CODE OF ETHICS FOR NURSING

Canadian Nurses Association

1985, revised 1991

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The introductory sections of the Canadian Nurses Association (CNA) code suggest a sophisticated view of the role of codes. For example, the code "provides clear direction for avoiding ethical violations," that is, "the neglect of moral obligation," but it cannot resolve "ethical dilemmas," in which there are "ethical reasons both for and against a particular course of action." The code also cannot relieve the "ethical distress" that occurs "when nurses experience the imposition of practices that provoke feelings of guilt, concern or distaste." The CNA code is unique in its explicit organization around values, which "express broad ideals of nursing"; obligations, which are "moral norms that have their basis in nursing values"; and limitations, which "describe exceptional circumstances in which a value or obligation cannot be applied."

Preamble

Nursing practice can be defined generally as a "dynamic, caring, helping relationship in which the nurse assists the client to achieve and maintain optimal health." Nurses in clinical practice, education, administration and research share the common goal of maintaining competent care and improving nursing practice. "Nurses direct their energies toward the promotion, maintenance and restoration of health, the prevention of illness, the alleviation of suffering and the ensuring of a peaceful death when life can no longer be sustained."

The nurse, by entering the profession, is committed to moral norms of conduct and assumes a professional commitment to health and the well-being of clients. As citizens, nurses continue to be bound by the moral and legal norms shared by all other participants in society. As individuals, nurses have a right to choose to live by their own values (their personal ethics) as long as those values do not compromise care of their clients.

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Ethical Problems

Situations often arise that present ethical problems for nurses in their practice. These situations tend to fall into three categories:

1. Ethical violations involve the neglect of moral obligation; for example, a nurse who neglects to provide competent care to a client because of personal inconvenience has ethically failed the client.
2. Ethical dilemmas arise where ethical reasons both for and against a particular course of action are present and one option must be selected. For example, a client who is likely to refuse some appropriate form of health care presents the nurse with an ethical dilemma. In this case, substantial moral reasons may be offered on behalf of several opposing options.
3. Ethical distress occurs when nurses experience the imposition of practices that provoke feelings of guilt, concern or distaste. Such feelings may occur when nurses are ethically obliged to provide particular types of care despite their personal disagreement or discomfort with the course of treatment prescribed. For example, a nurse may think that continuing to tube feed an irreversibly unresponsive person is contrary to that client's well-being, but nonetheless is required to do so because that view is not shared by other caregivers.

This Code provides clear direction for avoiding ethical violations. When a course of action is mandated by the Code, and there exists no opposing ethical principle, ethical conduct requires that course of action.

This Code cannot serve the same function for all ethical dilemmas or for ethical distress. There is room within the profession of nursing for conscientious disagreement among nurses. The resolution of any dilemma often depends upon the specific circumstances of the case in question, and no particular resolution may be definitive of good nursing practice. Resolution may also depend upon the relative weight of the opposing principles, a matter about which reasonable people may disagree.

The Code cannot relieve ethical distress but it may serve as a guide for nurses to weigh and consider their responsibilities in the particular situation. Inevitably, nurses must reconcile their actions with their consciences in caring for clients.

The Code tries to provide guidance for those nurses who face ethical problems. Proper consideration of the Code should lead to better decision-making when ethical problems are encountered.

It should be noted that many problems or situations seen as ethical in nature are problems of miscommunication, failure of trust or management dilemmas in disguise. There is, therefore, a distinct need to clarify whether the problem is an ethical one or one of another sort.

Elements of the Code

This Code contains different elements designed to help the nurse in its interpretation. The values and obligations are presented by topic and not in order of importance. There is intentional variation in the normative terminology used in the Code (the nurse should or must) to indicate differences in the moral force of the statements; the term should indicates a moral preference, while must indicates an obligation. A number of distinctions between ethics and morals may be found in the literature. Since no distinction has been uniformly adopted by writers on ethics, these terms are used interchangeably in this Code.

