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The ANA Code of Ethics for Nurses With Interpretive Statements: Resource for Nursing Regulation Linda L. Olson, PhD, RN, NEA-BC, FAAN, and Felicia Stokes, JD, RN

The American Nurses Association (ANA) Code of Ethics for Nurses With Interpretive Statements informs decision making

about ethical violations by nurses and nursing education programs. The Code is the nursing profession’s ethical standard of

practice and nursing’s contract with society. Nurse practice acts (NPAs) and the standards of practice are the profession’s

legal standard. This article describes the nine provisions of the Code and provides cases of ethical violations and the disciplin-

ary actions that were taken. The intent of this article is to serve as an educational resource on how the Code can be used with

NPAs to support nurse regulators in their decision making.

Keywords: Boards of nursing, Code of Ethics for Nurses, ethics, nurse practice acts, nursing regulation

Objectives ⦁ Discuss the ANA’s Code of Ethics for Nurses with Interpretive

Statements as the profession’s ethical standard of practice. ⦁ Describe how nurse regulators use the Code of Ethics to sup-

port decision making. ⦁ Identify the nine provisions of the Code of Ethics.

The American Nurses Association (ANA) Code of Ethics for Nurses With Interpretive Statements (the Code) (American Nurses Association [ANA], 2015a), the

profession’s ethical standard of practice, provides a framework for ethical practice and decision making, guides the profession in self-regulation, establishes the profession’s social contract with society, and educates the profession on ethical responsi- bilities. The Code consists of nine main provisions with inter- pretive statements that exemplify the application of the Code in nursing practice.

As the profession’s ethical standard, the Code is non- negotiable (ANA, 2015a, p. viii). Neither individual nurses nor groups of nurses can negotiate changes in the language of the Code. Nurses in all roles and settings must adhere to the Code in their practice. Ethics occurs within the framework of all relationships nurses encounter in their professional roles (Olson, 2012). As licensed professionals, nurses have a relation- ship with their state boards of nursing (BONs), which regu- late nursing practice and protect the public by ensuring that the standards of nursing practice are met and that nurses are competent to practice. “Nurses must always comply with and adhere to state nurse practice acts [NPAs], regulations, stan-

dards of care, and ANA’s Code of Ethics for Nurses with Interpretive Statements” (ANA, 2015a, p. 15).

The 2015 version of the Code is the first revision since 2001, and the ANA declared 2015 as the “Year of Ethics” (ANA, 2015b). This emphasis on ethics calls for nurses in all roles and settings to know the Code and encourage col- leagues to read and discuss it. In 2014, Johns Hopkins School of Nursing and Johns Hopkins Berman Institute of Bioethics led a national summit meeting on Nursing Ethics for the 21st Century. The meeting focused on the commitment of nursing’s professional organizations to uphold the professional values of nursing and to identify the strategic nursing ethics priorities for the profession. The ANA, the National Council of State Boards of Nursing (NCSBN), and 18 other organizations par- ticipated as collaborating partners in this initiative, which identified ways to improve the ethical environment for nurses, and therefore the quality of care provided to patients and fami- lies (Rushton & Broome, 2014).

The purpose of this article is to describe and exemplify how the Code is used as a resource by nurse regulators as they consider cases related to violations of the NPA. Actual cases of such violations are presented for five of the first six provisions. Each violation also reflects an ethical violation. Because the last three provisions emphasize the importance of leadership by individuals and groups of nurses as well as of professional nursing organizations, no cases are presented.

Continuing Education

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Background The ANA Code of Ethics was formally adopted in 1950; how- ever, its focus on the profession’s core values and nurses’ obliga- tions and duties dates to the 1893 Nightingale Pledge. Early versions of the Code emphasized obligations to carry out physi- cian orders, rules of conduct, and duties. By contrast, later ver- sions emphasized obligations to patients, increased awareness of technological advances, and increased autonomy of nursing practice. The 1985 Code incorporated bioethical language in alignment with society’s focus on bioethics and the use of life- saving and life-prolonging technologies. New provisions in the 2001 Code stressed nurses’ primary obligation to the patient, defined as an individual, a family, a group, a community, or a population. The 2001 Code also addressed duties of the nurse to self; stressed the responsibility of nurses for contributing to ethical workplace environments that are conducive to safe, quality health care; and made clear that the application of ethi- cal guidelines expressed in the Code applied to nurses in all roles and settings.

The process for revising the Code in 2001 included the establishment of working groups that coordinated obtaining feedback and input from several thousand nurses through pub- lic comment and surveys to determine the need for clarification, changes, or additions. The Code is a dynamic, living docu- ment that reflects changes in society, the nursing profession, and the health care delivery system. What remains unchanged are the fundamental commitments of the profession, includ- ing its commitment to society, and the ethical values, obli- gations, duties, and professional ideals of nurses individually and collectively (ANA, 2015a, p. viii). Therefore, the Code is evaluated and assessed for needed revisions approximately every 10 years. Based on comments, the nine provisions of the 2001 Code were retained, but were made more clear and con- cise. The interpretive statements expanding on the provisions were updated to include the changes that affected the profes- sion since the 2001 revision. The first three provisions describe the fundamental values and commitments of the nurse, such as respect for patients, colleagues, and others; the next three address issues of duty and loyalty, such as duties to self and others and responsibilities for the health care environment. The final three provisions address aspects of duty that go beyond individual patient encounters, such as advancing the profession through research and scholarly inquiry and advancing health policy. These provisions also address the role of professional organizations. Provisions 7, 8, and 9 have an enhanced focus on social justice, the role of nurses in global health, the ethical use of social media and electronic medical records, boundary issues, ethical practice environments, the importance of interdisci- plinary work and collaboration, the role of nurse leaders, and the inclusion of nurses in all roles and settings (ANA, 2015a; Epstein & Turner, 2015).

Provision 1 The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person (ANA, 2015a, p. 1).

In all roles and settings, nurses must respect the beliefs and values of all patients without prejudice.

