Ethics in Nursing: An Overview

Nurses have been at the top of Gallup’s annual honesty and ethics poll results as the most trusted professionals in America year after year, and 2023 was no different. Seventy-eight percent of polled Americans ranked nurses as number one in trustworthiness, highlighting the caliber of the nurses who serve patients and the medical community and how core ethics are to the work they do.

Effective Bachelor of Science in Nursing programs bring ethics in nursing into all aspects of study so that graduates are ready to step into a leadership role.

Ethics, a field of study since ancient times, considers what is right, what is wrong, what is good, and what is bad. Working through these big questions helps us make appropriate choices in our everyday lives. Applied ethics focuses these questions on issues related to a given field: law, government, business, medicine, and others.

Ethics in nursing developed in parallel with ethics for physicians. Though both professions provide health care to the ill and injured, their scope and focus differ enough that each profession created its own code of ethics over time.

A Brief History of Ethics in Nursing

The origin of any code of ethics is real people who struggle in real situations. For example, imagine a nurse in the 1900s helping an injured soldier. There’s a limited supply of pain medication, and the leading surgeon suggests to the nurse that another patient is more deserving of the medication. What should the nurse do? Without a framework of sound decision-making to rely on, this nurse might feel unsure and overwhelmed.

A professional code of ethics is like a backbone for confident decision-making. When a profession adopts a code and the people within it agree to uphold it, each individual and team is stronger and more clear-minded about it.

In the nursing field, the process of developing a code of ethics began in 1893 with the Nightingale pledge, an oath named after Florence Nightingale, the mother of modern nursing. The pledge is a promise to serve patients with their best interests at heart and support the larger medical team. It’s similar to the Hippocratic oath that physicians take.

The Code of Ethics for Nurses

As modern medicine developed and the Nightingale pledge no longer covered enough topics to remain relevant, the American Nurses Association (ANA), which was established in 1896, set out to develop a more formal code of ethics in nursing, the first version of which was published in 1926.

According to the American Nurses Association, the code upholds four principles of medical ethics:

• Autonomy — a patient’s right to make their own medical decisions
• Beneficence — serving patients for the purpose of their comfort and integrity
• Justice — distributing medical care equally among patients
• Nonmaleficence — providing care in a way that minimizes harm to the patient

Today, the Code of Ethics for Nurses With Interpretive Statements lays out nine provisions — statements that describe a core belief or behavior for nurses — with additional interpretations or explanations of the provision’s importance and application. The code is reviewed and updated every 10 years as the field evolves in response to technological, organizational, and societal shifts.

9 Provisions in the Code of Ethics for Nurses

The nine provisions in the Code of Ethics for Nurses serve the four principles of medical ethics but are specific to nursing practice and the types of challenges that nurses routinely face on the front lines of medical care. They pertain to the following behaviors and beliefs.

1. Treating Patients With Compassion

The first provision focuses on respecting every person — patients as well as colleagues — but paramount is seeing patients as real people with unique identities and backgrounds who deserve to understand and own their medical options.

2. Committing to Serving Patients

The second provision outlines that nurses are primarily committed to serving patients to the best of their abilities. It also makes it clear that, whether a nurse is advocating for a single patient or a whole group of people, if a conflict of interest arises in their advocacy, the nurse must disclose it and will likely be removed from the case.

3. Advocating for Patient’s Rights

This provision is connected to the first in the idea that a patient’s need for medical care in no way strips them of their autonomy or agency as a person, deserving of their own decision-making and privacy. Nurses protect this right.

4. Accepting Authority Over Nursing Practices

Some people may think that nurses always take direction from physicians and other clinicians on the medical team. But, while members of a medical team certainly align and collaborate with each other, this provision makes it clear that nurses are accountable for their own nursing practices and decisions.

5. Caring for Self and Continuing Growth as a Professional

Provision five is all-important for nurses, who give so much of themselves in their daily work. It refers to a nurse’s responsibility to take care of themselves, to ensure that they are safe, healthy, and whole when they care for others and that they communicate their needs when they arise.

6. Promoting Ethics and Safety in the Workplace

This provision highlights how each nurse’s awareness of ethics in nursing and health and safety best practices makes the environment in the health care institution safer and better for both the medical staff and the patients and their families.

7. Engaging in Research and Policy to Advance the Profession

Provision seven asserts that nurses’ work can and should go beyond the day-to-day care of patients to include involvement in research studies, to help research teams investigate and discover new information about medicine and patients, and policymaking, to take what nurses know and believe about medicine and patient’s rights into the world.

8. Reducing Health Inequities Across the World

Though a lofty goal, provision eight is similar to provision seven in that it broadens the scope of what it means to be a nurse. It states that nurses don’t stop being nurses when they leave their place of work, but rather, they carry the responsibility of promoting health equity into their lives.

