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Rising to “The Highest Morals”—The Rich History of Nursing Ethics
Keywords
bioethics, Code of Ethics for Nurses, history, Nightingale Pledge, nursing, nursing ethics
Authors
Fowler, Marsha D. Schoonover-Shoffner, Kathy
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Source:
Journal of Christian Nursing
April/June 2023, Volume 40 Number 2 , p 86 - 95
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Abstract
ABSTRACT: Modern nursing is supported by a rich ethical tradition dating back to
the mid-19th century. Moving illustrations of nursing practice and "the highest
morals" (McIsaac, 1901) relay the distinguished history and distinctives of nursing
ethics from the 1860s to the present day. Of note is that nursing ethics is
relationally focused, virtue-based, preventative, and central to the identity of
nursing. A brief history of how bioethics emerged in the mid-20th century and an
overview of the development of nursing ethics unveils differences between the two
ethical paradigms.
Article Content
Unfortunately, too many people regard nursing as a mere occupation, not a
profession, and such persons fail to recognize its ethical side, which should
stand for the highest morals in human life.... No other class of people, not even
the clergy or medical profession, has better opportunity to know life as it really
is, stripped of all pretense and make believe, as we have. (McIsaac, 1901, pp.
483, 484)
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These words, penned over 120 years ago, strikingly reveal the profound and
intimate work of nursing and the heart of ethical practice. McIsaac captured
the essence of good nursing-rising to the highest morals. Nurses throughout
history have faced extraordinary ethical demands in caring for people in the
most difficult challenges of life. The nurses who first cared for COVID patients
in Wuhan, Hubei Province, China, encountered frightening dilemmas and yet
rose to the highest morals (Liu et al., 2022):
When I first came to the ward, I was worried that my protection was not good
enough and I didn't dare get too close to the patient. But, when I saw the
patient was in pain, I want to help him or her from the bottom of my heart. (p.
14)
Even [though] there are pressure ulcers and blisters on my face [from masks,
goggles], I have to take protection properly and continue to finish my job. It is
my responsibility to hold my ground. (p. 11)
The patient was so young, and his desire to live was so strong. We already
know we couldn't save his life, but we try to because we knew there were his
wife and child waiting for him. (p. 14)
Nurses in the United States also were challenged in caring for COVID patients
and rose to the highest morals:
I'm barely upright. More than 80 hours in the last week. All our patients are on
ventilators. I do this work to help people. Now we just help them die. The
patients that are awake and understand cry when I hold their hands and pray
aloud for them while they try to breathe. I do that with every single one of
them. We're getting crushed physically and emotionally. Every day it gets
worse. (ICU nurse, personal communication, 2020)
After Russia invaded Ukraine in 2022, nurses like Tetiana Freishyn working in
Ivano-Frankivsk rose to the highest moral standards:
When the explosions first went off on 24 February, I turned up the volume of
my children's TV cartoons, so that they wouldn't hear the noise. I was very
much in doubt whether to stay or leave, but as a medical surgical nurse, I
quickly realized that my skills were needed here. So, I stayed. (World Health
Organization [WHO], 2022, para. 1)
These nurses' selfless actions not only reflect the highest morals, they vividly
portray the essence of nursing ethics-relationship. Their words and McIsaac's
reflections reveal the richness of nursing ethics, a relational ethics that
developed long before the bioethics of today. What is our ethical heritage in
nursing? How is it different from bioethics, and why does nursing ethics
matter?
A BRIEF HISTORY OF BIO(MEDICAL) ETHICS
Since the 1970s, nurses have been taught biomedical ethics or bioethics and its
four major principles: respect for autonomy (the right to make one's own
choices); beneficence (acting with the best interest of the other);
nonmaleficence (doing no harm); and justice (fairness and equality)
(Beauchamp & Childress, 1979; Belmont Report, 1979). Nurses are educated to
let these principles guide patient care, research, education, and policy. How
bioethics and the four principles came to dominate clinical ethics is important
to understand.
Bioethics is a recent development, born out of technological advances and
calamities in medical treatments and research from the mid-20th century
forward (see timeline). It is an applied ethical field dealing with medicine, the
environment, and animals (Gordon, n.d.; Resnik, 2021). Bioethics studies the
ethical, social, and legal issues that arise in biomedicine and biomedical
research. Note that "medical ethics" focuses on proper physician conduct and
the physician-patient relationship, dating back to the Oath of Hippocrates from
the fifth century B.C.E. or even the Code of Hammurabi (1750 B.C.E.) (Gordon,
n.d.).
Prior to the passage of the Pure Food and Drug Act in 1906 (History, Art &
Archives, n.d.), no regulations protected consumers from fraudulent foods,
drugs, or for the most part, duplicitous healthcare. There was no Food and
Drug Administration (FDA), no Federal Policy for the Protection of Human
Subjects known as the "Common Rule" (Office for Human Research Protections
[OHRP], 2016), no Institutional Review Boards to evaluate research. These all
arose following the medical brutalities of World War II, the Helsinki Accords,
leaps in medical technology, loss of medical prestige in the consumerist
movement, and more.
