The 9 Core Principles of Nursing Ethics

Applying the Core Principles

There’s a reason nurses continue, for the 20th year in a row, to rank highest in the Gallup annual index of professions with the most honesty and ethics. This year’s poll found 81 percent of respondents rated nurses as having high honesty and ethics, followed in second place by physicians at 67 percent.

Nurses are guided by the 2015 American Nurses Association (ANA) “Code of Ethics for Nurses with Interpretive Statements.” The nursing ethics code, outlined in a 48-page document, presents nine provisions that guide nurses in their everyday practice.

“The Code of Ethics can be used in several different ways,” said Liz Stokes, JD, MA, RN, director for the Center of Ethics and Human Rights at the ANA. “The code is guidance for decision making.”

The Center for Ethics fields hundreds of questions from nurses about ethical principles in nursing. The center will provide nurses with the tools, skills, and guidance to work through a dilemma. The top three concerns nurses are inquiring about have changed since the COVID-19 pandemic rocked the profession.

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“COVID has changed everything,” Stokes said. “It has drastically changed healthcare and the nursing profession.”

Now the top nursing ethical issue has to do with human resource allocation, such as staffing, Stokes explained.

“When you do not have enough resources to properly care for your patients it results in moral distress,” Stokes said. “This is what nurses are experiencing, especially during COVID. Patients were critically ill, and [nurses] were understaffed and the under-resourced.”

As a result of that moral distress, she explained, more nurses are dealing with mental health issues and are leaving the profession or leaving the bedside.

Racial injustice has emerged as another concern, as COVID-19 disproportionately affected people of color.

“COVID brought out racial injustices in the world,” Stokes said. “It’s more evident to more people in the profession. ANA is looking at how racism is affecting the nursing profession.”

How to apply the Code of Nursing Ethics

Stokes encourages all nurses to read the entire Code of Ethics and then go back when they are in a troubling situation and reread the relevant provision.

Provision 1: Nurses practice with compassion and respect for the inherent dignity, worth, and unique attributes of every person.

End-of-life conversations often fall under this first provision and the “Right to SelfDetermination.” The code indicates patients have the legal and moral right to decide what will be done to their body, including the right to refuse treatment. The code states “nurses have an obligation to be familiar with and to understand the moral and legal rights of patients.” The code clearly places nurses at the forefront of protecting and supporting patients’ rights.

Provision 2: The nurse’s primary commitment is to the patient whether an individual, family, group, community, or population.

Conflicts of interest may arise from conflicting expectations, for instance, a family member of a patient might want the nurse to take care of him as well, Stokes explained. A cut-and-dry answer is not available.

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Whether to proceed and give that aid might depend on whether other nurses are available or if no one can help to save that other person’s life, it would be OK to proceed.

Provision 3: The nurse promotes, advocates for, and protects the rights, health, and safety of the patient.

Among the items in this provision, ethical principles in nursing include promoting a culture of safety, maintaining patient confidentiality and privacy, and ensuring nurses continue learning and have the latest knowledge when caring for patients. 

Provision 4: The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to provide optimal patient care.

Nursing ethics discussed in provision 4 include nurses’ accountability and responsibility for care delivery, judgments, actions, and their competencies. For instance, if a patient’s needs are more than the nurse feels qualified to provide for, the nurse must reach out to other nurses or healthcare professionals. This provision also deals with delegating tasks. 

Provision 5: The nurse owes the same duties to self as to others, including the responsibility to promote health and safety

The ethical principles of nursing in provision 5 deal with self-care, personal health, and integrity.
The provision described the importance of eating a healthy diet, exercising, resting, and
maintaining relationships. Sometimes, with demands on nurses so high, as during the COVID19 surges, self-care often took a back seat to care for others. However, the Code of Ethics is
clear: nurses must also take care of themselves.

Provision 6: The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care.

The nursing ethics described in this provision have to do with creating and maintaining a healthy
environment in which to practice the profession. Nurses are expected to do what’s right for
their patients and their workplaces. They foster ethical practice by helping to put in
place clear policies and procedures that establish ethical guidelines, including equitable
and fair treatment for all.

Provision 7: Nurses advance the profession through research and scholarly inquiry, professional standards development, and the generation of nursing and health policy.

This provision deals with contributing to a growing body of knowledge and developing and
implementing professional practice standards and health policy. Nurses can advocate for
changes in their institutions’ policies and lead on multiple levels.

Provision 8: Nurses collaborate with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities.

Nurses may want to give their time to provide care for people in an underserved country. Stokes
explained that the code of nursing ethics reinforces the need to be culturally humble and
respectful of the culture. It also brings to light the need to ensure the sustainability of care for
patients and not just flying in and out, with patients not able to continue with the plan of care.

Provision 9: This provision pertains to professional nursing organizations.

This final provision states that the nursing profession, as represented by associations
and their members, is responsible for articulating nursing values, maintaining the
integrity of the profession and its practice, and shaping social policy.

Individual members and leaders in these nursing organizations should take these
guidelines to heart when pursuing initiatives, making public statements, or representing
the nursing profession in any way.

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