Provisions 4-6 Boundaries of Duty and Loyalty

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 also 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.

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." (Code of Ethics, 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. (Code of Ethics, p. 16)

Responsibility "refers to the specific accountability or liability associated with the performance of duties of a particular role." (Code of Ethics, p. 16) Responsibility embraces the ability to make moral or rational decisions on one's own and therefore be answerable for one's own behavior. 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 describes, is grounded in fidelity and respect for the patient. But in this area of the Code, the important, but so far implied, concept of nurses' moral autonomy is beginning to emerge.

Recognizing the complexity of nursing today, accountability and responsibility become increasingly important components of nursing practice as nurses take on new responsibilities, such as becoming nurse practitioners; delegating tasks to others, and seeking the counsel of others if there are questions regarding patient care. Both the NP and the bedside nurse are responsible for the decisions made and the tasks subsequently carried out.

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. Nurses are required to always assess and improve their own competence through education, self-study, networking, obtaining advanced degrees, and participating in professional development programs. This assessment is to be performed by all nurses, not just those providing direct patient care. 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.

In these times of increasing patient-to-nurse ratios, the delegation of tasks to others, particularly to 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 is specific that nurses must not only assess their own competencies, but also the competencies of others to whom they delegate tasks.

The Code of Ethics reminds each nurse that he or she must "make reasonable efforts to assess individual competence" when delegation of tasks occurs. (Code of Ethics, p. 17) The Code is explicit, however, that assessment and evaluation responsibilities are not to be delegated to assistive personnel. Only tasks may be assigned to others. Again, 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." (Code of Ethics, p. 17)

This moral responsibility in delegating and being always accountable makes it incumbent on nurse administrators to provide safe staffing levels, so that individual nurses do not find themselves in unsafe situations. Nurses are morally bound to refuse unsafe assignments and to work to change unsafe working environments.

Nurses do not leave their moral autonomy at the front door of the hospital, but must express it 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 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, then, serves as a kind of ethical 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 helps nurses reclaim their rightful place as health care collaborators, not followers.

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. Nurses have a duty to themselves to participate in "authentic expression of one's own moral point-of-view in practice." (Code of Ethics, p. 19) This includes expressing opinions to the patient if the patient requests such an opinion. Being aware of the importance nursing roles and the undue influence such roles can have on a patient is also important.

Virtues and excellences 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 structures in ways that improve patient care and the work environment. To this end, nurses must be part of the organizational decision-making processes. The Code supports collective bargaining or workplace advocacy to address workplace issues. Interestingly, this revised Code includes an extensive Provision Five that could be subtitled Self-Regarding Duties. The interpretive statements include such things as moral self-respect, professional growth, wholeness of character, and the preservation of integrity. It is in this particular provision that moral autonomy of the nurses is most explicitly described.

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." (Code of Ethics, p. 18) Whereby peer review has heretofore been a mechanism to maintain quality care for patients, now it serves to enhance nurses' self respect and integrity.

The Code 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.