The Ethics of Caring


This independent study has been developed for nurses to better understand about ethical decision making including Ohio Nursing law and rules.

1.86 contact hour of Category A (Law and Rules) will be awarded for successful completion of this independent study.

**Author’s Note:  The situations and ethical questions contained in this learning activity are presented only to make the reader think about potential ethical issues commonly found in today’s health care arena.  The views presented are not necessarily reflective of any position of the Ohio Nurses Association or the author.  Situations, points of view and questions are posed for the sake of argument and to assist the learner in assimilating the information contained within the learning activity.  This learning activity will not provide any answers, because in the area of ethics, especially healthcare ethics, there are no right answers, only more questions.  The goal of this learning activity is to provide the nurse with tools to help the patient ferret out the questions that hopefully assist the patient in voicing their opinion of what they want done with respect to their own lives and healthcare and to inform the nurse of the laws within which such decision must be made.

The Ohio Nurses Association (OBN-001-91) is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

Expires 1/2018


1. Please read the below article carefully.

2. Complete the post-test, evaluation form and the registration form.

The post-test will be reviewed. If a score of 70 percent or better is achieved, a certificate will be sent to you. If a score of 70 percent is not achieved, a letter of notification of the final score and a second post-test will be sent to you. We recommend that this independent study be reviewed prior to taking the second post-test. If a score of 70 percent is achieved on the second post-test, a certificate will be issued.

If you have any questions, please feel free to call Sandy Swearingen, 614-448-1030, Ohio Nurses Association at (614) 237-5414.

OUTCOME: The nurse will apply their knowledge when dealing with ethical dilemmas in their nursing practice.

About the Author

R. Wynne Simpkins has been in nursing for 32 years, having worked as a nurse aide and an RN.  Wynne has worked in a variety of positions in both acute are and long term care.  Upon completion of her Master’s Degree in nursing at Wright State University in 1992, Wynne began as a staff member at the Ohio Board of Nursing and remained there for 10 years.  In 2003 Wynne began a new phase of her career as she became the Executive Director for the Licensed Practical Nurse Association of Ohio, Inc.  At present, Wynne works as an independent consultant, writing and presenting programs for continuing education.

The author and planners have no conflict of interest.

Disclaimer: Information in this study is intended for educational purposes only. It is not intended to provide legal and/or medical advice or to be a comprehensive compendium of evidence-based practice. For specific implementation information, please contact an appropriate professional, organization, legal source, or facility policy.


“Give me your tired, your poor,
Your huddled masses yearning to breathe free,
The wretched refuse of your teeming shore,
Send these, the homeless, tempest-tost to me,
I lift my lamp beside the golden door!”

The above excerpt is likely familiar to you, if you were born and educated in the United States.  It was taken from a poem, The New Colossus, written by Emma Lazarus, in 1883 and placed on the bronze plaque that has been held by Lady Liberty (Statue of Liberty) since 1903 (JWA, 2007).  These words symbolize, to most Americans, what it means to be an American, taking into account that we were all from a foreign land at one time, as there are relatively few of us who may lay claim to being Native Americans (US Census Bureau, 2010).  These words also allow us to understand how, as one country, we can be a land of diverse cultures, values, and religions: all of which make it difficult to define an ethical framework from which nurses are expected to function.  The ethical challenges faced by nurses are multifaceted just like the culture in which we live and work.

Anyone with a computer or internet compatible device may access the demographic data for any state, county or city in the United States through the US Census Bureau’s home page at 2010 Census Interactive Population Search ( to view the general make up of a population.  Included in the census data is information regarding age, income levels, and ethnicity.  Alternately, take a trip to the local shopping mall or airport and notice the people milling about.  Notice not only the differences in age, skin color, or hair color, but how each group or individual is dressed and the language that is being spoken.  Notice also the family units represented: how the children are treated, placement of the adults in the group in relationship to the children.  All of these differences are a part of the various cultures so common to the United States.

Now how do such differences or likenesses affect ethical behavior and decision making?  Nurses, like the populations of people we are to care for, originate from a variety of backgrounds.  We too have a rich heritage complete with cultural and religious differences.  Inherent in our cultural and religious differences are differences in value systems.  Something as seemingly inconsequential as a male nurse caring for a female patient may be viewed as offensive by some cultures (Stoller, 2007).  Yet, with the current make up of the nursing population, the patient may not have a choice of caregivers.  The 2013 RN Workforce Data Summary Report indicates that the make-up of the RN workforce in Ohio consists primarily of English speaking Caucasian females between the ages of 51 and 60, who are educated at the Associate Degree level. Still, 8 percent (approximately 13,000) of RNs in Ohio are men and roughly 10 percent are from ethnic backgrounds other than Caucasian (African American, American Indian, Hispanic, etc.).  All nurses licensed to practice in Ohio are bound by rules established by the Ohio Board of Nursing and as found in Rule 4723-4-06 (J) of the Ohio Administrative Code (OAC) to “Treat each client with courtesy, respect, and with full recognition of dignity and individuality,” regardless of age, sex, skin color, socioeconomic status, insurance coverage, or cultural, religious, or ethnic background.  Values and morals together help to form the ethical framework from which we must work as nurses (Aiken, 2004).  Given the diversity within the ranks of the profession called nursing, it is extremely important that each nurse form an ethical framework early in his/her career to enable the nurse to move through his/her practice on a daily basis and do what is in the best interest of the patient/client (Ludwick, & Silva, 2003).

Definition of terms

Autonomy-The right to choose one’s own health care. This is a highly valued concept in the United States.

Values-Concepts that give meaning to an individual’s life and serve as the framework for making decisions.

Morals-Fundamental standards of right and wrong that an individual internalizes.

Laws-Rules of societal conduct devised by people to protect society.

Ethics-Declaration of what is right and wrong; systems of valued behaviors and beliefs.

