Select one of the following ethical/legal topics: Autonomy, Beneficence, Justice, Fidelity, Veracity, Involuntary hospitalization and due process of civil commitment, Informed

www.journalofnursingregulation.com 9Volume 7/Issue 2 July 2016

The ANA Code of Ethics for Nurses With Interpretive Statements: Resource for Nursing Regulation Linda L. Olson, PhD, RN, NEA-BC, FAAN, and Felicia Stokes, JD, RN

The American Nurses Association (ANA) Code of Ethics for Nurses With Interpretive Statements informs decision making

about ethical violations by nurses and nursing education programs. The Code is the nursing profession’s ethical standard of

practice and nursing’s contract with society. Nurse practice acts (NPAs) and the standards of practice are the profession’s

legal standard. This article describes the nine provisions of the Code and provides cases of ethical violations and the disciplin-

ary actions that were taken. The intent of this article is to serve as an educational resource on how the Code can be used with

NPAs to support nurse regulators in their decision making.

Keywords: Boards of nursing, Code of Ethics for Nurses, ethics, nurse practice acts, nursing regulation

Objectives ⦁ Discuss the ANA’s Code of Ethics for Nurses with Interpretive

Statements as the profession’s ethical standard of practice. ⦁ Describe how nurse regulators use the Code of Ethics to sup-

port decision making. ⦁ Identify the nine provisions of the Code of Ethics.

The American Nurses Association (ANA) Code of Ethics for Nurses With Interpretive Statements (the Code) (American Nurses Association [ANA], 2015a), the

profession’s ethical standard of practice, provides a framework for ethical practice and decision making, guides the profession in self-regulation, establishes the profession’s social contract with society, and educates the profession on ethical responsi- bilities. The Code consists of nine main provisions with inter- pretive statements that exemplify the application of the Code in nursing practice.

As the profession’s ethical standard, the Code is non- negotiable (ANA, 2015a, p. viii). Neither individual nurses nor groups of nurses can negotiate changes in the language of the Code. Nurses in all roles and settings must adhere to the Code in their practice. Ethics occurs within the framework of all relationships nurses encounter in their professional roles (Olson, 2012). As licensed professionals, nurses have a relation- ship with their state boards of nursing (BONs), which regu- late nursing practice and protect the public by ensuring that the standards of nursing practice are met and that nurses are competent to practice. “Nurses must always comply with and adhere to state nurse practice acts [NPAs], regulations, stan-

dards of care, and ANA’s Code of Ethics for Nurses with Interpretive Statements” (ANA, 2015a, p. 15).

The 2015 version of the Code is the first revision since 2001, and the ANA declared 2015 as the “Year of Ethics” (ANA, 2015b). This emphasis on ethics calls for nurses in all roles and settings to know the Code and encourage col- leagues to read and discuss it. In 2014, Johns Hopkins School of Nursing and Johns Hopkins Berman Institute of Bioethics led a national summit meeting on Nursing Ethics for the 21st Century. The meeting focused on the commitment of nursing’s professional organizations to uphold the professional values of nursing and to identify the strategic nursing ethics priorities for the profession. The ANA, the National Council of State Boards of Nursing (NCSBN), and 18 other organizations par- ticipated as collaborating partners in this initiative, which identified ways to improve the ethical environment for nurses, and therefore the quality of care provided to patients and fami- lies (Rushton & Broome, 2014).

The purpose of this article is to describe and exemplify how the Code is used as a resource by nurse regulators as they consider cases related to violations of the NPA. Actual cases of such violations are presented for five of the first six provisions. Each violation also reflects an ethical violation. Because the last three provisions emphasize the importance of leadership by individuals and groups of nurses as well as of professional nursing organizations, no cases are presented.

