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The New 'Code of Ethics for Nurses with Interpretative Statements'.

In June 2015, over 300 registered nurses (RNs) gathered in Baltimore, MD, to examine the newly revised Code of Ethics for Nurses with Interpretive Statements (Code) (American Nurses Association [ANA], 2015a). Participants represented all nursing specialties and ranged from new graduates to nurses with more than 40 years of practice experience. All had one thing in common: a need to learn more about this revised Code.

Part I of this series introduced the reader to the revised Code, discussed the glossary, and used a nursing case scenario to illustrate Provisions 1 through 4 (Winland-Brown, Lachman, & Swanson, 2015). This article will complete the discussion of the Code, concentrating on Provisions 5 through 9 and including the interpretative statements for each provision. A nursing case scenario will be used to illustrate ethical dilemmas nurses may encounter.

Provisions 5 and 6 focus on ethical issues related to boundaries of duty and loyalty. The language used in the revised Code makes these provisions more precise and the interpretive statements supporting the provisions are organized more logically. As a result, the intent of Provisions 5 and 6 is easier to understand. Provisions 7 through 9 concentrate on the nurse's ethical duties beyond individual patient encounters. These provisions had the most significant changes. They focus on the nurse's obligation to address social justice issues through direct action and involvement in health policy, as well as a responsibility to contribute to nursing knowledge through scholarly inquiry and research. A case scenario illustrating ethical issues addressed in Provisions 5 through 9 follows.

Keisha and Kyle are two RNs working the night shift. They have been out of school for several years and have remained close friends. Kyle was one of Keisha's major supporters when she re-entered nursing. Keisha suffered an addiction to oxycodone after a shoulder injury. This forced Keisha to leave nursing until her successful completion of the recovering professional program administered by the Board of Nursing. Keisha continues to see a counselor on an as-needed basis.

Kyle has heard some rude comments about Keisha from co-workers. He heard Lindsey, a coworker, describe Keisha as "that bleeding heart liberal woman I have to work with every shift." Keisha earned this name after she was overheard discussing the death penalty with a patient one night. Lindsey has worked on the unit for many years. Keisha is uncomfortable when she has to interact with Lindsey.

Keisha admits to Kyle that working nights have been taking a toll on her health. She is beginning to feel "down" and has had difficulty finding time to go on any bicycle rides. Keisha is a passionate cyclist and was a member of a local cycling team known for its community work with the homeless. She also admits to Kyle she has not been motivated to complete continuing education requirements needed to finish her recertification. Furthermore, she has not been participating actively in the unit research council and has not met the deadline for an article about recovering nurses she had agreed to submit to a journal.

Kyle is concerned his friend is suffering from burnout. Keisha has used inappropriate jargon when describing patients in shift report and her grooming is not as neat and professional as when they began working together. Moreover, Keisha stated this is the first time in her professional career she feels uncomfortable going to work.

Provision 5

The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth.

This provision delineates personal behaviors in which the nurse must engage to achieve the expectations of the Code. These self-regarding behaviors include maintaining personal health, personal safety, and overall well-being. The nurse also must remain a competent nursing professional, growing in his or her professional and personal life.

The first interpretive statement addresses "duty to self and others." The virtue of respect encompasses respect for self as well as for patients. Keisha is having difficulty engaging in self-regarding behaviors; her behaviors indicate she is not caring for her physical, emotional, and spiritual self. Keisha is talking to patients about personal opinions (e.g., capital punishment), is not attending to her grooming, and has made derogatory statements about patients during shift change. These behaviors do not demonstrate respect for self or others.

The second interpretive statement focuses on "promotion of personal health, safety, and well-being." This interpretive statement centers on the importance of the nurse's care of self to mitigate burnout, fatigue, and compassion fatigue. This statement recommends "nurses should eat a healthy diet, exercise, get sufficient rest, maintain family and personal relationships, engage in adequate leisure and recreational activities, and attend to spiritual or religious needs" (ANA, 2015a, p. 19). Keisha is complaining of feeling "down" and admits to an inability to schedule leisure activities for exercise. Her change in grooming indicates a lack of attention to her role as a professional, and she is having difficulty working with at least one member of her team. These signs suggest a nurse suffering from burnout. However, because Keisha does not recognize the signs, she is not seeking advice and treatment from an appropriate source (Krischke, 2013). Kyle should discuss his concerns with her.