• Values express broad ideals of nursing. They establish correct directions for nursing. In the absence of a conflict of ethics, the fact that a particular action promotes a value of nursing may be decisive in some specific instances. Nursing behaviour can always be appraised in terms of values: How closely did the behaviour approach the value? How widely did it deviate from the value? The values expressed in this Code must be adhered to by all nurses in their practice. Because they are so broad, however, values may not give specific guidance in difficult instances.
• Obligations are moral norms that have their basis in nursing values. However, obligations provide more specific direction for conduct than do values; obligations spell out what a value requires under particular circumstances.
• Limitations describe exceptional circumstances in which a value or obligation cannot be applied. Limitations have been included separately to emphasize that, in the ordinary run of events, the values and obligations will be decisive.

It is also important to emphasize that even when a value or obligation must be limited, it nonetheless carries moral weight. For example, a nurse who is compelled to testify in a court of law on confidential matters is still subject to the values and obligations of confidentiality. While the requirement to testify is a justified limitation upon confidentiality, in other respects confidentiality must be observed. The nurse must only reveal that confidential information that is pertinent to the case at hand, and such revelation must take place within the appropriate context. The general obligation to preserve the client's confidences remains despite particular limiting circumstances.

Rights and Responsibilities

Clients possess both legal and moral rights. These serve as one foundation for the responsibilities of nurses. However, for several reasons this Code emphasizes the obligations of nurses, rather than the rights of clients. Because the rights of clients do not depend upon professional acceptance of those rights, it would be presumptuous for a profession to claim to define the rights of clients. Emphasizing the rights of clients may also seem unduly legalistic and restrictive, ignoring the fact that sometimes ethics require nurses to go beyond the letter of the law. (For one example, see Value II, Obligation 3.) Finally, because it is sometimes beyond the power of a nurse to secure the rights of a client—an achievement that requires the cooperative and scrupulous efforts of all members of the health care team—it is better for a professional code of nursing to emphasize the responsibilities of nurses rather than to detail the entitlements of clients.

Nurses, too, possess legal and moral rights, as persons and as professionals. It is beyond the scope of this Code to address the personal rights of nurses. However, to the extent that conditions of employment have an impact on the establishment of ethical nursing, this Code must deal with that issue.

The satisfaction of some ethical responsibilities requires action taken by the nursing profession as a whole. The fourth section of the Code contains values and obligations concerned with those collective responsibilities of nursing; this section is particularly addressed to professional associations. Ethical reflection must be ongoing and its facilitation is a continuing responsibility of the Canadian Nurses Association.

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Clients

VALUE I: RESPECT FOR NEEDS AND VALUES OF CLIENTS

Value

A nurse treats clients with respect for their individual needs and values.

Obligations

1. The client's perceived best interests must be a prime concern of the nurse.
2. Factors such as the client's race, religion or absence thereof, ethnic origin, social or marital status, sex or sexual orientation, age, or health status must not be permitted to compromise the nurse's commitment to that client's care.
3. The expectations and normal life patterns of clients are acknowledged. Individualized programs of nursing care are designed to accommodate the psychological, social, cultural and spiritual needs of clients, as well as their biological needs.
4. The nurse does more than respond to the requests of clients; the nurse accepts an affirmative obligation within the context of health care to aid clients in their expression of needs and values, including their right to live at risk.
5. Recognizing the client's membership in a family and a community, the nurse, with the client's consent, should attempt to facilitate the participation of significant others in the care of the client.

VALUE II: RESPECT FOR CLIENT CHOICE

Value

Based upon respect for clients and regard for their right to control their own care, nursing care reflects respect for the right of choice held by clients.