Continuing Education

10 Journal of Nursing Regulation

Background The ANA Code of Ethics was formally adopted in 1950; how- ever, its focus on the profession’s core values and nurses’ obliga- tions and duties dates to the 1893 Nightingale Pledge. Early versions of the Code emphasized obligations to carry out physi- cian orders, rules of conduct, and duties. By contrast, later ver- sions emphasized obligations to patients, increased awareness of technological advances, and increased autonomy of nursing practice. The 1985 Code incorporated bioethical language in alignment with society’s focus on bioethics and the use of life- saving and life-prolonging technologies. New provisions in the 2001 Code stressed nurses’ primary obligation to the patient, defined as an individual, a family, a group, a community, or a population. The 2001 Code also addressed duties of the nurse to self; stressed the responsibility of nurses for contributing to ethical workplace environments that are conducive to safe, quality health care; and made clear that the application of ethi- cal guidelines expressed in the Code applied to nurses in all roles and settings.

The process for revising the Code in 2001 included the establishment of working groups that coordinated obtaining feedback and input from several thousand nurses through pub- lic comment and surveys to determine the need for clarification, changes, or additions. The Code is a dynamic, living docu- ment that reflects changes in society, the nursing profession, and the health care delivery system. What remains unchanged are the fundamental commitments of the profession, includ- ing its commitment to society, and the ethical values, obli- gations, duties, and professional ideals of nurses individually and collectively (ANA, 2015a, p. viii). Therefore, the Code is evaluated and assessed for needed revisions approximately every 10 years. Based on comments, the nine provisions of the 2001 Code were retained, but were made more clear and con- cise. The interpretive statements expanding on the provisions were updated to include the changes that affected the profes- sion since the 2001 revision. The first three provisions describe the fundamental values and commitments of the nurse, such as respect for patients, colleagues, and others; the next three address issues of duty and loyalty, such as duties to self and others and responsibilities for the health care environment. The final three provisions address aspects of duty that go beyond individual patient encounters, such as advancing the profession through research and scholarly inquiry and advancing health policy. These provisions also address the role of professional organizations. Provisions 7, 8, and 9 have an enhanced focus on social justice, the role of nurses in global health, the ethical use of social media and electronic medical records, boundary issues, ethical practice environments, the importance of interdisci- plinary work and collaboration, the role of nurse leaders, and the inclusion of nurses in all roles and settings (ANA, 2015a; Epstein & Turner, 2015).

Provision 1 The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person (ANA, 2015a, p. 1).

In all roles and settings, nurses must respect the beliefs and values of all patients without prejudice.

Interpretive Statement 1.2: Relationships With Patients

“Factors such as culture, value systems, religious or spiritual beliefs, lifestyle, social support system, sexual orientation or gender expression, and primary language are to be considered when planning individual, family and population-centered care” (ANA, 2015a, p. 1). Interpretive statement 1.2 further states that although nurses may not agree with a patient’s choices, nurses are obligated to promote patient safety and pro- vide opportunities to eradicate risky or self-destructive behav- iors (ANA, 2015a).

Violation of Provision 1: Failure to Conform to Standards of

Acceptable Conduct

Stephanie, a registered nurse (RN), who worked in an inpatient psychiatric unit, was caring for Amanda, a 20-year-old trans- gender patient with diagnoses of bipolar disorder and schizo- phrenia. Amanda identified as female, although her legal name was Eric. During Stephanie’s shift, Amanda demonstrated disruptive behavior in a group activity and placed herself and other patients at risk. Stephanie attempted to diffuse the situa- tion but intentionally chose to call her patient Eric, rather than the patient’s preferred name, demonstrating a lack of respect for the patient’s gender expression. Amanda became visibly irritated, and her behavior escalated into a physical alterca- tion with another patient, resulting in harm. The incident was reported to Stephanie’s nurse manager, who reported it to the BON.

Stephanie had an ethical duty to respect the values of her patient, including sexual orientation or gender expression. The Code states that “the need for and right to health care is uni- versal” (ANA, 2015a, p.1). Nurses must respect the values of each patient. Stephanie had a duty to promote the health and safety of Amanda and protect other patients in the vicinity from harm. Stephanie chose to call her patient by a name she knew the patient had rejected, causing an escalation of an already compromised situation. Stephanie’s actions constituted a viola- tion of the Code and thereby established sufficient grounds for disciplinary action. The BON charged her with failure to con- form to standards of acceptable conduct, resulting in a 4-month suspension from the practice of registered nursing.

