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Table of Contents

• Abstract
• Objectives
• Introduction
• The Evolution of Nursing's Code of Ethics
• The Preface to the Code
• Provisions 1-3 Fundamental Values and Commitments of the Nurse
• Provisions 4-6 Boundaries of Duty and Loyalty
• Provisions 7-9 Duties to the Broader Community
• Conclusion
• References

Abstract

Although nursing has a long history of an ethic of care, embodied in prior Codes of Ethics, the context in which nurses now practice has changed and expanded. Some historical concepts, such as patient advocacy, have been expanded and new concepts, such as duty to self, have been added in the latest revision of the Code of Ethics for Nurses. In addition, many nurses now fill broader roles than those historically performed at the bedside. For these reasons, nurses may need assistance in ethical decision-making as they practice in both traditional and expanded nursing roles.

The primary purpose of this independent study module is to familiarize nurses with the nine major planks of the current Code and the accompanying interpretive statements. It will orient nurses to the ethical code and how it affects their own nursing practice; facilitate nurses' ability to use the Code as a guide; and demonstrate how it directs the profession of nursing as a whole. In addition, the module will provide nurses with a brief history of the development of the Code of Ethics by the American Nurses Association.

Objectives

By completing this independent study module, the nurse will be able to:

1. Present a brief history of the code of Ethics for Nurses, the revision process and reasons for the current changes.

2. Identify the nine planks of the 2001 Code of Ethics for Nurses.

3. Analyze the key interpretive statements.

4. Explain the significance of the Code in guiding and empowering nurses in their practice.

5. Apply the 2001 Code of Ethics for Nurses to their own nursing practice and to the practice of nursing within their workplace.

Introduction

What makes a code of ethics an important document for nurses? Generally, a code of ethics functions as a tool for professional self-definition. 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 code provides a positive argument that a group self-identifies as "professional," not just as occupational. In fact, the formulation of "a code of ethics itself is commonly taken to be one of the defining marks of a profession." (Alexandra, p. 226) 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. As Alexandra and Woodruff write, "...membership in a profession...entails duties, but also rights...of a distinctive kind."(Alexandra, p. 227) A Code of Ethics outlines these distinctive duties and rights.

Fundamentally, then, 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, 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 recently revised "Code of Ethics for Nurses with Interpretive Statements" 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 cost-conscious hospitals, managed care payment plans, nursing staffing problems, the looming nursing shortage, and complex medical conditions that affect not just individuals, but whole communities.

In the current health care delivery system and as a result of these expanded responsibilities, 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, p.366) The revised Code is now available to help nurses navigate this new "moral paradigm" in an era "when hospitals have become marketplaces...". (Curtin, p.56) The nursing profession is challenged to assume a new mantle of leadership and relocate the patient at the center of health care.

The Code is the promise that nurses are doing their best to provide care for their patients and their communities while supporting each other in the process, so that all nurses can fulfill their ethical and professional obligations, as well as meet their own professional and career goals. In the midst of these challenges, the Code of Ethics 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 should contribute to what Rankin refers to as "empowered caring." (Rankin, p. 194)

The Evolution of Nursing's Code of Ethics

Whatever the version of the Code, it has always been fundamentally concerned with the principles of doing no harm, of benefiting others, of loyalty, and of truthfulness. The Code has been focused on social justice and, in later versions, with the changing context of health care as well as with the autonomy of the patient and the nurse.

1893	The "Nightingale Pledge," patterned after medicine's Hippocratic Oath, is understood as the first nursing code of ethics.
1896	The Nurses' Associated Alumnae of the United States and Canada (later to become the American Nurses Association), whose first purpose was to establish and maintain a code of ethics.
1926	"A Suggested Code" is provisionally adopted and published in the American Journal of Nursing (AJN), but is never formally adopted.
1940	"A Tentative Code" is published in AJN, but also is never formally adopted.
1950	The Code for professional Nurses, in the form of 17 provisions that are a substantive revision of the "Tentative Code" of 1940, is unanimously accepted by the ANA House of Delegates.
1956	The Code for Professional Nurses is amended.
1960	The Code for Professional Nurses is revised.
1968	The Code for professional Nurses is substantively revised, condensing the 17 provisions of the 1960 Code into 10 provisions.
1976	The Code for Nurses with interpretive Statements, a modification of the provisions and interpretive statements is published as 11 provisions.
1985	The Code for Nurses with Interpretive Statements retains the provisions of the 1976 version and includes revised interpretive statements.
2001	The Code of Ethics for Nurses with Interpretive Statements, as completely revised, is accepted by the ANA House of Delegates.