Origins of Bioethics
At the end of World War II, atrocities committed by Nazi physicians against
prisoners in concentration camps led to the international Nuremberg Code of
1947. The code laid out principles of voluntary participation and informed
consent (autonomy) of research subjects (Shuster, 1997). In 1948, the World
Medical Association (WMA, 2018) passed the Declaration of Geneva, a pledge for
physicians to serve humanity, practice with conscience and dignity, make the
patient's health a first consideration, and maintain anonymity of practice
information. The pledge is updated regularly (last in 2017) and now includes
patient autonomy, prohibition against discrimination, upholding civil rights
and human liberties, and maintenance of self-care (WMA, 2018).
In the 1950s, thousands of babies were born with severe deformities after their
mothers took thalidomide for nausea in pregnancy. The drug originated in
Germany, was distributed worldwide, was not adequately tested, and, in the
United States, did not receive FDA approval. This tragedy spurred the Kefauver-
Harris Amendments of 1962 requiring manufacturers to prove efficacy as well as
safety of products before release to the public (Greene & Podolsky, 2012).
Ironically, the American Medical Association opposed regulation of drugs by a
government body because "the only possible final determination as to the
efficacy and ultimate use of a drug is the extensive clinical use of that drug by
large numbers of the medical profession over a long period of time" (Greene &
Podolsky, 2012, p. 1482).
Two years later in 1964, the WMA passed the Declaration of Helsinki to guide
ethical medical research and research combined with clinical care (WMA, 2022).
In its seventh revision (2013), the Declaration addresses issues of informed
consent and benefit to research participants, requiring that risk should not
outweigh benefit (autonomy, beneficence, nonmaleficence) (WMA, 2022).
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In 1966, physician Henry Beecher documented exploitation of human subjects
in multiple prestigious hospital and government programs in a landmark paper
in the New England Journal of Medicine. Beecher (1966) relayed 22 studies with
deleterious effects and/or where the subject or guardian did not fully
understand what was to be undertaken or the hazards of the experiment (one
investigator had 15 deaths in his first 150 cardiac catheterizations). The paper
was a cry for ethically designed studies where "the gain anticipated from an
experiment must be commensurate with the risk involved" (p. 1360) and for
better procedures for obtaining and reporting informed consent.
The most egregious ethical breach in medicine and research in U.S. history was
the Tuskegee Study of Untreated Syphilis in the Negro Male (Centers for Disease
Control and Prevention [CDC], 2021). From 1932 to 1972, the U.S. Public Health
Service enrolled 600 African American men and monitored them to discover
what untreated syphilis does to the body. While participation in the study was
voluntary, informed consent was not obtained. The men (399 of 600) were not
told they had syphilis, were not treated even though a cure (penicillin) became
available in 1943, were not allowed treatment when other physicians diagnosed
their syphilis, and many died. The study ended in 1972 when an Associated
Press article exposed the project (CDC, 2021).
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Figure. Pledge of Florence Nightingale. Wellcome Collection. Used with permission.
The Tuskegee tragedy led to passage of the 1974 National Research Act and
formation of the National Commission for the Protection of Human Subjects of
Biomedical and Behavioral Research. The Commission created the famous
Belmont Report of 1979 (OHRP, 1979), once again establishing specific ethical
principles as cornerstones for research involving human participants.
Furthermore, the Commission differentiated between research, an "activity
designed to test an hypothesis, permit conclusions to be drawn, and thereby to
develop or contribute to generalizable knowledge" (OHRP, 1979, Part A), and
medical practice, " interventions that are designed solely to enhance the well-
being of an individual patient or client and that have a reasonable expectation
of success...to provide diagnosis, preventive treatment or therapy to particular
individuals" (OHRP, 1979, Part A). Later in 1979, philosophers Tom Beauchamp
and James Childress published Principles of Biomedical Ethics. They
differentiated between beneficence, that is maximizing good, and
nonmaleficence, or doing no harm. Thus, 32 years after the Nuremberg Code,
philosophers and now the government called for these same ethical
principles-autonomy, beneficence, justice, non-maleficence-for human
subjects research and medical practice. By the early 1980s, the principles for
biomedical ethics were imported into nursing.
Of note is that bioethics grew out of medical concerns-medical experiments,
medical treatments, medical problems. The four principles and the field of
bioethics were created to guide medical research and medical practice.
Although nurses carry out medical orders, unless they are in advanced
practice, nurses do not order or discontinue medical treatments. Nurses
benefit from bioethics, especially in relation to supporting medical care and in
nursing research; however, nurses do not practice medicine.
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The question arises: If bioethics is the foundation of ethical medicine, is there
a foundational ethics for nursing? First, it is important to distinguish between
medicine and nursing.
