Professional Nursing Ethics: Code, Values, and Obligations

Introduction

It is possible — though not advisable — to enter the nursing profession today without knowing what the Nightingale Pledge is, or more importantly, what it represents. The reason this is inadvisable is straightforward: nursing is a field that carries enormous social, moral, and ethical responsibility. That accountability is now guided by the Code of Ethics with Interpretive Statements; however, the original blueprint was the Nightingale Pledge, which can be considered nursing's equivalent to the physicians' Hippocratic Oath. The modern version — the Code of Ethics with Interpretive Statements — is a thorough guide that helps both new and experienced nurses carry out their responsibilities in a way that meets all ethical duties required by the profession.

The Nightingale Pledge has evolved over more than a century, and throughout that time the healthcare industry has changed in countless ways — as have the responsibilities of nurses. At each step, the code of ethics has been present to provide goals, values, and obligations for those practicing the art of nursing. The code's ethical commitments have been updated as needed, and this paper will describe several of these ethical principles and their real-world implications.

The Nightingale Pledge has moved beyond its original principles and evolved into the Code of Ethics with Interpretive Statements, which incorporates more modern social and ethical values. For example, the code holds that the nursing community should collaborate with other health professions and citizens in order to promote community and national efforts to advance societal health. This obligation extends into the political arena as well. During the legislative push for the Affordable Care Act, nurses across the country worked alongside policymakers to advance meaningful healthcare reform. As then-ANA President Rebecca M. Patton noted:

"This has been a historic week of events for advocates of health care reform. The House passed H.R. 3962, 'The Affordable Health Care for America Act.' I wanted to take the opportunity to thank nurses across the country for their help and support in advancing meaningful health care reform. Whether you took part in town halls, wrote letters to the editor, or contacted your own representatives to voice your opinion — your actions had an impact." (Patton)

Social Responsibility

This example illustrates how the nursing community's ethical obligations can direct its members well beyond the clinical setting and into all aspects of civic life.

Like any industry, healthcare understands that delivering quality service requires commitment at every level of an organization. Nurses fulfill this commitment through two core ethical duties: respecting patient autonomy and meeting patient needs. Through these duties, nurses must act to safeguard clients and the public from incompetent, unethical, or illegal acts by any person. It is equally important, however, to distinguish between legal and ethical obligations, as the two do not always align — though they frequently overlap.

Consider healthcare fraud and its impact on the duty of autonomy. If a nurse knowingly updates an official medical record — whether for a real or fictitious patient — with false information, such as claiming a medication was administered when it was not, that action is clearly unethical. More significantly, it is also illegal. In such a situation, the nurse has not only violated the profession's ethical code but has also crossed into the territory of criminal statutes.

Legal and Ethical Issues

There are ample opportunities to commit fraud — whether deliberately or accidentally — over the course of a nursing career. Submitting false billing for services either rendered or not rendered is one clear example of failing a legal and ethical obligation. A common form of this fraud involves requesting reimbursement for non-covered or non-performed services, costing Medicare and communities millions — possibly billions — of dollars annually.

Other illegal practices in healthcare include billing for duplicate services, performing medically unnecessary procedures, exaggerating the severity of a condition, and other forms of misrepresentation. If a night-shift staff claims to have taken a patient's temperature every hour when they were in fact absent from their duties, they are falsifying the description of services rendered. All of these actions constitute fraud and carry legal consequences. In no way can such conduct be considered consistent with the standards of professional nursing.

An area where nursing can become ethically challenging is the intersection of personal values and professional ethics. Nurses must maintain their competence even when their personal values differ significantly from those of their patients. A client's race, sex, or religion must not interfere with the nurse's professional obligations. Everyone is entitled to equal care.

A troubling example of this failure occurred in the weeks following September 11, 2001. In some instances, Muslim and Middle Eastern patients — and anyone who appeared to be of Middle Eastern descent — were subjected to overt profiling and racism. Most disturbingly, some of these incidents took place in hospital emergency rooms, where staff refused to treat individuals they perceived as potential terrorists. Such conduct is a direct violation of nursing ethics. A homosexual man must not be treated poorly because of his sexual orientation. A Black woman who has been assaulted must not be judged differently than any other patient. Nurses must exercise sound ethical judgment and accept the full responsibilities of their profession without exception.

Nurses provide services rooted in respect for human dignity, and that responsibility cannot be altered by a patient's social or economic status, personal attributes, or the nature of their medical condition. This principle is also tested in hazardous work environments. Nurses are exposed to communicable diseases daily and frequently encounter patients who are violent or noncompliant. As nursing ethicist Ann Gallagher observed: "It was an opportunity to learn about the challenges nurses encounter in their everyday practice — health and social inequalities, HIV/AIDS, TB, poverty and compromised professionalism. Throughout the conference we heard reports of the harrowing working conditions of many nurses, of their fear of violence and their frustration at not having the resources to deliver the quality of care to which they are committed." (Gallagher)

Conclusion

Patton, Rebecca M. "A Message From ANA President Rebecca M. Patton." American Nurses Association, 2009.

Whitty-Rogers, Joanne, et al. "Working with Children in End-of-Life Decision Making." Nursing Ethics, vol. 16, no. 6, Nov. 2009, pp. 743–758.