The history of nursing is discussed in detail in Chapter 2. The focus here is a brief history of nursing and public health ethics and the relationship between them and nursing.

Modern nursing has a rich heritage of ethics and morality, beginning with Florence Nightingale (1820–1910). Her values and the moral significance she inculcated into the profession have endured. She saw nursing as a call to service and viewed the moral character of persons entering nursing as important. She also viewed nursing within a broad social context, where poor people mattered and where soldiers harmed in the Crimean War (1854–1856) did not have to endure unhealthy environments. Because of her commitment to poor individuals in communities, as well as her stances on primary prevention and population-based evidence that healthy environments save soldiers’ lives, she is seen as nursing’s first enduring moral leader who defined the community as her client.

In 1860, Nightingale established the first nursing program in London. It was hospital based, but the curriculum contained not only care of the sick, but also public health concepts with their inherent ethical tenets. Many of these programs were associated with religious institutions. Students, therefore, often received ethics courses with a slant toward a particular religion’s values. Soon thereafter in the United States, the notion of hospital-based nursing programs took hold, but nursing practice in the community was not a part of the curricula.

In the 1960s, two seminal events occurred. First, the American Nurses Association (ANA) recommended that all nursing education should occur in institutions of higher education. As this process slowly took place, ethics, as a course per se, was removed from many schools of nursing, although ethical values remained. Second, because of major advances in science and technology that affected health care, the field of bioethics began to emerge and was reflected in nursing curricula. Today, the vast majority of nursing programs integrate bioethical content into their courses or have separate courses on this topic; some do both. Although some of these courses relate bioethics to community nursing, the emphasis has been primarily on acute care nursing.

Nurses’ codes of ethics are important in the history of public health nursing practice. The Nightingale Pledge is generally considered to be nursing’s first code of ethics (ANA, 2001). After the Nightingale Pledge, a “suggested” code and a “tentative” code were published in the American Journal of Nursing but were not formally adopted. In 1950, however, the Code for Professional Nurses was formally adopted by the ANA House of Delegates. In 1956, 1960, 1968, 1976, and 1985, the code was amended or revised. In 2001, after 5 years of work, the Code of Ethics for Nurses with Interpretive Statements was adopted by the ANA House of Delegates (ANA, 2001).

Nurses should also be familiar with the first known international code of ethics, developed by the International Council of Nurses (ICN) in 1953 (ICN, 1953). Like the ANA code, the ICN code has undergone various revisions and adoptions. The most recent version of the ICN Code of Ethics for Nurses was adopted in 2006 (ICN, 2006).

In addition to codes of ethics, the nursing literature and nursing associations have consistently reflected a commitment to ethics, as well as an awareness of nursing’s ethical obligations to society. From the 1980s to the present, the number of centers for nursing and health care ethics has increased steadily. The majority of these centers are located in academic settings; however, in 1991 the ANA founded its Center for Ethics and Human Rights. The historical contributions have affected the persistent ethicality of nursing. In 2008, the ANA published Nursing and Health Care Ethics: A Legacy and a Vision, which creatively assesses historical contributions of nursing scholars in ethics and explores a vision for the future scholarship of nursing ethics (Pinch and Haddad, 2008).

The bioethics movement of the late 1960s influenced not only nursing ethics, but also public health ethics. However, until recently, the relationship between public health and ethics was implicit rather than explicit (Callahan and Jennings, 2002; Petrini, 2010).

Finally, in 2000, public health professionals, individually and through their associations, initiated the writing of a code of ethics that was supported by the American Public Health Association (APHA). In 2001 the Public Health Code of Ethics was widely disseminated via the APHA website for critique (www.apha.org) and was adopted in 2002 (Olick, 2005). The code presents principles, rules, and ideals to guide public health practice but is not intended to provide a specific action plan for ethical decision making.

Before discussing ethics related to nursing practice in the community, some key ethical terms are defined in Box 6-1. Other ethical terms are defined within the context of the chapter.

Ethical decision-making frameworks use problem-solving processes. They provide guides for making sound ethical decisions that can be morally justified. Many such frameworks exist in the health care literature, and some are presented in this chapter. A caveat, however, is in order. Weston (2006, p 22) notes that the first requirement of ethics is to think appreciatively and carefully about moral matters. We should not simply obey rules or authorities without thinking for ourselves; thinking for ourselves is both a moral responsibility and a hard-won right.

Keeping the preceding caveat in mind, the following generic ethical decision-making framework is presented:

The steps of a generic ethics framework are often non-linear, and, with the exception of step 5, they do not change substantially. The rationale for each of the seven steps is presented in Table 6-1. The six approaches to actions or options in the ethical decision-making framework (step 5) are outlined throughout the chapter in the “How To” boxes.

Callahan (2000) offers useful insights into these conflicts. He describes four situations in which ethnic diversity can be judged in relationship to cultural standards:

Callahan (2000, p 43) discusses how to judge diversity in the four situations. Regarding situation 1, he states that “we in America imposed some standards on ourselves for important moral reasons; and there is no good reason to exempt [ethnic] subgroups from those standards.” Regarding situations 2 and 3, he suggests a thoughtful tolerance but also some degree of moral persuasion (not coercion) for ethnic groups to alter values so that they are more in keeping with what is normative in the American culture. However, Callahan notes that “in the absence of grievous harm, there is no clear moral mandate to interfere with those values” (p 43). Finally, regarding situation 4, he believes in moral tolerance of non-threatening ethnic traditions, since there is no moral mandate to do otherwise.

Second, since decision making is so central to the practice of nursing, and many decisions are not easy ones to make, spending more time on the experience of ethical or moral distress is useful. Moral or ethical distress occurs when a person is unable to act in a way that he or she thinks is right. You do not feel that you are able to act in a manner consistent with your own values, cultural expectations, and religious beliefs. When this conflict occurs, it can lead to a personal sense of failure in the kind of care you give and to subsequent performance issues and may lead to work and/or career dissatisfaction. However, there are ways to handle moral distress:

It is often useful to talk with colleagues. You may learn that they have similar concerns or that they have found ways to interrupt the stressful situation(s) (Carlock and Spader, 2007). Understanding both multiculturalism and moral distress enhances ethical decision making.