The third interpretive statement considers the "preservation of wholeness of character," and addresses the nurse's dual identity--professional and personal. It was appropriate for Keisha to discuss the capital punishment issue with a patient as long as she was speaking as an individual on the issue, as "authentic expression of one's own moral viewpoint is a duty to self" (p. 20). Nurses are free to express a personal opinion, as long as they preserve proper professional or personal boundaries. Interpretive statement 3 asserts, "Nurses must be aware of the potential for undue influence attached to their professional role" (p. 20). Because nurses will encounter situations with patients that test their personal beliefs, giving compassionate and respectful care thus can be challenging at times.

Interpretive statement 4 upholds "preservation of integrity." "Personal integrity is an aspect of wholeness of character that requires reflection and discernment: its maintenance is a self-regarding duty" (p. 20). Nurses face threats to their integrity in any health care setting. These threats can include demands for falsification of records, requests to deceive patients or families, and physical or verbal abuse from anyone in the setting. Lindsey has violated the Code by verbally abusing Keisha, and a manager needs to intervene and assure Keisha will not be bullied (Rocker, 2012). If the unit administrator fails to respond, Keisha has an obligation to take the next step up the chain of command to resolve this problem of bullying. Interpretive statement 4 maintains nurse administrators "must respond to concerns and act to resolve the concern in a way that preserves the integrity of the nurses" (p. 21).

This fourth interpretative statement also addresses the concept of conscientious objection. This means refusing to participate in a decision or action the nurse believes may endanger a patient, family, or community, or nursing practice itself because it violates the nurse's moral standards. Nurses must understand these acts of moral courage do not insulate them from formal or informal consequences (Lachman, 2014). Any eroding of the ethical environment could result in moral distress for nurses. Therefore, they have an obligation to express their conscientious objection to the appropriate authority.

Interpretive statement 5 focuses on "maintenance of competence and continuation of personal growth." Maintaining competence is not only important to professional growth, but also is a necessary lifelong duty. Keisha has violated this through her unwillingness to complete required necessary education to maintain certification. She has not participated in the nursing research council, and has failed to submit an article on recovering professionals to a journal. Kyle has a duty to encourage Keisha to complete her certification requirements and other professional commitments.

Interpretive statement 6 reflects on the necessity of "the continuation of personal growth." "Professional and personal growth reciprocate and interact" (p. 22). Nurses are encouraged to engage in activities that increase their knowledge and understanding of the world in which they live. This interpretive statement urges nurses to participate in activities, such as social advocacy, civic activities, and recreational activities. Keisha stopped going on team rides; these were not only recreational, but also a way to participate in community service. While these outside activities cannot be required of nurses, nurses are encouraged to participate.

Provision 6

The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care.

This provision describes the nurse's responsibility for creating a moral environment and expands the definitions of the virtues of nursing. The provision states "certain particular attributes of moral character might not be expected of everyone, but are expected of nurses" (p. 23). Nurses in all roles are responsible for instituting, sustaining, and cultivating an ethical work environment. Nurse managers/executives must involve nurses in decisions related to workplace conditions and professional practice. Nurse executives also need to advocate for appropriate organizational change to create a morally good environment.

Interpretive statement 1 focuses on expanding the definitions of the virtues of nursing and states nurses are expected to have specific attributes of moral character. Keisha has violated the Code by making derogatory comments about patients, thereby failing to demonstrate respect and compassion for those in her care. Keisha also is not caring for herself, placing her physical well-being at risk. The interpersonal communication between Lindsey and Keisha is hostile, leading both nurses to be in violation of the Code. Neither is practicing the expected nurse virtues of compassion, patience, or respect.

Interpretative statement 2 focuses on "the environment and ethical obligation." This statement asserts, "Nurses in all roles must create a culture of excellence and maintain practice environments that support nurses and others in the fulfillment of their ethical obligations" (p. 24). This means each nurse has a responsibility to address Lindsey's bullying to help ensure Keisha does not continue to be a target. Peer pressure may influence the team's response, but if members continue to allow the bullying through their silence, they are in violation of the Code. Understanding the Code and other ethical position statements will provide nurses the knowledge necessary to construct an environment needed for professional nursing practice.

Interpretative statement 3 addresses the "responsibility for the healthcare environment." This statement emphasizes, "nurses are responsible for contributing to a moral environment that demands respectful interactions among colleagues, mutual peer support, and open identification of difficult issues..." (p. 24). Nurses on the team have a collective responsibility to confront Keisha regarding her unprofessional remarks about patients, her lack of involvement in team professional activities, and the hostile relationship between Keisha and Lindsey. "The workplace must be a morally good environment to ensure safe, quality patient care and professional satisfaction for nurses and to minimize and address moral distress, strain, and dissonance" (p. 24).

Provision 7

The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy.

