rural health and nursing

September-October 2015 • Vol. 24/No. 5 363

Vicki D. Lachman, PhD, APRN, MBE, FAAN, is President, V.L.
Associates, a consulting and coaching firm, Avalon, NJ, and Sarasota,
FL. She is Chair, American Nurses Association Ethics and Human
Rights Advisory Board, and serves on a hospital ethics committee.
Elizabeth O’Connor Swanson, DNP, MPH, APRN-BC, is Assistant
Professor of , Mary Black School of , University of
South Carolina Upstate; Nurse Practitioner/Clinical Nurse Specialist,
South Carolina Department of Juvenile Justice; and member of the
American Nurses Association Ethics and Human Rights Advisory
Board.
Jill Winland-Brown, EdD, FNP-BC, DPNAP, is Professor Emeritus,
Christine E. Lynn College of , Florida Atlantic University, and
member of American Nurses Association Ethics and Human Rights
Advisory Board.

The New ‘Code of Ethics for Nurses
with Interpretative Statements’

(2015): Practical Clinical Application,
Part II

I n June 2015, over 300 registered nurses (RNs) gath-ered in Baltimore, MD, to examine the newlyrevised Code of Ethics for Nurses with Interpretive
Statements (Code) (American Nurses Association [ANA],
2015a). Participants represented all nursing specialties
and ranged from new graduates to nurses with more
than 40 years of practice experience. All had one thing
in common: a need to learn more about this revised
Code.

Part I of this series introduced the reader to the
revised Code, discussed the glossary, and used a nursing
case scenario to illustrate Provisions 1 through 4
(Winland-Brown, Lachman, & Swanson, 2015). This
article will complete the discussion of the Code, concen-
trating on Provisions 5 through 9 and including the
interpretative statements for each provision. A nursing
case scenario will be used to illustrate ethical dilemmas
nurses may encounter.

Provisions 5 and 6 focus on ethical issues related to
boundaries of duty and loyalty. The language used in
the revised Code makes these provisions more precise
and the interpretive statements supporting the provi-
sions are organized more logically. As a result, the intent
of Provisions 5 and 6 is easier to understand. Provisions
7 through 9 concentrate on the nurse’s ethical duties
beyond individual patient encounters. These provisions
had the most significant changes. They focus on the
nurse’s obligation to address social justice issues
through direct action and involvement in health policy,
as well as a responsibility to contribute to nursing
knowledge through scholarly inquiry and research. A

case scenario illustrating ethical issues addressed in
Provisions 5 through 9 follows.

Keisha and Kyle are two RNs working the
night shift. They have been out of school for
several years and have remained close friends.
Kyle was one of Keisha’s major supporters when
she re-entered nursing. Keisha suffered an
addiction to oxycodone after a shoulder injury.
This forced Keisha to leave nursing until her
successful completion of the recovering profes-
sional program administered by the Board of
. Keisha continues to see a counselor on
an as-needed basis.

Kyle has heard some rude comments about
Keisha from co-workers. He heard Lindsey, a co-
worker, describe Keisha as “that bleeding heart
liberal woman I have to work with every shift.”
Keisha earned this name after she was over-
heard discussing the death penalty with a
patient one night. Lindsey has worked on the
unit for many years. Keisha is uncomfortable
when she has to interact with Lindsey.

Keisha admits to Kyle that working nights
have been taking a toll on her health. She is
beginning to feel “down” and has had difficulty
finding time to go on any bicycle rides. Keisha
is a passionate cyclist and was a member of a
local cycling team known for its community
work with the homeless. She also admits to Kyle
she has not been motivated to complete contin-
uing education requirements needed to finish
her recertification. Furthermore, she has not
been participating actively in the unit research
council and has not met the deadline for an
article about recovering nurses she had agreed
to submit to a journal.

