Previous versions of the ANA Code of Ethics for Nurses (1968, 1976, 1985) focus on the role of the staff nurse in the hospital setting. The 2001 Code recognizes that nurses in all roles and settings face ethical issues and conflicts that should be addressed. It also recognizes the changing context within which health care is provided and nurses practice. Thus, the revised Code applies to nurses who are in practice, education, administration, research, consultation, and all other settings where nurses work, including situations of self-employment.

The Code of Ethics has historically changed in response to the social context in which nursing is practiced, and is therefore a dynamic and living document (Fowler, 1999; ANA, 2000). Both the 1976 and 1985 versions of the Code of Ethics recognized that nurses may participate in collective action as a means to achieve control
of nursing practice and employment conditions that are “conducive to high quality nursing care” and to meeting the professional standards of nursing practice. Previous versions of the Code included content related to nurses’ economic and general welfare. Today’s healthcare environment is one in which it is imperative to attend to concerns for providing quality patient care in ways that are cost-effective. Concerns for both patient and staff safety are emphasized. In order to continue to serve as a resource for nurses in the current healthcare context, it was thought important to include a provision about the importance of the work environment as an influence on nurses’ ethical and professional practice. The revised International Council of Nurses (ICN) Code of Ethics (2006) also emphasizes the role of the work environment as an influence on nurses’ ethical practice. The Task Force for the revision of the Code concluded that nurses’ responsibility for creating and maintaining an ethical work environment needed to receive greater attention in the 2001 version of the Code of Ethics for Nurses.

Interpretive Statement 6.1 addresses the importance of nurse participation in constructing an environment that will contribute to the flourishing of the virtues and values central to the nursing profession and its practice. While the focus of the interpretive statement is on the influence of environment on moral virtues and values, there is an underlying interrelationship that is understood. The work environment acts upon the nurse; the nurse acts upon the work environment. The work setting can either obstruct or support nursing values and virtues. The nurse can either remain silent when the work environment is obstructive or work to change the environment. The Code is clear in its expectation of moral activism.

The interpretive statement identifies some of the values central to nursing: human dignity; well-being; and respect for persons, health, and independence. The interpretive statement also identifies some of the virtues and excellences essential to good nursing: wisdom, honesty, courage, compassion, patience, and skill. It assumes that the nurse, shaped by nursing education, brings these values, virtues, and excellences to the work setting; the nurse does not come to the work or clinical setting as a “clean slate.” These values, virtues, and excellences lead some persons to choose nursing and other healthcare professions in the first place, particularly those with dispositions of helpfulness, kindness, courage, compassion, caring, and integrity. These moral virtues can be nurtured—or challenged, or thwarted— through the experiences one has in becoming a professional nurse (through the educational environment) and working in a healthcare organization.

Some ethical theories give priority to who we are morally over what we are to do. Moral character is the core of who we are as a person and is expressed in who we are and what we do, even when no one else sees. The virtues that form the basis of moral character are developed and learned throughout life from family nurturing and relationships with others. For some, these virtues are developed through faith and education, specifically the process of socialization into the values of the profession.

Although the ANA Code of Ethics does not support one specific ethical theory, virtue ethics provide some perspective on the relationship between the individual nurse’s values and those of the organization and employer. The ancient Greek philosopher Aristotle described the theory of virtue ethics as habits, which are learned, providing the core of who we are as persons, in essence our moral character. In virtue ethics, moral character is learned or habituated and should not be confused with “personality traits.” At the core of character is the concept of integrity. Leaders are expected to have personal and professional integrity and to exhibit behavior that is congruent with stated beliefs, or, in other words, leading by their own example, role modeling, or “walking the talk.” One particularly effective way to communicate personal and professional virtue and values is through modeling them in one’s behavior. When managers or colleagues recognize the contributions of a coworker by offering words of encouragement or listening to the opinions of others in a nonjudgmental way, they are demonstrating their value of respect for persons. In creating and managing an ethical work environment, organizational leaders serve to promote the personal and professional integrity of the employees by supporting a moral milieu that fosters these values and virtues.

Professional nurses make decisions that significantly affect the lives of others on a daily basis. Just as personal ethics occur within the context of relationships with others, professional ethics occurs within the context of relationships with whom one works (Gini, 2003). Although one may know the right thing to do, the context of the decision often puts nurses in ethically difficult situations. When there is a conflict between what is best for the patient versus the requirements and demands of the institution, the physician, and/or one’s own self-interest, one’s professional and personal integrity can be tested. Ethical behavior may require nurses to have the courage to confront their colleagues when they behaving inappropriately or in an unsafe manner. By expressing the values that underlie the profession of nursing and its practice, the Code of Ethics serves as a framework to guide nurses in their everyday practice.

