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MORAL IMPLICATIONS OF DECISION MAKING IN CODE OF NURSING

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MORAL IMPLICATIONS OF DECISION MAKING IN CODE OF NURSING INTRODUCTION In Nursing when we speak of holistic care this means that the spiritual aspect is included as well. The code of ethics for Filipino nurses lists provision of spiritual environment as one of the responsibilities of the nurses. According to the Holy Bible the message of St. Pauls to the Collosssians is very apt for nurses. He said, You are the chosen people of God. He loves you and chose you for His own. So, then, clothe yourselves with compassion, kindness, humility, gentleness, and patience. The role of nurses in providing non-prejudicial, non-discriminatory care can well be based on the story of the Good Samaritan. God has asked us to loved one another as He loves us. Patients and families who are troubled with illness or anxiety will certainly look up to a compassionate nurse for understanding and kindness ( L. Venzon;R. Venzon,2005,p.123) As I chose Nursing as a profession I prepared myself to serve people in any ay sans as a nurse my major goal is to promote health, prevent any diseases, alleviate suffering and if healing is not possible towards a peaceful death. Lydia Venzon noticed that oftentimes, nurses find it difficult to resolve ethical issues partly because they do not have sensitivity to recognize ethical problem. What makes a code of ethics an important document for nurses? Generally, a code of ethics functions as a tool and necessary mark of a profession and professional self-definition (Davis, 2008). Professionals also engage in self-regulation. Nursing is no different. A code of ethics is one such structure that displays nursing are scope and responsibilities as a profession (ANA, 2003). As nursing continues to strengthen its model of professionalism, the relationship between that model and a code of ethics must be seriously considered. The mere existence of a

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code provides a positive argument that a group self-identifies as "professional," not just as occupational. 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 (Nursings Social Policy Statement, ANA, 2003). As Alexandra and Woodruff write, "...membership in a profession...entails duties, but also rights...of a distinctive kind"(Alexandra, 1990, p. 227). A code of ethics outlines these distinctive duties and rights. The importance of a code of ethics for nurses is also emphasized in nursings social policy statement and is considered a measurement criteria in nursings scope and standards of practice, requiring nurses to use the Code of Ethics for Nurses with Interpretive Statements, 2001, to guide practice (ANA, 2004). Ultimately, a code serves as the written word, or the public document, declaring 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, 1990, p. 1) 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 it. The Code of Ethics for Nurses with Interpretive Statements, 2001, herein referred to as the Code of Ethics, also reflects nurses expanded professional roles as administrators, care coordinators, educators, quality assurance managers, and researchers, as well as providers of direct patient care. All nurses in today's health care environment are faced with multiple ethical challenges, which are related either directly or indirectly to fiscal constraints, pay for

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performance initiatives, managed care payment plans, staffing shortages and complex medical conditions that affect not just individuals, but whole communities. In the current health care delivery system, and as a result of the expanded responsibilities of nurses, the relationship between nurses and patients has been challenged more than ever. Nurses face "ethical issues and stresses in intra-professional and inter-professional relationships not envisioned in years past" (Walleck, 1989, p. 366). The Code is available to help nurses navigate this new moral paradigm in an era "when hospitals have become marketplaces...." (Curtin, 2000, p. 56) The nursing profession is challenged to remain vigilant in its advocacy for patient and family centered care through leadership, political action, and collective unity. The Code articulates nursings commitment to provide high quality care to patients and communities, supporting each other in the process, so that all nurses can fulfill their ethical and professional obligations, as well as meet their own professional career goals. The Code of Ethics for Nurses, 2001 exists as concrete evidence of nursing's thoughtful and considered ethical commitments. 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 contributes to what Rankin refers to as "empowered caring" (Rankin, 2000, p. 194).. History of Codes of Ethics for Nurses The first official nursing code of ethics was adopted by the American Nurses Association (ANA) in 1950. However, an early nursing organization, the Nurses Associated Alumnae of the United States and Canada (which became the American Nurses Association in the early 1900s), met as early as 1896 to discuss the adoption of a code of ethics for nurses (Fowler, 2008). In 1926 a Suggested Code was discussed but not adopted by ANA. Fourteen years later, in 1940,

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a Tentative Code was published by ANA. After seeking counsel and input the Tentative Code was adopted by ANA as The Code for Professional Nurses in 1950. It was 10 years before a substantive revision of the 1950 Code was proposed, but would not be adopted until 1968. This was followed by a revised version in 1976, then 1985. The Code of Ethics for Nurses with Interpretive Statements, 2001, is the first revision of the Code of Ethics since that time (Fowler, 2008). Despite the long history of deliberation and the drafting of versions of a code and the actual adoption of codes of ethics, nursings moral past and present is always represented in each version. In spite of what may seem a weakness, having revisions of the code of ethics is in reality the Codes strength. Fowler writes that The Code for Nurses reflects both constancy and changeconstancy in the identification of the ethical virtues, values, ideals, and norms of the profession, and change in relation to both the interpretation of those virtues, values, ideals and norms, and the growth of the profession itself (Fowler, 2008, p. xviii). The ANA code, when first developed, was used as a model by nursing organizations worldwide (Davis, 2008). Provisions 1-3: Fundamental Values of the Professional Nurse Provision 1: The Nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems. Provision 2: The nurses primary commitment is to the patient, whether an individual, family, group, or community. Provision 3: Then nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.