(Aiken, 2004)

As defined by the American Heritage Dictionary (2005), ethics is a set of principles of right conduct.  Generally presented as a system of value based beliefs and behaviors, ethics serve to govern the conduct of individuals, or in our case, nurses, to ensure that the rights of our patients/clients are protected (Aiken, 2004).  Synonyms for ethics include morality, righteousness, and rightness (Roget’s Thesaurus, 2003).  “A code of ethics is a written list of professional values and standards of conduct which provide a framework for decision making by the members of the profession on a day-to-day basis” (Aiken, 2004. P. 100).

Florence Nightingale Pledge

This modified “Hippocratic Oath” was composed in 1893 by Mrs. Lystra E. Gretter and a Committee for the FarrandTraining School for Nurses, Detroit, Michigan. It was called the Florence Nightingale Pledge as a token of esteem for the founder of modern nursing.

I solemnly pledge myself before God and in the presence of this assembly, to pass my life in purity and to practice my profession faithfully. I will abstain from whatever is deleterious and mischievous, and will not take or knowingly administer any harmful drug. I will do all in my power to maintain and elevate the standard of my profession, and will hold in confidence all personal matters committed to my keeping and all family affairs coming to my knowledge in the practice of my calling. With loyalty will I endeavor to aid the physician in his work, and devote myself to the welfare of those committed to my care. ( 2014)

The Florence Nightingale Pledge (insert) is taken by many nurses as they graduate from their respective pre-licensure nursing education programs.  The oath symbolizes the embodiment of what all nurses strive to do, serve patients.  Remnants of this oath may be found in the ANA Code of Ethics For Nurses (Table 1) and in the Ohio Standards of Practice found in Chapter 4723-4 OAC (Highlights, p. 3).  Together, these documents serve to guide the nurse in Ohio through the process of ethical decision making on a daily basis.  For example, the phrase from the Florence Nightingale Pledge, “…will hold in confidence all personal matters committed to my keeping and all family affairs coming to my knowledge in the practice of my calling” is reflected in Chapter 4723-4 OAC in that the nurse is to “provide privacy.”

Nurses are generally considered by the American public to be ethical individuals.  Just ask your neighbor which profession they consider to be the most ethical.  In response to the question, “Please tell me how you would rate the honesty and ethical standards of people in these different fields—very high, high, low, or very low?” as asked by the Gallup Poll News Service in December 2013, 82% of respondents ranked nurses as high or very high.  Since 2002, nurses have been ranked high to very high by 79% or more of those responding to this same question (Gallup Poll, December 2013).  Nurses do have an obligation to know right from wrong and to deliver the nursing care that meets established legal and ethical standards.  As nurses have become more autonomous in their respective practices, with practice moving out of institutional settings and into the community and home based settings, the nurse must remain ever vigilant of his/her ethical responsibilities to the patient/client (CNA, 2008).

Nurses care for a variety of individuals often considered to be a part of a vulnerable population.  A vulnerable population is generally considered to be anyone who is physically or mentally disabled, limited or non-English speaking, geographically or culturally isolated, chemically-addicted or dependent, seriously or chronically ill, homeless, frail or elderly, and children. Individuals who are part of a vulnerable population are considered to be at a disadvantage in that it is difficult if not impossible for these individuals to act to protect their own health care interests (AMA, 2014) and (Anderson, Ahrens, and Marny, March 2007).  Now take that same vulnerable population and place them in a situation of being acutely ill.  Illness in any individual invokes a range of emotions including anxiety, fear, powerlessness and vulnerability (Armstrong, 2006).

An ethical dilemma is a situation that requires that a choice be made between two different sets of values.  Each value may be credible for each person, i.e. religious values, cultural beliefs, etc. which are equally valued, just different.  An ethical dilemma generally has aspects of conflicts between one individual’s rights and those of another, between one individual’s obligations and the rights of another, or any other possible combination of obligations and rights which conflict.  A potential ethical situation exists every time a nurse interacts with a patient in a health care setting.  It is up to the nurse to reduce an ethical dilemma to its elemental aspects then move on through a problem solving process to accomplish what is in the best interest of the patient/client (Aiken, 2004).


Chapter 4723-4 OAC (Highlights)

Standards of Practice Relative to a Registered Nurse or Licensed Practical Nurse

  • Promotion of client safety: The licensed nurse shall:

–  Display appropriate title or initials to identify the nurse’s relevant licensure level at all times when providing direct nursing care to a patient;

–  At all times when a nurse is involved in nursing practice through any form of telecommunication, the nurse shall identify to each patient, or health care provider on behalf of the patient, the nurse’s title or initials to identify the nurse’s relevant licensure level;

–  Delegate a nursing task, including medication administration, only in accordance with in Chapter 4723-13, Chapter 4723-23, Chapter 4723-26, or Chapter 4723-27 OAC;

–  Completely, accurately and timely report and document nursing assessments or observations, care provided and the patient’s response to the care;

–  Accurately and timely report to the appropriate practitioner errors in or deviations from the current, valid order;

–  Not falsify any patient record or any other document prepared or utilized in the course of, or in conjunction with, nursing practice;

–  Implement measures to promote a safe environment for each patient;

–  Delineate, establish, and maintain professional boundaries with each patient;

–  Provide privacy during examination or treatment in the care of personal or bodily needs;

–  Treat each patient with courtesy, respect, and with full recognition of dignity and individuality;

  • NO Licensed Nurse Shall:

–  Engage in behavior that causes or may cause physical, verbal, mental or emotional abuse to a patient;

–  Engage in behavior toward a patient that may be reasonably interpreted as physical, verbal, mental or emotional abuse;

–  Misappropriate a patient’s property;

–  Engage in behavior to seek or obtain personal gain at the patient’s expense;

–  Engage in behavior toward a patient that may be reasonably interpreted as behavior to seek or obtain personal gain at the patient’s expense;

–  Engage in behavior that constitutes inappropriate involvement in the patient’s personal relationships or financial matters;

–  Engage in behavior toward a patient that may be reasonably interpreted as behavior that constitutes inappropriate involvement in the patient’s personal relationships or financial matters;

–  Engage in sexual conduct with a patient;

–  Engage in conduct in the course of practice that may be reasonably interpreted as sexual;

–  Engage in any verbal behavior that is seductive or sexually demeaning to a patient;

–  Engage in verbal behavior that may reasonably be interpreted as seductive, or sexually demeaning to a patient;

–  Use social media, texting, emailing, or other forms of communication with, or about a patient, for non-health care purposes or for purposes other than fulfilling the nurse’s assigned job responsibilities.

