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Nursing Excellence

The Online Newsletter for Children's Nurses
e-Edition, Issue 9 

Jo Lyons

Code of Ethics for Nurses

By Jo A. Lyons, MOB, BS, RN-BC

The objectives of this continuing education program are to:

Explore the code of ethics in relationship to the professional nurse.
Describe the history of the code of ethics for nurses.
List and apply the nine provisions of the American Nurses Association (ANA) code of ethics to everyday practice.



The Nightingale Pledge was composed by Lystra Gretter, an instructor of nursing at the old Harper Hospital in Detroit, Michigan, and was first used by its graduating class in the spring of 1893. It is an adaptation of the Hippocratic Oath taken by physicians.

I solemnly pledge myself before God and in the presence of this assembly, to pass my life in purity and to practice my profession faithfully. I will abstain from whatever is deleterious and mischievous, and will not take or knowingly administer any harmful drug. I will do all in my power to maintain and elevate the standard of my profession, and will hold in confidence all personal matters committed to my keeping and all family affairs coming to my knowledge in the practice of my calling. With loyalty will I endeavor to aid the physician in his work, and devote myself to the welfare of those committed to my care.1

Perhaps nurses remember repeating those words at their graduation and not fully comprehending their scope. In the beginning of one’s nursing career, this pledge may not have had much meaning behind it. It isn’t until one has been practicing nursing over a period of time that these words finally make sense.

This article serves as a guide to assist nurses today who are faced with issues and stresses not encountered in the past. In today’s nursing, there are more regulatory requirements to meet, the average life span has lengthened, and technology has gone global.


History of the Code

The first code of ethics for nurses was adopted in 1950 by the ANA. In early 1896, however, just after the Nightingale Pledge was composed, an early organization, the Nurses’ Associated Alumnae of the United States and Canada, met to discuss a code of ethics for nurses. A “suggested” code was discussed in 1926 by the ANA. In 1940, 14 years later, a “tentative” code was published by the ANA. It was adopted by the ANA as “The Code for Professional Nurses” in 1950. The code has been revised several times; in 1976, 1985, 2001 and 2008. The interpretative statements were included in the 2001 Code of Ethics. The code of ethics guides nurses when decisions have an ethical component and may involve conflict between duties to patient and self; there may also be conflict between religious beliefs and professional responsibilities.2

The Code applies to all nurses, including those involved in patient care, administration, education and research. The various nurses’ roles will affect their decision making. Nurses need to be constantly aware of what’s occurring with their patients and serve as their advocate. Advocacy is a key element of patient- and family-centered care; as a nurse one continually strives to keep abreast of political action and healthcare news that may affect the patient.

Webster’s dictionary defines ethics as: the rules of conduct recognized in respect to a particular class of human actions or a particular group, culture, etc.: medical ethics; Christian ethics. Moral principles, as of an individual: His ethics forbade betrayal of a confidence.3 The code of ethics provides a reminder of standards of conduct that the nurse has a duty to keep confidentiality, and has a responsibility to maintain competence and safeguard patients from unethical practice of others.4


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 nurse’s primary commitment is to the patient, whether an individual, family, group, or community.


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


The responsibilities that nurses assume come from these first three provisions of the ANA code of ethics. They are the core of a nurse’s sense of professionalism. These first three provisions are reminiscent of the Golden Rule – Treat others in the same manner as you want to be treated.5 This translates into respect for all people. Respecting people means that nurses respect patients and their families, as well as relate respectfully in their interactions with peers. The concept of family-centered care is being respectful of the family-professional partnership. It honors the strengths, cultures, traditions and expertise that everyone brings to this relationship. Family-centered care is the standard of practice at Children’s which results in high quality services. Family-centered care acknowledges the family as the constant in a child’s life.6 Parents should be partners in care as they have firsthand knowledge, which enhances the care of their child. Trust and respect is essential for information sharing to take place.

“Nurses have an obligation to be knowledgeable about the moral and legal rights of all patients to self-determination.” 7 This is fundamental to the concept of informed consent. Nurses need to do their best to ensure that the decisions made are in the best interest of their patient, and to recognize the role of family and community. The nurse needs to respect each patient who may rely on family or community traditions when making medical decisions.

Provision 1 stresses the importance of professional relationships with each other and our patients and families. The nurse learns to ask questions sensitively in order to respect different cultural beliefs. The perception of illness and disease can vary by culture. Culture affects how the individual seeks healthcare and how they view healthcare providers. Adapting to different cultural beliefs requires flexibility and respect for another’s point of view. The provision of safe, quality care requires respect for all and is the focus of this provision.

