From the beginning of professional nursing in the 1870s in the United States, after the Civil War when nurses served in military hospitals, nursing care was limited only to those sick or injured individuals who were usually cared for in homes through “private duty nursing.” The nurse was customarily employed by the family, through a “registry,” at the request of a physician. Often the physician would request a specific nurse for one of “his patients.” In this relationship, there were four potentially competing ethical loyalties: patient, registry, physician, self.

Later, both patient care and nursing moved into hospitals. Nurses continued to be employed as private duty nurses, even within hospitals, until World War II, after which nurses predominantly became employees of the hospital rather than the patient or patient’s family. Now the nurse faced loyalties to an institution instead of a registry, a physician whom the nurse may or may not have known, the patient, and self. In the days of registries and, subsequently, in hospitals, nurses could be blackballed, sometimes solely at the request of a physician, sometimes for reasons unrelated to practice. This heightened to need for nurses to be “loyal” to the physician. It has only been in recent years that a physician could not march into a nursing administration office and demand the firing of a particular nurse. Such power placed nurses in a terrible position—not only did the nurse have to “obey” and not oppose a physician, but the nurse also had to “please” the physician with a proper attitude of deference. Loyalty to the patient could be jeopardized where nurses believed their livelihood to be at stake. In addition, nurses were expected to serve, sometimes without remuneration, placing yet another strain on the nurse’s loyalty to the patient. And yet, nursing, in its literature and its practice consistently articulated a primary commitment to the patient. After the 1950s, health care, or more specifically, illness care, has become far more complex than in the days of the inception of modern nursing in the United States in the 1870s. Nursing has moved out of diploma programs and into colleges and universities, and uniform mandatory registration and licensure has been instituted across the nation.

Both medicine and nursing have developed specialties and subspecialties, so the patients (and the nurses) now deal with a battalion of physicians in each case. Third party payors have entered into the mix, including both insurance companies and government agencies. Unionization and collective bargaining on behalf of nurses has increased. Accrediting bodies, both for institutions and for professions, have also become a part of the system. Many formerly independent hospitals have either gone out of business or coalesced into multihospitals and multiagency megacompanies. Restrictions may now be placed on care for economic rather than clinical reasons. And, importantly, there has been a rise in technological interventions available and both rising costs and access to care has become a problem for many. Increasingly, “competition” between ethical “loyalties” for nurses have become ever more robust and complex. In addition, though illness care remains the focus of the “healthcare system,” there is an awareness of the importance of preventive care.

Preventive care was not greatly valued until an understanding of disease etiology came about in the 1870s and 1980s when Robert Koch and Louie Pasteur worked out the germ theory. Florence Nightingale, who was at Scutari and the Crimea in 1854, had no scientific knowledge of the germ theory, nor did she support the idea later, yet she was among the first to value prevention and to see the benefit of keeping people out of hospitals, which were often defined then as death houses. Before she became the famous “Lady with the Lamp,” she had become convinced that improved public health measures were the royal road to making Britain a healthier nation, and became known in London social circles for her panoramic expertise in this field. Her much read Notes on Nursing (Nightingale, 1860) and her reorganization of the military health system reflected this knowledge and her value of disease prevention. Her vision enlarged the definition of the patient role and redefined the nursing role.

Once modern public health systems were established in the United Kingdom and the United States, the roles and functions of nurses expanded to include not only the sick, but the well; and not only individuals, but groups of people; with emphasis on cleanliness, vaccination, and prenatal and well-baby care. Though the nurse’s role had expanded, the professional and ethical emphasis continued to be on the “patient,” who might now be a family unit, a group, a community, or an individual.

In her book, Nursing Ethics, the American nurse Isabel Hampton Robb wrote:

These words demonstrate the central place of all patients, with unique and individual attributes, in nursing and nursing ethics.

In each ANA Code since the first one in 1950, the patient, whether individual, family, group, or community, has been at the center of the nursing profession’s ethics. That is still the case today, but life in general, nursing practice in particular, and the structure of the healthcare system, have become far more complex and the new ANA Code reflects these changes.

Though it has been the case that, throughout modern nursing in the United States, nurses have been morally obligated to put the patient first, the previous versions of the Code commingled this obligation with others. The Task Force for the Revision of the Code felt strongly that the primacy of the patient was of sufficient importance, historicity, and priority that it necessitated an emphatic and unequivocal statement in the provisions. Thus, the previous Provision 2 was bumped to third place and the duty to the patient placed second.

Historically, nurses had ethical obligations that placed emphasis on attending to the patients’ needs, and yet the context of nursing was not necessarily supportive of this obligation. Today, the nurse’s ethical obligation to the patient, first, is even more complex to negotiate. Our present day ethics has moved from a fairly recent physician-oriented, paternalistic model in which physicians, using the ethical principle of nonmaleficence or “do no harm,” knew what was “best for the patient.” As nursing expanded its educational offerings, developed specialized practice areas, escalated its research, and even developed forms of independent practice, nurses generally moved into the realm of independent nursing functions while retaining the so-called dependent functions of carrying out medical orders. In recognizing its own right to participate in decision making and formulate plans of patient care, nursing moved to ethics that recognized patient’s rights, including the right to know and discuss their health status and make healthcare decisions. Simultaneously, nurses began coming to a greater awareness of “nursing rights,” particularly as they related to the delivery of high-quality health care. This changed ethics
model functions in the midst of increased clinical complexities that include economic constraints and managed care environments. This does not mean that nurses see patients (or themselves) as sidelined by events and priorities, but it does mean that nurses must learn to deal with economic pressures that may compete with moral values or with patients’ rights. The patients and their rights must remain central. At the same time, ethical obligation to the patient is primary, but it is not the sole ethical obligation.

In this latest edition of the Code, Provision 5 has been added with the potential of creating additional ethical conflicts between the needs and rights of the patient and the nurse as it describes a nurse’s duty to self. The function of duties to self is not some sort of entitlement; it is care for the self in such as way as to enable nurses to fulfill other moral duties. At times, nurses have, wrongly, placed their own needs before those of the patient in situations as simple as failing to confront a physician colleague who is indifferent or worse to the needs of the patient. Such situations, and others like it, that present the nurse with possible conflicting obligations raise several questions. First, does the nurse’s primary obligation always mean a focus on the patient, as has historically been the case, even to the harm of the nurse? A “no” answer to this would require a strong ethical argument to support it. There may be an exception to this primary commitment, but a nurse would have to think long and hard about the ethical reason to act on this exception. Importantly, even in situations of conflicting moral claims, where the nurse must act in a morally self-regarding manner, the nurse must never abandon the patient. This means that if one nurse cannot, on ethical grounds, engage in some treatment, activity, or procedure, then another nurse or caregiver must be found who does not object to such involvement.