Excerpted from Chapter 4723-4 OAC, 2014

Organizational ethics is a key principle to be observed in any organization. In recent years, say over the past 20 plus years, health care has experienced multiple changes. We have seen increasing costs in the delivery of health care, increasing use of technology, competitive markets, and a globalization of the economy, all of which have resulted in conflicts that affect the ethical environment of a health care organization (Wlody, 2007). The overall effect on the nursing staff may be that the nurse finds that changes which have occurred in the organization may be inconsistent with his/her own personal value system. It is important for the nurse to recognize such differences and make acceptable changes that will permit the patient/client to receive the care he/she needs/desires even if that means transferring the patient/client to the care of another nurse (Canadian Nurses Association, 2008).

The nurse and the law
“Laws are rules made by people to guide society and regulate human beings” (Aiken, 2004, p. 98). The law that governs nurses in the state of Ohio, Section 4723 of the Ohio Revised Code (ORC), is frequently referred to as the Ohio Nurse Practice Act (NPA). These laws were formulated by legislators, people elected by the constituents they serve and who are charged with protecting society. The goal of the NPA is to protect the citizens in the state of Ohio who are consumers of healthcare; the patients cared for by nurses. While nothing in the current NPA or the Rules Promulgated from the Law (aka, OAC) specifically state that nurses are bound by the law to behave ethically, one may imply that nurses are to behave ethically from information contained in both the NPA and the Rules found in Chapter 4723-4 OAC, Standards of Practice Relative to a Registered Nurse or Licensed Practical Nurse (See insert). If the learner accepts that, as previously mentioned, “A code of ethics is a written list of professional values and standards of conduct” (Aiken, 2004), then the Ohio NPA and the rules emanating from it, may be viewed as one code of ethics.

Historically, ethics has been an integral part of nursing practice, yet attempts to define ethics have focused on medical ethics (See definition from the American Heritage Dictionary) or on the virtues of the nurses themselves (McHale & Gallagher, 2003). The Ohio Board of Nursing has carefully delineated specific behaviors on the part of the licensed nurse that are expected and behaviors that are never expected to occur between a nurse and client (see insert). Nurses are bound by the law and subsequent rules (OAC) to protect the safety of the client and to avoid behaviors that are considered socially unacceptable in a professional relationship; i.e, engaging in behavior that constitutes inappropriate involvement in the client’s personal relationships (Chapter 4723-4 OAC).

Specifically, the following excerpts from Chapter 4723-4 OAC may be considered components of ethical behavior even though the word “ethics” is not used. The nurse must:

– Accurately and timely report to the appropriate practitioner errors in or deviations from the current, valid order;
– Not falsify any client record or any other document prepared or utilized in the course of, or in conjunction with, nursing practice;
– Implement measures to promote a safe environment;
– Delineate, establish, and maintain professional boundaries with each client;
– Provide privacy during examination or treatment in the care of personal or bodily needs;
– Treat each client with courtesy, respect, and with full recognition of dignity and individuality;
– Do Not Use social media,…forms of communication with, or about a patient, for non-health care purposes or for purposes other than fulfilling the nurse’s assigned job responsibilities.

For the full text of Chapter 4723-4, the learner is directed to the Board of Nursing’s web site at

Codes of Ethics

Nurses are educated to care for the physical and emotional issues faced by their patients/clients.  Codes of ethics are established as general guides to practice.  For a nurse to practice ethically, he/she must be knowledgeable about the physical, emotional, and ethical issues faced by the patient/client.  Nursing practice involves both legal and ethical dimensions. Nurses are responsible for their own practice and as such are expected to practice ethically (CNA, 2008).  Every day highly qualified nurses are faced with ethical dilemmas and are called upon to make ethical decisions.  Ideally, the nurse has access to an internal ethics committee in his/her respective health care facility.  Frequently, situations occur that need to be addressed readily by the nurse rather than reviewed by the facility’s ethics committee.

In a study reported on the Nursing Ethics Network, currently employed nurses practicing in 6 New England states were asked to identify the ethical issues they face and the frequency with which the nurses face ethical issues.  Protection of patient’s rights and respecting/not respecting informed consent were among the most frequently experienced ethical issues faced by nurses.  The ethical issue found to be most disturbing to nurses was that staffing patterns limited patient access to nursing care.  Of those surveyed, 30% reported facing such ethical issues in their clinical practices 1-4 times per week (Fry, Luce, & Riley, 2007).

One role of the nurse is that of patient advocate.  Nurses are expected to advocate for the interests of people for whom the nurse provides nursing care, while exercising respect and kindness for the individual regardless of diagnosis, skin color, ethnic origin, or economic status (Lachman, 2009). To help nurses face ethical dilemmas, the American Nurses Association developed a code of ethics for nurses (Table 1).  Please note that ANA has echoed the concept of the nurse as advocate in Provision 3 of the ANA Code of Ethics, “The nurse promotes, advocates for, and strives to protect the health, safety and rights of the patient” (ANA, 2015).