The Preface to the Code

Nurses have strong ethical responsibilities. The Code of Ethics with Interpretive Statements exists to assist nurses in identifying those ethical responsibilities and engaging in serious ethical reflection. Such assistance and engagement are crucial in an era when health care is undergoing fundamental changes in delivery systems and personnel. A code of ethics makes explicit the primary goals, values and obligations of the profession. Traditionally, health care ethics have relied on the principles of respect, autonomy, beneficence, non-malfeasance, and justice. The Code of Ethics addresses these principles and the responsibilities derived from them and relies on humanist, feminist, and social ethics as well as the cultivation of virtues. The Code of Ethics assists nurses when they recognize that many of the decisions they make have an ethical component and may involve conflicts among ethical responsibilities. These conflicts may involve the clash between two ethical duties (such as duty to respect autonomy and duty to benefit the patient). The conflicts, though, may be between professional ethical positions and religious ones. The conflicts may also be between duties to self and duties to the patient. In addition, there may be conflicts between rights versus benefits. "Many situations faced by the nurse pose the problem of the rights of the patient conflicting with benefits to the patient; that is, one course seems to protect the patient's right while another course would produce more good for the patient." (Fry and Veatch, p. 32)

As stated in the Preface, the "values and obligations expressed in this Code apply to all nurses in all roles and settings." (Code of Ethics, p. 6) This may come as a surprise to those familiar with the Code, as now the definition of nursing practice includes all nurses in all roles, including those involved in direct patient care, as well as nurse administrators, educators and researchers. Simultaneously, the definition of patient in this Code is broadened to include not only those who are acutely ill, but those persons who are undergoing rehabilitation as well as individuals who want to enhance their health.

Understanding 'roles' is important in this revised Code since sometimes the resolution of an ethical dilemma is based on understanding the different obligations that arise from nurses' various roles. "If we can achieve clarity about the role or roles involved, and about our movement from one role to another, we will achieve more clarity about our ethical obligations as well. The existence of role ambiguity and conflict does not negate the importance of roles in determining ethical obligations." (Lebazq, p. 58) Clearly, different nurse roles will affect nurses' ethical discourse.

Provisions 1-3 Fundamental Values and Commitments of the Nurse

The fundamentals of nursing ethics, the fundamental values and responsibilities nurses assume, are expressed in the first three provisions of the Code. 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 will it be demonstrated? The concept of human dignity, flowing from the principle of respect, is expressed in numerous ways when nurses go about their work. The idea is based on the principle of respect for persons and is derived from the 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 attitude translates into respect for all persons.

Respecting all persons means the nurse should honor human dignity in every encounter with every patient and in all encounters with other professionals. 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 delivery of health care. The nurse's responsibility is paramount in ensuring that patients are fully informed and understand their options. "Each nurse has an obligation to be knowledgeable about the moral and legal rights of all patients to self-determination." (Code of Ethics, 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." (Code of Ethics, 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 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 supports this, stating, that "support 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 community values in decision making." (Code of Ethics, 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 considers limiting such autonomy appropriate. The Code, however, 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. (Code of Ethics, p. 9)

With regard to end-of-life care, the Code of Ethics reiterates the obligation to respect all persons and their autonomy. The Code reminds nurses that they are "leaders and vigilant advocates for the delivery of dignified and humane care." (Code of Ethics, 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.

The revised Code 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." (Code of Ethics, 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. In a cost-cutting era, it is ethically incumbent upon the nurse in the hospital or in other settings to be sensitive to the potential effects of financial cutbacks and conflicts which may put a patient at risk of sub-standard care in difficult health care settings.

