ANA Code of Ethics for Nurses:Revision Adds Bold New Provision 5
Editor’s note: The American Nurses Association’s Code of Ethics for Nurses contains nine provisions that are the foundation of nursing care. The purpose of the code is to provide concise statements of ethical obligations and duties to all nursing professionals.1 It is the profession’s ethical standard and commitment to society, and all acute and critical care nurses should practice in accordance with this code. Following is the fifth in a series of articles applying the provisions of the ANA Code of Ethics to critical care nursing practice. This article highlights the fifth provision and its underlying principles.
By Cynda Hylton Rushton, RN, DNSc, FAAN
Immediate Past Chair, AACN Ethics Work Group
The latest revision of the ANA Code of Ethics for Nurses adds a bold new Provision 5:
The nurse owes the same self-regarding duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence and to continue personal and professional growth.1
This statement acknowledges the importance of caring for oneself in order to care for others. These “self-regarding duties” include the nurse’s obligation to act to preserve personal and professional integrity, authenticity and competence. Provision 5 is consistent with AACN’s emphasis on creating ethical work environments that allow critical care nurses to make optimal contributions to the care of critically and terminally ill patients and patients’ families.2,3
For critical care nurses, clinical competence is a foundation of integrity. According to the AACN Synergy Model for Patient Care, competence is defined by the dimensions of critical care practice: clinical judgment, advocacy/moral agency, caring practices, facilitation of learning, collaboration, systems thinking, response to diversity, clinical inquiry and patient needs.4 Provision 5 affirms the obligation of critical care nurses to attain and maintain their clinical competence through lifelong learning, professional growth, self assessment, peer review, competency-based standards of practice and ongoing education. Practicing in a manner that upholds the profession’s standards enhances the critical care nurse’s self-respect, self-esteem, professional stature, work satisfaction and meaning.
Integrity is essential to maintaining a professional identity based on compassion, caring, trust and self-esteem. Integrity requires nurses to have trustworthy relationships with patients and families by establishing therapeutic boundaries, and with colleagues by engaging in authentic collaboration, honest dialogue, and creative problem solving.5 Nurses must believe that their actions are consistent with their personal and professional standards. Their sense of integrity is threatened if they believe what they do is inconsistent with how they behave. Such threats undermine the professional confidence the nurse conveys to patients and colleagues, undercut attempts at communication and erode the ability to respond compassionately to the needs of others. In the end, the quality of patient care is diminished.
The sense of doing “the right thing” is challenged in the critical care setting and its high levels of ambiguity and uncertainty. The work environment for nurses may threaten their professional ideal and goals, their self-image, moral character and personal identity. They may judge themselves harshly if the outcomes they pursue do not occur, if they are treated with disrespect or punished by other healthcare professionals or the institution where they practice, or if they fail to act because they lack skills or courage. The assault upon their basic values—their understanding of life, death, disability and relationships—may compromise how they perceive the meaning of their work. Disruptions may emerge as changes in their autonomy and moral well-being, and in the care they provide.6
When individuals are unable to translate their moral choices into action, moral distress occurs.7 Acting in a manner contrary to personal or professional values undermines the nurse’s integrity. Initially, nurses may become frustrated, angry and anxious, and conflicts with others about important values may begin to surface. Recognition of that initial moral distress makes integrity-preserving compromise possible. This requires what Provision 5 calls “an open forum for moral discourse and an atmosphere of mutual respect and regard.” The process involves an appraisal of how the situation and the actions taken or not taken affect the integrity and ethics of those involved.7
To give critical care nurses the tools they need to recognize and address moral distress in their practice, AACN’s Ethics Work Group has developed the 4 A’s for Addressing Moral Distress.8 This fall, a new Moral Distress tool kit will be available, including the 4 A’s guide, facilitator’s guide, slides, case studies and resources.
Developing institutional strategies to create a culture of integrity is essential to support ethical practice. Critical care nurses can anticipate and address ethical concerns in a proactive manner by:
• Providing a forum for staff to discuss and understand decisions and a decision-making process that is not focused on coercing others who have contrary views.
• Developing policies regarding end-of-life care and decision making, including “do not attempt resuscitation” orders, forgoing life-sustaining treatment, including medically provided hydration and nutrition, pain management, terminal sedation, surrogate decision making and organ donation.
• Honoring providers’ requests not to participate in morally objectionable situations based on hospital policy. Conscientious objection is one option that nurses may exercise when other mechanisms are ineffective or when their personal integrity is compromised.9
• Involving outside parties, such as ethics committees or ethics consultants, when standard methods fail. JCAHO now requires healthcare institutions to have a mechanism in place to clarify, analyze and resolve difficult ethical issues. Generally, ethics committees function in an advisory capacity, but may also provide education, mediation, support and external review.