Interpretive Statement 1.2: Relationships With Patients

“Factors such as culture, value systems, religious or spiritual beliefs, lifestyle, social support system, sexual orientation or gender expression, and primary language are to be considered when planning individual, family and population-centered care” (ANA, 2015a, p. 1). Interpretive statement 1.2 further states that although nurses may not agree with a patient’s choices, nurses are obligated to promote patient safety and pro- vide opportunities to eradicate risky or self-destructive behav- iors (ANA, 2015a).

Violation of Provision 1: Failure to Conform to Standards of

Acceptable Conduct

Stephanie, a registered nurse (RN), who worked in an inpatient psychiatric unit, was caring for Amanda, a 20-year-old trans- gender patient with diagnoses of bipolar disorder and schizo- phrenia. Amanda identified as female, although her legal name was Eric. During Stephanie’s shift, Amanda demonstrated disruptive behavior in a group activity and placed herself and other patients at risk. Stephanie attempted to diffuse the situa- tion but intentionally chose to call her patient Eric, rather than the patient’s preferred name, demonstrating a lack of respect for the patient’s gender expression. Amanda became visibly irritated, and her behavior escalated into a physical alterca- tion with another patient, resulting in harm. The incident was reported to Stephanie’s nurse manager, who reported it to the BON.

Stephanie had an ethical duty to respect the values of her patient, including sexual orientation or gender expression. The Code states that “the need for and right to health care is uni- versal” (ANA, 2015a, p.1). Nurses must respect the values of each patient. Stephanie had a duty to promote the health and safety of Amanda and protect other patients in the vicinity from harm. Stephanie chose to call her patient by a name she knew the patient had rejected, causing an escalation of an already compromised situation. Stephanie’s actions constituted a viola- tion of the Code and thereby established sufficient grounds for disciplinary action. The BON charged her with failure to con- form to standards of acceptable conduct, resulting in a 4-month suspension from the practice of registered nursing.

Interpretive Statement 1.4: Right to Self-Determination

Autonomy affords patients the right to accept, refuse, or ter- minate treatment at any time. Nurses are obligated to respect a patient’s decision by supporting and protecting these rights. Nurses are often in a position to advocate for a patient’s choices

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and should always provide compassion and care through the various stages of medical decision making. Nurses in all set- tings must make sure patients are properly informed and understand the consequences of all decisions without coercion, duress, or undue influence. Furthermore, nurses have a duty to find alternatives when appropriate and use nursing judgment when patient safety is at risk.

Violation of Provision 1: Patient Abuse

Michael, an RN, was caring for several patients in a long-term care facility, including Mr. Smith, an alert, oriented 75-year- old. When Michael tried to administer medication to Mr. Smith, the patient refused to take the medication. Mr. Smith did not provide any justification for his refusal. Michael tried several verbal measures to coax Mr. Smith into taking his medi- cation. After Mr. Smith repeatedly refused and shook his head to avoid taking the medication, Michael grabbed Mr. Smith’s chin and forced the medication into his mouth. As a result, Mr. Smith suffered lacerations to his upper lip. Another nurse witnessed the incident and reported it to the BON.

Michael had an ethical duty to respect his patient’s right of refusal. Michael argued that he had several patients and did not have time to use an alternative method to adminis- ter the medication. However, a patient’s right of refusal must be protected, and the patient should be given necessary sup- port throughout the decision-making process (ANA, 2015a). Michael violated Mr. Smith’s autonomy to refuse medication and failed to assess the patient’s understanding of the refusal. Moreover, Michael harmed the patient by physically forcing him to take the medication. The BON evaluated the facts and determined that the nurse violated the Code and failed to con- form to an ethical or quality standard of the profession, thereby violating the state NPA.

Provision 2 The nurse’s primary commitment is to the patient, whether an individ- ual, family, group, community, or population (ANA, 2015a, p. 5).

Nurses are caring and compassionate and often spend numerous hours with a patient and family at the bedside. Rapport and trust are common attributes in a nurse-patient relationship. Nurses care for patients who are sick and may be vulnerable because of stress, illness, or medication. Nurses have an ethical duty to uphold professional boundaries and refrain from dating or engaging in sexually intimate relationships with patients (ANA, 2015a, p. 7).

Violation of Provision 2: Failure to Adhere to Professional Boundaries

Kelly, an RN, was a new nurse working in a postoperative care unit. Kelly had been caring for Jason, a postoperative heart bypass patient, for three shifts. Jason had been flirtatious every

shift and enjoyed having Kelly take care of him. Kelly also found Jason attractive and requested an assignment to care for him. Late into the shift, Jason proposed that Kelly close the door to his room. Kelly obliged, and they engaged in consen- sual sexual intercourse. The next day, Jason asked the attending physician if he can have home nursing care and requested that Kelly be his nurse. The attending physician found the request odd and initiated an investigation. Kelly and Jason admitted to having consensual sex during Kelly’s shift. The incident was reported to the BON, which evaluated the facts and deter- mined that Kelly violated the Code, thereby establishing suf- ficient grounds for disciplinary action. The BON determined that the nurse failed to conform to an ethical or quality stan- dard of the profession, thereby violating the state NPA. The nurse’s license was permanently revoked.

Kelly violated her ethical duty to maintain a professional boundary between herself and her patient, despite the consen- sual nature of the act. Many states have laws in their NPAs that specify professional boundary violations, including sexual contact, as violations of the standard of conduct for nurses, thus establishing sufficient grounds for discipline.

Provision 3 The nurse promotes, advocates for, and protects the rights, health, and safety of the patient (ANA, 2015a, p. 9).

Protection of patient rights to privacy and confidential- ity are fundamental to trust in a nurse-patient relationship. Violations of these rights include electronic postings, images, or commentary via social media or other public communica- tions of personal or clinical information that could breach a patient’s confidentiality or right to privacy. Several states have specific language in their NPAs that identifies a breach of con- fidentiality or right to privacy as a violation of the standard of care. For example, in Massachusetts, a nurse may be subject to disciplinary action if he or she fails to “safeguard patient information from any person or entity, or both, not entitled to such information” (Code of Massachusetts Regulations, n.d.). In Utah, unprofessional conduct subject to discipline includes “failure to safeguard a patient’s right to privacy as to the patient’s person, condition [or] diagnosis” (Utah State Legislature, 2016). In Oregon, a similar provision exists: “Violating the rights of privacy, confidentiality of information, or knowledge concerning the client, unless required by law to disclose such information or unless there is a ‘need to know’ may result in disciplinary action against the nurse” (Oregon Administrative Rules, 2012).