NURSING (NOT MEDICINE)
Although nursing and medicine have overlapping practice, conceptually,
nursing and medicine are different. Medicine is the science and practice of the
diagnosis, prognosis, treatment, and prevention of disease, derived from the
Latin medicus, meaning "a physician" (Oxford English Dictionary, 2022).
Medicine is about healing illness, as noted in The Origin of Medical Terms
(Skinner, 1949, p. 288), "Medicina, the art of healing, or the means of healing,
from medicinus, relating to healing... Medicus the adjective meant healing or
wholesome [and] ... doctor or physician." Medicine has been and continues to
be about the work of alleviation of illness and pathology (Charen, 1951; Quain,
1885).
Nursing carries out medical orders but is not medicine. Florence Nightingale,
founder of modern nursing, emphasized that nursing focuses on health.
Nightingale stated,
Nursing is putting us in the best possible condition for Nature to restore or to
preserve health-to prevent or to cure disease or injury. Health is not only to be
well, but to be able to use well every power we have to use. Sickness or disease
is Nature's way of getting rid of the effects of conditions which have interfered
with health. It is Nature's attempt to cure-we have to help her. Partly, perhaps
mainly, upon nursing must depend whether Nature succeeds or fails in her
attempt to cure by sickness. Nursing is therefore to help the patient to live.
(1885, p. 1043)
Nightingale (1885) continued the emphasis on health in describing "nurse
training":
Nursing needs its instruments nearly as much as surgery, and yet more than
medicine. The physician prescribes for supplying the vital force-but the nurse
applies it. Training is to teach the nurse how God makes health and how He
makes disease. Training is to teach a nurse to know her business, that is, to
observe exactly, to understand, to know exactly, to do, to tell exactly, in such
stupendous issues as life and death, health and disease.... Training is to teach
the nurse how to handle the agencies within our control which restore health
and life... how to keep the health-mechanism prescribed to her in gear. (p.
1043)
Throughout the last century and a half, nursing has continued its focus on
health. The International Council of Nurses (2022, para. 2-3) states within its
"long definition" of nursing,
Nursing...encompasses the promotion of health, prevention of illness, and care
of ... people of all ages, in all health care and other community settings. Within
this broad spectrum of health care, the phenomena of particular concern to
nurses are individual, family, and group "responses to actual or potential
health problems" [from ANA, 1980 Code of Ethics for Nurses, p. 9].... The unique
function of nurses in caring for individuals, sick or well, is to assess their
responses to their health status and to assist them in the performance of
those activities contributing to health or recovery or to dignified death that
they would perform unaided if they had the necessary strength, will, or
knowledge and to do this in such a way as to help them gain full or partial
independence as rapidly as possible.
The American Nurses Association (ANA) Code of Ethics for Nurses with
Interpretive Statements (2015) similarly states,
Nursing encompasses the protection, promotion, and restoration of health and
well-being; the prevention of illness and injury; and the alleviation of suffering,
in the care of individuals, families, groups, communities, and populations....
Nurses act to change those aspects of social structures that detract from
health and well-being. (p. vi)
In summary, nursing is about engaging in relationship with individuals,
families, and communities to promote, maintain, and restore health. Nurses
attend to the biopsychosocial and spiritual health of those we serve as we
have "opportunity to know life as it really is, stripped of all pretense and make
believe" (McIsaac, 1901, p. 438).
A RICH HISTORY: NURSING ETHICS
One hundred years before the emergence of bioethics in the mid-1960s,
nursing ethics began to be articulated as modern nursing coalesced as a
profession. In the earlier 1800s, nurses were men or unseemly women who
cared for patients mainly in homes or institutions for the sick poor. Of
significance to the development of nursing was that in the second half of the
1800s, women were hearing the call to learn, to grow, and to serve from highly
recommended books like Nightingale's 1859 Notes on Nursing: What it Is and
What it is Not (Coddington, 2020).
Nightingale and other nurse leaders demanded that nurses be intelligent
women of exceptionally good character and moral training. Nightingale noted,
"A good nurse should be the 'Sermon on the Mount' in herself" (1882, p. 1048).
Nurses were to be chaste, sober, honest, truthful, trustworthy in the unseen as
well as the seen, punctual, orderly, quiet, quick, gentle, cheerful, hopeful,
clean, thinking of her patient and not of herself (Maxwell & Pope, 1910;
Nightingale, 1882; Robb, 1894).
Civil War Ethics: Care for All
Nursing grew as a profession during the Civil War (1860-1865) (Fowler, 2017).
