Home Nursing Practice Ethics & Standards Center for Ethics Issues Update Update Archive Issues Update, Fall, 2001Code of Ethics

Empowered Caring and the Code of Ethics

What makes a code of ethics an important document for nurses? Nurses' historical "ethic of care" is deeply ingrained throughout their educational and socialization process. However, when providing patient care, it is doubtful that nurses are overtly conscious of a code of ethics as they go about their work. Interestingly, but not surprising to nurses, respondents in a recent Gallup poll ranked nurses above medical doctors, teachers and clergy when asked which profession they regarded "as the most honest and ethical." (Revolution).

Generally, a code of ethics works as a tool for professional self-definition. As nursing continues to struggle towards a model of professionalism, the relationship between that model and a code of ethics must be seriously considered. Among scholars and older professional groups, the absence of a code of ethics is detrimental to professional self-definition and professional legitimacy. The mere existence of a code provides a positive argument that a group self-identifies as "professional," not just as occupational. In fact, the formulation of "a code of ethics itself is commonly taken to be one of the defining marks of a profession." (Alexandra). As nurses continue to argue their case as professionals, then certainly "acceptance of a code seems likely to influence both the social and legal status of nursing." (ibid, p. 226).

Professionals recognize that they must embrace specific responsibilities and obligations to those they serve to legitimately call themselves professionals. A code, then, functions as a reminder of these duties to both the practitioner and the public. As Alexandra and Woodruff write, "..membership in a profession... entails duties, but also rights and privileges of a distinctive kind."(Alexandra, p. 226). A Code of Ethics outlines these "distinctive" duties. Although a profession's obligations may have been recognized implicitly, the formal nature of a code of ethics brings another level of commitment to the professional endeavor. "A group's adoption of a code of ethics, whatever its reasons, means it has explicitly avowed certain obligations...Perhaps it would have had these obligations whether it avowed them or not, but the explicit recognition that it has them gives another layer of responsibility to members of the group." (Lichtenberg).

Ultimately, a code serves as the written word, or the public document, about how professionals think of themselves, individually and collectively, and the serious responsibilities they have embraced. Indeed, the written word can "have a striking influence on our attitudes, understandings, and sometimes our behavior. (Fitzpatrick). Without a codification of duties and behaviors, the risk of losing professional clarity is high, especially for health care providers who practice in the midst of an ethically challenging environment. The written word provides that clarity and the moral power that flows from that.

As the Code of Ethics "defines the core ethical tenets, describes the normative behaviors desired, and reflects the ethical aspirations of the profession," (Scanlon), it also reflects the actual work of nurses. It reveals nursing to be, at its core, a "morally significant" relationship based on trust between nurse and patient, writes Pyne. (Pyne). Nurses are acting as autonomous moral agents when they build these relationships and are reminded by the Code of Ethics that they do not leave their moral agency at the front door of the hospital.

Unfortunately, nurses find their moral agency increasingly tested by their work environments. Persevering as morally independent professionals is challenging as the nurse practices within a matrix of several competing interests in complex hierarchical institutions that continue to try to control nursing practice. It is this busy intersection that makes nursing unique when it participates in moral or ethical reflection and action.

To act effectively, then, nurses may need assistance in articulating their ethical obligations to each other and to others with whom they work. The Code, then, serves as "educational armor" which should encourage nurses to exercise their moral power in pursuing ethical reflection and action when needed. The Code of Ethics becomes power-giving as it reminds nurses that, despite their complicated position in the hierarchy, their status as independent moral agents remains unchanged. Indeed, the Code helps nurses reclaim their rightful place as health care collaborators, not followers.

Nurses are not isolated professionals. To provide optimum care for patients, nurses are bound to each other since bedside nursing is a 24-hour responsibility. More broadly, creating a health care delivery system responsive to patients' and society's needs will not be achieved by one nurse alone. The Code provides strength to nurses as it reminds them of their membership in the larger professional nursing community. "The efficacy of the role of nurses envisioned in the Code largely depends on group action. It is often only within appropriately structured institutions that individual nurses can act as autonomous and collaborative workers. Given institutional inertia and conservatism, such structures are unlikely to be erected without concerted action by nurses as a group." (Alexandra, p. 243).