The ANA and NCSBN have endorsed each other’s guide- lines for the legal and ethical use of social media and other electronic communication, emphasizing the critical importance of protecting patient rights to privacy and confidentiality and to safeguarding professional boundaries (National Council of

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State Boards of Nursing [NCSBN], 2011a). The NCSBN pub- lication, A Nurse’s Guide to the Use of Social Media (NCSBN, 2011b), presents several examples of violations of patient con- fidentiality via inappropriate use of social media. One describes a breach of patient confidentiality by a junior nursing student who took a photo of a 3-year-old patient with leukemia on a pediatric unit and posted it on her Facebook page. The photo showed not only the patient but also the patient’s room num- ber. As a result, the nursing student was terminated from her nursing program for breach of patient confidentiality and a HIPAA violation (NCSBN, 2011b, pp. 8-9). Nurses and nurs- ing students who inappropriately use social media and breach patient confidentiality or privacy may be violating state and federal laws and face disciplinary action by the BON as well as civil and criminal penalties.

Interpretive Statement 3.4: Professional Responsibility in Promoting a Culture of Safety

The nursing profession has an ethical duty to promote a safe culture for patients and families by reducing the number of errors and near misses. Historically, reporting errors to BONs resulted in punitive, disciplinary action. Many BONs now use remediation, supervision, and counseling for errors that do not involve deliberate, reckless, or malicious intent (Russell & Radtke, 2014). This Just Culture model is designed to reduce errors, not to conceal them (Marx, 2001). In efforts to increase patient safety when errors occur, the Just Culture model pro- motes education and remediation, rather than punishment. The Code identifies the Just Culture model as one that “rec- ognizes individuals choose and need to manage human error, at-risk behavior, and reckless behaviors; recognizes individuals make mistakes and systems fail” (ANA, 2015a, p. 43). The Code further states that Just Culture supports a nurse’s ability to learn from mistakes and encourages education on avoiding risky behaviors (ANA, 2015a). This shift in nursing practice to a Just Culture model eliminates fear of discipline and embar- rassment and deters nurses from remaining silent (Burhans, Chastain, & George, 2012).

Nurses have an ethical obligation to report errors and near misses to an appropriate authority to provide an oppor- tunity for education, remediation, and accountability for indi- vidual practice (ANA, 2015a; Lachman, 2007). The Code emphatically states that nurses may “neither participate in, nor condone through silence, any attempts to conceal the error” (ANA, 2015a, p. 12). Nurse managers, administrators, and educators must provide an open and accessible process for reporting errors and determining and analyzing the root causes of errors to obtain and maintain a healthy and ethical work environment. By creating and supporting an ethical work envi- ronment in which nurses feel free to disagree with one another and with other members of the health care team without fear

of reprisal and to discuss difficult or unsafe conditions openly, nurses in leadership roles promote a culture of safety.

Interpretive Statement 3.6: Patient Protection and Impaired Practice

Nurses have a duty to protect the patient, the public, and the integrity of the nursing profession when they observe physical or mental impairment in a nurse or other health care professional. Substance use disorder (SUD) in the nursing profession has been recognized for more than 100 years (Monroe & Kenaga, 2011). Stress, fatigue, and access to drugs place nurses at increased risk for developing SUD and addiction (NCSBN, 2011b).

Although research has shown that 20% of RNs were reluctant to report a colleague suspected of drug diversion (Bettinardi-Angres & Bologeorges, 2011), nurses who suspect their colleagues of diversion or physical or mental impair- ment have an ethical duty to protect patients from harm. Reporting suspected impairment of a colleague to an appro- priate authority protects the safety of the patient and initi- ates a path of recovery for the nurse (NCSBN, 2011c). Nurses must also uphold the integrity of the profession by reporting a colleague suspected of diversion. Such a report should not be construed as betrayal. Many nurses fear reporting an impaired colleague because of the disciplinary action the colleague may face, including loss of licensure. However, reporting a nurse for suspected impairment may not result in adverse disciplinary action but in an offer of medical assistance that may save the lives of the colleague as well as the colleague’s patients.

Several BONs offer nurses an alternative-to-discipline program (ADP) to treat addiction and SUD. These programs are designed to protect the welfare and safety of the public and assist nurses with recovery. ADPs encourage nurses with SUD to seek help without fear of public BON discipline. Dunn (2005) posits that the nature of confidentiality encourages nurses to self-report and seek assistance with recovery. As such, the nursing profession promotes a nonpunitive environment that encourages rehabilitation and recovery for impaired nurses (Tanga, 2011).

In some jurisdictions, the ethical duty to report suspected impairment is required by law in the NPA or administrative code, and failure to report can result in disciplinary action. For example, in Michigan, a nurse “who has a reasonable cause to believe that a licensee…is impaired shall report that fact to the department” (Michigan Legislature, 2007). Failure to report may result in disciplinary action. A nurse who has a bona fide nurse-patient relationship with the impaired nurse is exempt from the requirement to report. In West Virginia, a failure “to report through proper channels…impaired practice of another person who provided health care” (West Virginia Board of Examiners, 2015, §14.1.bb) may constitute profes- sional misconduct. The Alabama BON mandates that nurses report unsafe or incompetent nursing practice; failure to do so

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is a violation and may warrant disciplinary action (Alabama Administrative Codes, 2014). Not all BONs have mandatory reporting laws.

In states with mandatory reporting laws, nurse managers and administrators may also be subject to discipline for failure to report a nurse suspected of impairment. Nurse managers and administrators must be aware of and educated about the signs of physical or mental impairment. Nurses who report colleagues must also be supportive and caring throughout recovery, especially when a recovering nurse is returning to the workforce. A nurse who has a strong recovery program that includes accountability and monitoring has much to offer to patients and the profession (NCSBN, 2011c, Appendix J).