Kyle is concerned his friend is suffering
from burnout. Keisha has used inappropriate
jargon when describing patients in shift report
and her grooming is not as neat and profession-
al as when they began working together.
Moreover, Keisha stated this is the first time in
her professional career she feels uncomfortable
going to work.

Ethics, ,
and Policy

Vicki D. Lachman
Elizabeth O’Connor Swanson

Jill Winland-Brown

September-October 2015 • Vol. 24/No. 5364

Provision 5
The nurse owes the same duties to self as to others,

including the responsibility to promote health and
safety, preserve wholeness of character and integrity,
maintain competence, and continue personal and pro-
fessional growth.

This provision delineates personal behaviors in
which the nurse must engage to achieve the expecta-
tions of the Code. These self-regarding behaviors include
maintaining personal health, personal safety, and over-
all well-being. The nurse also must remain a competent
nursing professional, growing in his or her professional
and personal life.

The first interpretive statement addresses “duty to
self and others.” The virtue of respect encompasses
respect for self as well as for patients. Keisha is having
difficulty engaging in self-regarding behaviors; her
behaviors indicate she is not caring for her physical,
emotional, and spiritual self. Keisha is talking to
patients about personal opinions (e.g., capital punish-
ment), is not attending to her grooming, and has made
derogatory statements about patients during shift
change. These behaviors do not demonstrate respect for
self or others.

The second interpretive statement focuses on “promo-
tion of personal health, safety, and well-being.” This
interpretive statement centers on the importance of the
nurse’s care of self to mitigate burnout, fatigue, and com-
passion fatigue. This statement recommends “nurses
should eat a healthy diet, exercise, get sufficient rest,
maintain family and personal relationships, engage in
adequate leisure and recreational activities, and attend to
spiritual or religious needs” (ANA, 2015a, p. 19). Keisha is
complaining of feeling “down” and admits to an inability
to schedule leisure activities for exercise. Her change in
grooming indicates a lack of attention to her role as a pro-
fessional, and she is having difficulty working with at
least one member of her team. These signs suggest a nurse
suffering from burnout. However, because Keisha does
not recognize the signs, she is not seeking advice and
treatment from an appropriate source (Krischke, 2013).
Kyle should discuss his concerns with her.

The third interpretive statement considers the
“preservation of wholeness of character,” and addresses
the nurse’s dual identity — professional and personal. It
was appropriate for Keisha to discuss the capital punish-
ment issue with a patient as long as she was speaking as
an individual on the issue, as “authentic expression of
one’s own moral viewpoint is a duty to self” (p. 20).
Nurses are free to express a personal opinion, as long as
they preserve proper professional or personal bound-
aries. Interpretive statement 3 asserts, “Nurses must be
aware of the potential for undue influence attached to
their professional role” (p. 20). Because nurses will
encounter situations with patients that test their per-
sonal beliefs, giving compassionate and respectful care
thus can be challenging at times.

Interpretive statement 4 upholds “preservation of
integrity.” “Personal integrity is an aspect of wholeness

Ethics, , and Policy

of character that requires reflection and discernment: its
maintenance is a self-regarding duty” (p. 20). Nurses
face threats to their integrity in any health care setting.
These threats can include demands for falsification of
records, requests to deceive patients or families, and
physical or verbal abuse from anyone in the setting.
Lindsey has violated the Code by verbally abusing
Keisha, and a manager needs to intervene and assure
Keisha will not be bullied (Rocker, 2012). If the unit
administrator fails to respond, Keisha has an obligation
to take the next step up the chain of command to
resolve this problem of bullying. Interpretive statement
4 maintains nurse administrators “must respond to con-
cerns and act to resolve the concern in a way that pre-
serves the integrity of the nurses” (p. 21).

This fourth interpretative statement also addresses the
concept of conscientious objection. This means refusing to
participate in a decision or action the nurse believes may
endanger a patient, family, or community, or nursing
practice itself because it violates the nurse’s moral stan-
dards. Nurses must understand these acts of moral
courage do not insulate them from formal or informal
consequences (Lachman, 2014). Any eroding of the ethi-
cal environment could result in moral distress for nurses.
Therefore, they have an obligation to express their con-
scientious objection to the appropriate authority.