9. Upholding the Integrity of the Profession

This last provision holds that nurses should belong to collective organizations where knowledge and power can be shared for the advancement of the profession.

These provisions define ethics in nursing and orient the profession as a dedicated practice in serving the patient and the wider community. This is especially relevant when other influences — members of the medical team, insurance companies, family members, or external forces — are in conflict with a patient’s desires and care.

Ethics in Nursing: Why It Matters

Following a code of ethics in nursing is both a high-minded commitment to sound practice and a pragmatic tool to help nurses do their jobs day in and day out.

Ethics helps nurses:

• Reduce burnout: Quick and confident decision-making helps nurses keep a clear head and feel good about the work they do. It can be considered a form of self-care for nurses .

• Increase collaboration: When members of a medical team can each point back to a central or similar code of ethics, it’s easier for them to collaborate productively and respectfully.

• Provide quality care: The code first and foremost puts the patient’s consent, beliefs, and choices at the forefront of how their care is handled, which has been shown to be an essential part of providing high-quality medical care.

• Move into leadership positions: Ethics can be used to guide interactions between nurses and patients as well as between nurses and other nurses, enabling highly educated and ethical registered nurses (RNs) to become leaders.

By using ethics in nursing as their north star, nurses can find more fulfillment in their work, communicate more effectively with their colleagues and patients, and expand their practice into better care and leadership in nursing.

Careers for Leaders Guided by Ethics in Nursing

Certain leadership roles in nursing call for an RN with a Bachelor of Science in Nursing (BSN) who uses ethics to guide them as leaders. They manage their teams with respect and fairness and bring patient-centered care to the core of what they do. Though there are many leadership styles in nursing , each of these roles requires a commitment to ethics.

Nurse or Nursing Unit Manager

• Job description: Nurse managers lead and supervise a nursing team, making sure the workplace is safe and equitable and that nurses have what they need to provide quality care to patients. Unit managers may manage multiple teams of nurses and may take on higher administrative duties.

• Importance of ethics: As both a supervisor of and advocate for the nursing team, nurses or patients and their families may bring scenarios to their attention that require ethical decision-making and guidance.

Utilization Management Nurse

• Job description: Utilization management (or review) nurses focus on how patients’ insurance plans can be used most effectively to cover the costs of their medical care. They often work with a representative from the insurance company to negotiate and determine the prudent use of the plan that benefits the patient as much as possible.
• Importance of ethics: Ethics in nursing can seem high-minded in terms of insurance plan evaluations, but applying it pragmatically in these situations can turn a dedication to patient advocacy into real dollars and cents that the patient might owe — or not owe.

Nurse Preceptor

• Job description: Nurse preceptors are experienced RNs who take on the responsibility of modeling best practices, coaching new nurses, and ensuring a safe environment for their growth.
• Importance of ethics: The core of a preceptor’s work is guidance and mentorship, so new nurses are likely to raise questions about the struggles they’re facing. With a focus on ethics in nursing, preceptors can help teach the next generation sound decision-making strategies.

Nurse Case Manager

• Job description: Nurse case managers handle long-term care plans for patients, helping them understand how to best follow the medical advice they’re given over time and how to navigate their insurance plans. They also act as medical liaisons for patients, reviewing their results and explaining changes to their care.
• Importance of ethics: A patient-first approach is core to ethics in nursing, and case managers certainly put patients and their families first while maintaining a professional boundary.

Hospice Nurse

• Job description: Hospice is a type of end-of-life care, and hospice nurses care for patients in the last months of their lives.
• Importance of ethics: Preserving a patient’s comfort, dignity, and agency are paramount ethical concerns, and never are they more important than when a patient is at their most vulnerable at the end of their life.

Offering meaningful work, favorable job prospects, and competitive salaries, any of these roles can be an excellent next step for RNs who are considering stepping into leadership roles or making a career change to nursing . Ethics is core to each of these roles, as are other essential skills.

Professional Skills for Leaders Focused on Ethics in Nursing

When an RN with a few years’ experience is ready to reach for a leadership role, the first step is often seeking education. As a part of that education, it can be helpful to understand how the skills nurses are using today relate to those needed for success in a leadership role. Often, the skills for both fall within the same categories.

Skills for nurses looking to become nursing leaders are often focused on:

• An expansion of their scope of work
• An increase in the depth of the knowledge needed to carry out tasks
• Higher expectations of professional collaboration to solve issues
• A willingness to tackle higher-level issues and oversee more people and patients

The following skills pertain to those capabilities that help nurses do their work each day with a focus on leveling up for ethics and leadership roles.