Provision 4 The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to promote health and to provide optimal care (ANA, 2015a, p. 15).

Nurses function in various roles and are responsible for assessing their own competence. Nurse managers and execu- tives not involved in direct patient care have a duty to share responsibility for the care provided by the nurses they super- vise. Nurse managers must ensure that nurses are practicing within their scope of practice and that they do not delegate activities to others that are prohibited by their NPAs. Nurse educators have a duty to nursing students to ensure their learn- ing needs are assessed and satisfied. The role of the BON is essential in the regulation of curriculum, oversight, and enforcement of satisfactory education programs.

The Code mandates that nurse educators assess the knowledge and skills of nurses and nursing students to deter- mine whether they are competent to provide the nursing care to which they are assigned under appropriate supervision (ANA, 2015a). If nursing education is unsatisfactory, not in compliance with state or federal law, or fraudulent in nature, BONs have a legal duty according to their NPAs to take action to protect patients and uphold the integrity of the profession.

Interpretive Statement 4.3: Responsibility for Nursing Judgments, Decisions, and Actions

“Nurses in administration, education, policy, and research also have obligations to the recipients of nursing care” (ANA, 2015a, p. 16). Nurses in administrative or supervisory roles who direct care do not relinquish responsibility to safeguard patients and promote health. Nurses, including advanced prac- tice registered nurses (APRNs), are accountable for nursing judgments, decisions, and actions they delegate or supervise. The delegating or supervising nurse has an obligation to assess the skills, education, and experience of the supervisee or del- egatee. Also, APRNs must provide education, instruction, and assistance to those individuals whom they supervise.

Violation of Provision 4: Failure to Conform to Ethical and Quality

Standards

Robert, an APRN, was the owner and delegating nurse of an assisted-living facility. Robert had a contract to precept and supervise four students in an RN program. After a complaint was filed with the Department of Health, an investigation into Robert’s assisted-living facility revealed that the students were unsupervised when performing nursing tasks. Each stu- dent stated that Robert was often absent from the facility and no other licensed personnel were present. The students also reported that patients were found in wet diapers and soiled sheets. The students were instructed to give medications with- out supervision and were instructed not to sign the medication administration record. The Department of Health investigator was unable to find adequate documentation of nursing care. The students were instructed to feed the residents outdated and spoiled meals.

Robert had an ethical duty to safeguard patients from harm by providing proper supervision. “Nurses must make a reasonable effort to assess individual competence when del- egating selected nursing activities. This assessment includes the evaluation of the knowledge, skill, and experience of the individual to whom the care is assigned or delegated; the com- plexity of the tasks; and the nursing care needs of the patient” (ANA, 2015a, p. 17).

After review, the BON determined that Robert violated the Code and failed to conform to an ethical or quality stan- dard of the profession, thereby violating the NPA. Specifically, the BON charged Robert with delegation of nursing acts to an individual lacking the ability to perform, failure to prop- erly supervise nursing students, failure to provide instructions, and failure to assess the skill or experience of the individual he supervised. The BON ordered an emergency suspension of the APRN’s license.

Provision 5 The nurse owes the same duties to self as to others, including the respon- sibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and profes- sional growth (ANA, 2015a, p. 19).

Nurses working at the bedside often endure long hours of physically and emotionally demanding work. Fatigue can easily occur in nurses working long hours with varying day and night shifts. Nurses must be cognizant of their health and well-being. Nurses must be aware of work activities that may contribute to fatigue and adopt ergonomic techniques and practical solutions to adjust their daily nursing practice (Chen, Daraiseh, Davis, & Pan, 2014). Nurses should maintain the same healthy work and life balance that they teach patients (ANA, 2015a, p. 19).

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Significant evidence indicates that nurses have an increased risk of making errors because of fatigue from working extended shifts (Geiger-Brown & Trinkoff, 2010). Although BONs recognize the seriousness of nurse fatigue, they also expect nurses to maintain a safe environment for patients and to recognize when their level of fatigue and physical condition could place patients at risk. The Texas BON addressed nurse fatigue by taking a position that nurses are accountable for making sound clinical judgments and protecting patient safety when accepting an assignment. The “prudence and account- ability of the nurse is especially significant in the context of fatigue” (Cropley, 2015, p. 4). Many jurisdictions offer safe har- bor protection and whistleblower protection for nurses who, in good faith, deem patient safety to be in jeopardy. Processes by which a fatigued nurse can request peer review of an assign- ment he or she believes to be in violation of the NPA or BON rules are available (Cropley, 2015).

Violation of Provision 5: Failure to Conform to Ethical and Quality Standards

Sasha, an RN, was caring for five patients in a step-down unit. She was working the night shift but also worked a day shift as a home care nurse. Around 4 a.m., Sasha’s patient Mr. Goodman came out of his room for something to eat. Sasha was sitting at the nurses’ desk with her head down. Mr. Goodman was at risk for falls and used a walker. However, Mr. Goodman forgot his walker and fell onto the floor in the middle of the hall. Sasha was asleep and did not hear the commotion. A nursing assistant woke her and informed her of the fall. Sasha stood up to see Mr. Goodman, but did not assess the patient or take any action. Instead, Sasha instructed the nursing assistant to help Mr. Goodman back to bed. The incident was reported to the BON.

Sasha had a duty to evaluate and assess her fatigue and resulting physical condition, which posed a risk to her patients, and a duty to explain this risk to her supervisor. The BON evaluated the facts and determined that the nurse violated the Code and failed to conform to an ethical or quality standard of the profession, thereby violating the NPA. The BON charged the nurse with failure to conform to standards of acceptable conduct, which resulted in a 2-month suspension from the practice of nursing.

Provision 6 The nurse, through individual and collective effort, establishes, main- tains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care (ANA, 2015a, p. 23).