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The fundamentals of nursing ethics, the fundamental values and responsibilities nurses assume, are expressed in the first three provisions of the Code of Ethics. When nurses need help expressing their primary commitment, that is, what serves as the core of their professional activity they can find that core commitment outlined in the first three provisions of the Code. These values include nurses' respect for human dignity , nurses primary commitment to the patient and nurses protection of patient privacy. What does respect for human dignity mean in health care and how is it demonstrated? The concept of human dignity is based on the principle of respect for persons, and is derived from philosopher Immanuel Kant's rationalist theory, as well the Judeo-Christian texts, that people should treat others in the same manner in which they desire to be treated: that persons should be treated as ends in themselves, not as means to an end. This ethic translates into respect for all persons. The concept of respect is a dynamic concept that not only requires the person to make a conscious decision to act in a respectful manner but also requires the development of a pattern of behavior that can be applied to a variety of persons in similar situations (Bosek, 2008, p. 105). Respecting all persons means the nurse respects other and honors their dignity in every encounter. This includes patients as well as interactions with colleagues, other professionals, and in fact, in encounters with everyone. For the bedside nurse, this can be expressed in small gestures such as closing curtains for privacy, and in large gestures, such as assuring patient autonomy through the establishment of conditions necessary to provide truly informed consent. The concept of informed consent is fundamental to the ethical delivery of health care and springs from respect for persons and the support of patient autonomy. The nurse's responsibility is paramount in ensuring that patients are fully informed and understand their options. "Each nurse

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has an obligation to be knowledgeable about the moral and legal rights of all patients to selfdetermination" (ANA, 2001, p. 8). The nurse does this by assessing the patient's comprehension of the treatment options presented and the implications of each. If the nurse feels that the patient's comprehension is questionable, the nurse enlists the use of a surrogate. In the absence of a surrogate, the nurse does his or her best to ensure that decisions are made in the best interest of the patient, considering "the patient's personal values to the extent that they are known" (ANA, 2001, p. 9). What if the patient's idea of self-determination includes relying on others for medical decision-making? Is it the nurse's ethical responsibility to enforce individual expressions of autonomy? Should the nurse intervene to enforce his or her concept of autonomy? The Code of Ethics recognizes that professional nurses encounter an increasingly pluralistic and diverse culture and that individualism can be culturally defined. Some patients may choose to defer to the values of others, such as family or community, as they make decisions. The Code of Ethics supports this, stating, that "supports of autonomy in the broadest sense also includes recognition that people of some cultures place less weight on individualism and choose to defer to family or or community values in decision making" (ANA, 2001, p. 9). There may be times when the nurse is confronted with situations in which the support of autonomy and individual rights may bring severe harm to others, for example, a public health crisis. While supporting patient autonomy is paramount, the Code of Ethics considers limiting such autonomy appropriate, but reminds the nurse that the limitation of individual rights must always be considered a serious deviation from the usual standard of care" and is justified only as a last resort (ANA, 2001, p. 9).

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With regard to end-of-life care, the Code of Ethics reiterates the obligation to respect all persons and their autonomy. The Code of Ethics reminds nurses that they are "leaders and vigilant advocates for the delivery of dignified and humane care" (ANA, 2001, p. 9). The prohibition, however, still exists that nurses may never act with the direct intent of ending a patient's life. They may act only to alleviate suffering, albeit with the knowledge that some palliative care may hasten death. Because of the moral distress this kind of nursing care can provoke, nurses are encouraged to learn more about end-of-life care and contribute to the expansion of end-of-life care practices through research, education, practice, and policy development. Provision 2 emphasizes the patient (whether person, family, group, or community) as the primary recipient of the nurses commitment of caring. This emphasis is an acknowledgement of nursings history, whereby nursing in the late 1800s and even after the Civil War, was practiced in family homes or military hospitals. The model of work was more private duty nursing and the nurse was employed by a family, sometimes in conjunction with physicians request for a particular nurse. It is easy to see that, conceivably, there could be four entities making claims on a nurses ethical loyalty: patient, the registry, physicians, and oneself (Davis, 2008). The Code of Ethics reflects the changes in health care financing and delivery systems that interfere with the delivery of humane respectful care and pose new possibilities of "conflict between economic self-interest (bonuses, sanctions, and financial incentives) and professional integrity" (ANA, 2001, p. 10). These conflicts are not restricted to clinical practice, but may occur in administration, education or research and be interpersonal or intra-personal in nature. Nurses in all roles are reminded to be aware of such conflicts of interest that may thwart the kind of respectful care nurses have historically given. If not addressed, conflicts may lead to ethical

