality assurance mechanisms must be disclosed only under defined policies, mandates, or protocols. These written guidelines must assure that the rights, well being, and safety of the client are maintained.

2.3 Access to Records
If in the course of providing care there is a need for the nurse to have access to the records of persons not under the nurse's care, the persons affected should be notified and whenever possible, permission should be obtained first. Although records belong to the agency where the data are collected, the individual maintains the right of control over the information in the record. Similarly, professionals may exercise the right of control over information they have generated in the course of health care.

If the nurse wishes to use a client's treatment record for research or non-clinical purposes in which anonymity cannot be guaranteed, the client's consent must be obtained first. Ethically, this ensures the client's right to privacy; legally, it protects the client against unlawful invasion of privacy.

3.2 Acting on Questionable Practice
When the nurse is aware of inappropriate or questionable practice in the provision of health care, concern should be expressed to the person carrying out the questionable practice and attention called to the possible detrimental effect upon the client's welfare. When factors in the health care delivery system threaten the welfare of the client, similar action should be directed to the responsible administrative person. If indicated, the practice should then be reported to the appropriate authority within the institution, agency, or larger system.

There should be an established process for the reporting and handling of incompetent, unethical, or illegal practice within the employment setting so that such reporting can go through official channels without causing fear of reprisal. The nurse should be knowledgeable about the process and be prepared to use it if necessary. When questions are raised about the practices of individual practitioners or of health care systems, written documentation of the observed practices or behaviors must be available to the appropriate authorities. State nurses associations should be prepared to provide assistance and support in the development and evaluation of such processes and in reporting procedures.

When incompetent, unethical, or illegal practice on the part of anyone concerned with the client's care is not corrected within the employment setting and continues to jeopardize the client's welfare and safety, the problem should be reported to other appropriate authorities such as practice committees of the pertinent professional organizations or the legally constituted bodies concerned with licensing of specific categories of health workers or professional practitioners. Some situations may warrant the concern and involvement of all such groups. Accurate reporting and documentation undergird all actions.

3.3 Review Mechanisms.
The nurse should participate in the planning, establishment, implementation, and evaluation of review mechanisms that serve to safeguard clients, such as duly constituted peer review processes or committees and ethics committees. Such ongoing review mechanisms are based on established criteria, have stated purposes, include a process for making recommendations, and facilitate improved delivery of nursing and other health services to clients wherever nursing services are provided.

4.1 Acceptance of Responsibility and Accountability.
The recipients of professional nursing services are entitled to high quality nursing care. Individual professional licensure is the protective mechanism legislated by the public to ensure the basic and minimum competencies of the professional nurse. Beyond that, society has accorded to the nursing profession the right to regulate its own practice. The regulation and control of nursing practice by nurses demand that individual practitioners of professional nursing must bear primary responsibility for the nursing care clients receive and must be individually accountable for their own practice.

4.2 Responsibility for Nursing Judgment and Action
Responsibility refers to the carrying out of duties associated with a particular role assumed by the nurse. Nursing obligations are reflected in the ANA publications Nursing. A Social Policy Statement and Standards of Clinical Nursing Practice. In recognizing the rights of clients, the standards describe a collaborative relationship between the nurse and the client through use of the nursing process. Nursing responsibilities include data collection and assessment of the health status of the client; formation of nursing diagnoses derived from client assessment; development of a nursing care plan that is directed toward designated goals, assists the client in maximizing his or her health capabilities, and provides for the client's participation in promoting, maintaining, and restoring his or her health; evaluation of the effectiveness of nursing care in achieving goals as determined by the client and the nurse; and subsequent reassessment and revision of the nursing care plan as warranted. In the process of assuming these responsibilities, the nurse is held accountable for them.

The nursing profession continues to develop ways to clarify nursing's accountability to society. The contract between the profession and society is made explicit through such mechanisms as (a) the Code for Nurses, (b) the standards of nursing practice, (c) the development of nursing theory derived from nursing research in order to guide nursing actions (d) educational requirements for practice, (e) certification, and (f) mechanisms for evaluating the effectiveness of the nurse's performance of nursing responsibilities.

Nurses are accountable for judgments made and actions taken in the course of nursing practice. Neither physicians' orders nor the employing agency's policies relieve the nurse of accountability for actions taken and judgments made.