Provision 6 of the Code focuses on the responsibility of nurses to contribute to health care environments that are conducive to safe, quality health care. One component is the ethical duty to respect the worth, dignity, and human rights

of all individuals with whom nurses interact in the workplace (Longo, 2012). Incivility, bullying, lateral or psychological violence, and behaviors that include threats, verbal abuse, and physical abuse are considered acts of workplace violence and create a hostile work environment. The incidence of workplace incivility has been linked through research to medical errors, negative patient outcomes, and unsafe work environments (Skarbek, Johnson, & Dawson, 2015). Such unprofessional con- duct can lead to complaints about nurses being reported to the BON in light of its role in protecting public safety.

The role of nurse executives and leaders in creating a healthy, ethical work environment is emphasized through- out the Code as a key mechanism for the promotion of safe patient care and public protection. Such an environment must be one of respect for diverse opinions and perspectives and include “respect, mutuality, openness, transparency, and moral equality” (Fowler, 2015, p. 108). An ethical work envi- ronment is one in which nurses feel free to speak out about unsafe practices, mistakes, lack of support, incompetence, poor teamwork, disrespect, and micromanagement. As found in the study by the American Association of Critical Care Nurses and VitalSmarts, Silence Kills: The Seven Crucial Conversations for Healthcare, nurses should stay in a work environment only when hope for change and the ability to speak out without fear of retaliation exist (Fowler, 2015, p. 108; Maxfield, Grenny, McMillan, Patterson, & Switzler, 2005).

Violation of Provision 6: Failure to Conform to Ethical and Quality Standards

Jacob, an RN, and Melanie, an RN, were working an evening shift in a long-term care facility. Melanie had 17 years of nurs- ing experience, and Jacob had 2 years. Jacob was assigned to Mr. Tyson, a patient diagnosed with dementia. On rounds, Melanie entered Mr. Tyson’s room and noted that his gown was too tight. When Jacob entered the room, Melanie stated that Mr. Tyson’s gown was too tight. Jacob disagreed. Melanie turned to Jacob and put her finger in his face, demanding that he recognize her authority. Jacob asked Melanie to lower her voice. Melanie began screaming and grabbed Jacob’s uniform. When Jacob turned to leave the room, Melanie hit him on his back. The supervisory nurse reported the incident to the police and the BON.

Jacob declined to press criminal charges, but the BON investigated the incident and determined that Melanie vio- lated the Code and failed to conform to an ethical or quality standard of the profession, thereby violating the NPA. This case exemplifies how disrespectful, uncivil interactions among employees affect the delivery of safe, quality patient care and creates an unhealthy work environment. Although this case is an egregious example, numerous examples of uncivil behaviors and the importance of using evidence-based interventions to prevent workplace incivility and bullying have been published

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(Bartholomew, 2006; Longo, 2012). The Code clearly states that nurses at all levels are responsible for creating an ethical envi- ronment and culture of respect with zero tolerance for incivility, bullying, and workplace violence (ANA, 2015a; Clark, 2015).

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 (ANA, 2015a, p. 27).

Interpretive Statement 7.1: Contributions Through Research and Scholarly Inquiry

Nurses have multiple ways to advance the profession through knowledge development, research, and evidence-informed practice. The Code states that all nurses have an obligation to advance the profession and identifies several ways to do so. Not all nurses must conduct research, but all nurses can partici- pate in research by utilizing research findings and evidence in practice and maintaining their current knowledge of research, especially in their practice areas (Fowler, 2015, p. 117). The nurse who is a researcher or caregiver for patients who are par- ticipants in research must adhere to Provision 1 that recog- nizes the principle of respect and right to self-determination, Provision 2 that recognizes nurse’s primary commitment to the patient, and Provision 3 that identifies the obligation to pro- tect patients from potential harm.

Interpretive Statement 7.2: Contributions Through Developing, Maintaining, and Implementing Professional Practice Standards

Standards of professional nursing practice are “authoritative statements of the duties that all registered nurses, regardless of role, population, or specialty, are expected to perform com- petently” (Fowler, 2015, p. 122). Practice standards reflect nursing’s responsibility to society, change as “new patterns of professional practice are developed and accepted by the nursing profession and the public,” and “interface with state nurse prac- tice acts and federal laws governing nursing” (Fowler, 2015, p. 122). The ethical practice of nursing requires that practice standards for all areas of nursing be developed by nurses. In compliance with state and federal law and regulations and NPAs, nursing identifies its own scope of practice (ANA, 2015a, p. 28). Nurses must be aware of their own scope of prac- tice as well as the scopes of practice of those with whom they work. Nurses have professional, ethical, and legal responsibili- ties to assume accountability and control of their own practice and actions and to practice according to prevailing standards of safe nursing care within their scope of practice.

Interpretive Statement 7.3: Contributions Through Nursing and Health Policy Development

Nurses in all roles and settings have a variety of opportuni- ties to participate in local, regional, state, national, and global nursing and health policy development as individuals, employ- ees in their workplaces, or as members of professional associa- tions. Nurses can be involved in generating awareness of and collecting evidence on issues that ultimately lead to changes in policy at any of these levels as well as using evidence-informed approaches to influence others to make changes that ultimately lead to improvements in quality and safe care.

Provision 8 The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities (ANA, 2015a, p. 31).

At the core of this provision is the commitment to health as a fundamental, universal human right. As a profession, nurs- ing evolves from and is responsible to the society that autho- rizes nurses to practice through licensure and regulation. The primary role of nursing regulation and NPAs is to protect the public. Collaboration with other health care professionals and the public to achieve health care equity, advance health and human rights across various practice settings and geographic areas, and prevent violations of human rights is stressed in all four interpretive statements of this provision. Collaboration to achieve goals that cannot be achieved individually requires respect, trust, inclusion, the ability to deal with varied opin- ions, and equality.

Interpretive Statement 8.1: Health is a Universal Right

The commitment to health as a universal right is not new to the profession; however, it is now stated directly in the Code and is an affirmation held in common with the United Nations, the International Council of Nurses, and the World Health Organization (ANA, 2015a, p. 31; Fowler, 2015, p. 131).

