New gold standard in nursing ethics guides evolving practice
A much-anticipated revision of the Code of Ethics for Nurses (Code) published in January explicitly connects the health and safety of nurses and their patients, underscoring that although a nurse’s primary commitment remains to patients, they aren’t expected to compromise their well-being to meet the demands of their practice.
“There is no ethical expectation nor obligation inherent in the nurse’s duty to care that requires nurses to unreasonably sacrifice or trade their own safety or health for the benefit of others,” Provision 5.1 notes.
“This really describes how if a nurse isn’t whole and healthy and in a good place then the health of their patient inevitably will suffer,” said Aimee Milliken, PhD, RN, HEC-C, associate clinical professor at the Boston College Connell School of Nursing. “Making the argument in that way helps clarify the mutual obligation that we have and the way we’re all connected.” An ANA Massachusetts member, Milliken was one of 49 experts who spent more than 600 hours refining this foundational document to address key issues such as health disparities, racism, allyship, workplace safety, and emerging technologies.
The Code’s emphasis on nurse well-being is one of many the panelists considered in evaluating how both nursing practice and our society have evolved since 2015 when the Code was last revised.
Pursuing human flourishing
The COVID-19 pandemic and its enduring effects infused the panel’s deliberations, leading to an emphasis on human flourishing, an aspirational state for both nurses and patients, according to lead co-chair Jennifer L. Bartlett, PhD, MEDSURG-BC, CNE, CHSE. “We, as nurses and as a profession, want our patients not only to survive but also to thrive and flourish, and we want nurses to flourish as individuals and professionals,” said Bartlett. “Our use of the word flourishing doesn’t belie our understanding and recognition of the challenges nurses face.” Bartlett is an associate professor of nursing at Georgia Baptist College of Nursing at Mercer University and a Georgia Nurses Association member.
She added that the revised Code also recognizes complex system and societal issues laid bare during the pandemic. “We could have just stated that all patients have worth, dignity, and deserve our care,” she explained. “However, our environment was and remains untenable in certain respects, so we needed to articulate what that looks like for individuals, communities, and populations who are marginalized, disenfranchised, disempowered, or socially stigmatized. We need to intentionally consider the context of care and structural issues.”
Provision 8.3 asserts that “Nurses stress human rights protection with particular attention to preserving the human rights of disenfranchised, marginalized, or socially stigmatized groups.”
Social and structural challenges
The Code strongly calls out societal issues that affect how people receive and access healthcare. “Nurses ought to and must condemn all forms of oppression and demonstrate intentional efforts to reflect and act upon social justice issues that influence health outcomes and healthcare equity,” Provision 9.4 stresses.
The revised Code also introduces the concept of intersectionality, which considers how overlapping social constructs such as race, gender, and religion have a reinforcing effect on social advantage or disadvantage.
“Social determinants of health come from structural determinants of health, so we really can’t address social determinants without first looking at structural determinants,” said Daniela Vargas, MSN, MPH, MA-Bioethics, RN, PHN, one of six revision panel co-chairs. The Code’s call to consider these challenges as well as racism and intersectionality “is really asking nurses to be in self-reflection and to constantly analyze the structures that we, as nurses, have to interact with—not only for ourselves and the profession, but also for the patients and the communities that we serve,” added Vargas. A public health nurse, doctoral student, and ANA\California member, Vargas also served as a co-lead of the National Commission to Address Racism in Nursing.
Current and future practice
The panel considered in “frank discussions” many other issues that have affected nurses and nursing practice over the past 10 years, according to Bartlett. Examples include deepening use of both social media and artificial intelligence, laws and regulations that affect patients’ access to care, and growing recognition of nursing’s societal and global roles. In an iterative process, co-chairs, expert panelists, and writing panelists representing a diverse range of expertise and practice discussed historic underpinnings and new considerations, then drafted and refined each provision. The revision panel also offered multiple opportunities for nurses to weigh in through a public comment period, eventually receiving more than 6,000 comments. The co-chairs reviewed all comments, identified the ones considered actionable—for example, pointing out language that seemed vague—and incorporated edits from that feedback.
The goal of the revision was to offer ethical guidance that supports current nursing practice while articulating the profession’s ambitions and envisioning its future. Panelists stressed that the revised Code elaborates on concepts and certain situations but isn’t intended as a “How do I…” Google search. “Every situation is unique and usually carries specifics that aren’t possible to capture,” noted Sophia Robinson-Harris, DNP, RN, FNP-C, PMHNP-BC, who served on the writing committee for Provision 3. “Ethics is a little tricky because ethics isn’t black and white. We’re offering general guidance and hope that our readers can glean from the examples that have been provided.” A Georgia Nurses Association member, Robinson-Harris is an assistant professor at the Tanner Health System School of Nursing at the University of West Georgia.
Code of Ethics for Nurses Provisions
- The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person.
- A nurse’s primary commitment is to the recipient(s) of nursing care, whether an individual, family, group, community, or population.
- The nurse establishes a trusting relationship and advocates for the rights, health, and safety of recipient(s) of nursing care.
- Nurses have authority over nursing practice and are responsible and accountable for their practice consistent with their obligations to promote health, prevent illness, and provide optimal care.
- The nurse has moral duties to self as a person of inherent dignity and worth including an expectation of a safe place to work that fosters flourishing, authenticity of self at work, and self-respect through integrity and professional competence.