Interpretive Statement 1.4: Right to Self-Determination

Autonomy affords patients the right to accept, refuse, or ter- minate treatment at any time. Nurses are obligated to respect a patient’s decision by supporting and protecting these rights. Nurses are often in a position to advocate for a patient’s choices

www.journalofnursingregulation.com 11Volume 7/Issue 2 July 2016

and should always provide compassion and care through the various stages of medical decision making. Nurses in all set- tings must make sure patients are properly informed and understand the consequences of all decisions without coercion, duress, or undue influence. Furthermore, nurses have a duty to find alternatives when appropriate and use nursing judgment when patient safety is at risk.

Violation of Provision 1: Patient Abuse

Michael, an RN, was caring for several patients in a long-term care facility, including Mr. Smith, an alert, oriented 75-year- old. When Michael tried to administer medication to Mr. Smith, the patient refused to take the medication. Mr. Smith did not provide any justification for his refusal. Michael tried several verbal measures to coax Mr. Smith into taking his medi- cation. After Mr. Smith repeatedly refused and shook his head to avoid taking the medication, Michael grabbed Mr. Smith’s chin and forced the medication into his mouth. As a result, Mr. Smith suffered lacerations to his upper lip. Another nurse witnessed the incident and reported it to the BON.

Michael had an ethical duty to respect his patient’s right of refusal. Michael argued that he had several patients and did not have time to use an alternative method to adminis- ter the medication. However, a patient’s right of refusal must be protected, and the patient should be given necessary sup- port throughout the decision-making process (ANA, 2015a). Michael violated Mr. Smith’s autonomy to refuse medication and failed to assess the patient’s understanding of the refusal. Moreover, Michael harmed the patient by physically forcing him to take the medication. The BON evaluated the facts and determined that the nurse violated the Code and failed to con- form to an ethical or quality standard of the profession, thereby violating the state NPA.

Provision 2 The nurse’s primary commitment is to the patient, whether an individ- ual, family, group, community, or population (ANA, 2015a, p. 5).

Nurses are caring and compassionate and often spend numerous hours with a patient and family at the bedside. Rapport and trust are common attributes in a nurse-patient relationship. Nurses care for patients who are sick and may be vulnerable because of stress, illness, or medication. Nurses have an ethical duty to uphold professional boundaries and refrain from dating or engaging in sexually intimate relationships with patients (ANA, 2015a, p. 7).

Violation of Provision 2: Failure to Adhere to Professional Boundaries

Kelly, an RN, was a new nurse working in a postoperative care unit. Kelly had been caring for Jason, a postoperative heart bypass patient, for three shifts. Jason had been flirtatious every

shift and enjoyed having Kelly take care of him. Kelly also found Jason attractive and requested an assignment to care for him. Late into the shift, Jason proposed that Kelly close the door to his room. Kelly obliged, and they engaged in consen- sual sexual intercourse. The next day, Jason asked the attending physician if he can have home nursing care and requested that Kelly be his nurse. The attending physician found the request odd and initiated an investigation. Kelly and Jason admitted to having consensual sex during Kelly’s shift. The incident was reported to the BON, which evaluated the facts and deter- mined that Kelly violated the Code, thereby establishing suf- ficient grounds for disciplinary action. The BON determined that the nurse failed to conform to an ethical or quality stan- dard of the profession, thereby violating the state NPA. The nurse’s license was permanently revoked.

Kelly violated her ethical duty to maintain a professional boundary between herself and her patient, despite the consen- sual nature of the act. Many states have laws in their NPAs that specify professional boundary violations, including sexual contact, as violations of the standard of conduct for nurses, thus establishing sufficient grounds for discipline.

Provision 3 The nurse promotes, advocates for, and protects the rights, health, and safety of the patient (ANA, 2015a, p. 9).

