Abstract

Introduction

Since the 1980s, the Canadian Nurses Association (CNA) has maintained a Code of Ethics that serves as a foundation for ethical practice in nursing. CNA revises its Code every few years to ensure that it reflects changing societal values and conditions and the needs of nurses in practice. After a rigorous consultative process, CNA will be launching a newly revised Code in June 2008 at the CNA Biennial Convention in Ottawa. The consultation for this revision was particularly complex, as divergent perspectives came forth surrounding the Code's ability to remain useful as a regulatory tool and also provide a vision of nursing in regard to broader aspects of social justice. Some ethicists and regulators may have differing viewpoints on the purpose of a code of ethics. The editorials below offer two perspectives on the issue.

The newly revised CNA Code will be available for free download as of June 17, 2008 from CNA's website (www.cna-aiic.ca).


Seeing Our Way through the Responsibility-vs-Endeavour Conundrum: The Code of Ethics as Both Product and Process*

Elizabeth Peter, RN, PhD
Associate Professor & Associate Dean,
Academic Programs Lawrence Bloomberg Faculty of Nursing Member
Joint Centre for Bioethics University of Toronto
Chair of the CNA Ethics Advisory Committee

The 2008 Canadian Nurses Association Code of Ethics has been organized in a new two-part framework. Because of divergent feedback about the purpose of the Code and its usefulness in regulation, the nursing values and ethical responsibilities of providing safe, compassionate, competent and ethical care, promoting health and well-being, promoting and respecting informed decision-making, preserving dignity, maintaining privacy and confidentiality, promoting justice and being accountable have been named the core ethical responsibilities. Those statements related to broader societal issues, such as social justice, health policy and healthy work environments, have been placed in a separate category called ethical endeavours because they are not readily enforceable. This paper will address concerns that arise from this approach of separating these types of statements and will also explore ways to avoid this problem in the next revision of the Code.  

Concerns

Although the CNA has stated no intention of lessening the significance of the latter statements, the term "endeavour" carries much less moral weight than "responsibility" because an endeavour could imply simply an attempt, while a responsibility is more firmly a requirement. The structure of the new framework may imply to nurses that the "ethical endeavours" are less important than the "core ethical responsibilities." This structure is undesirable for three reasons.

First, for many nurses these statements are, or should be, central to their everyday work. For example, the statements related to social justice and primary health are absolutely central to the everyday work of many community nurses, and those statements related to health system and policy change are often central to nurses in leadership positions. Codes should not focus too heavily on hospital nurses in direct care because such an emphasis could make the ethical concerns of others less visible, or it might imply that others are not required to be as accountable. Second, not to make societal responsibilities a core of nursing practice is out of step with other codes. The Canadian Medical Association (2004), American Nurses Association (2001) and International Council of Nurses (2000) codes of ethics make responsibilities to society explicit. Attention to ethical responsibilities, particularly given growing inequities in health and social resources here in Canada and abroad, is essential. Third, the creation of healthy work environments is the responsibility of all nurses. In recent years, work environments have been widely recognized as places that can facilitate or encumber ethical behaviour (Austin 2007), to the extent that we should maximize, not minimize, these responsibilities.

Moving forward  

No doubt the CNA Code serves multiple purposes, both regulatory and ethical, that are important for the safety of the public and for ethical guidance to nurses. Although regulation and ethics are both informed by values and norms of what is right and good, regulation is concerned with enforcement to a much greater degree than is ethics. In the case of a regulatory document, including social responsibility as a core responsibility could lead to the unjustifiable disciplining of more nurses whose working conditions or roles do not permit them to meet their societal responsibilities along with their core responsibilities. Clearly, this outcome is to be avoided.

The solution to this conundrum, I believe, exists in attending to the Code, not only as a product, but also as a process. In the field of law, law can be conceptualized as a product, that is, a collection of statutes, rules and principles, or it can be conceptualized as a process, that is, an interpretative practice that informs and is informed by law as a product (Van der Burg 1998). Currently, redevelopment of the Code has focused on a product approach with an emphasis on those statements that function as rules - the "what" of the Code. Very little discussion has occurred related to the Code as a process - the "how" of the Code - beyond concerns regarding enforceability. Given the debates that occurred regarding this new revision, I believe that, as a beginning, we must address how the Code should be interpreted by regulators. In this way, it would be possible to avoid the two-part framework and still retain the Code's usefulness as a regulatory tool that includes the range of nurses' ethical responsibilities.

Most important, the context of a nurse's behaviour and practice must be understood, because under some circumstances even the core responsibilities may be unattainable. More than 30 years ago, questions were raised as to whether codes of nursing practice could always be realized given the realities of practice environments (Davis and Aroskar 1978). There is a well-known principle in ethics, generally attributed to Kant, that states that "ought implies can." In other words, we can be expected to fulfill only those moral responsibilities that are possible for us to fulfill. The process of interpreting the Code, especially when enforcing it, requires that context be fully understood. What is possible or expected of one nurse may not be possible or reasonably expected of another given his or her context and role. Ultimately, the nature of a responsibility, as opposed to an endeavour, is a matter of context and need not be divided in the Code.