Table 1.  ANA Code of Ethics for Nurses (2001)

Provision 1 The nurse, practices with compassion and respect for the inherent dignity, worth and unique attributes of every person.
Provision 2 The nurse’s primary commitment is to the patient, whether an individual, family, group, community, or population.
Provision 3 The nurse promotes, advocates for, and protects the rights, health, and safety of the patient.
Provision 4 The nurse has authority, accountability, and responsibility for nursing practice; makes decisions and takes actions consistent with the obligation to promote health and provide optimal care.
Provision 5 The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth.
Provision 6 The nurse through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care.
Provision 7 The nurse in all roles and settings, advances the profession through research and scholarly inquiry, professional standards of development, and the generation of both nursing and health policy.
Provision 8 The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities.
Provision 9 The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy.

Excerpted from the ANA Code of Ethics for Nurses with Interpretative Statements, 2015

Similarly, the Canadian Nurses Association  and the International Council of Nurses, based in Geneva, Switzerland, (2012) have developed their own respective codes of ethics (See Table 2 for the International Council of Nurses Code of Ethics for Nurses).  Given our global society and the mobility of many nurses, it is in the best interest of the nurse and the clients for whom the nurse is caring, to become familiar with at least one of these codes of ethics.  Nurses in the United States tend to use the ANA Code of Ethics for Nurses (Table 1) as the accepted standard (Aiken, 2004).

Table 2  The International  Council of Nurses Code of Ethics for Nurses (2012)
  • The nurse’s primary professional responsibility is to people requiring nursing care.
  • In providing care, the nurse promotes an environment in which the human rights, values, customs and spiritual beliefs of the individual, family and community are respected.
  • The nurse ensures that the individual receives sufficient information on which to base consent for care and related treatment.
  • The nurse holds in confidence personal information and uses judgment in sharing this information.
  • The nurse shares with society the responsibility for initiating and supporting action to meet the health and social needs of the public, in particular those of vulnerable populations.
  • The nurse advocates for equity and social justice in resource allocation, access to health care and other social and economic   services.
  • The nurse demonstrates professional values such as respectfulness, responsiveness, compassion, trustworthiness and integrity
  • The nurse carries personal responsibility and accountability for nursing practice, and for maintaining competence by continual learning.
  • The nurse maintains a standard of personal health such that the ability to provide care is not compromised.
  • The nurse uses judgment regarding individual competence when accepting and delegating responsibility.
  • The nurse at all times maintains standards of personal conduct which reflect well on the profession and enhance public confidence.
  • The nurse, in providing care, ensures that use of technology and scientific advances are compatible with the safety, dignity and rights of people.
  • The nurse strives to foster and maintain a practice culture promoting ethical behaviour and open dialogue.


  • The nurse assumes the major role in determining and implementing acceptable standards of clinical nursing practice, management, research and education.
  • The nurse is active in developing a core of research-based professional knowledge that supports evidence-based practice.
  • The nurse is active in developing and sustaining a core of professional values.
  • The nurse, acting through the professional organization, participates in creating a positive practice environment and maintaining safe, equitable social and economic working conditions.
  • The nurse practices to sustain and protect the natural environment and is aware of its consequences on health.
  • The nurse contributes to an ethical organizational environment and challenges unethical practices and settings.
  • ·The nurse sustains a co-operative relationship with co-workers in nursing and other fields.
  • ·The nurse takes appropriate action to safeguard individuals, families and communities when their health is endangered by a coworker or any other person.
  • ·The nurse takes appropriate action to support and guide co-workers to advance ethical conduct.
International Council   of Nurses, Geneva, Switzerland, 2012. Approved 2012.

The Patient Bill of Rights may also be viewed as a code of ethics, one that is designed to inform consumers what they may expect from health care. In 1997, President Clinton created the Advisory Commission on Consumer Protection and Quality in the Health Care Industry, which was charged with recommending measures to promote and assure health care quality and value and protect consumers and workers in the health care system. Out of this advisory commission was born the Patient Bill of Rights (HHS, 1999), which has since been adapted by a number of organizations. One example of a Patients’ Bill of Rights may be found in Appendix A, as adopted by the American Cancer Society.  Then in 2010, a new Patient’s Bill of Rights was created with the Affordable Care Act.  The Primary change in 2010 being that people have certain protections in dealing with insurance companies to have insurance coverage for health care expenses (American Cancer Society, 2014).  However, concepts found in the 1999 Patients’ Bill of Rights remain and are commonly shared by various other renditions adopted by various organizations. These concepts include:

  • Right to information;
  • Right to choose;
  • Right to emergency services;
  • Right to be a full partner in health care decisions;
  • Right to care without discrimination;
  • Right to privacy; and
  • Right to speedy complaint resolution (HHS, 1999).

The nurse, as patient advocate, then has an ethical responsibility to uphold the Patient’s Bill of Rights in all settings.

Ethical decision making

As nurses we have been educated to use scientific principles to guide us in providing the art known as nursing care.  We are a caring profession.  So is it any wonder then that nurses often find themselves in the middle of ethical dilemmas that leave the nurse feeling torn?  Issues related to short staffing, communication, withholding or withdrawing treatments, hydration, nutrition, sedation, etc. are often faced by nurses

By and large, the ethical decision making processes represented in this learning activity are based on the nursing process, a problem-solving process with which the learner should be familiar.  In the Aiken model, the nurse is expected to gather/collect and analyze information relevant to the ethical dilemma, then to define the dilemma at hand.  The nurse must then examine and clarify the values and moral positions represented.  It is at this point that the nurse should consult with the internal ethics committee, should that option be available.  Next, a decision must be made and carried out by the nurse.  Once the actions are completed, the nurse is then to evaluate the effects of his/her actions on the patient/client, deciding whether or not to begin the entire process again.  While each model may have slight variations, the nurse will likely find the processes similar and quite familiar.

