Ethics in Nursing > Chapter 1

Ethics in Nursing

Presented by
Riki Salerno, RN, BSN


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Provider approved by the California Board of Registered Nursing, Provider Number CPE 14462
for 7 contact hours


At the completion of this course, the healthcare professional shall be able to:

1. Describe the historical influences and discuss the background to ethics in Nursing.

2. Identify all the provisions to the code of ethics for nursing as well as their application and benefits to nurses or patients.

3. Explain the value of ethical practices for the applied protection of clients as well as nurses.

4. Explain the correct and accepted interpretations of the code of ethics as they connect with the field of nursing.

5. Use the code of ethics as a guideline for the betterment of the patients, the working environment as well as the nursing field.

6. Apply ethical principles contained in the ANA Code of Ethics (2001) to manage ethics related situations in the medical field with regard to:
  • Nursing practice
  • The nursing profession
  • Relationships with patients
  • Relationships with coworkers

7. Detect and use the ethical guidelines for reporting a lapse in ethical behavior.

The Basics of Nursing Ethics

This chapter discusses the historical influences towards the field of ethics in general and the relationship of ethics to nursing in particular.

Topics Covered

  • What are ethics?
  • History of nursing ethics
  • Current ethical guidelines

What Are Ethics?

The word ethics comes from the Greek word ethikos which means "based on habit." In present terminology, ethics is a branch of philosophy which discusses individual and collective actions as being right, wrong, good or bad. In business and professional fields like finance, construction, public relations, advertising and many others, the application of ethical principles is said to be a part of the good practices which create and increase credibility (Alexandra & Woodruff, 1990).

The medical field is not exempt from the practice of ethics and there is an entirely different branch of ethics connected with the actions of doctors and nurses i.e. medical ethics. In fact, medical researchers who have little or no contact with human patients also have to follow bioethics which includes legal guidelines that govern how research can be done on any particular topic (Scanlon, 2000). The field of ethics is so broad that it often becomes difficult to define it in any particular shape or form.

Not Ethics

Therefore, it is important to know what ethics is not before we can define what it is. Velasquez et. al. (1987) report that when people on the street were inquired about the meaning of ethics, they said that ethics have to do with internal feelings of what is right and wrong or that ethics are religious beliefs or that ethics are legal requirements. People also considered ethics to be acceptable behavior as per the rules of society and some simply did not know what it meant.

While the responses stated above may come naturally given the context the word ethics is so often used in. It must be clarified that ethics have nothing to do with the internal feelings of a person (Alexandra & Woodruff, 1990). Feelings and emotions about something may lead a person to do what is wrong rather than what is right. Moreover, religion has little to do with ethics because if ethics were based on religion then every person might be free to follow their own set of ethical guidelines. Additionally, those who do no believe in any religion might consider them free of ethical concerns while clearly everyone has to accept the given ethical guidelines for his or her profession (Velasquez, et. al. 1987).

Laws are not ethics because legal clauses may include or be based on ethical principles, but all laws at all times may not be ethical. Consider the example of the discriminatory laws which were in place before the civil rights movement, or the slave ownership laws before the civil war. If we take ethics to mean whatever is acceptable to society, then it would be ethically acceptable to be anti-Semitic if a person were living in Germany during the Nazi era (Velasquez, et. al. 1987). Moreover, it is nearly impossible to accurately judge what is acceptable to society since the acceptance of certain things changes dynamically with time.

Two Parts of Ethics

In and of themselves, ethics as they apply to nurses cover two things which were discussed by Gillon (2003) and these include: Professionally mandated standards of right and wrong, supported by reasonable arguments given by experts in the field, that explain how nurses ought to perform their duties. The further development of the ethical standards a nurse adheres to.

A nurse can develop and improve the first part of ethics by studying and understanding the rules which are applicable to the nursing profession. The second part is somewhat more difficult to develop since it requires continual practice of ethical standards, and the ability to recognize ethical problems and their solutions (Velasquez, et. al. 1987). However, with a little bit of effort and study a nurse can soon come to a high standard of ethics and understand how ethical principles can guide the actions taken by the nurse.

The History of Ethics in Nursing

The primary body which creates ethical guidelines and monitors the field of nursing in the US is the American Nursing Association (Fowler, 2000). The present code of ethics for nurses was presented in 2001 and continues to be widely accepted as the correct set of ethical guidelines for the nursing field across the world. The code itself does not come out of thin air since more than a hundred years of perpetration started with the "Nightingale Pledge" in 1893, which is similar to the Hippocratic Oath for doctors (Bett, 1960).