Obligations

1. The competent client's consent is an essential precondition to the provision of health care. Nurses bear the primary responsibility to inform clients about the nursing care available to them.
2. Consent may be signified in many different ways. Verbal permission and knowledgeable cooperation are the usual forms by which clients consent to nursing care. In each case, however, a valid consent represents the free choice of the competent client to undergo that care.
3. Consent, properly understood, is the process by which a client becomes an active participant in care. All clients should be aided in becoming active participants in their care to the maximum extent that circumstances permit. Professional ethics may require of the nurse actions that exceed the legal requirements of consent. For example, although a child may be legally incompetent to consent, nurses should nevertheless attempt to inform and involve the child.
4. Force, coercion and manipulative tactics must not be employed in the obtaining of consent.
5. Illness or other factors may compromise the client's capacity for self-direction. Nurses have a continuing obligation to value autonomy in such clients; for example, by creatively providing clients with opportunities for choices within their capabilities, the nurse helps them to maintain or regain some degree of autonomy.
6. Whenever information is provided to a client, this must be done in a truthful, understandable and sensitive way. The nurse must proceed with an awareness of the individual client's needs, interests and values.
7. Nurses have a responsibility to assess the understanding of clients about their care and to provide information and explanation when in possession of the knowledge required to respond accurately. When the client's questions require information beyond that known to the nurse, the client must be informed of that fact and assisted to obtain the information from a health care practitioner who is in possession of the required facts.

VALUE III: CONFIDENTIALITY

Value

The nurse holds confidential all information about a client learned in the health care setting.

Obligations

• 1. The rights of persons to control the amount of personal information revealed applies with special force in the health care setting. It is, broadly speaking, up to clients to determine who shall be told of their condition, and in what detail.
• 2. In describing professional confidentiality to a client, its boundaries should be revealed:
• (a) Competent care requires that other members of a team of health personnel have access to or be provided with the relevant details of a client's condition.
• (b) In addition, discussions of the client's care may be required for the purpose of teaching or quality assurance. In this case, special care must be taken to protect the client's anonymity.
  Whenever possible, the client should be informed of these necessities at the onset of care.
• 3. An affirmative duty exists to institute and maintain practices that protect client confidentiality—for example, by limiting access to records or by choosing the most secure method of communicating client information.
• 4. Nurses have a responsibility to intervene if other participants in the health care delivery system fail to respect the confidentiality of client information.

Limitations

The nurse is not morally obligated to maintain confidentiality when the failure to disclose information will place the client or third parties in danger. Generally, legal requirements or privileges to disclose are morally justified by these same criteria. In facing such a situation, the first concern of the nurse must be the safety of the client or the third party.

Even when the nurse is confronted with the necessity to disclose, confidentiality should be preserved to the maximum possible extent. Both the amount of information disclosed and the number of people to whom disclosure is made should be restricted to the minimum necessary to prevent the feared harm.

VALUE IV: DIGNITY OF CLIENTS

Value

The nurse is guided by consideration for the dignity of clients.

Obligations

1. Nursing care must be done with consideration for the personal modesty of clients.
2. A nurse's conduct at all times should acknowledge the client as a person. For example, discussion of care in the presence of the client should actively involve or include that client.
3. Nurses have a responsibility to intervene when other participants in the health delivery system fail to respect any aspect of client dignity.
4. As ways of dealing with death and the dying process change, nursing is challenged to find new ways to preserve human values, autonomy and dignity. In assisting the dying client, measures must be taken to afford the client as much comfort, dignity and freedom from anxiety and pain as possible. Special consideration must be given to the need of the client's family or significant others to cope with their loss.

VALUE V: COMPETENT NURSING CARE

Value

The nurse provides competent care to clients.

Obligations

1. Nurses should engage in continuing education and in the upgrading of knowledge and skills relevant to their area of practice, that is, clinical practice, education, research or administration.
2. In seeking or accepting employment, nurses must accurately state their area of competence as well as limitations.
3. Nurses assigned to work outside an area of present competence must seek to do what, under the circumstances, is in the best interests of their clients. The nurse manager on duty, or others, must be informed of the situation at the earliest possible moment so that protective measures can be instituted. As a temporary measure, the safety and welfare of clients may be better served by the best efforts of the nurse under the circumstances than by no nursing care at all. Nurse managers are obligated to support nurses who are placed in such difficult situations and to make every effort to remedy the problem.
4. When called upon outside an employment setting to provide emergency care, nurses fulfil their obligations by providing the best care that circumstances, experience and education permit.

Limitations

A nurse is not ethically obliged to provide requested care when compliance would involve a violation of her or his moral beliefs. When that request falls within recognized forms of health care, however, the client must be referred to a health care practitioner who is willing to provide the service. Nurses who have or are likely to encounter such situations are morally obligated to seek to arrange conditions of employment so that the care of clients will not be jeopardized.