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drift described by Kleinman (2006) as an incremental deviation from ethical practice that goes unnoticed by individuals who justify the deviations as acceptable and who believe themselves to be maintaining their ethical boundaries (Kleinman, 2006, p. 73). It is ethically incumbent upon the nurse in the hospital and in other workplace settings to be sensitive to the potential effects of financial cutbacks and conflicts which may put a patient at risk of sub-standard care. Frequent use of the Code of Ethics for guidance can help all nurses avoid ethical drift Privacy, confidentiality, and safety are the issues central to Provision 3. Privacy and confidentiality derive directly from Provision 1 since autonomy informs privacy and confidentiality (Twomey, 2008). The Code of Ethics recognizes this dynamic as more health care professionals and others make an assortment of claims to information about a patient's health state. Nurses must be especially aware of changes in their institutions charting and record-keeping mechanisms and alert the appropriate individuals when privacy and confidentiality safeguards appear to be threatened. Given these new complexities, how do nurses keep the patient as their primary commitment when so many take care of the patient? They do this by recognizing that nursing is accomplished "through the interdependence of nurses in differing roles and working to make sure that all relevant parties are involved and have a voice in decision-making about patient care issues. (ANA, 2001, p. 11). Nurses are not isolated professionals. Creating a health care delivery system responsive to patients' and society's needs will not be achieved by one nurse alone. The Code of Ethics provides strength to nurses as it reminds them of their membership in the larger professional nursing community. Research funding is available to test new drugs and therapies. The nurse has a responsibility to ensure patients will be protected if they choose to be part of such a research project. Special concerns are raised when research involves vulnerable populations or

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individuals, "including children, prisoners, students, the elderly and the poor" (ANA, 2001, p. 13). The Code of Ethics allows for the nurse to be a conscientious objector with regard to research if he or she questions the ethics of a particular research project. Nurses "have the duty to question and, if necessary, to report and to refuse to participate in research they deem morally objectionable" (ANA, 2001, p. 13). Research nurses must be ever vigilant as universities are experiencing intense pressure to generate the revenue tied to clinical trials. What may be especially challenging for the bedside nurse is the Code's mandate that nurses be involved in review mechanisms. Nurses are crucial in planning, establishing, implementing, and evaluating review mechanisms that will ensure patient care and safety. Nurses are crucial in planning, establishing, implementing, and evaluating review mechanisms that will ensure patient care and safety. This includes being part of peer review committees, credentialing, quality assurance procedures and hospital ethics committees. This ability to evaluate not only systems, but fellow colleagues, may prove uncomfortable for nurses, requiring nurse administrators to provide educational opportunities to assist nurses in these responsibilities. Specifically, nurse administrators must ensure that all nurses have access to hospital ethics committees and that ethics committees have nurse representation. Multiple ethical obligations to the patient, colleagues, the organization, the profession and ones self may sometimes compete or be in conflict. Focusing on the probable consequences of a moral act that promises to resolve a conflict or taking action to resolve moral conflicts often takes moral courage. In 1999, the Institute of Medicine reported large numbers of patients are harmed by medical errors (IOM, 1999). Nurses have key roles in the safe and accurate administration of medications. The Code of Ethics explicitly states the expectation that nurses are expected "to

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follow institutional guidelines in reporting errors committed or observed to the appropriate supervisory personnel and for assuring responsible disclosure of errors to patients" (ANA, 2001, p. 14). However, acknowledging the importance of systems theory, the Code of Ethics states that nurses are not expected to participate in "punitive responses to errors that exist only to fix blame rather than correct systems conditions that lead to errors (ANA, 2001, p. 14). What about incompetence or negligence? The nurse "must be alert to and take appropriate action regarding any instances of incompetent, unethical, illegal or impaired practice by any member of the health care team or the health care system or any action on the part of others that places the rights or best interests of the patient in jeopardy" (ANA, 2001, p. 14). The Code of Ethics makes an interesting distinction between questionable practice and impaired practice, acknowledging the difference between such things as a self-medicating nurse under a great deal of stress, a colleague who is overtly incompetent due to drug abuse, or a clinically incompetent practitioner. According to the Code of Ethics, "the nurse's duty is to take action designed both to protect patients and to assure that the impaired individual receives assistance in regaining optimal function" (ANA, 2001, p. 15). This is a form of patient advocacy and in some cases may result in whistleblowing. The Code exhorts professional associations to assist and support nurses who may have to take a "whistleblower" course of action, recognizing that nurses often become whistleblowers at their own professional peril. When the rights of the patient collide with what is best for the patient, nurses may endure considerable moral distress. For example, consider the dilemma of a nurse working on a psychiatric unit specializing in the treatment of teenage patients with anorexia nervosa. The treatment program includes withdrawing rewards from the patients if their weight goes down.

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The nurse, however, believes, in principle, that people have the right, under most situations, to achieve a weight that they want. (Fry & Veatch, 2000, p. 32) However, in this instance, the patient's desired weight is detrimental to her health. Or consider a situation where nurses struggle to balance respect for a patient's desire to ambulate at will on the unit and the risk that this patient will hurt Himself ( as he has already done ) if he climbs out of bed without the assistance of nursing personnel. (Fry & Veatch, 2000, p. 18) Provisions 4-6: Duty and Loyalty Provision 4: The nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurses obligation to provide optimum patient care. Provision 5: The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth. Provision 6: The nurse participates in establishing, maintaining, and improving health care environments and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession through individual and collective action. Provisions 4-6 in the revised Code of Ethics reinforce and extend Provisions 1-3 as they take the fundamental responsibilities of nurses and move directly into the more practical ethical applications of respect for persons. This set of provisions provides for the ethical application of respect for persons to include not only patients, but begins to address the issue of self-respect as well. Lastly, this section describes moral virtues and values and how these aspects of ethical conduct find their expression in nurses' efforts to create work environments conducive to the carrying out of ethical responsibilities.