Interpretive statement 5 focuses on “maintenance of
competence and continuation of personal growth.”
Maintaining competence is not only important to pro-
fessional growth, but also is a necessary lifelong duty.
Keisha has violated this through her unwillingness to
complete required necessary education to maintain cer-
tification. She has not participated in the nursing
research council, and has failed to submit an article on
recovering professionals to a journal. Kyle has a duty to
encourage Keisha to complete her certification require-
ments and other professional commitments.

Interpretive statement 6 reflects on the necessity of
“the continuation of personal growth.” “Professional
and personal growth reciprocate and interact” (p. 22).
Nurses are encouraged to engage in activities that
increase their knowledge and understanding of the
world in which they live. This interpretive statement
urges nurses to participate in activities, such as social
advocacy, civic activities, and recreational activities.
Keisha stopped going on team rides; these were not only
recreational, but also a way to participate in community
service. While these outside activities cannot be
required of nurses, nurses are encouraged to participate.

Provision 6
The nurse, through individual and collective effort,

establishes, maintains, and improves the ethical envi-
ronment of the work setting and conditions of employ-
ment that are conducive to safe, quality health care.

This provision describes the nurse’s responsibility for
creating a moral environment and expands the defini-
tions of the virtues of nursing. The provision states “cer-

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The New ‘Code of Ethics for Nurses with Interpretative Statements’ (2015): Practical Clinical Application, Part II

tain particular attributes of moral character might not
be expected of everyone, but are expected of nurses” (p.
23). Nurses in all roles are responsible for instituting,
sustaining, and cultivating an ethical work environ-
ment. Nurse managers/executives must involve nurses
in decisions related to workplace conditions and profes-
sional practice. Nurse executives also need to advocate
for appropriate organizational change to create a moral-
ly good environment.

Interpretive statement 1 focuses on expanding the
definitions of the virtues of nursing and states nurses are
expected to have specific attributes of moral character.
Keisha has violated the Code by making derogatory
comments about patients, thereby failing to demon-
strate respect and compassion for those in her care.
Keisha also is not caring for herself, placing her physical
well-being at risk. The interpersonal communication
between Lindsey and Keisha is hostile, leading both
nurses to be in violation of the Code. Neither is practic-
ing the expected nurse virtues of compassion, patience,
or respect.

Interpretative statement 2 focuses on “the environ-
ment and ethical obligation.” This statement asserts,
“Nurses in all roles must create a culture of excellence
and maintain practice environments that support nurs-
es and others in the fulfillment of their ethical obliga-
tions” (p. 24). This means each nurse has a responsibil-
ity to address Lindsey’s bullying to help ensure Keisha
does not continue to be a target. Peer pressure may
influence the team’s response, but if members continue
to allow the bullying through their silence, they are in
violation of the Code. Understanding the Code and other
ethical position statements will provide nurses the
knowledge necessary to construct an environment
needed for professional nursing practice.

Interpretative statement 3 addresses the “responsibil-
ity for the healthcare environment.” This statement
emphasizes, “nurses are responsible for contributing to
a moral environment that demands respectful interac-
tions among colleagues, mutual peer support, and open
identification of difficult issues…” (p. 24). Nurses on the
team have a collective responsibility to confront Keisha
regarding her unprofessional remarks about patients,
her lack of involvement in team professional activities,
and the hostile relationship between Keisha and
Lindsey. “The workplace must be a morally good envi-
ronment to ensure safe, quality patient care and profes-
sional satisfaction for nurses and to minimize and
address moral distress, strain, and dissonance” (p. 24).

Provision 7
The nurse, in all roles and settings, advances the

profession through research and scholarly inquiry, pro-
fessional standards development, and the generation
of both nursing and health policy.