Ethical Awareness and an Understanding of the Code

Knowing the evolution of ethics in nursing and, specifically, the Code of Ethics for Nurses With Interpretive Statements helps nurses orient themselves in ethical nursing practice. RNs need to study these ethics and practice them so that in a leadership role they’re second nature.

In health care settings, when patients need care quickly and challenging scenarios routinely pop up, recognizing instances that call upon ethical decision-making is essential for nurse leaders. Following the code means upholding the integrity of patients’ wishes while carrying out sound nursing practices to deliver the highest quality care in a complex environment.

Organized Collaboration With Colleagues

While RNs collaborate with their medical teams each day to handle their regular tasks, nurse leaders collaborate with their colleagues to deliver organized care across teams to many patients at a time. This requires skills in both organization and ethics.

Nurse leaders must have a clear mind to know and direct who should be where doing what when, but they also must manage common issues as they arise with a consistent ethical awareness. This consistency helps nurse leaders collaborate more effectively across medical teams as it brings cohesiveness to their decision-making and communication style.

Creative and Consistent Problem-Solving

An RN upholds the code of ethics by communicating medical information clearly so that patients understand their choices and are able to communicate their preferences. A nurse leader balances patients’ desires with medical team opinions and constraints, insurance company plans, and organizational hierarchies. They use ethics as a map to navigate the varying influencing factors while upholding a patient-first approach in this more complex environment.

Focus on Upholding Safety and Health Regulations

An RN carries out safety measures in their work, as it keeps patients, visitors, and medical staff safe. A nurse leader actively works to meet safety and health regulations on an organizational level, applying an increased depth of knowledge about regulations and the workings of the institution to safety protocols. This responsibility relates to the ethical principle of beneficence, or doing good at each step of nursing practice.

Engagement With Professional Growth

A provision in the code recommends continuing professional growth, particularly with a focus on research and inquiry. An example of this would be for a nurse to join a research committee that has been formed at their workplace to learn more about a particular issue, such as the recovery rates of patients diagnosed with a certain type of cancer at a certain age. In leadership, unit managers and case managers are often responsible for data and information collection. Collecting and analyzing documentation from review cycles and patient charts, for instance, can help a nurse leader improve efficiency and patient outcomes in their unit.

Organized Patient Care and Management

A major ethical principle in nursing is promoting beneficence, or good practices that lead to the comfort and safety of patients. Carrying out this principle falls into two areas:

1. Compassionate care: A nurse uses interpersonal skills to make patients and their families feel comfortable and cared for.
2. Organized care: A nurse uses clinical knowledge, attention to detail, and strategic collaboration with colleagues to serve the patient’s wishes and medical needs.

Lead With Ethics as a Next-Generation Nurse With TU’s Online RN to BSN

Ethics in nursing has a long and important history. Basic nursing practices took shape in the 1800s under Florence Nightingale, and nurses thereafter took the Nightingale pledge. The establishment of the American Nurses Association in 1896 began the formal development of a code of ethics for nurses. First published in 1926 and updated regularly since then, the ANA’s Code of Ethics for Nurses With Interpretive Statements stands as an essential benchmark for ethical nursing practices in the profession.

If you’re an RN who relies on this code of ethics each day and is considering advancing into a leadership position, see how The University of Tulsa’s online RN to Bachelor of Science in Nursing program can help you deepen your ethical awareness, clinical knowledge, and understanding of how health care organizations function.

Learn how to lead with ethics as a next-generation nurse in TU’s online RN to BSN program.

Recommended Readings

RN vs. BSN: Benefits of a BSN for Nurses

Nurse Case Manager Career Overview

Why Critical Thinking Skills in Nursing Are Essential

Sources:

American Nurses Association, View the Code of Ethics for Nurses

American Nurses Association, “Why Ethics in Nursing Matters”

Gallup, “Ethics Ratings of Nearly All Professions Down in U.S.”

Indeed, “Nurse Manager: What They Do, Skills and Job Requirements ”

Indeed, “What Does a Hospice Nurse Do? (Plus Skills and Salary) ”

Indeed, “What Is a Nurse Case Manager? (With Skills and Salary Info) ”

Indeed, “What Is a Nurse Preceptor? (And How to Become One)”

Indeed, “What Is a Unit Manager? Responsibilities and Skills ”

Indeed, “What Is a Utilization Review and Who Performs Them? ”

IntelyCare, “What the Nightingale Pledge Means to Today’s Nurses ”

The Online Journal of Issues in Nursing, “Ethical Awareness: What It Is and Why It Matters ”

The Online Journal of Issues in Nursing, “The Nursing Code of Ethics: Its Value, Its History ”