Nightingale Pledge

The pledge itself was little more than a paragraph and is reproduced below, but it must be noted that many of the ideals contained in the pledge continue to be seen in the present day code of ethics.

"I solemnly pledge myself before God and in the presence of this assembly, to pass my life in purity and to practice my profession faithfully. I will abstain from whatever is deleterious and mischievous, and will not take or knowingly administer any harmful drug. I will do all in my power to maintain and elevate the standard of my profession, and will hold in confidence all personal matters committed to my keeping and all family affairs coming to my knowledge in the practice of my calling. With loyalty will I endeavor to aid the physician, in his work, and devote myself to the welfare of those committed to my care (McDonald, 2006, Pg. 1)".

This pledge was used as the basis for developing a code of ethics by the American Nurses Association (ANA) which was founded in 1896. The association presented its first draft in 1926 and a tentative code in 1940, but it was only in 1950 that a code of ethics for nurses was first established. The code was revised and amended several times afterwards as the influence of time and society changed the scope of a nurse's duties and responsibilities (Rambur, 1998). Substantial revisions took place in 1968 when the code was condensed and later in 1985 with the additional of interpretive statements. The present code as it is seen today was created in 2001 (ANA, 2001).

It must be noted that whatever shape or form the code was presented in, the basic ideas behind the code of ethics have always remained the same. As discussed by the American Nursing Association (2001), these principles are:
  • Doing no harm
  • Performing beneficial services
  • Remaining loyal to the profession
  • Honesty to oneself and the care receivers

Current Ethical Guidelines

The current code of ethics contains nine principles on which the entire structure is based. A brief deblockedion of those principles is given below, and an understanding of these principles is essential before their application and interpretation can be discussed. While some of the provisions are more or less self-explanatory, others require extensive explanations because the ethical questions associated with those provisions have no easy answers. The following summary of the provisions is a good starting point for ethics in nursing.

Provision 1

The first provision is possibly the simplest since it asks nurses to treat all patients and professional associates with respect and compassion without any biases (ANA, 2001). The code seems to recognize that an individual can have several biases for or against people who are rich or poor, people who belong to a certain group, and individuals who have certain diseases, or even the personal characteristics of a patient/coworker. This does not stop a nurse from disliking someone for personal reasons but, in a professional capacity, the provision is very clear that there is no room for biases.

Provision 2

The second provision is the shortest of the nine since it simply clarifies to all nurses that their main professional obligation is towards the patient. That patient can be one person or many persons in the shape of a family unit, or a group of people like a community (ANA, 2001). While the provision is easy enough to understand, it is never easy to follow since very often a nurse could find that her behavior shows a greater commitment to her own person than anyone else (Rankin, 2000). This provision acts as a reminder that every ethical nurse will always keep the focus on the patient rather than any other individuals she comes across in a professional capacity.

Provision 3

The third provision also concerns itself with the patient, but here the focus is on the rights of the person who is being cared for. Ethically, a nurse should support and promote the rights of a patient as they are concerned with the privacy and confidentiality of the patient (ANA, 2001). At the same time, this provision demands that all nurses protect these rights and act with vigilance if they see the rights being tarnished in any way whatsoever. A breach of these rights can come from the nurse or those who are working with the nurse; therefore, the code also gives ethical guidelines on how a nurse is supposed to react to such issues. This idea is further explained in provision four of the code.

Provision 4

As is the case with other professions, whenever there is contact between two individuals certain responsibilities, duties and obligations are created based on ethical behavior (Lebacqz, 1985). This provision makes it clear that nurses are completely responsible and can be held accountable for their nursing practices (ANA, 2001). A nurse can certainly delegate certain duties to others but ethics demand that any such delegation should maintain the best ideals for patient care as a priority.

Provision 5

While several provisions ask the nurse to look outwards and focus on the patient or coworkers, provision five asks the nurse to look inwards because he owes the same responsibility to others as owed to himself (ANA, 2001). Ideally, a nurse should be able to spot problems with his own behavior and ethical lapses, if there are any, and personal integrity can be strongly supported by looking inwards (Curtin, 2000). The resulting practical benefit of this approach is increased self respect and an assurance that a nurse is experiencing continual growth in professional terms.