Ethical issue #1

Now let’s say that you are an RN working on a Med-Surg Unit in an inner city hospital. When you report for your shift on the unit where you normally work, you find that you are in charge and that the unit will be short staffed by one RN and 2 Nurse Aides. An LPN who normally works this same unit 2 shifts per week has agreed to come in, leaving you only 2 people short. How will you be able to assure that the patients receive the care they need?

In making the patient care assignments, what ethical issues and principles need to be considered? (Please refer to the ANA Code of Ethics for Nurses in Table 1.

  • The primary responsibility is to the patient: How to deliver safe, competent, and ethical nursing care to all patients on the unit. Using scarce resources to provide the best care that is possible and meet patient needs by setting priorities reflective of the resources available (Lachman, 2009).
  • The nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks: The LPN has a defined scope of practice and having worked with this LPN previously, you are familiar with the knowledge, skills and abilities of this particular nurse.  Nurses must practice within their own level of competence, i.e. legal scope of practice and knowledge, skills and abilities of all staff members on the shift (OAC, 2014). 
  • The nurse collaborates with other health professionals (Lachman, 2009): Work to make the best of the situation in which the unit has been placed.  Show respect for and value the knowledge and perspectives of the other health care providers.
  • The nurse, acting through the professional organization, participates in creating and maintaining safe, equitable social and economic working conditions in nursing:  Work to make staffing better to avoid such situations in the future on behalf of all patients.  Become a part of a committee to research the staffing problem and work to find equitable solutions (ANA, 2015).

 Technology and ethics

People everywhere are “connected” to one another electronically.  Fewer and fewer of us use land lines, opting instead for the ever present and extremely convenient smart phone, of which a newer and better version is released in an almost continuous stream.  Our phones keep us connected to everything at all times.  People are now connected to the internet, Facebook, Instagram, YouTube, etc., via their personal phone.  The convenient little device that rests in most of our hands on any given day makes it all too easy to let our virtual friends in on the events of our day almost instantly.

The Ohio Board of Nursing recently revised their rules to include that nurses are to NOT “use social media, texting, emailing, or other forms of communication with, or about a patient, for non-health care purposes or for purposes other than fulfilling the nurse’s assigned job responsibilities” (OAC, 2014). Nurses are duty bound to protect the privacy and identity of our patients.

That is not to suggest that the use of such devices and media are to never to be used in healthcare.  In fact, many work situations require nurses to use technology such as computers, internet, email, and cell phones for patient care. Such use of social media can be very beneficial to health care when used to promote timely communication with patients and family members or when used in patient education (NCSBN, 2011).

Ethical issue #2

A nurse who recently re-located to a small community in South Central Ohio, obtained her Ohio nursing license by endorsement, and then found a job working for a local long term care facility near her home was so excited to be working. The long term care facility was the only health care employer in the community.  She wanted to become a part of the community in which she lived and worked, so she asked a co-worker to become her “friend” via Facebook.  The co-worker, a native of the community, obliged, but was also friends (both virtual and actual) with the nurse manager of the unit.

Following a particularly busy week at work, the nurse posted the following to her co-worker via Facebook:

“Really rough week.  Not sure about this move, if every week at work is going to be this bad.  The nurse manager is a real bear.  She must be going through “the change.”  I just can’t stand her sometimes.  Can you believe it? She gave me 3 new admits! Which meant I had to go through the whole business of doing the MDS thing as well- for each one of them!  I think she forgets I am new to this type of nursing.  Is she always like that?  Then that guy, you know the old one who was admitted with only one leg?  He came in on Tuesday. The one in the 200 hall?  Wow!  Talk about cussing like a sailor!!! I was surprised anyone without teeth could be that clear when hailing verbal expletives.

Didn’t see you around much at work. So how was your week?”

 The comments above were provided by the nurse who thought she was only posting a private communication to her friend from work. She thought only her friend could see the posting. She did not provide the name of any other person and she did not openly provide any patient diagnosis. However, this is a small community with only one health care employer. What are the chances of other who view the posting being able to discern the identity of both the nurse manager and the patient?

After having read the posting, the co-worker chose to not respond on Facebook.  Instead the co-worker called the nurse using her personal cell phone and informed the nurse that she should be more careful with her Facebook postings because they were living and working in a very small community.  The co-worker also informed the nurse that she was friends with the nurse manager and that the patient was a well-respected member of the community. The co-worker chose to remain friends with the nurse at work, but decided to block her on Facebook.

Common Myths about Social Media

  • A mistaken belief that the communication or post is private and accessible only to the intended recipient.
  • A mistaken belief that content that has been deleted from a site is no longer accessible.
  • A mistaken belief that it is harmless if private information about patients is disclosed if the communication is accessed only by the intended recipient. This is still a breach of confidentiality.
  • A mistaken belief that it is acceptable to discuss or refer to patients if they are not identified by name, but referred to by a nickname, room number, diagnosis or condition. This too is a breach of confidentiality and demonstrates disrespect for patient privacy.
  • Confusion between a patient’s right to disclose personal information about himself/herself (or a health care organization’s right to disclose otherwise protected information with a patient’s consent) and the need for health care providers to refrain from disclosing patient information without a care-related need for the disclosure.
  • The ease of posting and commonplace nature of sharing information via social media may appear to blur the line between one’s personal and professional lives. The quick, easy and efficient technology enabling use of social media reduces the amount of time it takes to post content and simultaneously, the time to consider whether the post is appropriate and the ramifications of inappropriate content. (NCSBN, 2011).

How to Avoid Social Media Issues

Because the use of social media is a growing concern, the National Council of State Boards of Nursing (NCSBN) has developed the following guidelines to help nurses reduce the risk potential when using social media.