Protection of patient rights to privacy and confidential- ity are fundamental to trust in a nurse-patient relationship. Violations of these rights include electronic postings, images, or commentary via social media or other public communica- tions of personal or clinical information that could breach a patient’s confidentiality or right to privacy. Several states have specific language in their NPAs that identifies a breach of con- fidentiality or right to privacy as a violation of the standard of care. For example, in Massachusetts, a nurse may be subject to disciplinary action if he or she fails to “safeguard patient information from any person or entity, or both, not entitled to such information” (Code of Massachusetts Regulations, n.d.). In Utah, unprofessional conduct subject to discipline includes “failure to safeguard a patient’s right to privacy as to the patient’s person, condition [or] diagnosis” (Utah State Legislature, 2016). In Oregon, a similar provision exists: “Violating the rights of privacy, confidentiality of information, or knowledge concerning the client, unless required by law to disclose such information or unless there is a ‘need to know’ may result in disciplinary action against the nurse” (Oregon Administrative Rules, 2012).

The ANA and NCSBN have endorsed each other’s guide- lines for the legal and ethical use of social media and other electronic communication, emphasizing the critical importance of protecting patient rights to privacy and confidentiality and to safeguarding professional boundaries (National Council of

12 Journal of Nursing Regulation

State Boards of Nursing [NCSBN], 2011a). The NCSBN pub- lication, A Nurse’s Guide to the Use of Social Media (NCSBN, 2011b), presents several examples of violations of patient con- fidentiality via inappropriate use of social media. One describes a breach of patient confidentiality by a junior nursing student who took a photo of a 3-year-old patient with leukemia on a pediatric unit and posted it on her Facebook page. The photo showed not only the patient but also the patient’s room num- ber. As a result, the nursing student was terminated from her nursing program for breach of patient confidentiality and a HIPAA violation (NCSBN, 2011b, pp. 8-9). Nurses and nurs- ing students who inappropriately use social media and breach patient confidentiality or privacy may be violating state and federal laws and face disciplinary action by the BON as well as civil and criminal penalties.

Interpretive Statement 3.4: Professional Responsibility in Promoting a Culture of Safety

The nursing profession has an ethical duty to promote a safe culture for patients and families by reducing the number of errors and near misses. Historically, reporting errors to BONs resulted in punitive, disciplinary action. Many BONs now use remediation, supervision, and counseling for errors that do not involve deliberate, reckless, or malicious intent (Russell & Radtke, 2014). This Just Culture model is designed to reduce errors, not to conceal them (Marx, 2001). In efforts to increase patient safety when errors occur, the Just Culture model pro- motes education and remediation, rather than punishment. The Code identifies the Just Culture model as one that “rec- ognizes individuals choose and need to manage human error, at-risk behavior, and reckless behaviors; recognizes individuals make mistakes and systems fail” (ANA, 2015a, p. 43). The Code further states that Just Culture supports a nurse’s ability to learn from mistakes and encourages education on avoiding risky behaviors (ANA, 2015a). This shift in nursing practice to a Just Culture model eliminates fear of discipline and embar- rassment and deters nurses from remaining silent (Burhans, Chastain, & George, 2012).

Nurses have an ethical obligation to report errors and near misses to an appropriate authority to provide an oppor- tunity for education, remediation, and accountability for indi- vidual practice (ANA, 2015a; Lachman, 2007). The Code emphatically states that nurses may “neither participate in, nor condone through silence, any attempts to conceal the error” (ANA, 2015a, p. 12). Nurse managers, administrators, and educators must provide an open and accessible process for reporting errors and determining and analyzing the root causes of errors to obtain and maintain a healthy and ethical work environment. By creating and supporting an ethical work envi- ronment in which nurses feel free to disagree with one another and with other members of the health care team without fear

of reprisal and to discuss difficult or unsafe conditions openly, nurses in leadership roles promote a culture of safety.

Interpretive Statement 3.6: Patient Protection and Impaired Practice

Nurses have a duty to protect the patient, the public, and the integrity of the nursing profession when they observe physical or mental impairment in a nurse or other health care professional. Substance use disorder (SUD) in the nursing profession has been recognized for more than 100 years (Monroe & Kenaga, 2011). Stress, fatigue, and access to drugs place nurses at increased risk for developing SUD and addiction (NCSBN, 2011b).

