Monday September 16th 2019

Teaching ethics and the Code: Nurse educators weigh in

A wide range of ethical questions emerge in the bioethics class that Connie Ulrich, PhD, RN, FAAN, an associate professor of bioethics and nursing at the University of Pennsylvania Schools of Nursing and Medicine, teaches to second-degree nursing students. Questions like: How do you determine which patient should receive an organ transplant; how do you respond to patients who want a diagnosis when family members object; what is your professional and moral obligation to care for patients with Ebola; and what do you do if a patient asks you to assist with suicide?

“In the past, my students told me they felt there was a gap between what I might be teaching them from an idealistic perspective and what they were actually seeing in their clinical practice,” observed Ulrich, a Maryland Nurses Association member who teaches by case studies and uses ANA’s Code of Ethics for Nurses with Interpretive Statements to identify how nurses might respond to the ethical issues being discussed. “So I’m hopeful that this updated version, which is very thoughtful and substantive with respect to a variety of issues that nurses face today, will decrease the gap and serve as a clear guideline that can help them in the workplace.”

The Code provides educators with new opportunities

Connie Ulric

With the release of ANA’s revised Code in January, nurses have an important resource to help them navigate the ethical dilemmas that arise in an increasingly complex world of health care. But nurses must know the Code to use it, and nurse educators are on the front line in this effort.

“The first step is really making sure the Code is addressed in all undergraduate and graduate nursing programs, which is not always the case,” said Catherine Robichaux, PhD, RN, CNS, Alumnus CCRN, adjunct professor and guest lecturer at the University of Texas Health Science Center in San Antonio and faculty advisor for nursing ethics and Magnet® projects at its affiliated hospital. She also serves as an adjunct professor at the University of Mary in Bismarck, ND, and is a thesis chair for several students.

College and university schools of nursing vary in their approach to teaching ethics and the Code. Some have freestanding ethics courses that, depending on the instructor, may or may not address the Code at length. Others have made the decision to integrate ethics into other coursework. “In this case it’s left up to the individual instructor who may or may not be familiar with the Code,” said Robichaux, a Texas Nurses Association member who served on ANA’s steering committee to revise the Code. “So its importance to nurses may be diluted.”

Catherine Robichau

Nurse educators believe the publication of the 2015 Code provides them with an important opportunity to examine how the ethical foundation of nursing is included in curricula at all levels of nursing instruction and to ensure that nurse educators be well-versed in disseminating the Code and imbedding it into their coursework. And there is tremendous support for this approach.

In August 2014, a team of national nurse leaders gathered at Johns Hopkins University in Baltimore, MD, to discuss how best to create a health care culture in the United States that more strongly supports basic ethics principles and more effectively enables nurses to practice more ethically. A report from this first National Nursing Ethics Summit, A Blueprint for 21st Century Nursing Ethics, calls for reforms in the extent of ethics content, methods of teaching and enhanced capacities of faculty to teach ethics.

Cynda Hylton Rushto

“The 2015 Code is an integral part of this process,” said summit convener and co-chair Cynda Hylton Rushton, PhD, RN, FAAN, who is the Bunting Professor of Clinical Ethics and Nursing at the Johns Hopkins University Berman Institute of Bioethics and School of Nursing and a Maryland Nurses Association member. “Given the importance of competence in ethical practices, it offers educators new possibilities for making ethics real in everyday nursing practice.”

Nursing ethics education has always been aimed at promoting ethical, high quality care in nursing, and nurse educators agree that the 2015 Code will enhance their ability to achieve this goal.

According to Robichaux, there is greater clarity in the wording of the new Code to help nurses understand their ethical standards and obligations. “It provides guidance to nurses about their primary responsibility to the safety and well-being of their patients, which, in terms of their personal lives, means they should be vaccinated against the measles and the flu.”

The same applies to issues of fatigue, she said, which was the focus of an ANA professional issues panel in 2014. “Nurses will say they want to make a good living, they want to go back to school and they want to work nights,” Robichaux said. “But then they find themselves fighting fatigue, and the Code makes it very clear where their responsibility lies.”

Karen Zanni

Another steering committee member, Karen Zanni, MSN, RN, FNP-BC, an assistant professor in the School of Nursing at SUNY Empire State College in Saratoga Springs, NY, believes the 2015 Code is very strong in terms of acknowledging the changing times for nurses. “Take the issue of patient confidentiality and privacy,” she said. “This is always one of the biggest conversations that takes place in an ethics course. But these issues may rise to the top today because of all the different avenues for sharing information that exist.”

So in drafting the updated document, Zanni explained, the committee tried to include things that are part of nurses’ lives today and can create ethical issues in terms of patient privacy and confidentiality, including the use of social media and mobile devices. “It’s because of this focus that I believe the revised Code will be more hands-on and user-friendly for today’s nurse.”

Ethics and the Code in the curriculum

It’s still too early to say how the revisions to the Code may impact how ethics is taught going forward. But with the growing awareness that nurses need exactly this kind of hands-on tool to cope with the ethical dilemmas that dominate the modern workplace, nurse educators ponder how best to teach ethics and the Code to their students.

“This is something we have really struggled with,” Ulrich said. “I think it depends on the college or school of nursing and what they prioritize and value. We are fortunate here at the University of Pennsylvania to have a stand-alone ethics course at the school of nursing which is very valued and important. But I think it really depends on whether or not an institution has the faculty who have been trained in ethics and who are able to teach it.”

Zanni added, “I don’t think we want to push it into one particular area. I think we want to make it a foundational component of nursing and weave it throughout the curriculum because nurses face ethical dilemmas in genetics, pharmacology, research, community health and all areas that we teach.”

At the University of Texas at San Antonio, where Robichaux teaches, they have integrated the discussion of ethics and the Code within various courses. But she is also in favor of having a separate ethics class at all levels. Without it, she said, “nurses come out into practice like deer in the headlights. They don’t really know how to even identify an ethical issue and where to go with it to clarify their thinking.”

On March 12, ANA President Cipriano presented highlights of the revised Code of Ethics for Nurses with Interpretive Statements at an event at the University of Minnesota School of Nursing, cohosted with the Minnesota Organization of Registered Nurses.

Educating the educators

Going forward, a priority made clear in the recommendations from the Nursing Ethics Summit is the need to build capacity in teaching ethics among faculty. “Many faculty who are teaching ethics have no formal training in the subject,” Rushton said. “It is an unprecedented opportunity for organizations, such as the National League for Nursing and the American Association of Colleges of Nursing, and nurse ethicists to address this gap.”

In the meantime, said Robichaux, nurse educators, whether they work in a formal institution, hospital or other facility, must be made aware that they have a responsibility to seek out opportunities to learn and become familiar with the Code. “I think this should be acknowledged as something that’s very important to do and not just a side piece that is nice to do,” Robichaux said.

— Mary Davis is a professional writer.

ANA resources

Code of Ethics for Nurses with Interpretive Statements
ANA provides resources to help all nurses learn more about the revised Code of Ethics for Nurses with Interpretive Statements and how to apply it to their practices. For more information, go to

Nursing ethics for the 21st century

In August 2014, ANA participated as a strategic partner with 50 nursing leaders who came together in Baltimore for a summit on Nursing Ethics for the 21st Century. The group set an ambitious agenda that could culminate in changing the nation’s health care culture so that it more strongly supports basic ethics principles and more effectively enables nurses to practice more ethically. That long-term process starts with changing work environments for nurses across the board. In November 2014, the ANA Board of Directors endorsed the summit’s vision.

Read the group’s report, A Blueprint for 21st Century Nursing Ethics: Report of the National Nursing Summit, at

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