Nursing Roles and Relationships

VALUE VI: NURSING PRACTICE, EDUCATION, RESEARCH AND ADMINISTRATION

Value

The nurse maintains trust in nurses and nursing.

Obligations

1. Nurses accepting professional employment must ascertain to the best of their ability that conditions will permit the provision of care consistent with the values and obligations of the Code. Prospective employers should be informed of the provisions of the Code so that realistic and ethical expectations may be established at the beginning of the nurse–employer relationship.
2. Nurse managers, educators and peers are morally obligated to provide timely and accurate feedback to nurses, nurse managers, students of nursing and nurse educators. Objective performance appraisal is essential to the growth of nurses and is required by a concern for present and future clients.
3. Nurse managers bear special ethical responsibilities that flow from a concern for present and future clients. The nurse manager must seek to ensure that the competencies of personnel are used efficiently. Working within available resources, the nurse manager must seek to ensure the welfare of clients. When competent care is threatened due to inadequate resources or for some other reason, the nurse manager must act to minimize the present danger and to prevent future harm.
4. Student–teacher and student-client encounters are essential elements of nursing education. These encounters must be conducted in accordance with ethical nursing practices. The nurse educator is obligated to treat students of nursing with respect and honesty and to provide fair guidance in developing nursing competence. The nurse educator should ensure that students of nursing are acquainted with and comply with the provisions of the Code. Student–client encounters must be conducted with client consent and require special attention to the dignity of the client.
5. Research is necessary to the development of the profession of nursing. Nurses should be acquainted with advances in research, so that established results may be incorporated into clinical practice, education and administration. The individual nurse's competencies may also be used to promote, to engage in or to assist health care research designed to enhance the health and welfare of clients.

The conduct of research must conform to ethical practice. The self-direction of clients takes on added importance in this context. Further direction is provided in the Canadian Nurses Association publication Ethical Guidelines for Nursing Research Involving Human Subjects.

VALUE VII: COOPERATION IN HEALTH CARE

Value

The nurse recognizes the contribution and expertise of colleagues from nursing and other disciplines as essential to excellent health care.

Obligations

1. The nurse functions as a member of the health care team.
2. The nurse should participate in the assessment, planning, implementation and evaluation of comprehensive programs of care for individual clients and client groups. The scope of a nurse's responsibility should be based upon education and experience, as well as legal considerations of licensure or registration.
3. The nurse accepts responsibility to work with colleagues and other health care professionals, with nursing interest groups and through professional nurses' associations to secure excellent care for clients.

VALUE VIII: PROTECTING CLIENTS FROM INCOMPETENCE

Value

The nurse takes steps to ensure that the client receives competent and ethical care.

Obligations

• 1. The first consideration of the nurse who suspects incompetence or unethical conduct must be the welfare of present clients or potential harm to future clients. Subject to that principle, the following must be considered:
• (a) The nurse is obliged to ascertain the facts of the situation before deciding upon the appropriate course of action.
• (b) Relationships in the health care team should not be disrupted unnecessarily. If a situation can be resolved without peril to present or future clients by direct discussion with the colleague suspected of providing incompetent or unethical care, that discussion should be done.
• (c) Institutional mechanisms for reporting incidents or risks of incompetent or unethical care must be followed.
• (d) The nurse must report any reportable offence stipulated in provincial or territorial professional nursing legislation.
• (e) It is unethical for a nurse to participate in efforts to deceive or mislead clients about the cause of alleged harm or injury resulting from unethical or incompetent conduct.
• 2. Guidance on activities that may be delegated by nurses to assistants and other health care workers is found in legislation and policy statements. When functions are delegated, the nurse should be satisfied about the competence of those who will be fulfilling these functions. The nurse has a duty to provide continuing supervision in such a case.
• 3. The nurse who attempts to protect clients or colleagues threatened by incompetent or unethical conduct may be placed in a difficult position. Colleagues and professional associations are morally obliged to support nurses who fulfil their ethical obligations under the Code.