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Despite the repeated emphasis on collaboration seen throughout the Code, Provision 4 reminds nurses that each nurse is individually accountable and responsible for his or her own practice. What is the difference between accountability and responsibility? Accountability "means to be answerable to oneself and others for one's own actions" (ANA, 2001, p. 16). Nurses are accountable "for judgments made and actions taken in the course of nursing practice, irrespective of health care organizations policies or providers' directives," which may not always be in the best interest of the patient (ANA, 2001, p. 16). According to Badzek (2009) Accountability for nursing judgment and action means that nurses act under a code of ethical conduct that is grounded in moral principles of fidelity, and respect for dignity, worth and self-determination of patients (Badzek, 2009, p. 45). When policies of the hospital or actions by physicians are not in the patients best interest, nurses may have to take a personal risk to advocate for the patient. Responsibility "refers to the specific accountability or liability associated with the performance of duties of a particular role" (ANA, 2001, p. 16). Notable here is that nurses' accountability does not require organizational policy. If organizational policies require less than what nurses require of themselves, clearly, the nurse relies on nursing values and practice standards to strive for a higher accountability. Accountability, the Code of Ethics describes, is grounded in fidelity and respect for the patient. In this section of the Code of Ethics, the important, but so far implied, concept of nurses moral autonomy emerges. Recognizing the complexity of nursing today, accountability and responsibility become increasingly important components of nursing practice as nurses take on more responsibility, such as advanced practice roles, delegation and supervision and resource utilization. The interpretive statements address accountability and responsibility with regard to the daily responsibilities of direct nursing care as well as the delegation of these responsibilities to others.

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What exactly are nurses responsible for, other than providing good patient care? They are responsible for assessing their own competence, and seeking remedies when certain responsibilities fall outside their competency. Nurses do this by seeking educational resources, and collaborating with others, including nurse educators. All nurses are required to continually assess and improve their own competence through continuing education, self-study, networking, and formal programs. In these times of increasing patient-to-nurse ratios, the delegation of tasks to others, sometimes non-licensed personnel, can be challenging for nurses. Nurses must accept their accountability for a patient's care even as they direct others to perform certain patient-care tasks. To this end, the Code of Ethics is specific that nurses must not only assess their own competencies, but the competencies of others. The Code of Ethics explicitly states that assessment and evaluation responsibilities are not to be delegated to assistive personnel. Only tasks may be assigned to others. The interpretive statements allow for moral autonomy and decision-making. "Employer policies or directives do not relieve the nurse of responsibility for making judgments about the delegation and assignment of nursing care tasks" (ANA, 2001, p. 17). This moral responsibility in delegating and remaining accountable makes it incumbent on nurse administrators to provide safe staffing levels. Nurses are morally bound to refuse unsafe assignments, and to work to change unhealthy environments. Nurses must express their moral autonomy when institutions actively thwart nursing's values and/or the values of the nurse in question. Nurses can be, and occasionally may need to be, conscientious objectors, both individually and collectively, if they feel that they are being asked to put aside their own moral values when providing patient care. In the workplace, compromises

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can be made only if they preserve the professional integrity of the nurse. Otherwise, the nurse may need to make arrangements for another nurse to take over care of a particular patient The Code of Ethics, 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 of Ethics helps nurses claim their rightful place as health care collaborators, not followers. Provision 5 addresses duties to self in a very new and compelling way. In addition to physical health, continuing education and financial security, the new code includes wholeness of character, identity and integrity (Fowler, 2009). These themes can be found in interpretive statements 5.2, Professional Growth and Maintenance of Competence; 5.3, Wholeness of Character; and 5.4, Preservation of Integrity. Nurses must be aware that becoming a professional is a process of integration of professional and personal values and is key to wholeness of character. Professional growth moves the nurse beyond mere competence, as a minimum standard of practice, toward excellence and is thus directed toward an ideal of practice (Fowler, 2009, p. 59). Competence is a self regarding duty, essential to self respect, self esteem, professional status and the meaningfulness of work (Fowler, 2009, p. 60). Peer review and self evaluation are tools that can be used by nurses for achieving insight into their job performance. Wholeness of character acknowledges that nurses have a duty to themselves to participate in "authentic expression of one's own moral point-of-view in practice" (ANA, 2001, p. 19). This includes expressing informed opinions to the patient about health and illness if the patient requests such opinions. Always adhering to professional boundaries is essential. Developing and preserving

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integrity is articulated in provision five. The concept and practice of conscientious objection allows nurses to identify their own moral objections, if any, when an action would violate deeply help moral convictions. Creating, promoting and maintaining an environment for ethical practice is the responsibility of every nurse. Provision six provides guidance through explanation of the influence that the environment has on moral virtues, values and ethical obligations. It also describes methods and strategies for nurses individual and collective participation in maintaining an ethical environment. Virtues are an important feature of the professionalization of the nurse, but they can be thwarted by the work environment. Nurses are encouraged to change organizational processes and structures in ways that improve patient care and the work environment. To this end, nurses must be part of organizational decision-making bodies. Shared governance, collective bargaining and workplace advocacy are methods to address workplace issues. The principle of respect for others that has been so paramount prior to this section now turns the concept of respect for persons inward. The nurse must extend respect "to oneself as well; the same duties that we owe to others, we owe to ourselves" (ANA, 2001, p. 18). Peer review serves as a mechanism to maintain quality care for patients and to enhance nurses' self respect and integrity. The Code of Ethics recognizes nurses have personal and professional identities that, while not identical, are certainly merged into a wholeness of character. When varying values are expressed regarding a patient's care, the nurse has a moral responsibility to express his or her viewpoint, even if this viewpoint is not the prevailing one. Provisions 7-9: Expanded Duties Beyond Direct Patient Care