Interpretive Statement 8.2: Collaboration for Health, Human Rights, and Health Diplomacy

The 2015 Code has an increased emphasis on social justice and the leadership role of nurses (in collaboration with other health professionals) in developing “public health legislation, poli- cies, projects, and programs that promote and restore health, prevent illness, and alleviate suffering” (ANA, 2015a, p. 32).

Interpretive Statement 8.3: Obligation to Advance Health and Human Rights and Reduce Disparities

This statement reinforces the need for collaboration to reduce health disparities, especially in light of advances in technol- ogy, genetics, and environmental science. As noted, the Code

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changes in response to changes in society, the profession, and health care delivery.

Interpretive Statement 8.4: Collaboration for Human Rights in Complex, Extreme, or Extraordinary Practice Settings

During extreme circumstances, such as natural disasters, mass casualty events, epidemics, pandemics, and extreme emer- gencies, care may have to be delivered under altered stan- dards of care. When practicing in such circumstances, nurses must remain attentive to their primary commitment to the patient and the ethical obligation to protect the human rights of patients. These situations also require nurses to collaborate with other health professionals to meet the needs of individu- als, groups, communities, or populations.

Provision 9 The profession of nursing through its professional organizations must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy (ANA, 2015a, p. 35).

This provision, which is directed toward the profession through its professional associations rather than the individual nurse, was new to the 2001 Code and reaffirmed in the 2015 Code. Before the revisions in 2001, the previous Codes were directed primarily at the clinical nurse at the bedside. Since then, the Code applies to nurses in all roles and settings as well as to nursing’s professional organizations.

Interpretive Statement 9.1: Articulation and Assertion of Values

Within the domain of social ethics, associations that represent and regulate the nursing profession are expected to uphold, affirm, and disseminate the values and integrity of the pro- fession. Through professional and regulatory organizations at the organizational, local, national, regional, and international levels, nurses have many opportunities to influence changes in the profession, in health care delivery systems, in policy, and for patients and their access to safe, quality health care (Benton, 2012). By working within their national nursing associations, nurses can effectively work for health and public policies that improve standards of nursing practice, the quality of patient care, and the quality of nursing education.

Interpretive Statement 9.2: Integrity of the Profession

The documents, structures, decisions, and actions of nurs- ing associations and organizations are the means by which the values of the profession are articulated (Fowler, 2015). Maintaining the integrity of the profession is both a national and a global duty.

Interpretive Statement 9.3: Integrating Social Justice

Professional nursing organizations have a shared responsibility to speak for nurses in promoting improvement in health care systems and health care locally, nationally, and internationally by influencing leaders, legislators, and governmental, nongov- ernmental, and international agencies.

Interpretive Statement 9.4: Social Justice in Nursing and Health Policy

Through political action, professional nursing organizations address legislative and regulatory issues that have an impact on public health and safety. This includes global health and environmental issues.

Incorporation of the Code into NPAs The Code provides guidance to nurse regulators investigating and deliberating on violations of the ethical standard of care. Just as nurses should be familiar with the Code, they should also have a thorough understanding of the provisions in their NPA, which may incorporate the Code.

In the District of Columbia, the nurse’s responsibility to adhere to the standards in the Code is incorporated into the DC Municipal Regulations (Stokes, 2015). “A [registered or practi- cal] nurse shall adhere to the standards set forth in the ‘Code of Ethics for Nurses’ as published by the American Nurses Association, as they may be amended or republished from time to time” (District of Columbia, 2004). The South Carolina BON (n.d.) officially adopted the Code as the ethical standard for nurses, mandating that “nurses shall conduct themselves in accordance with the code of ethics adopted by the board in regulation” The BON’s policies and position statements cite the Code, and its website provides a link to the ANA website. The Delaware rules incorporating the Code state: “Standards of nursing practice and position statements developed by general and specialty nursing professional organizations may be used to address scope of practice accountability” (State of Delaware, 2015).

Several states, though not expressly citing the Code in their law or regulations, have incorporated it through general language or in a position or declaratory statement. For exam- ple, West Virginia holds that a nurse who fails to “adhere to standards established by a national professional nursing orga- nization” may be subject to disciplinary action by the BON (The West Virginia Board of Examiners, 2015, citation 19-3- 14.1.a). In Kentucky, the BON has an advisory opinion state- ment on the role of nurses in maintaining the confidentiality of patient information (Kentucky Board of Nursing, 2013). This statement refers to Provision 3 of the Code, which addresses the duty to maintain confidentiality of patient information and to protect patients’ rights to privacy and confidentiality.

www.journalofnursingregulation.com 17Volume 7/Issue 2 July 2016

Although an advisory opinion statement is not a BON regula- tion, it provides a guideline for safe nursing practice.

Conclusion Because of its history and significance, its articulation of the core values and ethical obligations of the profession, and its role in guiding the profession in self-regulation, the Code is an essential resource for BON members, employers, and all nurses practicing in the United States, making decisions on legal and ethical violations.

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.03(z). Retrieved from www.alabamaadministrativecode.state.al.us/ docs/nurs/610-X-8.pdf

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

American Nurses Association. (2015b). The Year of Ethics commences with first revision of Code since 2001. News Release, January 6, 2015. Retrieved from http://nursingworld.org/FunctionalMenuCategories/ MediaResources/PressReleases/2015-NR/The-Year-of-Ethics-Com- mences-with-First-Revision-of-Code-since-2001.html

Bartholomew, K. (2006). Ending nurse-to-nurse hostility: Why nurses eat their young and each other. Danvers, MA: HCPro.

Benton, D. (2012). Advocating globally to shape policy and strengthen nursing’s influence. OJIN: The Online Journal of Issues in Nursing, 17(1). doi:10.3912/OJIN.Vol17No01Man05

Bettinardi-Angres, K., & Bologeorges, S. (2011). Addressing chemically dependent colleagues. Licensed Practical Nurse, 2, 3–6. Retrieved from www.ncsbn.org/Addressing_Chemically_Dependent.pdf

Burhans, L., Chastain, K., & George, J. (2012). Just Culture and nursing regulation: Learning to improve patient safety. Journal of Nursing Regulation, 2(4), 43–49.