Wealthy gentlewomen sponsored nurses in military hospitals to support
soldier survival rates (Fowler, 2017). The Union Army acknowledged that nurses
were needed to care for wounded soldiers and on June 10, 1861, appointed
Dorothea Dix as its first superintendent of nurses (Wood, 2000). Dix, a national
champion for care of the poor mentally ill and disabled (Parry, 2006),
established strict standards of nurse training and care (feeding, dressing
wounds, sanitation, demeanor, decorum), creating 3-month assignments for
volunteers ("plain-looking" healthy women between 35 and 50). Women of
patriotic zeal looking for more in life flocked to nursing (Little, 2021; Wood,
2000). This expansion paralleled the growth of nursing in England in the late
1800s where women were called to the vocation (Fowler, 2021).
Of note is that Civil War nurses cared for soldiers on both sides of the conflict,
enduring great hardship not only from war conditions, but from gender
discrimination against women in general and specifically by soldiers and Army
physicians. Civil War nurse and historian Georgeanna Muirson Woolsey Bacon
(1833-1906) observed, "No one knows, who did not watch the thing from
beginning to end, how much opposition, how much ill-will, how much unfeeling
want of thought, these women nurses endured" (Coddington, 2020, p. xiv). She
added a profound insight about the nurses' sense of the highest morals of
care, responsibility, and relationship with their patients:
These annoyances could not have been endured by the nurses but for the
knowledge that they were pioneers.... This, and the infinite satisfaction of
seeing from day to day sick and dying men comforted in their weary and dark
hours, comforted as they never would have been but for these brave women,
was enough to carry them through all and even more than they endured... the
surgeons were most unwilling to see it [discrimination] fall, but the knowledge
that the faithful, gentle care of the women-nurses had saved the lives of many
of their patients, and that the small rate of mortality, or remarkable recoveries
in their hospitals, reflected credit immediately upon themselves. (Coddington,
2020, p. xv)
Civil War nurse Clara Barton went on to establish the American Red Cross,
another venue for high-quality service for women in nursing (Little, 2021).
Nursing emerged from the war as a respectable, specialized, and professional
service for women of high character.
Relationships as Foundational
In 1873, New York City's Bellevue Hospital opened one of the first American
nursing schools based on standards developed by Nightingale. That year,
hospitals in New Haven and Boston opened similar schools. Nursing ethics
began to emerge in nursing literature. In 1889, nurse "HCC" (identified only by
initials) wrote a series of articles on ethics in The Trained Nurse and Hospital
Review, a pioneer publication from 1893 to 1950. HCC delineated seven classes
of nursing relationships:
For convenience sake I will divide the duties of a nurse into seven classes: 1st.
Those she owes to the family. 2nd. Those she owes to the doctor. 3rd. Those
owing the family, friends, and servants of the patient. 4th. To herself. 5th. To
her own friends. 6th. To her own hospital or school. 7th. To other nurses. (HCC,
1889, p. 179; Fowler, 1984)
The first relationship referred to the nurse patient/family relationship, as
nursing took place in homes and nurses were hired by the family (Fowler, 2017).
HCC went on to discuss each of these relationships in detail in subsequent
Trained Nurse articles. Fowler (1984) identified HCC as nursing leader and
educator Harriet C. Camp. In 1912, HCC, writing as the now married Harriet
Camp Lounsbery, published Making Good on Private Duty: Practical Hints to
Graduate Nurses. She explicated the sacred trust of the nurse/patient
relationship:
The relation between nurse and patient should, from the first, be a more than
amicable one. You have come to bestow the priceless blessing of unwearied,
skillful care upon one who should thankfully receive it, and believe me, if you
do not go to your patient with a feeling of thankfulness to God for allowing you
to assume such a sacred trust as the care of a human life, you are in no
condition to undertake the work. Your nursing should be, in a way, an exponent
of your own spiritual state; looking at it in its highest aspect, an outward and
visible sign of an inward and spiritual grace. (Lounsbery, 1912, p. 17)
Later, Camp Lounsbery's seven nursing relationships were recombined by
others and reduced to five: (a) nurse-to-patient/family, (b) nurse-to-other
health professionals, (c) nurse-to-self, (d) nurse-to-profession, and (e) nurse-
to-society (Fowler, 2017), and sometimes as three umbrella relationships. This
basis of relational ethics continues in today's Code of Ethics for Nurses with
Interpretive Statements (ANA, 2015).
In 1893, Lystra Gretter and a Committee for the Farrand Training School for
Nurses in Detroit, Michigan, created The Nightingale Pledge, a moral oath for
nurses administered at commencement (Crathern, 1953; Fowler, 1997; Maxwell &
Pope, 1910; see Figure 1). Though now dated, the Pledge has been taken by
hundreds of thousands of nurses and is considered the first ethical code.
Gretter added the concepts of health promotion and social justice to the
pledge in 1935 with this statement, "With loyalty will I aid the physician in his
work, and as a missioner of health, I will dedicate myself to devoted service for
human welfare" (Crathern, 1953, p. 80).