Although research has shown that 20% of RNs were reluctant to report a colleague suspected of drug diversion (Bettinardi-Angres & Bologeorges, 2011), nurses who suspect their colleagues of diversion or physical or mental impair- ment have an ethical duty to protect patients from harm. Reporting suspected impairment of a colleague to an appro- priate authority protects the safety of the patient and initi- ates a path of recovery for the nurse (NCSBN, 2011c). Nurses must also uphold the integrity of the profession by reporting a colleague suspected of diversion. Such a report should not be construed as betrayal. Many nurses fear reporting an impaired colleague because of the disciplinary action the colleague may face, including loss of licensure. However, reporting a nurse for suspected impairment may not result in adverse disciplinary action but in an offer of medical assistance that may save the lives of the colleague as well as the colleague’s patients.

Several BONs offer nurses an alternative-to-discipline program (ADP) to treat addiction and SUD. These programs are designed to protect the welfare and safety of the public and assist nurses with recovery. ADPs encourage nurses with SUD to seek help without fear of public BON discipline. Dunn (2005) posits that the nature of confidentiality encourages nurses to self-report and seek assistance with recovery. As such, the nursing profession promotes a nonpunitive environment that encourages rehabilitation and recovery for impaired nurses (Tanga, 2011).

In some jurisdictions, the ethical duty to report suspected impairment is required by law in the NPA or administrative code, and failure to report can result in disciplinary action. For example, in Michigan, a nurse “who has a reasonable cause to believe that a licensee…is impaired shall report that fact to the department” (Michigan Legislature, 2007). Failure to report may result in disciplinary action. A nurse who has a bona fide nurse-patient relationship with the impaired nurse is exempt from the requirement to report. In West Virginia, a failure “to report through proper channels…impaired practice of another person who provided health care” (West Virginia Board of Examiners, 2015, §14.1.bb) may constitute profes- sional misconduct. The Alabama BON mandates that nurses report unsafe or incompetent nursing practice; failure to do so

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is a violation and may warrant disciplinary action (Alabama Administrative Codes, 2014). Not all BONs have mandatory reporting laws.

In states with mandatory reporting laws, nurse managers and administrators may also be subject to discipline for failure to report a nurse suspected of impairment. Nurse managers and administrators must be aware of and educated about the signs of physical or mental impairment. Nurses who report colleagues must also be supportive and caring throughout recovery, especially when a recovering nurse is returning to the workforce. A nurse who has a strong recovery program that includes accountability and monitoring has much to offer to patients and the profession (NCSBN, 2011c, Appendix J).

Provision 4 The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to promote health and to provide optimal care (ANA, 2015a, p. 15).

Nurses function in various roles and are responsible for assessing their own competence. Nurse managers and execu- tives not involved in direct patient care have a duty to share responsibility for the care provided by the nurses they super- vise. Nurse managers must ensure that nurses are practicing within their scope of practice and that they do not delegate activities to others that are prohibited by their NPAs. Nurse educators have a duty to nursing students to ensure their learn- ing needs are assessed and satisfied. The role of the BON is essential in the regulation of curriculum, oversight, and enforcement of satisfactory education programs.

The Code mandates that nurse educators assess the knowledge and skills of nurses and nursing students to deter- mine whether they are competent to provide the nursing care to which they are assigned under appropriate supervision (ANA, 2015a). If nursing education is unsatisfactory, not in compliance with state or federal law, or fraudulent in nature, BONs have a legal duty according to their NPAs to take action to protect patients and uphold the integrity of the profession.

Interpretive Statement 4.3: Responsibility for Nursing Judgments, Decisions, and Actions

“Nurses in administration, education, policy, and research also have obligations to the recipients of nursing care” (ANA, 2015a, p. 16). Nurses in administrative or supervisory roles who direct care do not relinquish responsibility to safeguard patients and promote health. Nurses, including advanced prac- tice registered nurses (APRNs), are accountable for nursing judgments, decisions, and actions they delegate or supervise. The delegating or supervising nurse has an obligation to assess the skills, education, and experience of the supervisee or del- egatee. Also, APRNs must provide education, instruction, and assistance to those individuals whom they supervise.