Provision 6

After looking inwards, the nurse can focus on the environment she is placed in to increase the value provided to patients as well as those who work in the same environment. Provision six asks nurses to work towards creating and keeping a work environment which is most conducive towards medical care (ANA, 2001). Undoubtedly, the environment has a great impact on how work is performed and how values are maintained in an office or hospital setting. Therefore, with individual and collective action, an ethical nurse should strive for improving his/her surroundings for the benefit of all concerned. At the same time, it must be remembered that the primary duty of all nurses has to be the medical care of the patients.

Provision 7

In an even larger sense, the environment of the profession can be improved if every nurse works ethically towards the improving the particular area she is focused on (ANA, 2001). For example, a nurse dealing with a patient can contribute by helping in research or by producing research material for other nurses. A nurse who works in administration can come up with better systems to manage a hospital. The methods for improvement are endless and it is an ethical obligation for all nurses to do whatever they can, whenever they can, to bring improvements to the field.

Provision 8

Of course such improvements in the local environment or the medical field may not be easy to do on your own. Therefore, provision eight recommends that it would be ethical, as well as a recommended procedure, to cooperate and collaborate with other nurses and health related professionals to bring about such changes (ANA, 2001). These efforts do not need to remain within the same state or even within the same country, since international collaboration is often required to understand how the profession can be developed further.

Provision 9

Finally, the ninth provision brings the focus back to the various bodies and groups who give ethical and other guidelines, and says that these organizations are ethically responsible for creating and maintaining the values for the nursing community (ANA, 2001). These groups also have the ethical responsibility to maintain and develop social policy and assist in the creation of local, as well as international laws, which deal with the medical fields.

Knowing all the provisions and the general flavor of the code of ethics is only the first step towards being an ethical nurse and a valued professional to the field (Walleck, 1989). The second and more important step is to understand how this code of ethics is actually beneficial for a nurse in his/her day to day work life. Additionally, the code provides significant benefits for patients under the care of the nurse, therefore it is doubly useful for all people who are influenced by the code. These practical benefits are explained in the following chapters.
Question No.1. Generally speaking, most businesses and professions have a code of ethics for practitioners because the code:

a. Is a legal requirement
b. Is a religious requirement
c. Increases the credibility of the profession
d.Decreases the legal fees if a malpractice lawsuit is brought against the organization

Question No.2. Ethics are not based on government laws because:

a. Ethics are the same as laws
b. All laws may not be ethical at all times
c. Laws cover only legal requirements and have no bearing on the social value of a nurse
d. Professional bodes who govern the field of nursing do not agree with the laws of most countries

Question No.3. None of the following should be used in a code of ethics EXCEPT:

a. Social norms
b. Personal feelings
c. Religious doctrine
d. Professionally mandated standards

Question No.4. The primary body which regulates and creates ethical guidelines for the field of nursing in America is the:

a. Nursing Association of America (NAA)
b. Nursing Federation of America (NFA)
c. American Nursing Association (ANA)
d. US Nurses (USN)

Question No.5. There have been many changes and additions made to the code of ethics for nurses but the basics principles have remained the same. All of the following are a part of those basic principles EXCEPT:

a. Doing no harm
b. Performing beneficial services
c. Remaining loyal to the profession
d. Not switching to a different field of nursing

Question No.6. If a nurse shows a preference for and provides services with more diligence/care to an economically better off person as compare to another who is economically worse off, she is violating the code of ethics by ignorin:

a. Provision 1, which says that a nurse must not do any harm
b. Provision 1, which says that a nurse should not have any biases
c. Provision 6, which says that services must be given equally to all patients
d. Provision 6, which says that no difference in treatment can be maintained between the rich and the poor

Question No.7. An ethical nurse wishes to improve the level of research done in the nursing field and spends a lot of her time on that to the point that her patients begin to suffer. This act would be:

a. Ethical, because the nurse would be helping a lot more people by active research
b. Ethical, because research is one of the primary duties of the nurse
c. Unethical, because the basic responsibility of that nurse are the patients under her care
d. Unethical, because research is only supposed to be done by doctors

Question No.8. When it comes to the rights of the patient, the most important ethical obligation for a nurse is the patient's right towards:

a. Privacy and confidentiality
b. Assisted suicide
c. Euthanasia
d. Abortion
Ethics in Nursing > Chapter 1
Page Last Modified On: August 15, 2021, 07:20 AM