A most interesting and critical component of professional nursing education today surround nurses’ principled thinking and their moral reasoning abilities in the practice environment. Popular moral development theories have been associated with Kolberg (1981), Gilligan (1982), and Rest (1986, 1994). Moral development theories attempt to explain stages of personal moral development that are operational at the time we are faced with ethical, legal, or moral dilemmas. In a study by Ham (2004), the level of nursing education was reported to have “nonsignificant” impact on nursing principled thinking (Ham, 2004). Looking back to Astrom, Jansson, Norberg, and Hallberg (1993), nurses had increasingly voiced feelings of personal uncertainty in dealing with ethical dilemmas despite years of exposure and involvement in the practice setting. Now, over two decades later, advocates of nursing education and practice are striving continually to elevate the development of moral reasoning of nurses at the pre-licensure level and of those who are seasoned professionals. With so many distractions such as social media, internet access, limitations of human and material resources within the changing healthcare system, peer pressure, and changing social norms, the understanding and application of the Code of Ethics become less clear. Are traditional nursing students able to the make the connection between the tenets of nursing ethics and their personal and professional behaviors and practices? Further, to what extent are experienced nurses able to function ethically as patient/family advocates and caregivers within the constraints of a resource-challenged healthcare system?
In an opening statement by Marsha D.M. Fowler, editor of the 2010 reissue of the “Guide to the Code of Ethics for Nurses: Interpretation and Application” (ANA, 2010), the Code of Ethics for Nurses is an historical document that has “evolved and developed in accordance with the changing social context of nursing…and with the progress and aspirations of the profession (Fowler, 2010).” It is the principle foundation of our professional practice thought, roles and obligations, and behavior that is articulated though its nine provisions. For the registered nurse (RN) in pursuit of a baccalaureate degree (BSN) or higher, understanding the Code of Ethics for Nurses is paramount to effecting personal and professional change, elevating the standards of practice, and ensuring the delivery of safe and just patient care. For the RN in pursuit of his/her professional degree, it becomes imperative to revisit the Code and re-commit to upholding the time honored values promised in earlier entry into practice.
In December 2015, in a release by the American Nurses Association, nurses were “ranked as the most honest, ethical profession for the 14th straight year” according to the Gallup poll (2015) ranking honesty and ethics in other fields. Despite this public acknowledgement, my students in the RN-BSN program (NURS 440: Leadership and Management for the RN) frequently discuss issues of unreported medication administration error, documentation dishonesty, work-arounds (“working around standards by unknowingly or unknowingly bending the rules,” Pugh, 2011), and failure to address interpersonal conflict and/or report unprofessional conduct in the clinical setting. Collectively, all these clinical events have potentially negative outcomes on patient care and on the providers themselves. As nurses, we know that events happen clinically that are in direct opposition to our Code. We all have been in situations that challenge our values and leave us feeling vulnerable. We want to do the right thing. However, for some, the decision-making process may be reflective of the distractions mentioned earlier or reside in the individual’s level of moral development.
Let us look at the ANA code of ethics provisions and reflect on some real clinical situations that oppose our fundamental values and practices as professional nurses:
“Respect to Others…” (ANA, 2001)
- Have you/another publically been rude or offensive to a peer or colleague in the clinical environment?
- Have you or a peer answered your cell phone in a patient’s room or used your mobile device to text message someone in the presence of a patient?
“Commitment to Others…” (ANA, 2001)
- Have you/peer neglected to report suspicions or observations of drug diversions, impaired colleagues, or other events that pose harm to patients?
- Do you promise things to patients but fail to deliver?
“Protection of Others…” (ANA, 2001)
- Have you/peer assessed the competence of unlicensed personal to validate skill before delegating tasks?
- Do you/another safeguard all medical information of patients from public view?
- Do you wash your hands between each patient under your care?
“Responsibility, Accountability, and Liability to Practice…” (ANA, 2001)
- Have you made a medication error and left it unreported?
- Have you falsely documented assessments on patients without actually doing the assessment?
“Responsible and Accountable for one’s own competence, safe practice, and continuing education.” (ANA, 2001)
- Are you habitually delinquent in meeting annual competencies?
- Do you follow policy and procedure when performing all clinical skills?
- Would you skip steps in protocol if pressed for time to complete a task?
“Establish and maintain work environments that provide quality healthcare and reflect the values of the profession.” (ANA, 2001)
- Are you actively participating in shared governance and committee work?
- Do you have a personal commitment to reduce bullying in your unit/facility?
“Advance the profession through contributions to practice, education, administration, knowledge development.” (ANA, 2001)
- Do you role –model evidence-based practice?
- Are you a participant in nursing research projects impacting nurse-sensitive indicators?
- Do you serve as a preceptor or mentor?
“Collaboration with other professionals and the public to meet healthcare needs of community, the USA, and/or internationally?
- Do you participate in any community volunteerism, national committees or task forces?
- Do you advocate for under-served populations?
As a member of a profession, offer voice to the values and integrity of the profession that impacts social policy.” (ANA, 2001)
- Have you joined a professional nursing organization?
- Have you written an article for the local newspaper or a nursing journal?
- Have you advocated for a population/public health concern through your local or state representative?
For more insight into moral development theory and understanding of the ANA nursing code of ethics, explore the references provided. If you would like to learn more about Widener University’s RN-BSN online program and how “NURS 440: Leadership and Management for the RN” applies the nursing code of ethics in its curriculum call 844-386-7321 to speak with a Program Manager.
Written by: Lorraine C. Igo, Assistant Professor of Nursing
American Nurses Association (2015, December). Nurses rank as most honest, ethical profession
for 14th straight year. News release, 12/21/15. Silver Spring, MD: Author.
American Nurses Association (2010). Guide to the coded of ethics for nurses:
Interpretation and application (reissue), Silver Spring, MD: Author.
American Psychological Association (2010). Publication manual of the American Psychologial
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Baxter, P.E. & Boblin, S. J. (2007). The moral development of baccalaurate nursing students:
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Fowler, M.D.(2001). The code of ethics for nurses: Something old and something new. (In Guide to the
coded of ethics for nurses:Interpretation and application (Introduction), Martha Fowler, Ed.).
Spring, MD: American Nurses Association, xiii.
Ham, K. (2004, March/April). Principled thinking: A comparison of nursing students and
experienced nurses. The Journal of Continuing Education, 35(2), 66-73.
Pugh, D. (2011). A fine line: the role of personal and professional vulnerability in allegations of
unprofessional conduct. Journal of Nursing Law, 14(1), 21-31. Springer Publishing Company,