The Code of Ethics recognizes that the current changes in healthcare financing may cause “conflict between economic self-interest (bonuses and financial incentives) and professional integrity.” Nurses in all roles (administration, education, research) need to be aware of potential conflicts of interest and be sensitive to any adverse effects.8 

Maintaining professional boundaries is described in Provision 2. Blurring of the boundaries occurs more often in long-term relationships found in patients with multiple hospital admissions due to chronic disorders. This may lead a nurse to develop a friendship or bond with the patient. The nurse must, in all encounters with the patient, maintain professional boundaries.9  The purpose of the relationship is not friendship but protecting and restoring health.

Provision 3 addresses safety, confidentiality and patient privacy. Nursing care is accomplished by an interdependence of varying roles. Nurses must continue to keep abreast of the organization’s documentation and privacy policies. As nurses we are a part of a larger interdisciplinary professional community and we need to ensure that confidentiality is maintained for the patient and shared appropriately. Another portion of this provision deals with incompetent practice. It doesn’t matter if the incompetence is due to impairment, or lack of knowledge or skill; the nurse has an obligation to report this to the appropriate person in the organization. Reporting unethical or illegal practices to the appropriate authorities ensures safety for the patient and promotes quality patient care.  


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 nurse’s 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 healthcare environments and conditions of employment conducive to the provision of quality healthcare and consistent with the values of the profession through individual and collective action.


These provisions go beyond Provisions 1-3. Provisions 4-6 provide for self-respect, as well as respect for patients and families. One must take care of one’s self in order to care for others. Accountability is grounded in self-respect and respect for the patient. This provision addresses accountability and responsibility to nursing care with delegation of responsibilities to others so they can practice to the full extent of their abilities. The code of ethics states that assessment and evaluation of patients are not to be delegated to assistive personnel; only “tasks” may be assigned. The nurse assigns or delegates tasks to unlicensed assistive personnel (UAP’s) based on the condition of the patient, the complexity of the task, stability of the patient, and the ability of the staff to whom the task is delegated. The delegation of an activity passes on the responsibility for the task performance, but not the accountability.10  


Many times a patient or family member will ask the nurse’s opinion. The nurse, instead of offering an opinion, may encourage the patient to clarify their own values in reaching informed decisions to avoid unintended persuasion.

Provision 6 addresses the nurse’s responsibility in improving patient care and the work environment. Participatory governance, through established governance structures, welcomes the nurse’s participation in maintaining and improving the healthcare environment. Peer review, which is part of nursing governance at Children’s, allows care providers the opportunity to be evaluated by persons knowledgeable of their job duties, scope of practice and responsibilities. The Nursing Peer Review Committee is responsible for monitoring the quality of nursing care offered to patients, and provides a venue for identifying and recommending opportunities for improvement.

The nurse is accountable for individual nursing practice. In some situations a nurse may have the knowledge and/or skill to correctly diagnose and treat a certain problem, but according to the scope of their nursing practice, is not legally allowed to act upon this knowledge. In essence, to carry out tasks that are outside of the nurse’s scope of their license is unlawful. In certain defined situations, advanced/extended practice nursing standardized procedures approved by nursing, leadership and medical staff can be used to further enhance the nurse’s role.


Provisions 7-9: Expanded Duties Beyond Direct Patient Care

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.


The three provisions for expanded duties of the nurse address advancement of the nursing profession through participation in professional associations and contributing new knowledge. 2 These three provisions also remind the nurse of their responsibility to work on issues of social reform in areas that contribute to illness.

To become a nurse is not just a job, but to view oneself as a professional and to collaborate with other nurses to advance the profession. To comply with Provision 7 nurses can advance through higher education and specialized certifications, and continue to learn and grow through participation in professional organizations. There is also the opportunity to serve on shared governance committees or in professional organizations. Participating in implementing evidence-based practice or nursing research contributes new knowledge to enhance patient care. Sharing new knowledge through presentations or publications provides an opportunity for other healthcare providers to learn from our experiences and areas of research.

Do nurses have an obligation to pay attention to world peace and pollution? Provision 8 answers these questions. Nurses should be committed to helping solve social issues that interfere with the well-being of all. Nurses have a professional obligation to be aware of their prejudices and respect those from different cultures.