The recently revised Code of Ethics for Nurses with Interpretive Statements reflects nurses expanded professional roles in today's health care environment. (ANA, 2001). Nurses today are faced with multiple challenges, including cost-conscious hospitals, managed care payment plans, nursing staffing problems, the looming nursing shortage, and complex medical conditions that affect not just individuals, but whole communities. Since new situations require new responsibilities, the revised Code now expresses expanded ethical obligations. So, although the Code reflects enduring precepts "that undergird the profession, it remains a dynamic and living document in the face of changes within health care and professional life." (Scanlon, p. 263).

Managed care has altered relationships in all spheres of health care, so much so that it has "generated a parallel moral paradigm shift that fundamentally challenges medical ethics and the patient-physician relationship, as they have traditionally been understood." (Baker). The relationship between nurses and patients has been challenged as well and nurses face "ethical issues and stresses in intra-professional and inter-professional relationships not envisioned in years past." (Walleck). The revised Code is now available to help nurses navigate this new "moral paradigm" in an era "when hospitals have become marketplaces..." (Curtin).

The revised Code of Ethics challenges the nursing profession to assume a new mantle of leadership and relocate the patient to the center of health care. Many feel that nurses now have a significant opportunity to challenge the loss of the patient-centered ethic and step into more highly visible roles as public advocates. Bemoaning the lack of leadership in health care today, Rambur writes nurses have "an unusually pronounced leadership responsibility: to publically champion reform toward more ethical health care financing and delivery." (Rambur). She argues that true leadership exists when the best interest of the patient it kept center stage. With nursing's patient-centered history, she concludes that nursing "is the profession poised to take this leader/advocate role." (ibid, p. 70).

By making nursing's professional duties and commitments explicit to society, the Code serves to increase the trust between professional nurses and those they serve. With this trust secure, nurses will be in an ever better position of power and leadership "to bring about the social change necessary to enhance" health care. (Fowler).

Increased knowledge of the Code and its interpretations should inspire nurses to find ways to become comfortable with increasingly higher levels of ethical deliberation. As Walleck states, "No longer can the nurse simply react in ethical discussions; he or she must be able to state a position clearly and accept the responsibility for the decision." (Walleck, p. 366). Erlen agrees: "one factor that will facilitate an atmosphere of mutual respect and collegiately is the demonstration of competence. Nurses need to possess knowledge and skill related to ethical decision making so that they can articulate their positions clearly. Nurses need to provide a sound rationale for their views." (Erlen). And although nurses are still deeply committed to caring, they can no longer "care" at the expense of being disempowered in relationships and systems. The Code of Ethics should contribute to what Rankin refers to as "empowered caring." (Rankin).

The Code is the promise that nurses are doing their best to provide care for their patients and their communities, supporting each other in the process so that all nurses can fulfill their ethical and professional obligations, as well as increase their goals of professionalization. In the midst of these challenges, the Code of Ethics will be there as concrete evidence of nursing's thoughtful and deliberate ethical posture.

References

(Alexandra) Alexandra, A., and Woodruff, A., Ethics and the Professions, D. Appelbaum and S. Lauton, ed., Prentice-Hall, 1990.

American Nurses Association, Code of Ethics for Nurses with Interpretive Statements . Washington, DC, ANA Publications, 2001.

Baker, R., (1999). American independence and the right to emergency care. Journal of the American Medication Association 28(9): 859-60.

Curtin, L., (2000). On being a person of integrity...or ethics and other liabilities. The Journal of Continuing Education in Nursing, 31(2): 55-8.

Erlen, J., (1993). Empowering nurses through nursing ethics committees. Orthopaedic Nursing, 12( 2): 69-72.

Fitzpatrick, J., (1990). The power of the written word. Applied Nursing Research, 3(1): 1.

Fowler, M., (2000). A new code of ethics for nurses. American Journal of Nursing, 100(7): 69-72.

Lichtenberg, J., Codes of Ethics and the Professions, M. Coady and S.Bloch, ed., Melbourne University Press, 1996.

Pyne, R., (1994). Empowerment through use of the code of professional conduct. British Journal of Nursing, 3(12): 631-4.

Rambur, B., (1998). Ethics, economics and the erosion of physician authority: a leadership role for nurses. Quality and Accountability in Practice, 20(4): 62-71.

Rankin, W., (2000). Ethics of care and the empowerment of nurses. Journal of Pediatric Nursing, 15(3): 193-4.