The Centrality of Ethics
In 1900, influential nurse leader Isabel Hampton Robb (1860-1910) began her
treatise on Nursing Ethics: For Hospital and Private Use, quoting Scripture, "All
things whatsoever ye would that men should do to you, do ye even so to them.-
Matthew vii, 12." Robb, an 1882 graduate of Bellevue Hospital and
superintendent of nurses and principal of the Training School for Nurses at
Johns Hopkins Hospital and later the Illinois Training School for Nurses,
defined ethics this way:
By ethics is meant the science that treats of human actions from a standpoint
of right and wrong. This capability of discriminating between right and wrong is
based on a knowledge of human nature and of the various relations in which
man as a moral or social being is or may be placed. (Robb, 1900, p. 16)
She elaborated upon the need for an "adopted" moral code of ethics for the
entire profession:
Any ideas of special moral responsibilities have been vague and indefinite to
the many, while the few have evolved them for themselves as a result of
observation and experience. Now, however, not only as individuals, but as a
profession, we are beginning to feel an increasing necessity for some such
definite moral force or laws that shall bind us more closely together in this
work of nursing, and that will bring us into more uniform and harmonious
relations. I know of no other body of workers outside of physicians who need
just such strength and stimulus as come from unity of purpose than do trained
nurses, accustomed as they must become to deal with all sorts and conditions
of men and circumstances. (Robb, 1900, pp. 11-12)
About the critical importance of instantiating ethics in the nursing student,
Robb (1900) emphasized,
As the standard of education and requirements become of a higher character
and the training more efficient, the trained nurses will draw nearer to science
and its demands and take a greater share as a social factor in solving the
world's needs. But there is another side to nursing-the ethical-without which
all the work accomplished would be dead and spiritless.... From this standpoint
the nurse's work is a ministry; it should represent a consecrated service,
performed in the spirit of Christ, who made himself of no account but went
about doing good. (pp. 37-38)
In addition to Camp and Robb, hundreds of articles and approximately 100
nursing ethics textbooks and editions were published by nurses between the
late 1800s and 1965 (Fowler, 1984). Annie Warburton Goodrich, in her 1932 book,
The Social and Ethical Significance of Nursing, wrote, "So much is nursing of the
essence of ethics that it is consistent to assert that the terms good and ethical
as applied to nursing practice are synonymous" (p. 5). Fowler noted that up
until the mid-1960s, when nursing education moved out of hospitals and into
university settings, ethics was as integral to the training of nurses as technical
and medical training, where "nursing viewed ethics not as the frosting on the
cake but as the cake itself" (2017, p. 297).
Influential Leadership
Nursing ethics was developed by the nursing leadership and educator elite.
Robb was the first president of the Nurses Associated Alumnae of the United
States and Canada (now ANA), helped organize with Lavinia Dock the Society of
Superintendents of Training Schools (later the National League for Nursing
Education [NLNE, later the NLN]), helped create the International Council of
Nurses, and helped found the American Journal of Nursing (AJN). She
revolutionized nursing with her 1893 publication of Nursing: Its Principles and
Practices that went on to three editions; published Nursing Ethics in 1900 and
Educational Standards for Nursing in 1907 (American Association for the History
of Nursing, 2018).
Isabel McIsaac (1858-1914) was an 1888 graduate and later administrator of the
Illinois Training School for Nurses. She was an incredible innovator in nursing
education, president of the AJN Company, president of the ANA, president of
the American Society of Superintendents of Training Schools for Nurses (NLN),
third superintendent of the U.S. Army Nurse Corps, and served as Interstate
Secretary of the American Red Cross Nursing Service. She, too, wrote a number
of influential nursing textbooks (Sarnecky, n.d.).
Other nurse leaders like Dorothea Dix (1802-1887), Clara Barton (1821-1912),
Linda Richards (1841-1930), Lavinia Dock (1858-1956), Lilian Wald (1867-1940),
and Charlotte Aikens (1868-1949) contributed to the development of nursing's
rich ethical heritage through their work and extensive writings. One sees in
Nightingale's, Robb's, Camp's, McIsaac's, and other leaders' writings (i.e.,
Aikens, 1916; Talley, 1925) the ethical commitment, termed devotion to the
patient, of keeping not only professional secrets (similar to confidentiality) but
patients' life secrets (fidelity). In their writings, we find loyalty to the physician,
to colleagues, and to nursing (pride of profession); fairness (social justice);
adequate training and growing knowledge to provide the best care (virtue as
excellence); and the call to serve the poor or anyone who needed the nurse's
help. There was massive emphasis on moral character, moral formation, and
moral courage.
NURSING'S OFFICIAL CODE OF ETHICS
The ANA, founded in 1896 as the Nurses Associated Alumnae of the United
States of America, stated,
The object of the Association shall be: to establish and maintain a code of
ethics, to the end that the standard of nursing education be elevated; the
usefulness, honor, and interests of the nursing profession be promoted; public
opinion in regard to duties, responsibilities, and requirements of nurses be
enlightened; emulation and concert of action in the profession be stimulated;
professional loyalty be fostered, and friendly intercourse between nurses be
facilitated. (ANA, 2015, p. 38)
Although the ANA, Robb, and others called for an official code of ethics, no
profession-wide code was adopted until 1950. In August 1926, the ANA
published in AJN but never adopted a "Suggested Code of Ethics" (ANA, 1926).