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Provision 7: The nurse participates in the advancement of the profession through contributions to practice, education administration and knowledge development. Provision 8: The nurse collaborates with other health professionals and the public in promoting community, national, and international efforts to meet health needs. Provision 9: The profession of nursing, as represented by associations and other members, is responsible for articulating nursing values, for maintaining the integrity of the profession and its practice, and for shaping social policy. Provisions 7-9 of the Code of Ethics for Nurses discuss the broader range of a nurses responsibilities, specifically in advancing the profession of nursing, such as through active participation in professional associations. It is also in this section that nurses are reminded of their responsibility to collaborate with other health professionals and the public to work toward social reform in those areas that contribute to human illness and distress, such as poverty. Although many of these ethical obligations have been discussed earlier in the Code of Ethics, it is in this last section of provisions that the professional associations duties are made explicit and nursing's overall concern for human rights is discussed. Provision 7 creates a moral link between the nurse as a person, the individual practice of the nurse, and the nursing professional as a whole (Drought & Epstein, 2008, p. 91). In Provision 7, nurses are reminded to contribute to the larger spectrum of nursing through "leadership, activities, and the viability of their professional organizations" (ANA, 2001, p. 22). To become a nurse, then, is not to practice nursing as merely a job, but to see oneself through a professional's eyes, which means collaborating with other nurses to advance the profession. Through professional associations, standards and guidelines for nurses are developed and advanced. Because a professional has obligations to society as a whole, Provision 7 refers to the obligation

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nurses have to engage in "ongoing scholarly activities" ANA, 2001, p. 23). Nurses must be aware of ongoing challenges and anticipate future challenges that nursing must prepare itself to meet. Provision 7 mandates that nurses engage to some degree in policy and regulation of the profession through continual research that sets standards of clinical, administrative, and educational practice. It is Provision 7 that continues the argument that a hallmark of a profession is that is self-regulating Do nurses have an ethical obligation to pay attention to world hunger? World peace? Pollution? Relying on ethical theories of justice, Provision 8 answers these questions. Nurses are to be committed to the resolution of social ills that hinder the well-being of all people. Provision 8 reminds nursing that nurses, individually and collectively, have a responsibility to know the health needs of their communities as well as the large communities in which they live. Accessibility and availability of health care requires collaborating with other disciplines at the local, national and international levels (ANA, 2001). Many feel nurses have a significant opportunity to challenge the loss of the patient-centered ethic and step into more highly visible roles as public advocates. With nursing's patient-centered history, Rambur concludes that nursing "is the profession poised to take this leader/advocate role" (Rambur, 1998, p 64). 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, 2000, p. 72). Again, collaboration is necessary for this to happen. Nurses, individually and collectively, have an obligation to educate the public through different means about the health of

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individual communities. "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 & Woodruff, 1990, p. 227). Provision 9 addresses professional associations and their responsibilities in "articulating nursing values, for maintaining the integrity of the profession and its practice, and for shaping social policy (ANA, 2001, p. 24). As individual nurses have these obligations, so do their professional associations. This provision addresses nurses obligations to participate in civic responsibilities and for advocating for appropriate health-related legislation. The provision crystallizes the role of professional association I social ethics on behalf of the profession (Fowler, 2008). About The Code The Code of Ethics project was initiated by the ANA Board of Directors and the Congress on Nursing Practice in 1995. The Code of Ethics Project Task Force, appointed in 1996, was charged with establishing a comprehensive process of review, analysis and revision of the Code for Nurses (1985), providing initial substantive critique and suggested modifications, creating open review process, and developing final recommendations. The revised Code for Nurses proposed as the Code of Ethics for Nurses was forwarded to the Congress of Nursing Practice and Board of Directors to the 1998 House of Delegates (HOD) for approval. The HOD voted to refer the Code of Ethics for Nurses back to the ANA Board of Directors for further work. The ANA Board decided that further revisions with increased staff nurse input were needed.

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During the ANA Convention 2000 in Indianapolis, Indiana, a continuing education session about the Code revision process and a policy issues forum were convened. The continuing education session demonstrated how the new draft Code could be usefully applied to actual case situations. In June of 2001, the ANA House of Delegates voted to accept the nine major provisions of a revised Code of Ethics. In July, 2001, the Congress of Nursing Practice and Economics voted to accept the new language of the interpretive statements resulting in a fully approved revised Code of Ethics for Nurses With Interpretive Statements. Throughout this revision process, the Task Force has attempted to seek the opinions and suggestions of a wide range of nurses, individuals, and groups. This is done through regional conference calls, presentations, extensive field reviews, and numerous individual. THE ICN CODE OF ETHICS FOR NURSES An international code of ethics for nurses was first adopted by the International Council of Nurses (ICN) in 1953. It has been revised and reaffirmed at various times since, most recently with this review and revision completed in 2005. PREAMBLE Nurses have four fundamental responsibilities: to promote health, to prevent illness, to restore health and to alleviate suffering. The need for nursing is universal. Inherent in nursing is respect for human rights, including cultural rights, the right to life and choice, to dignity and to be treated with respect. Nursing care is respectful of and unrestricted by considerations of age, colour, creed, culture, disability or illness, gender, sexual orientation, nationality, politics, race or social status. Nurses render health services to the individual, the family and the community and co-ordinate their services with those of related groups. THE ICN CODE