- Nurses, through individual and collective effort, establish, maintain, and improve the ethical environment of the work setting that affects nursing care and the well-being of nurses.
- Nurses advance the profession through multiple approaches to knowledge development, professional standards, and the generation of policies for nursing, health, and social concerns.
- Nurses build collaborative relationships and networks with nurses, other healthcare and non-healthcare disciplines, and the public to achieve greater ends.
- Nurses and their professional organizations work to enact and resource practices, policies, and legislation to promote social justice, eliminate health inequities, and facilitate human flourishing.
- Nursing, through organizations and associations, participates in the global nursing and health community to promote human and environmental health, well-being, and flourishing.
Finding guidance
Readers also may find issues mentioned across provisions rather than in a single, comprehensive discussion because distinct aspects of the Code might inform thinking about a topic. Workplace violence serves as one example. Provision 2.4 states that “unsafe behaviors or actions must not be tolerated and must be addressed in a timely manner to restore safety and to help the patient safely participate in healthcare encounters,” while Provision 4.2 notes that “nurses who experience workplace violence, aggression, or hostility may have difficulty exercising their nursing practice authority.
Together, these provisions enable nurses “to go to the Code and see this is something for which I should be receiving support. I should be able to work in a safe environment,” said Georgina Morley, PhD, MSc, HEC-C, director of the Cleveland Clinic nursing ethics program and nurse ethicist in Cleveland Clinic’s Center for Bioethics. “Then they can use the Code to say to their leaders, ‘This is what I’m experiencing but this is what my work environment should look like’.” An ANA-Ohio member, Morley served on the writing panel for Provision 2.
Throughout the year, the American Nurses Association is issuing Decoding the Code, a series of peer-reviewed online courses that present common ethical challenges related to each provision of the Code and explore strategies for resolving them. In addition, each issue of the Ethics Inbox in American Nurse Journal will involve an ethical challenge related to a Code provision.
Although the authors want to give context and guidance that would illuminate how the Code relates to everyday practice, they emphasized that it isn’t a code of conduct, which is a common misperception, according to Barlett.
“This document doesn’t just talk about how nurses should behave. We’re talking about their actual relational responsibilities,” Morley added. “It’s not just saying, ‘You need to be honest and transparent with people.’ It’s saying, ‘You have a responsibility to communicate with your patient and understand what their goals and values are and provide care that is in alignment with those goals and values’.”
Why the Code matters
“The Code underpins who we are as nurses and who we are as a profession of nursing.”
—Jennifer L. Bartlett, PhD, MEDSURG-BC, CNE, CHSE
“The Code serves as the profession of nursing’s promise to society and the people we care for.”
—Aimee Milliken, PhD, RN, HEC-C
“The Code outlines what the nursing profession could and should look like and how nurses should be able to practice in ethical work environments.”
—Georgina Morley, PhD, MSc, HEC-C
“The Code is a set of guidelines that direct my actions when I’m in practice as a nurse.”
—Sophia Robinson-Harris, DNP, RN, FNP-C, PMHNP-BC
“The Code is the covenant with our patients, other nurses, and the society and communities that trust us.”
—Daniela Vargas, MSN, MPH, MA-Bioethics, RN, PHN
A global community
Reflecting the continuity of nursing practice and the profession’s ethical commitments through time, the structure of the revised Code rests on the relational nature of nursing. The first three provisions involve the nurse-to-patient relationship and introduce “recipients of care” as the new inclusive term for individuals, families, communities, or populations who receive nursing care. Provisions 4 through 6 concern nurse-to-nurse and nurse-to-self relationships, while Provisions 7 through 9 consider nurse-to-profession, nurse-to-others, and nurse- and nursing-to-society connections.
The revised Code adds a new 10th Provision, which deals with nursing-to-the global community. As the revision process began, the initial thought was to keep societal and global concerns in a single provision, but this idea changed as deliberations continued, according to Milliken, who served on the writing panel for Provision 9.
“We realized we were talking about two considerations—Provision 9 has a lot to do with policy on a local, state, and federal level, the way nurses participate in policy, and the way policy can facilitate human flourishing. Provision 10 similarly has to do with nurses and our outward facing obligations towards communities but on a global level and thinking about public health for the entire world,” she said. “Calling that out specifically was a really important step because, as we experienced during the COVID-19 pandemic, we’re all interconnected.”
Milliken and other panelists acknowledged that this provision reflects one of the more aspirational aspects of the Code. “Not everyone is going to feel drawn to that policy work in the same way,” said Milliken. “But the Code speaks to how (and I encourage nurses to realize that) advocacy work and political engagement can look different depending on who you are, what your interests are, and the phase of your career.”
The revised Code provides timely and relevant guidance, enabling nurses to manage current practice challenges while also reflecting on and envisioning their own as well as the profession’s advancement, according to Vargas. “This document is so multifaceted and talks about so many issues, we want nurses to be able to use it not only for guidance, but also to remind them about who they are,” she said.
Vargas stressed that the Code also empowers nurses to effect change wherever they practice. “Nurses have said ‘I feel powerless; I don’t have a voice.’ The Code reminds them that while each individual is one nurse, there are 5 million behind them affirming shared ethical values.”
— Genna Rollins is a writer/editor at the American Nurses Association
Read the Code of Ethics for Nurses at the QR code or hubs.ly/Q035MTdB0.
American Nurse Journal. 2025; 20(4). Doi: 10.51256/ANJ042546
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