Another "Tentative Code for the Nursing Profession" was published in 1940 but
again, not adopted by the ANA (1940). Why? The ANA Committee on Ethical
Standards wrote it was at work on a comprehensive study on formulating the
proposed principles (ANA, 1940, p. 977).
Finally, in 1950 the ANA House of Delegates adopted A Code for Professional
Nurses, with 17 enumerated provisions based on nursing's five relationships as
Camp delineated in 1889. The Code has been amended, revised, and the
number of provisions condensed multiple times, with interpretive statements
added in 1976. Today, the structure of the nine provisions of the Code of Ethics
for Nurses (ANA, 2015) continues to embed the relational nature of nursing
ethics of (a) nurse-to-patient/family, (b) nurse-to-other health professionals,
(c) nurse-to-self, (d) nurse-to-profession, and (e) nurse-to-society. Provisions 1
through 3 describe the most fundamental values and commitments of the
nurse; Provisions 4 through 6 address the boundaries of duty and loyalty; and
Provisions 7 through 9 speak to aspects of the nurses' duties beyond individual
patient encounters (ANA, 2015).
What happened to the rich nursing ethics literature of the late 1800s and early
1900s? In 1965, the ANA recommended that nursing education move from the
hospital to the university setting (ANA, 1965). Although in many ways this move
was good for nursing academics, nursing's ethical heritage literature held in
hospital libraries did not move into university libraries. Furthermore, ethics
education changed from being taught primarily by nurse educators to
philosophers and theologians who taught abstract European philosophies
unrelated to nursing or nursing practice (Fowler, 2020). Nursing ethics-that is,
moral character, moral formation, nursing relationships as essential to nursing
practice-was no longer central to nursing education. Contemporaneously,
technology exploded and led to ethical concerns that, in part, gave rise to the
field of bioethics.
IMPORTANCE OF NURSING ETHICS
First and foremost, nursing ethics is relationally focused and character or
virtue based. Nursing ethics was born out of a deep awareness of calling to
serve the sick and injured, no matter who or where they were, to restore and
improve health. It came from the sense of relationship that women of high
virtues and noble character had with those for whom they cared and with
whom they served. Nursing ethics continues today as relational and virtue-
based in our Code of Ethics for Nurses (ANA, 2015).
Nursing ethics is central to nursing identity; it is not just something nurses
think about in certain situations. Nursing ethics is inseparable from nursing
action; it is the ground note of nursing care. It is not episodic in certain
instances of problems; nursing ethics is constant. It is represented in every
clinical action and each nurse interaction, affirming the good intrinsic to
nursing. This includes being flexible, attuned, and responsive to changes in the
patient's immediate situation and to meet patients where they are in the
moment (Benner, 1984).
Nursing ethics reflects more than nursing duties; it is values, virtues, and
ideals-in relationship. These are all instantiated in nursing students as they
progressively become nurses, that is, as they interiorize a nursing identity.
Nursing ethics means the nurse meets every patient relationally, where the
person-of-the-nurse meets the person-of-the-patient in ways that respect,
support, and affirm the patient's dignity, individuality, humanity, choices, and
relational web of the patient and the instantiated norms and ends of the
nursing profession in the nurse.
Finally, nursing ethics not only predates bioethics by over 100 years, it comes
from and offers a different paradigm than bioethics. It was not born out of
ethical dilemmas or problems (research, technology, informed consent, etc.),
and is not problem, conflict, or medically focused. Rather, nursing's ethics is
preventative, centering on averting ethical dilemmas before problems arise by
fostering and preserving relationships (Fowler, 2020).
Perhaps nurses who have responded with the highest morals to recent ethical
burdens best portray the centrality of nursing ethics to nursing. Nurses in
Wuhan, China, treating COVID patients said, "Our country is in trouble, due to
the responsibility and the sense of mission, I have to be a warrior, a front-line
staff... I decided to postpone the wedding date" (Liu et al., 2022, p. 11), and "We
have to make ourselves stronger before we comfort the patient" (Liu et al.,
2022, p. 14).
Tetiana Freishyn, the Ukrainian nurse caught in war, noted (WHO, 2022, para 7,
12), "The recurrent air alarms mean that you never know when your work is
interrupted... We quickly need to upgrade our skills," and, "My nursing
profession is my life; it's what gets me out of bed every day; it's the state of my
soul."