This provision first focuses on the nurse’s role in
knowledge development through research and scholarly
inquiry. The second emphasis is on the importance of

developing practice standards consistent with the Code
and other foundational documents. The third focus
underscores the nurse’s responsibility to lead or serve on
institution, local, state, regional, or global civic or orga-
nizational policymaking committees.

The first interpretative statement focuses on “contri-
butions through research and scholarly inquiry.”
Knowledge development, whether through research or
scholarly inquiry, is necessary to advance the theory
and practice of nursing. Clinical nurses have the ethical
obligation to know and disseminate the most recent
research findings to support best practices. They also
have the obligation to protect patient rights in research.
Kiesha had demonstrated an initial interest in research
and joined the unit research council. Now she is disen-
gaged and is not meeting scholarly publication obliga-
tions. While this level of involvement is not a require-
ment, all nurses must remember clinical questions
developed at the bedside often generate research ques-
tions. “All nurses must participate in the advancement
of the profession…” (p. 27).

The second interpretative statement addresses “con-
tributions through developing, maintaining, and imple-
menting professional practice standards.” Professional
nurses have an obligation to develop practice standards
that support ethical practice and nursing’s body of
knowledge. Because of her compassion fatigue or
burnout, Keisha appears to be doing little and is not
meeting the obligations of professional nurses. Nurse
managers and executives must support the autonomy of
nurses in executing these standards to maintain quality
patient care.

The third interpretative statement centers on “contri-
butions through nursing and health policy develop-
ment.” Nurses can meet their ethical obligations by par-
ticipating in a variety of local, state, national, or global
initiatives. Keisha could use her addiction recovery
experience to help change nursing regulations in her
state and present at state and national conferences on
needed policy changes.

Provision 8
The nurse collaborates with other health profession-

als and the public to protect human rights, promote
health diplomacy, and reduce health disparities.

First, in comparison to the previous Code (ANA,
2001), this provision adds health as a universal right
and significantly increases the focus of the nurse on
human rights and health disparities. Second, it increases
the nurse’s obligation to take action on social injustice.
For the first time, it also addresses nurse’s moral obliga-
tions in extreme and extraordinary practice settings
(e.g., Ebola, Hurricane Sandy).

The first interpretative statement, “health is a univer-
sal right,” is new in this Code revision. This assertion is
held in common with many human rights treaties; it
includes many public health measures (e.g., sanitation,
potable water, immunizations), basic access to preven-

September-October 2015 • Vol. 24/No. 5366

Ethics, , and Policy

tion, and treatment of illness and injury. The Code lists
16 different entitlements included in this right (e.g.,
access to care, emergency care, prevention education).
Keisha could take an active role in educating nurses and
public in the prevention and treatment of drug abuse.

The second interpretative statement is “collaboration
for health, human rights, and health diplomacy.”
Though nurses have a personal obligation to address
human rights and health disparities, only through col-
laboration with other health care professionals can they
make significant needed impact on these social justice
issues. Practicing nurses see on a daily basis how a social
problem becomes a health problem, as they view the
effects of poverty, drug-infested neighborhoods, and
food deserts (“urban neighborhoods and rural towns
without ready access to fresh, healthy, and affordable
food”) (U.S. Department of Agriculture, 2015, para. 1).
Keisha has seen health disparities among homeless per-
sons through previous work via her cycling.

Interpretative statement 3 addresses the “obligation
to advance health and human rights and reduce dispar-
ities.” Individually or through community organiza-
tions, nurses can educate the public and join in legisla-
tive efforts to promote health. Again, nurses know first-
hand the barriers to health; homelessness, abuse and
violence, and lack of cultural sensitivity are a few of the
obstacles to quality health care. Keisha has experienced
personally how drug addiction stops the outward focus
on others, and she could be a good addition to any team
that addresses addiction leading to homelessness.