  • First and foremost, nurses must recognize that they have an ethical and legal obligation to maintain patient privacy and confidentiality at all times.
  • Nurses are strictly prohibited from transmitting by way of any electronic media any patient-related image. In addition, nurses are restricted from transmitting any information that may be reasonably anticipated to violate patient rights to confidentiality or privacy, or otherwise degrade or embarrass the patient
  • Do not share, post or otherwise disseminate any information, including images, about a patient or information gained in the nurse-patient relationship with anyone unless there is a patient care related need to disclose the information or other legal obligation to do so.
  • Do not identify patients by name or post or publish information that may lead to the identification of a patient. Limiting access to postings through privacy settings is not sufficient to ensure privacy.
  • Do not refer to patients in a disparaging manner, even if the patient is not identified.
  • Do not take photos or videos of patients on personal devices, including cell phones. Follow employer policies for taking photographs or video of patients for treatment or other legitimate purposes using employer-provided devices.
  • Maintain professional boundaries in the use of electronic media. Like in-person relationships, the nurse has the obligation to establish, communicate and enforce professional boundaries with patients in the online environment. Use caution when having online social contact with patients or former patients. Online contact with patients or former patients blurs the distinction between a professional and personal relationship. The fact that a patient may initiate contact with the nurse does not permit the nurse to engage in a personal relationship with the patient.
  • Consult employer policies or an appropriate leader within the organization for guidance regarding work related postings.
  • Promptly report any identified breach of confidentiality or privacy.
  1. Be aware of and comply with employer policies regarding use of employer-owned computers, cameras and other electronic devices and use of personal devices in the work place.
  2. Do not make disparaging remarks about employers or co-workers. Do not make threatening, harassing, profane, obscene, sexually explicit, racially derogatory, homophobic or other offensive comments.
  3. Do not post content or otherwise speak on behalf of the employer unless authorized to do so and follow all applicable policies of the employer (NCSBN, 2011).

Advance directives

Many states have in place laws that govern the use of advance directives. Advance directives are prepared documents that contain a person’s verbal and written instructions about future medical care, in the event that the person becomes unable to speak for him or herself. For our purposes, we will focus on the laws established for Ohio.  Ohio recognizes several types of advance directives: the Living Will; Health Care Power of Attorney; Do-Not-Resuscitate; and Tissue and Organ Donation. All of these advance directives are set up to provide health care professionals with information about the types of actions the individual would wish health care professionals take should the individual not be able to speak for him/herself. The nurse should become acquainted with the advance directive laws specific to the state in which he/she is practicing. Health care professionals are bound and protected by the signed and dated document to abide by the wishes of the individual. This is one method developed to allow individuals to have autonomy when they are no longer in a position to speak for him/herself during a medical crisis.

 Living Will: This document includes the individual’s wishes regarding life sustaining treatments and donation of anatomical gifts should the individual be in a permanently unconscious state and/or be declared terminally ill and unable to communicate.  For the living will to go into effect, 2 physicians must agree that the individual is in a permanently unconscious state and/or terminally ill, and unable to communicate (Ohio Hospital Association, 2010).

Health Care Power of Attorney: This document allows the individual to appoint another individual to make health care decisions for him/her should the individual be unable to communicate their wishes, even if temporary. This document is not tied to the individual’s being declared in a permanently unconscious state or terminally ill and unable to communicate. It could be that the individual is anesthetized and therefore unable to communicate (Ohio Hospital Association, 2010).

Do-Not-Resuscitate:  This advance directive allows a person the right to die without heroic measures, such as cardiac or respiratory resuscitation. The DNR advance directive gives health care providers a legal means by which to respect those wishes. For a DNR order to be carried out, a physician must write a medical order in the person’s medical record. It is necessary to be enrolled in this program by a medical practitioner and have acceptable forms of DNR identification, such as a wallet identification care that bears the Ohio State DNR logo (Ohio Hospital Association, 2010).

 Tissue and Organ Donation: This is an advance directive that allows an individual to decide well in advance if he/she wishes to donate organs or tissues in the event of his/her death. It relieves loved ones of the burden of making this decision. In Ohio this information is frequently found on the driver’s license, but may also be found on the Living Will if one has been executed (Ohio Hospital Association, 2010).

For copies of current forms and complete information on advance directives in Ohio, the learner is directed to

Ethical issue #3

Mr. Smyth is a 73year old African American male in renal failure as a result of chronic uncontrolled malignant hypertension. Mr. Smyth was non-compliant with the medication regime on which he was placed 15 years ago by his primary care physician. At this time Mr. Smyth is in need of a kidney transplant following receipt of hemodialysis for the past 4 years. He has been placed on a cadaver list for receipt of a kidney. Mr. Smyth has 3 adult children, all with children of their own. All 3 adult children have undergone testing to see if anyone is a match as a possible kidney donor. The youngest of Mr. Smyth’s children, a 38 year old female, is the only one to match Mr. Smyth. She has agreed to consider kidney donation to her father.

Mr. Smyth’s 38 year old daughter has 2 school-aged children for whom she is the primary wage earner and care giver. She has not completed her decision making process, needing to consult with the father of her children in making her final decision. While driving to her ex-husband’s house to discuss the issue with him, the daughter is involved in a roll over car accident. She was not wearing a seat belt and upon admission to the ED where you, the nurse, encounter her, it is found that she has sustained major head trauma incompatible with life. The family members arrive in the ED and inform you of Mr. Smyth’s situation and what has transpired to date.

Nurses are often in a position to ask the family members of a deceased individual if the deceased is an organ donor. Luckily, Mr. Smyth’s daughter has tagged her driver’s license stating her wishes to be an organ/tissue donor. This is a situation in which the nurse and other health care professionals are protected from any legal action on the part of the family by the advance directive found on the driver’s license of the injured daughter (OHA, 2010).