• Implementing interventions that allow nurses to acknowledge and process their own grief and loss, restore and maintain their professional integrity, find meaning and reinvest in life.10,11 Effective interventions include such activities as debriefing sessions and forums.12 Debriefings after a patient dies allow caregivers to reflect on what has happened and identify opportunities for future changes in practices and structures. Forums with facilitated discussions create a safe place to tell and listen to stories, share concerns and fears, negotiate meaning and make sense of incomprehensible and confusing situations.
In an unprecedented effort, the ANA Code of Ethics highlights the centrality of respect, integrity, competence and self care. The new Provision 5 supports bold actions by critical care nurses to make their practice environment one where they can maintain their integrity and practice ethically.
1. ANA Code of Ethics for Nurses With Interpretive Statements. Available at http:/www.nursingworld.org/ethics/code/ethicscode150htm. Accessed July 7, 2005.
2. AACN Standards for Establishing and Sustaining Healthy Work Environments. Accessed July 7, 2005.
3. AACN Values Statement. Accessed July 7, 2005.
4. The AACN Synergy Model for Patient Care. Accessed July 7, 2005.
5. Rushton CH, Armstrong L, McEnhill M. Establishing therapeutic boundaries as patient advocates. Pediatr Nurs. 1996;22(3):185-189.
6. Rushton CH. Caregiver suffering in critical care nursing. Heart Lung. 1992;21(3):303-306.
7. Jameton A. Dilemmas of moral distress: moral responsibility and nursing practice. AWHONN’s Clin Issues Perinatal Women’s Health Nurs. 1993;4(4):542-51.
8. Wavra T (ed). The 4 A’s to Rise Above Moral Distress. American Association of Critical-Care Nurses. 2004.
9. Rushton CH, Scanlon C. When values conflict with obligations: safeguards for nurses. Pediatr Nurs. 1995; 21(3): 260, 261-268.
10. Papadatou D. Caring for dying children: a comparative study of nurses’ experiences in Greece and Hong Kong. Cancer Nurs. 2001;24(5):402-412.
11. Sanders J, Valente S. Nurse’s grief. Cancer Nurs. 1994;174(4):318-325.10.
12. Rushton CH. (in press). Being with dying: a framework for pediatric palliative care. J Pediatr Nurs.
Work Groups Focus on Association Initiatives
National AACN work groups will convene later this month to continue work on association initiatives in specific subject areas. The group members were selected from the pool of volunteers who registered in AACN’s just-in-time Volunteer Profile Database online (www.aacn.org > About AACN > Volunteer Opportunities).
Following are the appointments as well as the board and staff liaisons for 2005-06.
Advanced Practice Work Group
Kristine J. Peterson, RN, MS, MSN, CCRN, CCNS (chair)
Elisabeth G. Bradley, RN, MS, MSN, CCRN, APRN
Kathleen Ellstrom, RN, CNS, PhD
Pamela K. Popplewell, RN, RN-BC, MSN, CCRN, ARNP
Ellen M. Prewitt, RN-BC, MSN, CCRN, CRNP, APRN-BC, ACNP-C
Marcheta L. Rodgers, RN, RN-BC, MS, MSN, CCRN, APRN
Robin L. Watson, RN, MN, CCRN
Roberta Kaplow, RN, PhD, CCRN, CCNS (board liaison)
Linda J. Bell, RN, MSN (staff liaison)
Ethics Work Group
Debra Lynn-McHale Wiegand, RN, PhD, CCRN, FAAN (chair)
Margaret L. Campbell, RN, MSN, CS, FAAN
Gail P. Ciccarello, RN, MS, MSN
Peggy G. Kalowes, RN, CNS, MN, MS, CNRN, CCRC
Jennifer L. McCurdy, RN, BSN, MS
Valerie Ramsberger, RN, MSN, CNA, APRN, NP
Lucia D. Wocial, RN, CNS, DSN, PhD, CCNS
Denise Buonocore, RN, APRN-BC, CCRN (board liaison)
Teresa A. Wavra, RN, MSN, CCRN, CCNS (staff liaison)
Healthy Work Environment Work Group
Connie Barden, RN, MN, CCRN, CCNS (chair)
Maggie D. Carriker, RN, MSN
Kay Clevenger, RN, MS, MSN
Debra S. Gerardi, RN, MPH, JD
Joyce L. Maly, RN, BSN
Cynda H. Rushton, RN, DNS, FAAN
Karen Stutzer-Treimel, RN, MN, MS, CCRN, APRN
Nancy T. Blake, RN, MN, MS, CCRN (board liaison)
Dana K. Woods, MBA (staff liaison)
NTI Work Group
Marian S. Altman, RN, CNS, RN-BC, MSNc, CCRN, APRN, NP-C (chair)
Teri Lynn Kiss, RN, BSN, MS, CCRN, CFRN
Betsy M. McDowell, RN, MSN, PhD, CCRN
Patricia A. Radovich, RN, CNS, MS, MSN, FCCM
Laura S. Savage, CNS, MS, MSN
Mary A. Stahl, RN, CNS, MS, MSN, CCRN, CCNS, CS
Terry L. Tucker, RN, MS, MSN, CCRN, CEN
Polly Zahrt, RN, BS, BSN
Patricia Morton, RN, ND, PhD, APRN, NP, FAAN (board liaison)
Jodi E. Mullen, RN, CNS, MS, CCRN, CCNS (board liaison)
Bonnie L. Baker, RN, MHA (staff liaison)
Research Work Group
Sherill A. Cronin, RN, DSN, PhD (chair)