Privacy and confidentiality issues are paramount and may be compromised as health care professionals and others make an assortment of claims to information about a patient's health state. Also, as health care organizations put into place new information technologies required by the Health Insurance Portability and Affordability Act (HIPAA), access to personal information could be compromised. Nurses must be especially aware of changes in hospitals' 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 part in the 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." (Code of Ethics, 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 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 individuals, "including children, prisoners, students, the elderly and the poor." (Code of Ethics, p. 13) The Code 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." (Code of Ethics, 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. This includes being part of peer review committees, credentialing processes, 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.

Recently, the Institute of Medicine reported that large numbers of patients have been harmed by medical errors (Institute, 2000). Following that report, the Chicago Tribune reported that medication errors accounted for a large part of the harm caused patients. Nurses have key roles in the safe and accurate administration of medications. (Berens, 2000) Does the Code have anything to say about this issue? The Code is explicit. With respect to medication or other errors, nurses are expected "to follow institutional guidelines in reporting errors committed or observed to the appropriate supervisory personnel and for assuring responsible disclosure of errors to patients." (Code of Ethics, p. 14) However, acknowledging the importance of systems theory, the Code 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." (Code of Ethics, p. 14)

What about sheer 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." (Code of Ethics, p. 14) The Code 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 an intellectually incompetent practitioner.

According to the Code, "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." (Code of Ethics, 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. The nurse, however, believes, in principle, that people have the right, under most situations, to achieve a weight that they want (Fry, 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, p. 18)

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.

Provisions 7-9 Duties to the Broader Community

Provisions 7-9 of the Code of Ethics for Nurses discuss the broader range of a nurse's 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, 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.

In Section 7, nurses are reminded to contribute to the larger spectrum of nursing through "leadership, activities, and the viability of their professional organizations." (Code of Ethics, 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 nurses have to engage in "ongoing scholarly activities." (Code of Ethics, p. 23)

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. Many feel nurses now 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, 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, 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 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, 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." (Code of Ethics, ANA publications, p. 24) As individual nurses have these obligations, so do their professional associations.

Conclusion

The Code of Ethics for Nurses is for all nurses, regardless of practice setting or nursing role. It is especially helpful for today's nurses, who may find themselves challenged to fulfill the 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.

References

Alexandra, A., & Woodruff, A.(1990). Ethics and the professions. Englewood Cliffs, New Jersey: Prentice-Hall.

American Nurses Association.(2001). Code of Ethics for Nurses with Interpretive Statements ("read only", requires an Explorer browser, version 5.0 or above). Code of ethics for nurses with interpretive statements. Washington, DC: ANA Publications.
Purchase The Code

Berens, Michael, J.(September 10-11-12,2000). Three Part Series: Dangerous care: Nurses' hidden role in medical error. Chicago, Illinois: Chicago Tribune.

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.

Fitzpatrick, J. (1990). The power of the written word. Applied Nursing Research, 3(1): 1.

Fowler, M., (2000). A new code of ethics for nurses. American Journal of Nursing, 100(7): 69-72.

Fry, S., and Veatch, R.(2000). Case studies in nursing ethics (2nd Edition). Sudbury, Mass: Jones and Bartlett Publishers.

Institute of Medicine.(2000). To err is human: Building a safer health system. L.T. Kohn, J. M. Corrigan & M.S. Donaldson, eds. Washington, D.C.: National Academy Press.

Lebacqz, Karen. Professional ethics: power and paradox. Nashville. Abingdon Press, 1985. Rambur, B.(1998). Ethics, economics and the erosion of physician authority: a leadership role for nurses. Quality and Accountability in Practice, 20(4): 62-71.

Rankin,W.(2000). Ethics of care and the empowerment of nurses. Journal of Pediatric Nursing, 15(3): 193-4.

Scanlon, C. (2000). A professional code of ethics provides guidance for genetic nursing practice. Nursing Ethics, 7(3): 262-8.

Walleck, C.(1989). Ethical dimensions of nursing practice. Journal of Neurosurgical Nursing, 15(6): 366-9.

Authors

Kevin G. Hook, M.A., B.S.N., R.N.
Clinical, Nurse, Clarian Health System, Indianapolis, Indiana and Former Summer Intern at the Center for Ethics & Human Rights, ANA

Gladys B. White, Ph.D., R.N.
Former Director, Center for Ethics & Human Rights, ANA, current Deputy Director, National Center for Ethics in Health Care, Veterans health Administration

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