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The ICN Code of Ethics for Nurses has four principal elements that outline the standards of ethical conduct. ELEMENTS OF THE CODE 1. NURSES AND PEOPLE The nurses primary professional responsibility is to people requiring nursing care. In providing care, the nurse promotes an environment in which the human rights, values, customs and spiritual beliefs of the individual, family and community are respected. The nurse ensures that the individual receives sufficient information on which to base consent for care and related treatment. The nurse holds in confidence personal information and uses judgement in sharing this information. The nurse shares with society the responsibility for initiating and supporting action to meet the health and social needs of the public, in particular those of vulnerable populations. The nurse also shares responsibility to sustain and protect the natural Environment from depletion, pollution, degradation and destruction. 2. NURSES AND PRACTICE The nurse carries personal responsibility and accountability for nursing practice, and for maintaining competence by continual learning.The nurse maintains a standard of personal health such that the ability to provide care is not compromised. The nurse uses judgement regarding individual competence when accepting and delegating responsibility. The nurse at all times maintains standards of personal conduct which reflect well on the profession and enhance public confidence. The nurse, in providing care, ensures that use of technology and scientific advances are compatible with the safety, dignity and rights of people.

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3. NURSES AND THE PROFESSION The nurse assumes the major role in determining and implementing acceptable standards of clinical nursing practice, management, research and education. The nurse is active in developing a core of research-based professional knowledge. The nurse, acting through the professional organization, participates in creating and maintaining safe, equitable social and economic working conditions in nursing. 4. NURSES AND CO-WORKERS The nurse sustains a co-operative relationship with co-workers in nursing and other fields. The nurse takes appropriate action to safeguard individuals, families and communities when their health is endangered by a coworker or any other person. SUGGESTIONS FOR USE OF THE ICN CODE OF ETHICS FOR NURSES The ICN Code of Ethics for Nurses is a guide for action based on social values and needs. It will have meaning only as a living document if applied to the realities of nursing and health care in a changing society. To achieve its purpose the Code must be understood, internalized and used by nurses in all aspects of their work. It must be available to students and nurses throughout their study and work lives. APPLYING THE ELEMENTS OF THE ICN CODE OF ETHICS FOR NURSES The four elements of the ICN Code of Ethics for Nurses: nurses and people, nurses and practice, nurses and the profession, and nurses and co-workers, give a framework for the standards of conduct. The following chart will assist nurses to translate the standards into action. Nurses and nursing students can therefore: Study the standards under each element of the Code.

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Reflect on what each standard means to you. Think about how you can apply ethics in your nursing domain: practice, education, research or management. Discuss the Code with co-workers and others. Use a specific example from experience to identify ethical dilemmas and standards of conduct as outlined in the Code. Identify how you would resolve the dilemmas. Work in groups to clarify ethical decision making and reach a consensus on standards of ethical conduct. Collaborate with your national nurses association, co-workers, and others in the continuous application of ethical standards in nursing practice, education, management and research.5 Element of the Code # 1: NURSES AND PEOPLE Practitioners and Managers Provide care that respects human rights and is sensitive to the values, customs and beliefs of all people. Provide continuing education in ethical issues. Provide sufficient information to permit informed consent and the right to choose or refuse treatment. Use recording and information management systems that ensure confidentiality. Develop and monitor environmental safety in the workplace. Educators and Researchers In curriculum include references to human rights, equity, justice, solidarity as the basis for access to care. Provide teaching and learning opportunities for ethical issues and decision making. Provide teaching/learning opportunities related to informed consent. Introduce into curriculum concepts of privacy and confidentiality. Sensitize students to the importance of social action in current concerns. National Nurses Associations

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Develop position statements and guidelines that support human rights and ethical standards. Lobby for involvement of nurses in ethics review committees. Provide guidelines, position statements and continuing education related to informed consent. Incorporate issues of confidentiality and privacy into a national code of ethics for nurses. Advocate for safe and healthy environment. Element of the Code # 2: NURSES AND PRACTICE Practitioners and Managers Establish standards of care and a work setting that promotes safety and quality care. Establish systems for professional appraisal, continuing education and systematic renewal of licensure to practice. Monitor and promote the personal health of nursing staff in relation to their competence for practice. Educators and Researchers Provide teaching/learning opportunities that foster life long learning and competence for practice. Conduct and disseminate research that shows links between continual learning and competence to practice. Promote the importance of personal health and illustrate its relation to other values. National Nurses Associations Provide access to continuing education, through journals, conferences, distance education, etc.Lobby to ensure continuing education opportunities and quality care standards. Promote healthy lifestyles for nursing professionals. Lobby for healthy work places and services for nurses. Element of the Code # 3: NURSES AND THE PROFESSION Practitioners and Managers