Christine L. Schulman, RN, CNS, MS, CCRN
Marilyn P. Hravnak, RN, PhD, CCRN, FCCM, APRN-BC
Kathleen A. Miller, RN, CNS, RN-BC, MSN, PhD, APRN
Janice M. Powers, RN, MSN, CCRN, CCNS, CNRN, FCCM
Maureen A. Seckel, RN, MSN, CCRN, ARNP-BC
Cheri M. Smith, RN, BS, BSN
Beth Hammer, RN, MSN, APRN-BC (board liaison)
Deborah L. Barnes, RN, BSN, MSN, CCRN (staff liaison)
Sept. 1 Is Deadline to Submit Research and Creative Solutions Abstracts for NTI 2006
Sept. 1 is the deadline to submit Research and Creative Solutions Abstracts for AACN’s 33rd National Teaching Institute and Critical Care Exposition, May 20 through 25 in Anaheim, Calif. Selected abstracts will be exhibited as either a poster or oral presentation. Individuals whose abstracts are accepted will receive a $75 reduction in NTI registration fees.
In addition, four research abstracts will be selected to receive the Research Abstract Award. The award recipients will present their findings at one of the NTI research oral presentation sessions and will also receive an additional $1,000 toward NTI expenses.
The applications as well as guidelines and resources are available online at www.aacn.org.
Public Policy Update
Phase-in Planned for National Provider Identifier Requirement
The Centers for Medicare & Medicaid Services plans to phase in the National Provider Identifier requirement for the Medicare fee-for-service program. The plan will require healthcare providers covered by the Health Insurance Portability and Accountability Act to use an National Provider Identifier as of May 23, 2007.
The Administrative Simplification provisions of HIPAA mandated the adoption of the standard unique identifier for healthcare providers. The National Plan and Provider Enumeration System collects identifying information on healthcare providers and assigns each a unique National Provider Identifier.
Additional information is available at https://nppes.cms.hhs.gov/NPPES/StaticForward.do?forward=static.npistart.
Report Documents Deficiencies in Care
Despite the high quality of the U.S. healthcare delivery system, many Americans do not get all the healthcare that they need. Improving the quality of care that Americans receive could save thousands of lives, millions of lost workdays and billions of dollars each year.
To address this problem, Congress mandated that the Agency for Healthcare Research and Quality prepare annual reports on healthcare quality and disparities. First released in 2003, the National Healthcare Quality Report and the National Healthcare Disparities Report track the nation’s annual progress in improving quality and reducing disparities in healthcare.
The 2004 National Healthcare Quality Report and National Healthcare Disparities Report document continuing deficiencies in care, particularly for poor and minority women.
Selected findings related to women’s health are available online in a fact sheet titled “Women’s Health Care in the United States.” Go to http://www.ahrq.gov/qual/nhqrwomen/nhqrwomen.htm.
GAO Questions Tax-Exempt Criteria for Nonprofit Hospitals
After finding that the level of uncompensated care provided by nonprofit hospitals is hardly more than that provided by for-profit hospitals, the U.S. Government. Accountability Office is looking at establishing criteria to hold
For more information about these and other issues, visit the AACN Web site.
Evidence-Based Clinical Practice Grant
This grant funds awards up to $1,000 to stimulate the use of patient-focused data and/or previously generated research findings to develop, implement and evaluate changes in acute and critical care nursing practice. Grant proposals are accepted twice a year and must be received by either Oct. 1 or March 1.
AACN Clinical Practice Grant
This $6,000 grant supports research focused on one or more of AACN’s research priorities. Research conducted in fulfillment of an academic degree is acceptable. Oct. 1 is the annual application deadline for this grant.
AACN-Sigma Theta Tau Critical Care Grant
AACN and Sigma Theta Tau International cosponsor this $10,000 grant, which may be used to fund research for an academic degree. Principal investigators must be members of AACN or of Sigma Theta Tau International. The principal investigator must have at least a master’s degree. Oct. 1 is the annual application deadline for this grant.
To find out about AACN’s research priorities and grant opportunities, visit the Research area of the AACN Web site or