Nurses should also participate in civic causes that advocate for health-related legislation. There are many nurses who have demonstrated their dedication to migrant farm workers, people in refugee centers, or juvenile detention centers, and continue to educate the public on these vulnerable populations. Nurses individually and as a group should become familiar with the healthcare needs of their community and participate in their education. This can be accomplished through the participation in health fairs, school programs and community-based educational events and initiatives. Nurses should utilize their professional organizations to voice their concerns.10  Most professional organizations have a legislative advocacy/educational branch that gives their members a voice in health affairs. The nurse has a role in providing clarity to social issues and to become involved in educating the public, media and government leaders by a partnership with them. Nurses need to become involved with issues influencing public policy in healthcare to help shape the future of healthcare as demonstrated in Provision 9. 



The code of ethics is part of the foundation of nursing. It’s integrated into the mission, vision, philosophy of care, clinical ladders and performance appraisal processes at Children’s. The nine provisions from the code of cthics are integrated into the policies and processes that are used to govern nursing services.

Nurses positively affect the patient’s quality of life by implementing an individualized plan of care based on the nurse’s assessment of what the quality of life means for that particular patient. As a nurse, one has to decide how to organize competing values and beliefs to determine which satisfies all of their core moral responsibilities.

There are four basic elements to the code which are woven throughout: 1) nurses and people, 2) nurses and practice, 3) nurses and the profession, and 4) nurses and co-workers. These elements provide the framework for the nine provisions. As a nurse, one would be practical to reflect on these provisions and evaluate how they apply to one’s practice. Nurses are encouraged to collaborate with their professional colleagues both at work and in respective professional organization meetings. Despite all the challenges found in today’s health environment, nurses remain committed to making a difference in their patients’ lives. By doing this, nurses find joy and personal satisfaction by providing service to others. At the same time, they are professionally and personally transformed by the experience.


Florence Nightingale is our inspiration to renew our commitment to remain dedicated to this journey:

“Let us be anxious to do well, not for selfish praise but to honor and advance the cause, the work we have taken up. Let us value our training not as it makes us cleverer or superior to others, but inasmuch as it enables us to be more useful and helpful to our fellow creatures, the sick, who most want our help. Let it be our ambition to be good nurses, and never let us be ashamed of the name of ‘nurse’.” 11 




1 The Florence Nightingale Pledge. A Short History of Nursing 1893 by Lavinia Dock and Isabel Stewart


2 Code of Ethics for Nurses with Interpretive Statements. Washington, DC: American Nurses Association; 2001.


3 Webster’s online dictionary


4 Hook, Kevin, White, Gladys, Turner, Martha, Code of Ethics for Nurses with Interpretive Statements, 2001.




6 O'Malley P, Mace SE, Brown K. Patient and family-centered care and the role of the emergency physician providing care to a child in the emergency department. Ann Emerg Med 2006; 48:643-5.


7 Fowler, M., ed. (2008). Guide to the Code of Ethics for Nurses: Interpretation and Application. American Nurses Association, Silver Spring, MD.


8 Martin, Benjamin, Joy Curtis.  Ethics in Nursing.  4th. Ed. Oxford, New York:  Oxford University Press; 2010.


9 International Council of Nurses, 3, place Jean-Marteau, 1201 Geneva, Switzerland.


10 Taylor, C.R., (2008). Guide to the Code of Ethics for Nurses: Interpretation and Application. American Nurses Association, Silver Springs MD.


11 Notes on Nursing: What It is, and What It is Not by Florence Nightingale, New York:  D. Appleton and Company, (1898).



Process for Earning Continuing Education – 1.0 contact hour is available  

Note Continuing Education credit is only available for nurses employed at Children’s Hospital Central California. 

  1. Continuing education is available through November 2011 
  2. Read the continuing education article. 
  3. To complete a brief post test, click on the following link:


4.   You must achieve a score of 80% to earn credit; a continuing education certificate will be awarded you.


Children’s Hospital Central California is a continuing education provider accredited by the California Board of Registered Nursing (provider number RN:00316).



In This Issue

A Recipe for Advanced Clinical Systems

Code of Ethics for Nurses

Champions… A Key to Success

Optimizing the Wound Healing Environment

Electronic Documentation

The Pace of Regulatory Change

Alphabet Soup in the Ambulatory Division

Shared Governance: PICU Skin Care Program

Striving for Excellence in Children's Asthma Care

Patient Satisfaction Comments