VALUE IX: CONDITIONS OF EMPLOYMENT

Value

Conditions of employment should contribute in a positive way to client care and the professional satisfaction of nurses.

Obligations

1. Nurses accepting professional employment must ascertain, to the best of their ability, that employment conditions will permit provision of care consistent with the values and obligations of the Code.
2. Nurse managers must seek to ensure that the agencies where they are employed comply with all pertinent provincial or territorial legislation.
3. Nurse managers must seek to ensure the welfare of clients and nurses. When competent care is threatened due to inadequate resources or for some other reason, the nurse manager should act to minimize the present danger and to prevent future harm.
4. Nurse managers must seek to foster environments and conditions of employment that promote excellent care for clients and a good worklife for nurses.
5. Structures should exist in the work environment that provide nurses with means of recourse if conditions that promote a good worklife are absent.

VALUE X: JOB ACTION

Value

Job action by nurses is directed toward securing conditions of employment that enable safe and appropriate care for clients and contribute to the professional satisfaction of nurses.

Obligations

• 1. In the final analysis, the improvement of conditions of nursing employment is often to the advantage of clients. Over the short term, however, there is a danger that action directed toward this goal could work to the detriment of clients. In view of their ethical responsibility to current as well as future clients, nurses must respect the following principles:
• (a) The safety of clients is the first concern in planning and implementing any job action.
• (b) Individuals and groups of nurses participating in job actions share the ethical commitment to the safety of clients. However, their responsibilities may lead them to express this commitment in different but equally appropriate ways.
• (c) Clients whose safety requires ongoing or emergency nursing care are entitled to have those needs satisfied throughout the duration of any job action. Individuals and groups of nurses participating in job actions have a duty through coordination and communication to take steps to ensure the safety of clients.
• (d) Members of the public are entitled to know of the steps taken to ensure the safety of clients.

Nursing Ethics and Society

VALUE XI: ADVOCACY OF THE INTERESTS OF CLIENTS, THE COMMUNITY AND SOCIETY

Value

The nurse advocates the interests of clients.

Obligations

1. Advocating the interests of individual clients and groups of clients includes helping them to gain access to good health care. For example, by providing information to clients privately or publicly, the nurse enables them to satisfy their rights to health care.
2. When speaking in a public forum or in court, the nurse owes the public the same duties of accurate and relevant information as are owed to clients within the employment setting.

VALUE XII: REPRESENTING NURSING VALUES AND ETHICS

Value

The nurse represents the values and ethics of nursing before colleagues and others.

Obligations

1. Nurses serving on committees concerned with health care or research should see their role as including the vigorous representation of nursing's professional ethics.
2. Many public issues include health as a major component. Involvement in public activities may give the nurse the opportunity to further the objectives of nursing as well as to fulfil the duties of a citizen.

The Nursing Profession

VALUE XIII: RESPONSIBILITIES OF PROFESSIONAL NURSES' ASSOCIATIONS

Value

Professional nurses' organizations are responsible for clarifying, securing and sustaining ethical nursing conduct. The fulfillment of these tasks requires that professional nurses' organizations remain responsive to the rights, needs and legitimate interests of clients and nurses.

Obligations

• 1. Sustained communication and cooperation between the Canadian Nurses Association, provincial or territorial associations and other organizations of nurses are essential steps toward securing ethical nursing conduct.
• 2. Activities of professional nurses' associations must at all times reflect a prime concern for excellent client care.
• 3. Professional nurses's associations should represent nursing interests and perspectives before nonnursing bodies, including legislatures, employers, the professional organizations of other health disciplines and the public communication media.
• 4. Professional nurses' associations should provide and encourage organizational structures that facilitate ethical nursing conduct.
• (a) Education in the ethical aspects of nursing should be available to nurses throughout their careers. Nurses' associations should actively support or develop structures to enhance sensitivity to, and application of, norms of ethical nursing conduct. Associations should also promote the development and dissemination of knowledge about ethical decision-making through nursing research.
• (b) Changing circumstances call for ongoing review of this Code. Supplementation of the Code may be necessary to address special situations. Professional associations should consider the ethics of nursing on a regular and continuing basis and be prepared to provide assistance to those concerned with its implementation.