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Set standards for nursing practice, research, education and management. Foster workplace support of the conduct, dissemination and utilization of research related to nursing and health. Promote participation in national nurses associations so as to create favorable socio-economic conditions for nurses. Educators and Researchers Provide teaching/learning opportunities in setting standards for nursing practice, research, education and management. Conduct, disseminate and utilize research to advance the nursing profession. Sensitize learners to the importance of professional nursing associations. National Nurses Associations Collaborate with others to set standards for nursing education, practice, research and management. Develop position statements, guidelines and standards related to nursing research. Lobby for fair social and economic working conditions in nursing. Develop position statements and guidelines in workplace issues. Element of the Code #4: NURSES AND CO-WORKERS Practitioners and Managers Create awareness of specific and overlapping functions and the potential for Interdisciplinary tensions. Develop workplace systems that support common professional ethical values and behavior. Develop mechanisms to safeguard the individual, family or community when their care is endangered by health care personnel. Educators and Researchers Develop understanding of the roles of other workers. Communicate nursing ethics to other professions. Instill in learners the need to safeguard the individual, family or community when care is endangered by health care personnel.

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National Nurses Associations Stimulate co-operation with other related disciplines. Develop awareness of ethical issues of other professions. Provide guidelines, position statements and discussion for a related safeguarding people when their care is endangered by health care personnel. DISSEMINATION OF THE ICN CODE OF ETHICS FOR NURSES To be effective the ICN Code of Ethics for Nurses must be familiar to nurses. We encourage you to help with its dissemination to schools of nursing, practicing nurses, the nursing press and other mass media. The Code should also be disseminated to other health professions, the general public, consumer and policy-making groups, human rights organizations and employers of nurses. GLOSSARY OF TERMS USED IN THE ICN CODE OF ETHICS FOR NURSES Co-worker Other nurses and other health and non-health related workers and professionals. Co-operative A professional relationship based on collegial relationship and reciprocal actions, and behavior that aim to achieve certain goals. Family A social unit composed of members connected through blood, kinship, emotional or legal relationships. ETHICS IN NURSING JOB AND PROFESSION 1. Autonomy - Personal Liberty of Action - Independence

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- Self-reliance Nursing Implication - Promote client decision-making. - Support clients right to informed consent. - Make decisions when clients choice poses harm. - Autonomy is truly exercised when members of the health care team agree to importance of autonomy. 2. Nonmaleficence -Duty to do no harm Nursing Implication - Avoid deliberate harm, risk of harm, and harm that occurs during performance of nursing actions. - Consider degree of risk morally permissible. - Determine whether use of technological advances provides benefits that outweigh risks. -not assisting in or performing abortion -not assisting person to commit suicide -not performing euthanasia or mercy killing -not willfully subjecting patients to experimental drugs whose potential harm may be greater than the expected benefit. -not harming a persons reputation by revealing confidential information 3. Beneficence -Doing or active promotion of good Nursing Implication

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- Provide health benefits to clients. - Balance benefit and harm. - Consider how client is best helped. 4. Justice -Fairness or equity Nursing Implication - Ensures fair allocation of resources, such as appropriate staffing or mix-of-staff, to all clients. - Determines the order in which clients should be treated; for example, clients in pain are treated first.

As a CAREGIVER whether you are a Nursing Assistant (NA), Licensed Practical Nurse (LPN) or a Registered Nurse (RN) all of us are LEADERS in our own simple little ways. The people that surrounds us respect our know-how and by so doing have expectations from us. An expectation of others to be honest, trustworthy, protect privacy, wise decision maker, protector, caring, client advocate, comforter, teacher and most of all - a Leader! But what does it really takes to be a LEADER? L LISTEN to all sides of the story objectively E EXAMINE first anything and everything before judging A ACCOUNTABLE to his or her actions D DEPENDABLE whatever the situation is E EMPOWER people to be a better person R - RELAX and in control! Unleash the Leader in YOU

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Ethics in Nursing Jobs and Profession The nursing profession, just like that of teaching, is considered noble and beyond a pricing. A nurse is expected to be the embodiment of high values and tolerance. He or she is supposed to stand for undaunted faith in the treatment being extended and accordingly help the patients towards a speedy recovery Nursing is for the brave hearts - those driven beyond time and quantity to deliver medical attention to the sick and dying. However, over the past decades the monetary gains and the associated freebies have corrupted the practice. There is hardly any reference to the selflessness of Florence Nightingale or the efforts of those who served during difficult times in human history. And yet, at the same time, there is a community within the global community of nurses, who extol a vision and the right ethics. It is very difficult to narrow down to the dos and donts of the nursing code of ethics, but it is very important to understand the implications involved. The contemporary nursing practice is versatile and spreads across a spectrum of duties and responsibilities. Most of the responsibilities of nurses and professional nursing ethics are not spelt on paper because he or she is expected to emulate the best under any circumstance. ETHICS IN NURSING JOBS There are many nursing medical ethics and values specified by nursing schools that could be enumerated within this category, but more important is the realization and understanding that nursing goes beyond the administering of alternative medicines or holistic medicines or even the mainstream prescribed list when the doctor is not around. The vocation should ideally be the calling of those who understand the evolution of nursing ethics and feel intensely about social service.