However, Mr. Smyth is not the only person on the cadaver list awaiting a kidney. What are the elemental aspects in this case?

  • Mr. Smyth needs a kidney.
  • We know that the injured daughter would like to donate any useable organs and tissues as evidenced by the advance directive on her driver’s license.
  • Mr. Smyth’s daughter has 2 useable kidneys.
  • We can assume, based on the fact that the deceased daughter has completed compatibility testing, that she has considered donating one kidney to her father.
  • Cadaver lists are based upon a first come first served basis, if all other elements are equal.

Ethics committees

While nurses face ethical dilemmas in the regular course of day-to-day practice, there remain ethical dilemmas that should be referred for consideration by a multidisciplinary team or ethics committee. Generally speaking, the patient’s wishes will supersede independent decisions made by a health care practitioner.  Collaborative decisions made which include the patient, family, physician, nurses, and possibly the clergy, will generally result in fewer complications. For this reason, many health care facilities have an internal ethics committee.  If your facility has an ethics committee, there is likely a policy and procedure that you will be expected to follow in making referrals and respecting the recommendation made about the ethical dilemma in question. It is important that the nurse be familiar with the policy and procedure regarding referrals to the internal ethics committee.

Ethics committees may include representation from the family and the various health care disciplines, such as physicians, nurses, social workers, clergy, etc.  Ethics committees may also include a representative from the facility’s legal department, to ensure that the final decision protects the patient’s wishes and the facility.  Regardless of the individuals who make up the ethics committee or group involved in ethics consultation, it is important that the individuals involved understand their role and are competent to address the issues (Aulisio, Arnold, & Youngner, 2000).  An institutionally based ethics committee tends to work from what may be referred to as an ethics facilitation approach.  “Ethics facilitation recognizes that societal values, law, and institutional policy have implications for a morally acceptable consensus” (Aulisio et al., 2000), thus allowing for a socially acceptable ethical solution in today’s society.

The obligation to be fair to all people is called distributive justice (Aiken, 2004), a principle which underlies the first statement in the ANA Code of Ethics for Nurses (Table 1). Use of an ethics committee will also ensure that the facility handles ethical dilemmas consistently regardless of age, race, sex, marital status, medical diagnosis, social standing, economic level, religious belief, or sexual orientation. Institutions should encourage the use of ethics consultants, if no ethics committee is available (Aulisio et al., 2000).

Since no decisions were made with respect to Ethical Issue #3, let us return to examine it. Unfortunately, the facility does not have an internal ethics committee. As the nurse, you consult with the attending physician in the ED who asks you to bring Mr. Smyth’s 2 remaining daughters into the conference room for a consultation. You also ask the family if they would like a spiritual advisor present, to which they respond by giving you the phone number for a preferred member of the clergy. You contact the clergy member, as requested, and the house supervisor, both of whom are willing to participate. In essence, this could be considered to meet the elements of an ethical decision making group.

In accordance with the National Organ Transplant Act of 1984, the waiting list for donated organs is maintained by the Organ Procurement and Transplantation Network, administered by the United Network for Organ Sharing (UNOS). As such, donated organs are distributed by UNOS (OPTN, 2014). Hospital staff must notify the local organ procurement office when there is an organ donor.  The organs being donated by Mr. Smyth’s daughter will be distributed according to policies established by UNOS (OPTN, 2014). You and the other persons making up the ethical decision making group will need to assist the family in understanding how organs are distributed and that Mr. Smyth may or may not receive one of his daughter’s kidneys.

Since Mr. Smyth’s daughter is an organ donor, and a match for Mr. Smyth, who is already on the waiting list for a kidney, a decision is made by UNOS that Mr. Smyth is to receive one of his daughter’s kidneys.  The remaining viable organs and tissues are used to benefit 6 other individuals. 


“The very characteristics of an ethical problem make such examination and analysis crucial to appropriate resolution. Those characteristics include: 1) the right thing to do is not clear (that is, good arguments can be made on both sides of the issue); 2) the issue involves values rather than facts per se (although facts are essential to understanding what values are involved); 3) Whatever answer is reached, precisely because it does involve values, has profound and multiple ramifications. Clearly, each of these characteristics demands that the issue(s) involved be openly and carefully analyzed! …An ethical problem/issue arises when people do not know what is the right thing to do,” (Curtin, 2004).

Ethical dilemmas are faced by nurses in all healthcare settings.  Nurses are the individuals to whom the patient/client and families often look for answers to their ethical questions.  As a care giver, nurses are to provide safe and effective nursing care to all patients in his/her care and to protect the patient’s privacy. As the patient advocate, it is the nurse’s duty to carry out the wishes of the patient/client and to assist the patient/client in navigating through this veritable sea of endless questions.  Use of tools such as those found in this learning activity will assist the nurse to help the patient ferret out the right questions to ask and serve as a guide for the nurse as he/she encounters ethical situations in his/her nursing practice.


The Patient’s Bill of Rights

The following points became a part of the Patient Bill of Rights in 1998.

Information Disclosure. You have the right to accurate and easily understood information about your health plan, health care professionals, and health care facilities. If you speak another language, have a physical or mental disability, or just don’t understand something, assistance will be provided so you can make informed health care decisions.

Choice of Providers and Plans. You have the right to a choice of health care providers that is sufficient to provide you with access to appropriate high-quality health care.

Access to Emergency Services. If you have severe pain, an injury, or sudden illness that convinces you that your health is in serious jeopardy, you have the right to receive screening and stabilization emergency services whenever and wherever needed, without prior authorization or financial penalty.

Participation in Treatment Decisions. You have the right to know your treatment options and to participate in decisions about your care. Parents, guardians, family members, or other individuals that you designate can represent you if you cannot make your own decisions.

Respect and Nondiscrimination. You have a right to considerate, respectful and nondiscriminatory care from your doctors, health plan representatives, and other health care providers. 

