Know the code

EDITOR'S NOTE: Debra Anscombe Wood, RN, is a freelance writer.

Every day, nurses face ethical challenges. The Code of Ethics for Nurses with Interpretive Statements provides a framework for addressing concerns inherent in the profession.

“The kinds of quandaries nurses face are broad and far reaching,” said Cynda Rushton, PhD, RN, FAAN, a professor of nursing and pediatrics at Johns Hopkins University and the Anne and George L. Bunting professor of Clinical Ethics at Johns Hopkins Berman Institute of Bioethics in Baltimore. “Because of their proximity to patients, they see in an intimate way the consequences of the therapies and often the suffering of their patients.”

That can lead to moral distress. Futility of treatment is the No. 1 reason for ethical consults, said Carol R. Taylor, PhD, RN, professor of nursing and health studies and medicine at Georgetown University in Washington, D.C., and a founding member of the Pellegrino Center for Clinical Bioethics at Georgetown.

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People often like to reduce ethics to black and white, when issues are gray.

— Cynda Rushton, RN

Rushton explained that people often like to reduce ethics to black and white, when issues are gray. That’s where judgment comes in and a realization of a range of ethically permissible options in complex and value-laden situations.

“Resources, like the code, can help us navigate that ambiguous and uncertain territory,” Rushton said.

Taylor and Rushton provided the following examples for each of the provisions.

^PROVISION1

Nurses practice with compassion and respect.

Yet nurses and other health professionals may make derogatory remarks about patients or families — perhaps referring to them as “difficult,” Taylor said.

^PROVISION3

Nurses promote, advocate and protect the patient’s health, safety and rights.

This includes not sneaking a peak at a famous patient’s medical record, Taylor said.

^PROVISION5

Nurses’ duties to self.

When nurses cannot meet the needs of their patients, it forces them to practice in a way that does not meet this provision. Taylor offered as an example trying to stay under the radar and just do the minimal amount of work when short staffed.

^PROVISION7

Nurses are obligated to advance the profession through research, standards development and generation of policy.

As an example, Taylor said that this might take place on a pediatric unit, where nurses note infants whose feedings were increased based on individual assessments made faster gains than infants fed based on a hospital policy.

^PROVISION9

Nurses are responsible for taking action to support social justice.

“We are at an intersection,” Rushton said. She explained nurses deal with social justice issues every day, in every role, in every specialty. Taylor agreed, saying nurses need to think about their responsibilities and what it means to be a citizen to end sex trafficking, to improve access to mental health and other services or to fight global disparities.

“Nurses need to get galvanized and on fire about some of these issues,” Rushton said. “But not in a belligerent way. The code offers a language to articulate these issues in a way that reveals why they are so important and why they cause nurses distress.”

^PROVISION2

Nurses’ primary commitment is to the patient.

Respecting patients’ preferences for treatment and nontreatment has implications for the informed consent process, Rushton said. It’s important nurses are involved in supporting patients in making decisions and helping them clarify questions.

^PROVISION4

Nurses have the authority, accountability and responsibility for nursing practice.

This may come into play, Taylor said, when a discharge nurse in the ED is worried a patient is too sick to go home, and completes an assessment and brings the concerns to the physician, manager and charge nurse.

^PROVISION6

Nurses should elevate ethical environment.

Nurses can improve the ethical practice in the workplace and make a collective effort to maintain a work setting conducive to safe, quality care. Rushton said this requires nurses to advocate for doing the right thing.

^PROVISION8

Nurses collaborate with other health professionals and the public to protect human rights and reduce health disparities.

“Nurses see the inequities and disparities in healthcare,” Rushton said. She suggested nurses could use the code to explain their concern about unequal treatment.