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Selflessness: Within the paradigms of hospital jobs, a nurse is expected to go beyond the call of duty and walk that extra mile to provide the necessary medical assistance. Health care has placed many demands on the profession and so have patients. Selflessness is a virtue without which the profession lacks substance. A nurse should ideally be able to stay vigilant and aware of each case in his or her charge and be there whenever required. Treating every patient as an extension of the self is a very important part of mental health nursing ethics. The principles of morality can always be defended by rational argument, but the truth is that certain professions like the nursing profession and teaching should have set personal standards. The ability to deliver on time: The nursing profession may have ethical problems, but professionalism of nursing ethics across cultures demands that a nurse should be able to deliver assistance and administer the prescribed medical attention on time. Workplace ethics demand that the person understand the implications of a delayed service. A nurse must take part in every briefing and debriefing to be regularly educated on every case in his or her care. There is no explanation accepted for oversight and the resultant negligence. Honesty and Confidentiality: A nurse, by default, is expected to adhere to a strict display of honesty and confidentiality. The need for this arises out of the fact that many patients confide in a nurse in tender and sensitive moments. The patients do move on and so do the nurses, but what happens with the information shared is what really matters. Becoming a nurse involves giving up on many negative vices like lying and squealing. The very objective

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of the nursing ethics definition is delivering the best medial and moral support to the patients at hand. Character and Integrity: The Professional Codes of Nursing do spell out essentials applicable on job. But, ethics in the nursing profession come from the deepest recesses of the human psyche and experience. It hardly matters what remuneration a nurse is drawing or at what level in the hierarchy he or she features. The persons show of character and solidarity is what makes him or her special. A nurse is expected to be a person of immense character. One who can shoulder the weight of neglect that a patient might feel or the suffering of a little child while delivering dedicated child care. The philosophy, ethics, morality and objective truth behind the designing of this very important profession are more the values displayed by flourishing persons. A nurse is expected to deliver patient care with respect and attend to life and death situations in the most caring and professional manner. A nonchalant approach to medical ethics does not belong in the community. Ethics in the nursing profession involves a number of considerations that arise out of the need to be able to put total strangers at ease, whether the vocation comes out of a nursing degree online or through full time participation. The ethics need to be lived rather than read and developed forcefully. CONCLUSION Nursing is a profession that is not one opted for 'by chance', instead it is a calling 'by choice'. A nurse, as a health professional and a citizen, with society initiates and supports appropriate action to meet the health and social needs of the public. Personal health Mental, physical, social and spiritual wellbeing of the nurse. Personal Information obtained during

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professional information contact that is private to an individual or family, and which, when disclosed, may violate the right to privacy, cause inconvenience, embarrassment, or harm to the individual or family. Nurses, health care workers or other professionals providing service to an individual, family or community and working toward desired goals. Nurses may be challenged to fulfill moral and ethical obligations of their profession while providing care for their patients in a less-than-optimal health care system. The code sets the ethical standard for the profession of nursing and provides an enduring framework for all nurses to use in ethical decision-making Nurses, whatever their religion must be God-loving and God-fearing. They must realize that the nursing profession is a commitment both to God and people. They should emphasize the importance of providing spiritual care as a vital aspect of nursing care. They must uphold the sanctity of human life. We are not perfect of course we commit mistake but in the field of nursing theres no room for mistake so as we should be very careful in dealing and rendering nursing intervention to our patient. The Code of Ethics for Nurses was developed as a guide for carrying out nursing responsibilities in a manner consistent with quality in nursing care and the ethical obligations of the profession.

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References Books Alexandra, A., and Woodruff, A., Ethics and the Professions, Prentice-Hall, 1990. American Nurses Association, Code of Ethics for Nurses with Interpretive Statements, Washington, DC, ANA Publications, 2001. Badzek, L.A. in Fowler, M., ed. (2008). Guide to the Code of Ethics for Nurses: Interpretation and Application. American Nurses Association, Silver Spring, MD. Beauchamp, TL.& Childress, JF., (2009). Principles of Biomedical Ethics, 6th Edition. Oxford University Press Benner, P., Tanner, CA., & Chesla, CA., (eds.) (1996). Expertise in Nursing Practice: Caring, Clinical Judgment, and Ethics. Springer Publishing Company Bosek, M. S. D. (2008). Respecting a patient's religious values. JONA's Healthcare Law, Ethics, and Regulation, 10(4), 100-105. 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. Davis, A.J., in Fowler, M., ed. (2008). Guide to the Code of Ethics for Nurses: Interpretation and Application. American Nurses Association, Silver Spring, MD. Drought, T. & Epstein, E. in Fowler, M.., ed. (2008). Guide to the Code of Ethics for Nurses: Interpretation and Application. American Nurses Association, Silver Spring, MD. Mappes, T.A. & De Gracia, D. (1996). Biomedical ethics: Code of nursing, moral implications, 138-139.

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Mappes, T.A. & De Gracia, D. (2002).5th edition. Biomedical ethics. Hospitals, Nurses, families and medical confidentiality: American Nurses Association Code forNurses,159160. Venzon,L.M. & Venzon,R.M.(2005).Professional Nursing in the Philippines: Nursing Ethics,96-103,127-135. Internet //Web site: F:\bioethics\downloaded\ethics-in-nursing-jobs-and profession.htm F:\bioethics\downloaded\Code-of-Ethics.html http://www.nysna.org/practice/positions/position6.htm http://www.thefreelibrary.com/Ethics+and+the+decision+making+process www.icn.ch/ icn@icn.ch www.nurse-code-of-ethics-presentation.htm.com2009 SlideShare Inc.