5.1 Personal Responsibility for Competence
The profession of nursing is obligated to provide adequate and competent nursing care. Therefore it is the personal responsibility of each nurse to maintain competency in practice. For the client's optimum well-being and for the nurse's own professional development, the care of the client reflects and incorporates new techniques and knowledge in health care as these develop, especially as they relate to the nurse's particular field of practice. The nurse must be aware of the need for continued professional learning and must assume personal responsibility for currency of knowledge and skills.

5.2 Measurement of Competence in Nursing Practice
Evaluation of one's performance by peers is a hallmark of professionalism and a method by which the profession is held accountable to society. Nurses must be willing to have their practice reviewed and evaluated by their peers. Guidelines for evaluating the scope of practice and the appropriateness, effectiveness, and efficiency of nursing practice are found in nursing practice acts, ANA standards of practice, and other quality assurance mechanisms. Each nurse is responsible for participating in the development of objective criteria for evaluation. . In addition, the nurse engages in ongoing self-evaluation of clinical competency, decision-making abilities, and professional judgments.

5.3 Intra professional Responsibility for Competence in Nursing Care
Nurses shares responsibility for high quality nursing care. Nurses are required to have knowledge relevant to the current scope of nursing practice, changing issues and concerns, and ethical concepts and principles. Since individual competencies vary, nurses refer clients to and consult with other nurses with expertise and recognized competencies in various fields of practice.

6.1 Changing Functions
Nurses are faced with decisions in the context of the increased complexity of health are, changing patterns in the delivery of health services, and the development of evolving nursing practice in response to the health needs of clients. As the scope of nursing practice changes, the nurse must exercise judgment in accepting responsibilities, seeking consultation, and assigning responsibilities to others who carry out nursing care.

6.2 Accepting Responsibilities.
The nurse must not engage in practices prohibited by law or delegate to others activities prohibited by practice acts of other health care personnel or by other laws. Nurses determine the scope of their practice in light of their education, knowledge, competency, and extent of experience. If the nurse concludes that he or she lacks competence or is inadequately prepared to carry out a specific function, the nurse has the responsibility to refuse that work and to seek alternative sources of care based on concern for the client's welfare. In that refusal, both the client and the nurse are protected. Inasmuch as the nurse is responsible for the continuous care of patients in health care settings, the nurse is frequently called upon to carry out components of care delegated by other health professionals as part of the client's treatment regimen. The nurse should not accept these interdependent functions if they are so extensive as to prevent the nurse from fulfilling the responsibility to provide appropriate nursing care to clients.

6.3 Consultation and Collaboration
The provision of health and illness care to clients is a complex process that requires a wide range of knowledge, skills, and collaborative efforts. Nurses must be aware of their own individual competencies. When the needs of the client are beyond the qualifications and competencies of the nurse, consultation and collaboration must be sought from qualified nurses, other health professionals, or other appropriate sources. Participation on interdisciplinary or interdisciplinary teams is often an effective approach to the provision of high quality total health services.

6.4 Delegation of Nursing Activities
Inasmuch as the nurse is accountable for the quality of nursing care rendered to clients, nurses are accountable for the delegation of nursing care activities to other health workers. Therefore, the nurse must assess individual competency in assigning selected components of nursing care to other nursing service personnel. The nurse should not delegate to any member of the nursing team a function for which that person is not prepared or qualified. Employer policies or directives do not relieve the nurse of accountability for making judgments about the delegation of nursing care activities.

7.1 The Nurse and Development of Knowledge.
Every profession must engage in scholarly inquiry to identify, verify, and continually enlarge the body of knowledge that forms the foundation for its practice. A unique body of verified knowledge provides both framework and direction for the profession in all of its activities and for the practitioner in the pro vision of nursing care. The accrual of scientific and humanistic knowledge promotes the advancement of practice and the well being of the profession's clients. Ongoing scholarly activity such as research and the development of theory is indispensable to the full discharge of a profession's obligations to society. Each nurse has a role in this area of professional activity, whether as an investigator in furthering knowledge, as a participant in research, or as a user of theoretical and empirical knowledge.