Chen, J., Daraiseh, N. M., Davis, K. G., & Pan, W. (2014). Sources of work‐related acute fatigue in United States hospital nurses. Nursing & Health Sciences, 16(1), 19–25. doi:10.1111/nhs.12104

Clark, C. (2015). Conversations to inspire a more civil workplace. Ameri- can Nurse Today, 10(11), 18–23. Retrieved from https://american- nursetoday.com/cne-civility/

Code of Massachusetts Regulations. (n.d.). 244 CMR: §9.03(16). Retrieved from www.mass.gov/eohhs/docs/dph/regs/244cmr009.pdf

Cropley, S. (2015). Nursing fatigue: Avoiding patient safety risks. Texas Board of Nursing Bulletin, 46(2), 1–7.

District of Columbia. (2004). 17 D.C. Municipal Regulations Chapter 54, §5416.1 & Chapter 55, §5516.1. Retrieved from http://doh.dc.gov/ sites/default/files/dc/sites/doh/publication/attachments/registered_ nursing.pdf

Dunn, D. (2005). Substance abuse among nurses: Defining the issue. AORN Journal, 82(4), 572–596.

Epstein, B., & Turner, M. (2015, May). The nursing code of ethics: Its value, its history. OJIN: The Online Journal of Issues in Nursing, 20(2). doi:10.3912/OJIN.Vol20No02Man04

Fowler, M. (2015). Guide to the code of ethics for nurses with interpretive state- ments (2nd ed.). Silver Spring, MD: American Nurses Association.

Geiger-Brown, J., & Trinkoff, A. M. (2010). Is it time to pull the plug on 12-hour shifts? Part 1. The evidence. Journal of Nursing Administra- tion, 40(3), 100–102. doi:10.1097/NNA.0b013e3181d0414e

Kentucky Board of Nursing. (2013). Advisory opinion: Role of nurses in maintaining confidentiality of patient information. Retrieved from http://kbn.ky.gov/practice/Documents/aos34.pdf

Lachman, V. D. (2007). Patient safety: The ethical imperative. Medical- Surgical Nursing, 16(6), 401–403.

Longo, J. (2012). Bullying in the workplace: Reversing a culture. Silver Spring, MD: American Nurses Association.

Marx, D. (2001, April 17). Patient safety and the “just culture”: A primer for health care executives. Prepared for Columbia University under a grant provided by the National Heart, Lung, and Blood Institute. Retrieved from www.safer.healthcare.ucla.edu/safer/archive/ahrq/ FinalPrimerDoc.pdf

Maxfield, D., Grenny, G., McMillan, R., Patterson, K., & Switzler, A. (2005). Silence kills: The seven critical conversations in healthcare. Ameri- can Association of Critical Care Nurses and VitalSmarts. Retrieved from www.aacn.org/WD/Practice/Docs/PublicPolicy/ SilenceKillsExecSum.pdf

Michigan Legislature. (2007). Public Health Code. Act 368 of 1978. § 333.16223. Impairment of licensee, registrant, or applicant; report; excep- tion; liability. Retrieved from www.legislature.mi.gov/ (S(1toi5cfil3qfoyethki1hlgp))/mileg.aspx?page=getobject&objectNa me=mcl-333-16223

Monroe, T., & Kenaga, H. (2011). Don’t ask don’t tell: Substance abuse and addiction among nurses. Journal of Clinical Nursing, 20(3–4), 504–509. doi:10.1111/j.1365-2702.2010.03518.x

National Council of State Boards of Nursing. (2011a). ANA and NCSBN unite to provide guidelines on social media and networking for nurses. Retrieved from www.nursingworld.org/FunctionalMenuCategories/ MediaResources/PressReleases/2011-PR/ANA-NCSBN-Guidelines- Social-Media-Networking-for-Nurses.pdf

National Council of State Boards of Nursing. (2011b). A nurse’s guide to the use of social media. Retrieved from www.ncsbn.org/3739.htm

National Council of State Boards of Nursing. (2011c). Substance use disor- der in nursing: A resource manual and guidelines for alternative and disci- plinary monitoring programs. Retrieved from www.ncsbn.org/ SUDN_11.pdf

Olson, L. L. (2012). ANA Standard 7: Ethics. In K. M. White & A. O’Sullivan (Eds.), The essential guide to nursing practice: Applying ANA’s scope and standards in practice and education (pp. 113–122). Sil- ver Spring, MD: American Nurses Association.

Oregon Administrative Rules. (2012). Oregon Administrative Rule §851- 045-0070(m). Retrieved from http://arcweb.sos.state.or.us/pages/ rules/oars_800/oar_851/851_045.html

Rushton, C. H., Broome, M., & The Nursing Ethics for the 21st Century Summit Group. (2014, November). A blueprint for 21st century nurs- ing ethics: Report of the National Nursing Summit. Retrieved from www. bioethicsinstitute.org/nursing-ethics-summit-report

Russell, K. A., & Radtke, B. K. (2014). An evidence-based tool for regu- latory decision making: The regulatory decision pathway. Journal of Nursing Regulation, 5(2), 5–9. doi:http://dx.doi.org/10.1016/S2155- 8256(15)30078-8

Skarbek, A. J., Johnson, S., & Dawson, C. M. (2015). A phenomenologi- cal study of nurse manager interventions related to workplace bully- ing. Journal of Nursing Administration, 45(10), 492–497.