An American nurse also portrays this relational, virtue-based, contextual, in-
the-moment nursing ethics:
In 16 hours, I helped someone die, rubbed her daughter's back while she
sobbed and ached... helped my other patient reorient to a world after 2
months entering the hospital with COVID, held her hand and prayed to Jesus
aloud after she asked me to pray. I weaned her sedation, comforted her,
explained every detail, and just held her hand. All in a day's work, as they say. I
would say that's the power of a nurse. (Personal communication to Nurse
Christian Fellowship staff, 2021)
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test is 7 correct answers. If you pass, you can print your certificate of earned
contact hours and access the answer key. If you fail, you have the option of
taking the test again at no additional cost.
* For questions, contact Lippincott Professional Development: 1-800-787-8985.
* Registration deadline is March 6, 2026.
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hours for this nursing continuing professional development activity.
Lippincott Professional Development is accredited as a provider of nursing
continuing professional development by the American Nurses Credentialing
Center's Commission on Accreditation.
This activity is also provider approved by the California Board of Registered
Nursing, Provider Number CEP 11749 for 2.5 contact hours. Lippincott
Professional Development is also an approved provider of continuing nursing
education by the District of Columbia, Georgia, West Virginia, New Mexico,
South Carolina, and Florida, CE Broker #50-1223. Your certificate is valid in all
states.
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NCF members.
Aikens C. A. (1916). Studies in ethics for nurses. W. B. Saunders. https://books.google.com/books/about/Studies_in_ethics_for_nurses.html? id=_KilDN[Context Link]
American Association for the History of Nursing. (2018). Isabel Adams Hampton Robb: 1860-
1910. https://www.aahn.org/index.php?option=com_content&view=article&id=87:robb&catid= [Context Link]
American Nurses Association. (1926). A suggested code: A code of ethics presented for the
consideration of the American Nurses' Association. American Journal of Nursing, 26(8), 599-
600. https://doi.org/10.2307/3409122[Context Link]
American Nurses Association. (1940). A tentative code: For the nursing profession. American
Journal of Nursing, 40(9), 977-980. https://journals.lww.com/ajnonline/Abstract/1940/09000/A_Tentative_Code__For_the[Context Link]
American Nurses Association. (1965). Educational preparation for nurse practitioners and
assistants to nurses: A position paper. Author. https://eric.ed.gov/?id=ED021059[Context Link]
American Nurses Association. (2015). Code of ethics for nurses with interpretive statements.
Author. https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-of- e[Context Link]
Beauchamp T. L., Childress J. F. (1979). Principles of biomedical ethics. Oxford University Press. [Context Link]
Beecher H. K. (1966). Ethics and clinical research. New England Journal of Medicine, 274(24),
1354-1360. https://doi.org/10.1056/NEJM196606162742405[Context Link]
Benner P. (1984). From novice to expert: Excellence and power in clinical nursing practice (1st
ed.). Prentice Hall. [Context Link]
Camp H. C. (1889). The ethics of nursing: Talks of a superintendent with her graduating class.
The Trained Nurse and Hospital Review, 2(5), 179-183.
Centers for Disease Control and Prevention. (2021). The Tuskegee timeline. U.S. Public Health
Service Syphilis Study at Tuskegee. https://www.cdc.gov/tuskegee/timeline.htm[Context Link]
Charen T. (1951). The etymology of medicine. Bulletin of the Medical Library Association, 39(3),
216-221. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC195119/pdf/mlab00237- 0040.pdf[Context Link]
Coddington R. S. (2020). Faces of civil war nurses (1st ed.). Johns Hopkins University Press. [Context Link]
Crathern A. T. (1953). In Detroit courage was the fashion: The contribution of women to the
development of Detroit from 1701 to 1951. Wayne University Press. [Context Link]
Fowler M. D. (1984). Nursing's ethics, 1893-1983: The ideal of service, the reality of history
[Unpublished doctoral dissertation]. University of Southern California. [Context Link]
Fowler M. D. (1997). Nursing's ethics. In A. Davis & M. Aroskar (Eds.), Ethical dilemmas and
nursing practice (4th ed., pp. 16-33). Appleton & Lange. [Context Link]
Fowler M. D. (2017). Why the history of nursing ethics matters. Nursing Ethics, 24(3), 292-304. https://doi.org/10.1177/0969733016684581[Context Link]
Fowler M. D. (2020). Toward reclaiming our ethical heritage: Nursing ethics before bioethics.
OJIN: The Online Journal of Issues in Nursing, 25(2), Manuscript 4. https://doi.org/10.3912/OJIN.Vol25No02Man04[Context Link]
Fowler M. D. (2021). The Nightingale still sings: Ten ethical themes in early nursing in the
United Kingdom, 1888-1989. OJIN: The Online Journal of Issues in Nursing, 26(2), Manuscript 2. https://doi.org/10.3912/OJIN.Vol26No02PPT722[Context Link]
Goodrich A. W. (1932). The social and ethical significance of nursing: A series of addresses.
Macmillan.