7.2 Protection of Rights of Human Participants in Research
Individual rights valued by society and by the nursing profession that have particular application in research include the right of adequately informed consent, the right to freedom from risk of injury, and the right of privacy and preservation of dignity. Inherent in these rights is respect for each individual's rights to exercise self-determination, to choose to participate or not, to have full information, and to terminate participation in research without penalty.

It is the duty of the nurse functioning in any research role to maintain vigilance in protecting the life, health, and privacy of human subjects from both anticipated and unanticipated risks and in assuring informed consent. Subjects' integrity, privacy, and rights must be especially safeguarded if the subjects are unable to protect themselves because of incapacity or because they are in a dependent relationship to the investigator. The investigation should be discontinued if its continuance might be harmful to the subject.

7.3 General Guidelines for Participating in Research
Before participating in research conducted by others, the nurse has an obligation to (a) obtain information about the intent and the nature of the research and (b) ascertain that the study proposal is approved by the appropriate bodies, such as institutional review boards.

Research should be conducted and directed by qualified persons. The nurse who participates in research in any capacity should be fully informed about both the nurse's and the client's rights and obligations.

8.1 Responsibility to the Public for Standards
Nursing is responsible and accountable for admitting to the profession only those individuals who have demonstrated the knowledge, skills, and commitment considered essential to professional practice. Nurse educators have a major responsibility for ensuring that these competencies and a demonstrated commitment to professional practice have been achieved before the entry of an individual into the practice of professional nursing.

Established standards and guidelines for nursing practice provide guidance for the delivery of professional nursing care and are a means for evaluating care received by the public. The nurse has a personal responsibility and commitment to clients for implementation and maintenance of optimal standards of nursing practice.

8.2 Responsibility to the Profession for Standards.
Established standards reflect the practice of nursing grounded in ethical commitments and a body of knowledge. Professional standards or guidelines exist in nursing practice, nursing service, nursing education, and nursing research. The nurse has the responsibility to monitor these standards in daily practice and to participate actively in the profession's ongoing efforts to foster optimal standards of practice at the local, regional, state, and national levels of the health care system.

Nurse educators have the additional responsibility to maintain optimal standards of nursing practice and education in nursing education programs and in any other settings where planned learning activities for nursing students take place.

9.1 Responsibility for Conditions of Employment
The nurse must be concerned with conditions of employment that (a) enable the nurse to practice in accordance with the standards of nursing practice and (b) provide a care environment that meets the standards of nursing service. The provision of high quality nursing care is the responsibility of both the individual nurse and the nursing profession. Professional autonomy and self-regulation in the control of conditions of practice are necessary for implementing nursing standards.

9.2 Maintaining Conditions for High Quality Nursing Care
Articulation and control of nursing practice can be accomplished through individual agreement and collective action. A nurse may enter into an agreement with individuals or organizations to provide health care. Nurses may participate in collective action such as collective bargaining through their state nurses' association to determine the terms and conditions of employment conducive to high quality nursing care. Such agreements should be consistent with the profession's standards of practice, the state law regulating nursing practice, and the Code for Nurses.

The nurse does not give or imply endorsement to advertising, promotion, or sale of commercial products or services in a manner that may be interpreted as reflecting the opinion or judgment of the profession as a whole. The nurse may use knowledge of specific services or products in advising an individual client, since this may contribute to the client's health and well being. In the course of providing information or education to clients or other practitioners about commercial products or services, however, a variety of similar products or services should be offered or described so the client or practitioner can make an informed choice.

10.2 Maintaining the Integrity of Nursing
The use of the title registered nurse is granted by state governments for the protection of the public. Use of that title carries with it the responsibility to act in the public interest. The nurse may use the title R.N. and symbols of academic degrees or other earned or honorary professional symbols of recognition in all ways that are legal and appropriate. The title and other symbols of the profession should not be used, however, for benefits unrelated to nursing practice or the profession, or used by those who may seek to exploit them for other purposes.

Nurses should refrain from casting a vote in any deliberations involving health care services or facilities where the nurse has business or other interests that could be construed as a conflict of interest.

11.1 Collaboration with Others to Meet Health Needs
The availability and accessibility of high quality health services to all people require collaborative planning at the local, state, national, and international levels that respects the interdependence of health professionals and clients in health care systems. Nursing care is an integral part of high quality health care, and nurses have an obligation to promote equitable access to nursing and health care for all people.