Confidentiality of Health Information. You have the right to talk in confidence with health care providers and to have your health care information protected. You also have the right to review and copy your own medical record and request that your physician change your record if it is not accurate, relevant, or complete.

Complaints and Appeals. You have the right to a fair, fast, and objective review of any complaint you have against your health plan, doctors, hospitals or other health care personnel. This includes complaints about waiting times, operating hours, the conduct of health care personnel, and the adequacy of health care facilities.

Added in 2010

  • Annual and lifetime dollar limits to coverage of essential benefits have been removed.
  • People will be able to get health insurance in spite of pre-existing medical conditions.
  • You have the right to an easy-to-understand summary of benefits and coverage.
  • Young adults are able to stay on a parent’s policy until age 26 if they meet certain requirements.
  • You’re entitled to certain preventive screening without paying extra fees or co-pays.
  • If your plan denies payment for a medical treatment or service, you must be told why it was refused, and how to appeal (fight) that decision.
  • You have the right to appeal the payment decisions of private health plans (called an “internal appeal”). You also have the right to a review by an independent organization (called an “outside review”) if the company still doesn’t want to pay.
  • Larger insurance companies must spend 80 to 85% of their premiums on health care and improvement of care rather than on salaries, overhead, and marketing.
  • If you made an honest mistake on your insurance application, health insurance companies will no longer be able  to rescind (take back) your health coverage after you get sick.
  • If a company does cancel your coverage, they must give you at least 30 days’ notice.
  • Premium increases of more than 10% must be explained and clearly justified.

Revised: 2010

The Patient’s Bill of Rights (2010). American Cancer Society.  June 23, 2014.


 Continue to Post Test>>



Aiken, T. (2004), Legal, Ethical, and Political Issues in Nursing. F.A. Davis. Philidelphia.

American Cancer Society. Patient’s Bill of Rights: What is the Patient’s Bill of Rights? Accessed June 23, 2014.

American Medical Association Journal of Ethics June 2014, Volume 16, Number 6: 440-441. Accessed June 20, 2014.

American Nurses Association. (2015). Code of Ethics for Nurses with Interpretive Statements. Accessed October 27, 2015.

American Nurses Association. Florence Nightengale Pledge. Accessed June 19, 2014.

 Anderson-Shaw, L., Ahrens, W., and Marney, F. (March 2007) Ethics consultation in the emergency department. Journal of Nursing Administration. Volume9 Number 1 pages 32-35.  Accessed June 19, 2014.

 Armstrong, A. (2006). Towards a strong virtue ethics for nursing practice. Nursing Philosophy; 7 (3), 110-124.

Aulisio, M, Arnold, R, and Youngner, S. (2000). Health care ethics consultation: Nature, goals, and competencies.  Anals of Internal Medicine; 133, 59-69. 

CNA. Canadian Nurses Association Code of Ethics for Registered Nurses, PUBS-490-6 (2008). Accessed June 19, 2014.

Curtin, L. (April 2004). The Ethical handling of Ethical Issues. (

Department of Health and Human Services (2010). The Patients’ Bill of Rights in Medicare and Medicaid. Accessed June 19, 2014. 

Fry, S., Luce H., and Riley, J., (July 2007), Ethical issues in clinical practice: A multi-state study of practicing registered nurses. Nursing Ethics Network.

Honesty/ Ethics in Professions. (December 16, 2013), Gallup Poll News Service, Washington, D.C. Accessed June 19, 2014.

Lachman, V. “Practical Use of the Nursing Code of Ethics”, MEDSURG Nursing, 2009, Volume 18, Number 1, pp. 55-57.

Lazarus,E. 1883. “The New Colossus.”  Accessed June 19, 2014.

Ludwick, R., Silva, M. (December 19, 2003). Ethics Column: “Ethical Challenges in the Care of Elderly Persons”. Online Journal of Issues in Nursing. Available

McHale, J. and Gallagher, A. (2003), Human Rights and Nursing Practice. Saunders.

National Council of State Boards of Nursing (August 2012). White Paper: A Nurse’s Guide to the Use of Social Media Accessed June 23, 2014.

Ohio Administrative Code, Chapter 4723-4. (February 2014), as compiled by Anderson’s Online.

Ohio Board of Nursing. (2013). 2013 Registered Nurse Ohio Workforce Data Summary Report. Accessed June 19, 2014.

Ohio Hospital Association. Advance Directives Packet. August 2010. Accessed June 23, 2014. 

Ohio Revised Code, Section 4723.28. (March 2013), as compiled by Anderson’s Online.

Roget’s Thesaurus-II, Third Edition. (2003). Boston. Houghton Mifflin Company.

Stoller, G. (August, 24, 2007). Doing business abroad? Simple faux pas can sink you. USA Today. McLean, Virginia.

The American Heritage ® Dictionary of the English Language, Fourth Edition. (2005). Boston. Houghton Mifflin Company. 

The International Council of Nurses Code of Ethics for Nurses, 2012. International Council of Nurses, Geneva, Switzerland, 2012; See

Organ Procurement and Transplantation Network. OPTN Policies. April 10, 2014.  Accessed June 23, 2014.

US Census Bureau. Census Data (2010). Accessed June 19, 2014.

Willing, R. (August 3, 2007), DNA ‘near matches’ spur privacy fight. USA Today.

Wlody, G. (2007). Nursing management and organizational ethics in the intensive care unit. Critical Care Medicine; 35.


Suggested reading:

All of the books suggested in this list are works of fiction.  Each selection also deals with ethical issues in health care and the world at large.

Crichton, M. (2006). Next, Harper Collins Publishers, New York.

Picoult, J. (2004), My Sister’s Keeper, Washington Square Press, New York.

Cook, R. (1993). Fatal Cure, Berkley Publishing -Company, New York.