This provision first focuses on the nurse's role in knowledge development through research and scholarly inquiry. The second emphasis is on the importance of developing practice standards consistent with the Code and other foundational documents. The third focus underscores the nurse's responsibility to lead or serve on institution, local, state, regional, or global civic or organizational policymaking committees.

The first interpretative statement focuses on "contributions through research and scholarly inquiry." Knowledge development, whether through research or scholarly inquiry, is necessary to advance the theory and practice of nursing. Clinical nurses have the ethical obligation to know and disseminate the most recent research findings to support best practices. They also have the obligation to protect patient rights in research. Kiesha had demonstrated an initial interest in research and joined the unit research council. Now she is disengaged and is not meeting scholarly publication obligations. While this level of involvement is not a requirement, all nurses must remember clinical questions developed at the bedside often generate research questions. "All nurses must participate in the advancement of the profession ..." (p. 27).

The second interpretative statement addresses "contributions through developing, maintaining, and implementing professional practice standards." Professional nurses have an obligation to develop practice standards that support ethical practice and nursing's body of knowledge. Because of her compassion fatigue or burnout, Keisha appears to be doing little and is not meeting the obligations of professional nurses. Nurse managers and executives must support the autonomy of nurses in executing these standards to maintain quality patient care.

The third interpretative statement centers on "contributions through nursing and health policy development." Nurses can meet their ethical obligations by participating in a variety of local, state, national, or global initiatives. Keisha could use her addiction recovery experience to help change nursing regulations in her state and present at state and national conferences on needed policy changes.

Provision 8

The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities.

First, in comparison to the previous Code (ANA, 2001), this provision adds health as a universal right and significantly increases the focus of the nurse on human rights and health disparities. Second, it increases the nurse's obligation to take action on social injustice. For the first time, it also addresses nurse's moral obligations in extreme and extraordinary practice settings (e.g., Ebola, Hurricane Sandy).

The first interpretative statement, "health is a universal right," is new in this Code revision. This assertion is held in common with many human rights treaties; it includes many public health measures (e.g., sanitation, potable water, immunizations), basic access to prevention, and treatment of illness and injury. The Code lists 16 different entitlements included in this right (e.g., access to care, emergency care, prevention education). Keisha could take an active role in educating nurses and public in the prevention and treatment of drug abuse.

The second interpretative statement is "collaboration for health, human rights, and health diplomacy." Though nurses have a personal obligation to address human rights and health disparities, only through collaboration with other health care professionals can they make significant needed impact on these social justice issues. Practicing nurses see on a daily basis how a social problem becomes a health problem, as they view the effects of poverty, drug-infested neighborhoods, and food deserts ("urban neighborhoods and rural towns without ready access to fresh, healthy, and affordable food") (U.S. Department of Agriculture, 2015, para. 1). Keisha has seen health disparities among homeless persons through previous work via her cycling.

Interpretative statement 3 addresses the "obligation to advance health and human rights and reduce disparities." Individually or through community organizations, nurses can educate the public and join in legislative efforts to promote health. Again, nurses know firsthand the barriers to health; homelessness, abuse and violence, and lack of cultural sensitivity are a few of the obstacles to quality health care. Keisha has experienced personally how drug addiction stops the outward focus on others, and she could be a good addition to any team that addresses addiction leading to homelessness.

Interpretative statement 4 focuses on "collaboration for human rights in complex, extreme, or extraordinary practice settings." Nurses can face competing moral claims, for example, in caring for victims of natural disaster while needing to care for family. Nurses have a moral obligation to both groups, and only the individual nurse can determine which moral option to address (ANA, 2006). "Only in extreme emergencies and under exceptional conditions, whether due to forces of nature or human action, may nurses subordinate human rights concerns to other considerations" (p. 33). In such circumstance, the Code suggests a utilitarian framework could guide actions (greatest good for the greatest number) (ANA, 2011).

Provision 9

The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain integrity of the profession, and integrate principles of social justice into nursing and health policy.

In comparison to the previous Code (ANA, 2001), this Code (ANA, 2015a) addresses more in depth nurses' responsibilities to engage in rectifying social injustices and health disparities in the community and beyond. The interpretative statements address issues impacting nursing practice now (e.g., climate change, human trafficking).

The first interpretative statement about "articulation and assertion of values" identifies the need for professional nursing organizations to provide a unified voice for the profession. The various professional organizations of nursing "communicate to the public the values that nursing considers central to the promotion or restoration of health, the prevention of illness or injury, and the alleviation of suffering" (p. 35). By acting in unity, nurses can have a noteworthy impact on social justice and global health policies.