Gordon J. S. (n.d.). Bioethics. Internet Encyclopedia of Philosophy. https://iep.utm.edu/bioethics/#H2
Greene J. A., Podolsky S. H. (2012). Reform, regulation, and pharmaceuticals: The Kefauver-
Harris Amendments at 50. New England Journal of Medicine, 367(16), 1481-1483. https://doi.org/10.1056/NEJMp1210007[Context Link]
History Art & Archives. (n.d.). The Pure Food and Drug Act. United States House of
Representatives. https://history.house.gov/Historical-Highlights/1901-1950/Pure-Food-and- Drug-Act
International Council of Nurses. (2022). Nursing definitions. https://www.icn.ch/nursing- policy/nursing-definitions
Little B. (2021, November 1). How the US Civil War inspired women to enter nursing. History. https://www.history.com/news/nursing-women-civil-war[Context Link]
Liu X., Xu Y., Chen Y., Chen C., Wu Q., Xu H., Zhu P., Waidley E. (2022). Ethical dilemmas faced by
frontline support nurses fighting COVID-19. Nursing Ethics, 29(1), 7-18. https://doi.org/10.1177/09697330211015284[Context Link]
Lounsbery H. C. (1912). Making good on private duty: Practical hints to graduate nurses. J. B.
Lippincott. https://babel.hathitrust.org/cgi/pt?id=hvd.rsml67&view=1up&seq=1[Context Link]
Maxwell A. C., Pope A. E. (1910). Practical nursing: A text-book for nurses and a hand-book for
all who care for the sick (2nd ed.). G.P. Putnam's Sons. [Context Link]
McIsaac I. (1901). Ethics in nursing. American Journal of Nursing, 1(7), 483-485. https://journals.lww.com/ajnonline/Citation/1901/04000/ETHICS_IN_NURSING.8.aspx[Context Link]
Nightingale F. (1859). Notes on Nursing: What it is and what it is not. Harrison.
Nightingale F. (1882). Nurses, training of and nursing the sick. In Sir Richard Quain (Ed.), A
dictionary of medicine, including general pathology, general therapeutics, hygiene, and the
diseases peculiar to women and children Volume 2 (pp. 1038-1049). Longmans, Green, and
Company. [Context Link]
Office for Human Research Protections. (1979). The Belmont Report: Ethical principles and
guidelines for the protection of human subjects of research. Health & Human Services. https://www.hhs.gov/ohrp/regulations-and-policy/belmont-report/index.html[Context Link]
Office for Human Research Protections. (2016). Federal Policy for the Protection of Human
Subjects ('Common Rule'). Health & Human Services. https://www.hhs.gov/ohrp/regulations- and-policy/regulations/common-rule/index.ht[Context Link]
Oxford English Dictionary. (2022). Medicine. In Oxford English dictionary. https://www.oed.com/medicine[Context Link]
Parry M. S. (2006). Dorothea Dix (1802-1887). American Journal of Public Health, 96(4), 624-625. https://doi.org/10.2105/AJPH.2005.079152[Context Link]
Resnik D. B. (2021, April 28). Bioethics. National Institute of Environmental Health Sciences. https://www.niehs.nih.gov/research/resources/bioethics/index.cfm[Context Link]
Robb I. H. (1894). Nursing: Its principles and practices. W. B. Saunders. [Context Link]
Robb I. H. (1900). Nursing ethics: For hospital and private use. J. B. Lippincott. [Context Link]
Sarnecky M. T. (n.d.). Miss Isabel McIsaac: 3rd superintendent, Army Nurse Corps. Army Nurse
Corps Association. https://e-anca.org/History/Superintendents-Chiefs-of-the-ANC/Miss- Isabel-McIsaac
Shuster E. (1997). Fifty years later: The significance of the Nuremberg Code. New England
Journal of Medicine, 337(20), 1436-1440. https://doi.org/10.1056/NEJM199711133372006[Context Link]
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Skinner H. A. (1949). The origin of medical terms. Williams & Wilkins Co. [Context Link]
Talley C. (1925). Ethics: A text-book for nurses. G.P. Putnam's Sons. https://www.hhs.gov/ohrp/regulations-and-policy/belmont-report/index.html[Context Link]
Wood A. G. (2000). Dix, Dorothea Lynde (04 April 1802-17 July 1887). American National
Biography. https://doi.org/10.1093/anb/9780198606697.article.1500181[Context Link]
World Health Organization. (2022, May 12). "We risk dying when going to work" - Ukrainian
nurse shares her message on International Nurses Day [EN/RU]. OCHA Services. https://reliefweb.int/report/ukraine/we-risk-dying-when-going-work-ukrainian-nur
World Medical Association. (2018, July 9). WMA Declaration of Geneva. https://www.wma.net/policies-post/wma-declaration-of-geneva/[Context Link]
World Medical Association. (2022, December 6). WMA Declaration of Helsinki - Ethical
principles for medical research involving human subjects. https://www.wma.net/policies- post/wma-declaration-of-helsinki-ethical-principles[Context Link]
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