Interpretative statement 4 focuses on “collaboration
for human rights in complex, extreme, or extraordinary
practice settings.” Nurses can face competing moral
claims, for example, in caring for victims of natural dis-
aster while needing to care for family. Nurses have a
moral obligation to both groups, and only the individ-
ual nurse can determine which moral option to address
(ANA, 2006). “Only in extreme emergencies and under
exceptional conditions, whether due to forces of nature
or human action, may nurses subordinate human rights
concerns to other considerations” (p. 33). In such cir-
cumstance, the Code suggests a utilitarian framework
could guide actions (greatest good for the greatest num-
ber) (ANA, 2011).

Provision 9
The profession of nursing, collectively through its

professional organizations, must articulate nursing
values, maintain integrity of the profession, and inte-
grate principles of social justice into nursing and
health policy.

In comparison to the previous Code (ANA, 2001), this
Code (ANA, 2015a) addresses more in depth nurses’
responsibilities to engage in rectifying social injustices
and health disparities in the community and beyond.
The interpretative statements address issues impacting
nursing practice now (e.g., climate change, human traf-
ficking).

The first interpretative statement about “articulation
and assertion of values” identifies the need for profes-
sional nursing organizations to provide a unified voice
for the profession. The various professional organiza-
tions of nursing “communicate to the public the values
that nursing considers central to the promotion or
restoration of health, the prevention of illness or injury,
and the alleviation of suffering” (p. 35). By acting in
unity, nurses can have a noteworthy impact on social
justice and global health policies.

The “integrity of the profession” is the second inter-
pretative statement and is based on the knowledge and
observance of essential documents, such as the Code
(ANA, 2015a) and : Scope and Standards of Practice
(ANA, 2015b). These documents support the covenant
between the nursing profession and society. This prom-
ise also is supported by defined educational require-
ments for entry into practice, augmented utilization of
advanced practice nurses, increased focus on certifica-
tion, and nursing’s commitment to evidence-based
practice. Keisha is not doing the needed work for recer-
tification, which could be seen as a violation of this pro-
vision.

The focus of the third interpretative statement is
“integrating social justice,” with examples of the multi-
ple ways this can be accomplished. This interpretative
statement recognizes the responsibility of nursing
organizations to advocate for changes in health policies
on local, national, and international stages. Because
social determinants of health continuously foster social
injustice, nurses must take action with governmental
and nongovernmental bodies related to health affairs.
The statement also identifies the nurse’s responsibility
to “firmly anchor students in nursing’s professional
responsibility to address unjust systems and struc-
tures…” (p. 36). Keisha could address the issue of social
justice for recovering individuals by volunteering to
speak to nursing classes. Through content education,
staff development, or clinical experience, nurses can
help students and practicing professional nurses model
a commitment to eradication of social injustice.

“Social justice in nursing and health policy” is the
final interpretative statement in the new Code (ANA,
2015a). This final statement fittingly focuses on global
health and the need for voices of U.S. nurses to be heard
around the world. In this reiteration of the Code, the
health of the natural world is first addressed. Though
Florence Nightingale demonstrated concern for the
effects of environment on health, the profession today
must extend its advocacy as the “environmental assaults
disproportionately affect the health of the poor” (p. 37).
The “Laudato Si” statement by Pope Francis (2015)
starkly ties the effects of climate change to devastating
effects on the poor.

continued on page 368

September-October 2015 • Vol. 24/No. 5368

continued from page 366

Conclusion
This article elaborates on Keisha’s and Kyle’s obliga-

tions as professional nurses to meet the Code (ANA,
2015a). In preparing this article, the authors were con-
fronted with what they could be doing to advance the
profession and assist other nurses to do the same.
Hopefully, nurses reading this article will look inward,
find ways to promote this new Code, and improve the
ethical practice of nursing. This revised Code provides
nurses with the guidance to continue to earn the pub-
lic’s trust.

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Ethics, , and Policy

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