The "integrity of the profession" is the second interpretative statement and is based on the knowledge and observance of essential documents, such as the Code (ANA, 2015a) and Nursing: Scope and Standards of Practice (ANA, 2015b). These documents support the covenant between the nursing profession and society. This promise also is supported by defined educational requirements for entry into practice, augmented utilization of advanced practice nurses, increased focus on certification, and nursing's commitment to evidence-based practice. Keisha is not doing the needed work for recertification, which could be seen as a violation of this provision.

The focus of the third interpretative statement is "integrating social justice," with examples of the multiple ways this can be accomplished. This interpretative statement recognizes the responsibility of nursing organizations to advocate for changes in health policies on local, national, and international stages. Because social determinants of health continuously foster social injustice, nurses must take action with governmental and nongovernmental bodies related to health affairs. The statement also identifies the nurse's responsibility to "firmly anchor students in nursing's professional responsibility to address unjust systems and structures..." (p. 36). Keisha could address the issue of social justice for recovering individuals by volunteering to speak to nursing classes. Through content education, staff development, or clinical experience, nurses can help students and practicing professional nurses model a commitment to eradication of social injustice.

"Social justice in nursing and health policy" is the final interpretative statement in the new Code (ANA, 2015a). This final statement fittingly focuses on global health and the need for voices of U.S. nurses to be heard around the world. In this reiteration of the Code, the health of the natural world is first addressed. Though Florence Nightingale demonstrated concern for the effects of environment on health, the profession today must extend its advocacy as the "environmental assaults disproportionately affect the health of the poor" (p. 37). The "Laudato Si" statement by Pope Francis (2015) starkly ties the effects of climate change to devastating effects on the poor.

Conclusion

This article elaborates on Keisha's and Kyle's obligations as professional nurses to meet the Code (ANA, 2015a). In preparing this article, the authors were confronted with what they could be doing to advance the profession and assist other nurses to do the same. Hopefully, nurses reading this article will look inward, find ways to promote this new Code, and improve the ethical practice of nursing. This revised Code provides nurses with the guidance to continue to earn the public's trust.

REFERENCES

American Nurses Association (ANA). (2001). Code of ethics for nurses with interpretative statements. Silver Spring, MD: Author.

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

American Nurses Association (ANA). (2015b). Nursing: Scope and standards of practice. Silver Spring, MD: Author.

American Nurses Association (ANA). (2011). Short definitions of ethical principles and theories. Retrieved from http://www.nursingworld.org/MainMenuCategories/EthicsStandards/Resources/Ethics Definitions.pdf

American Nurses Association (ANA). (2006). Risk and responsibility. Retrieved from http://nursingworld.org/MainMenuCategories/ EthicsStandards/Ethics-Position-Statements/RiskandResponsibility.pdf

Krischke, M.M. (2013). Suffering from compassion fatigue, burnout of both? What a nurse can do. Retrieved from http://www.nursezone. com/Nursing-News-Events/more-news/Suffering-fromCompassion-Fatigue-Burnout-or-Both-What-a-Nurse-Can- Do_41375.aspx

Lachman, V.D. (2014). Conscientious objection in nursing: Definition and criteria for acceptance. MEDSURG Nursing, 23(3), 196-198.

Pope Francis. (2015). Laudato Si' on care for our common home. Retrieved from http://w2.vatican.va/content/dam/francesco/pdf/ encyclicals/documents/papa-francesco_20150524_enciclicalaudato-si_en.pdf

Rocker, C.F. (2012). Responsibility of a frontline manager regarding staff bullying. The Online Journal of Issues in Nursing. 18(2). Retrieved from http://nursingworld.org/MainMenuCategories/ANAMarket place/ANAPeriodicals/OJIN/TableofContents/Vol-17-2012/No3Sept-2012/Articles-Previous-Topics/Responsibility-of-Manager- Re-Bullying.html

U.S. Department of Agriculture. (2015). Food deserts. Retrieved from http://apps.ams.usda.gov/fooddeserts/foodDeserts.aspx

Winland-Brown, J., Lachman, V.D., & Swanson, E.O. (2015). The new 'Code of Ethics for Nurses with Interpretative Statements' (2015): Practical clinical application, Part I. MEDSURG Nursing, 24(3), 268-271.

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.

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.
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Title Annotation:2015): Practical Clinical Application, Part II. (Ethics, Law, and Policy
Author:Lachman, Vicki D.; Swanson, Elizabeth O'Connor; Winland-Brown, Jill
Publication:MedSurg Nursing
Date:Sep 1, 2015
Words:3581
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