South Carolina Board of Nursing. (n.d.). Position statements. Retrieved from www.llr.state.sc.us/pol/nursing/index. asp?file=positionstatements.htm

State of Delaware. (2015). 24 Del. Admin. Code §1900(7.2.2). Retrieved from http://regulations.delaware.gov/AdminCode/title24/1900. shtml

Stokes, F. (2015). Code of ethics for nurses. District of Columbia Nurse, 12(2), 6. Retrieved from http://doh.dc.gov/sites/default/files/dc/ sites/doh/release_content/attachments/DCNurse_43.pdf

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Tanga, H. Y. (2011). Nurse drug diversion and nursing leader’s responsi- bilities: Legal, regulatory, ethical, humanistic, and practical consid- erations. JONA’S Healthcare Law, Ethics and Regulation, 13(1), 13–16. doi:10.1097/NHL.0b013e31820bd9e6

Utah State Legislature. (2016). Utah Code Ann. § 58-31b-502(1). Retrieved from https://le.utah.gov/xcode/Title58/Chapter31B/58- 31b-S502.html

The West Virginia Board of Examiners for Registered Professional Nurses and The West Virginia State Board of Examiners for Licensed Practi- cal Nurses. (2015). West Virginia Code §30-7-1 et seq.; 19 CSR 3.14 Legislative Rule. Retrieved from www.wvrnboard.wv.gov/forms/Doc- uments/Scope%20of%20Practice%20Purple%20Book%201-28- 2015.pdf

Linda L. Olson, PhD, RN, NEA-BC, FAAN, is Director, Institute of Regulatory Excellence, National Council of State Boards of Nursing, Chicago, Illinois. Felicia Stokes, JD, RN, is Discipline Nurse Consultant, District of Columbia Board of Nursing.

www.journalofnursingregulation.com 19Volume 7/Issue 2 July 2016

The ANA Code of Ethics for Nurses With Interpretive Statements: Resource for Nursing Regulation

Objectives ⦁ Discuss the ANA’s Code of Ethics

for Nurses with Interpretive State- ments as the profession’s ethical standard of practice.

⦁ Describe how nurse regulators use the Code of Ethics to support decision making.

⦁ Identify the nine provisions of the Code of Ethics.

Ce

CE Posttest If you reside in the United States and wish to obtain 1.0 contact hour of continuing education (CE) credit, please review these instructions.

Instructions Go online to take the posttest and earn CE credit:

Members – www.ncsbninteractive. org (no charge)

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If you cannot take the posttest online, complete the print form and mail it to the address (nonmembers must include a check for $15, payable to NCSBN) included at bottom of form.

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The information in this CE does not imply endorsement of any product, service, or company referred to in this activity.

Contact hours: 1.0 Posttest passing score is 75%. Expiration: July 2019

Posttest

Please circle the correct answer.

1. When was the first ANA Code of Ethics formally adopted?

a. 1950 b. 1958 c. 1963 d. 1968

2. Which of the following issues has a new emphasis in the 2015 ANA Code of Ethics?

a. Bioethics and life-saving technology b. Obligation to carry out physician orders c. Ethical use of social media d. Duty to uphold professional boundaries

3. What two terms are used to describe the ANA Code of Ethics?

a. Exciting and modern b. Expansive and all-encompassing c. Up-to-date and trendy d. Dynamic and constant

4. What is the one of the purposes of the ANA Code of Ethics?

a. Identify strategic nursing actions b. Create a platform for health policy reform c. Express nursing’s understanding of its

commitment to society d. Issue a call to action for quality health

care

5. Which statement best describes the ANA Code of Ethics?

a. Flowchart for decision making b. Framework for an ethical standard of

practice c. Contract for patient- and family-centered

care d. Interpretation of the professional nursing

law

6. A violation of the nurse practice act for “patient abuse/unprofessional conduct” is in direct conflict with which Provision of the ANA Code of Ethics?

a. Provision 1 b. Provision 3 c. Provision 5 d. Provision 7

7. A violation of the nurse practice act for “failure to adhere to professional boundaries/unprofessional conduct” is in direct conflict with which Provision of the ANA Code of Ethics?

a. Provision 2 b. Provision 4 c. Provision 6 d. Provision 8

8. An alternative-to-discipline program is designed to protect the welfare and safety of the public, which relates to which Provision of the ANA Code of Ethics?

a. Provision 3 b. Provision 5 c. Provision 7 d. Provision 9

9. What is the relationship between the ANA Code of Ethics (the Code) and nursing laws/regulations?

a. Every jurisdiction directly identifies the Code in their laws or regulations.

b. All nursing laws include advisory opinion statements about ethical practice.

c. A few jurisdictions have officially adopted the Code into their nursing laws/ regulations.

d. Some jurisdictions use the Code to legally enforce nursing laws/regulations.

10. Why do nurses have an ethical responsibility to report medication errors?

a. Because doing so demonstrates a commitment to nonmaleficence

b. Because doing so promotes patient safety

c. Because doing so identifies whom the board of nursing must punish

d. Because doing so encourages the patient’s right to self-determination

11. What is one of the basic concepts associated with Provision 4?

a. Respect for human dignity b. Responsibility for nursing judgment and

action c. Influence of the environment on ethical

obligations d. Wholeness of character

20 Journal of Nursing Regulation

12. What action exemplifies Provision 7: Advancement of the Nursing Profession?

a. Decrease workplace incivility b. Ensure adequate staffing c. Recognize substance use disorder d. Perform research and scholarly inquiry

13. Identify one of the core concepts of Provision 8: Promotion of Community and World Health.

a. Personal and professional growth b. Proper supervision for delegated tasks c. Health as a universal human right d. Right to privacy and confidentiality

14. Which statement best characterizes Provisions 4, 5, and 6?

a. These provisions describe the duty of the profession beyond patient encounters.

b. These provisions identify the boundaries of duty and loyalty.

c. These provisions emphasize the fundamental values and commitments of the nurse.

d. These provisions describe the collaborative role of nurses.

Evaluation Form (required)

1. Rate your achievement of each objective from 5 (high/excellent) to 1 (low/poor).

• Discuss the ANA’s Code of Ethics for Nurses With Interpretive Statements as the profession’s ethical standard of practice.

1 2 3 4 5

• Describe how nurse regulators use the Code of Ethics to support decision making.

1 2 3 4 5

• Identify the nine provisions of the Code of Ethics.

1 2 3 4 5

2. Rate each of the following items from 5 (very effective) to 1 (ineffective):

• Were the authors knowledgeable about the subject?

1 2 3 4 5

• Were the methods of presentation (text, tables, figures, etc.) effective?

1 2 3 4 5

• Was the content relevant to the objectives?

1 2 3 4 5

• Was the article useful to you in your work?

1 2 3 4 5

• Was there enough time allotted for this activity?

1 2 3 4 5

Comments:

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