Watson, in her Ethics of Caring, bases the Theory of Human Science and Human Care on ten carative factors. Watson refers to caring as the “essence of nursing
practice,” and as a “moral ideal rather than a task-oriented behavior” (Neil, 2002; p. 147). Caring is considered one of nursing’s core values. As such, one must demonstrate caring in several spheres of practice, to include caring for patients, colleagues, ourselves, and the organization or employer. In Watson’s Nursing (1999) spirituality, caring, and the nature of the interpersonal relationships nurses have with their patients are recognized as key to healing and healthy behaviors. Acting with respect, caring, and compassion applies not only to one’s interactions with patients and families, but also to colleagues, co-workers, assistants, students, and others. Thus, within the context of this interpretive statement, caring is both a value and an excellence. (Within a duty-based or principle-based ethics, caring can also be considered to be a duty.)

In the context of the current healthcare environment, healthcare professionals must balance their values related to caring for patients and serving as their advocates, within the business policies of their work setting. Achieving this balance can sometimes create tension. Some work settings obstruct maintenance of nursing values, some challenge them and demand compromise. How far that compromise might go is important; compromise should ideally be integrity preserving. The tension between professional and work setting values may raise the question of whether nurses can continue to practice as morally good agents in situations where cost-constraints restrict care and staffing. Cost-cutting measures may lead to a lack of sufficient numbers of qualified and available professional nurses.

Nurses have traditionally faced situations of competing values, loyalties, and obligations within the workplace, with conflict occurring amongst these on a daily basis. In order to meet the needs of both the patient and the healthcare worker, a collaborative and supportive work environment is essential. Numerous articles have been published and studies conducted to identify the characteristics of healthy work environments. Characteristics of healthy work environments include effective leadership, interpersonal relationships and communication, as well as collaborative practice relationships among nurses and physicians (AACN, 2005). The manner in which one interacts with and relates to others, as well as the day-to-day ethical challenges and crisis-focused life and death issues, are the issues that can shape the ethical environment of the workplace. Several professional organizations and agencies, including the American Nurses Association, the Institute of Medicine, the American Association of Critical Care Nurses, and the American Organization of Nurse Executives, have identified the importance of creating a healthy and positive work environment. The American Nurses Credentialing Center (ANCC) Magnet Recognition Program gives recognition to organizations that demonstrate outstanding quality in nursing practice and provides a framework for creating cultures of excellence. The ANA Bill of Rights for
Registered Nurses was developed as a policy statement with specific attention to the workplace environment (ANA, 2001).

In corroboration of the expectations of the Code of Ethics, The Bill of Rights for Registered Nurses emphasizes nurses’ rights to:

In seeking out and choosing a place of employment, nurses should become familiar with the values and culture of the institution in which they seek to work. Just as individuals have their own values and principles on which to base behavior and decisions, organizations also have statements of values and a mission for which they exist. The nurse may review the organization’s mission statement, organizational values, and goals when considering employment. Another way to assess the organizational culture of a company is to obtain information through talking with staff, leaders, managers, and other key players in order to obtain an impression of what type of person fits in at this organization. The way an organization’s leaders treat their staff is an indicator of the organizational culture. When staff feel they are treated fairly and with respect, they translate this onto the way they treat their patients. The importance of the work environment in influencing nurses’ work and patient outcomes is reflected in the concepts of organizational fit and organizational culture, mission, values, and goals. As members of a healthcare institution, nurses are expected to promote and support the organization’s mission and goals. As is the case with individuals, institutions do not always live up to their stated values. It is not always possible to ascertain an institution’s level of congruence with its public statements of values in advance of accepting a position.

When nurses find themselves in an environment in which they perceive a conflict between their personal and professional values and those of the institution, they first need to assess the source of that conflict. When an institution has a value
structure that does not match that of the nurse, it might be better to seek employment elsewhere. However, when a situation arises because of an institutional failing to live up to its stated values, such as promising “high-quality patient care,” but regularly suffers from nurse understaffing, that creates a conflict with the values of the profession that the nurse has an obligation to attempt to correct. Where nurses works in a subpar environment and have made attempts to change it, then other avenues should be pursued depending upon the gravity of the situation.