Violation of Provision 4: Failure to Conform to Ethical and Quality

Standards

Robert, an APRN, was the owner and delegating nurse of an assisted-living facility. Robert had a contract to precept and supervise four students in an RN program. After a complaint was filed with the Department of Health, an investigation into Robert’s assisted-living facility revealed that the students were unsupervised when performing nursing tasks. Each stu- dent stated that Robert was often absent from the facility and no other licensed personnel were present. The students also reported that patients were found in wet diapers and soiled sheets. The students were instructed to give medications with- out supervision and were instructed not to sign the medication administration record. The Department of Health investigator was unable to find adequate documentation of nursing care. The students were instructed to feed the residents outdated and spoiled meals.

Robert had an ethical duty to safeguard patients from harm by providing proper supervision. “Nurses must make a reasonable effort to assess individual competence when del- egating selected nursing activities. This assessment includes the evaluation of the knowledge, skill, and experience of the individual to whom the care is assigned or delegated; the com- plexity of the tasks; and the nursing care needs of the patient” (ANA, 2015a, p. 17).

After review, the BON determined that Robert violated the Code and failed to conform to an ethical or quality stan- dard of the profession, thereby violating the NPA. Specifically, the BON charged Robert with delegation of nursing acts to an individual lacking the ability to perform, failure to prop- erly supervise nursing students, failure to provide instructions, and failure to assess the skill or experience of the individual he supervised. The BON ordered an emergency suspension of the APRN’s license.

Provision 5 The nurse owes the same duties to self as to others, including the respon- sibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and profes- sional growth (ANA, 2015a, p. 19).

Nurses working at the bedside often endure long hours of physically and emotionally demanding work. Fatigue can easily occur in nurses working long hours with varying day and night shifts. Nurses must be cognizant of their health and well-being. Nurses must be aware of work activities that may contribute to fatigue and adopt ergonomic techniques and practical solutions to adjust their daily nursing practice (Chen, Daraiseh, Davis, & Pan, 2014). Nurses should maintain the same healthy work and life balance that they teach patients (ANA, 2015a, p. 19).

14 Journal of Nursing Regulation

Significant evidence indicates that nurses have an increased risk of making errors because of fatigue from working extended shifts (Geiger-Brown & Trinkoff, 2010). Although BONs recognize the seriousness of nurse fatigue, they also expect nurses to maintain a safe environment for patients and to recognize when their level of fatigue and physical condition could place patients at risk. The Texas BON addressed nurse fatigue by taking a position that nurses are accountable for making sound clinical judgments and protecting patient safety when accepting an assignment. The “prudence and account- ability of the nurse is especially significant in the context of fatigue” (Cropley, 2015, p. 4). Many jurisdictions offer safe har- bor protection and whistleblower protection for nurses who, in good faith, deem patient safety to be in jeopardy. Processes by which a fatigued nurse can request peer review of an assign- ment he or she believes to be in violation of the NPA or BON rules are available (Cropley, 2015).

Violation of Provision 5: Failure to Conform to Ethical and Quality Standards

Sasha, an RN, was caring for five patients in a step-down unit. She was working the night shift but also worked a day shift as a home care nurse. Around 4 a.m., Sasha’s patient Mr. Goodman came out of his room for something to eat. Sasha was sitting at the nurses’ desk with her head down. Mr. Goodman was at risk for falls and used a walker. However, Mr. Goodman forgot his walker and fell onto the floor in the middle of the hall. Sasha was asleep and did not hear the commotion. A nursing assistant woke her and informed her of the fall. Sasha stood up to see Mr. Goodman, but did not assess the patient or take any action. Instead, Sasha instructed the nursing assistant to help Mr. Goodman back to bed. The incident was reported to the BON.

Sasha had a duty to evaluate and assess her fatigue and resulting physical condition, which posed a risk to her patients, and a duty to explain this risk to her supervisor. The BON evaluated the facts and determined that the nurse violated the Code and failed to conform to an ethical or quality standard of the profession, thereby violating the NPA. The BON charged the nurse with failure to conform to standards of acceptable conduct, which resulted in a 2-month suspension from

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