Also, there may be times when interpretation of the Code requires sensitivity to its multiple purposes as described in its introduction. Regulation is only one function described. Because regulation focuses mainly on individuals, a tension is created between regulation and relationally focused approaches to ethics. If we eliminate or lessen the importance of the relational aspects, the role that nurses can play as a collective in the moral life of a profession could be lost. Many of the social responsibilities of nurses are often best achieved in groups. Thus, while focusing on individuals may make regulation possible, it seriously limits ethics. The best process may be to step back and respect the wisdom of ethics to improve practice in this regard.

This iteration of the Code brings to light some of the tensions that exist between regulation and ethics when they are brought together. Despite the differences, however, they share a common goal of excellent nursing practice. In the end, resolving the two may simply be a matter of process.

* The opinions expressed are those of the individual authors and are not necessarily those of the CNA Ethics Advisory Committee.

References

Austin, W. 2007. "The Ethics of Everyday Practice. Healthcare Environments." Advances in Nursing Science 30(1): 81-88.

Davis, A.J. and M.A. Aroskar. 1978. Ethical Dilemmas and Nursing Practice. New York: Appleton-Century-Crofts.

Van der Burg, W. 1998. "Law and Bioethics." In H. Kuhse and P. Singer, eds., A Companion to Bioethics (pp. 49-57). Oxford: Blackwell.


Codes of Ethics: Aspirational or Regulatory? *

Janet L. Storch, RN, PhD, DSc (Hon)
Professor Emeritus, School of Nursing, University of Victoria, Victoria BC
Ex Officio Member of the CNA Ethics Advisory Committee and
Lead for the Revision of the 2008 Code.

All professions, including health professions, are under scrutiny today, at varying levels in different provinces and territories in Canada. Some of the professional nursing bodies, having shifted from association to college status, are feeling particularly vulnerable to this scrutiny, as well as to increased government involvement in nursing regulation. Yet, public trust in nursing as a profession continues to run high. To what extent does the Canadian Nurses Association (CNA) Code of Ethics for Registered Nurses serve to foster that trusting relationship, and how might it be useful towards that end?

Ethical values are at the root of self-regulation. To be granted self-regulatory powers by government is important to nurses in Canada. It signifies that nurses know best how to ensure safe, compassionate, competent and ethical practice. This recognition affirms nursing's unique body of knowledge and skill and the fact that no one else can know this knowledge and skill set well enough to evaluate nurses' competency to enter and continue in practice. It also signifies that the public is convinced that our ideal is to use our knowledge and skill to serve others (and not merely for our own ends), and that we are accountable to provide care and service in keeping with our Code of Ethics. Thus, the Code is integral to who we are as nurses and how we carry out our nursing practice.

Codes of ethics can be aspirational statements and can also serve as a basis for self-regulation. These two purposes are not in diametrical opposition, but rather in harmony with each other. One goal speaks to the broader goals of nursing; the other provides a basis for developing ethical expectations or standards for nursing practice. What is important is that these two purposes be held in balance, since the Code needs to be useful for many purposes while maintaining public trust as our key goal.

A code should state what, as a profession, we value in order to inform those receiving care or service, and also to inform other health professionals of our values. It should offer guidance to individual professionals, serve as a tool for self-evaluation of our own ethical practice and guide the actions of committees struck to rule on professional conduct. A code should also serve as an ethical basis from which nurses advocate for practice environments in which they can provide safe, compassionate, competent and ethical care, as well as work to change laws or policies that are incompatible with ethical practice. Finally, a code should match the learning needs of students. Clearly, these multiple purposes include both aspirational and regulatory items.

During the revision of the CNA Code of Ethics for Registered Nurses (2008), nurses across Canada were actively engaged in providing input and debating the substance of the Code. It is not surprising, therefore, that differing perspectives of what the Code should be were aired and discussed by electronic means and in person at various meetings and presentations. The two most extreme differences centred on the Code's regulatory focus and its aspirational focus, particularly in relation to issues of social justice. Some held the view that each statement in the Code must serve a self-regulatory purpose, i.e., must enable regulators to evaluate competence and ethical conduct. Others felt strongly that nursing's original goals of addressing broader societal issues and notions of health should be a major emphasis, independent of how these statements might serve those responsible for ensuring appropriate self-regulation.

In an attempt to reconcile the two divergent views, CNA recommended a two-part Code. The specific values and ethical responsibilities expected of registered nurses, and for which they are accountable, would be set out in part I of the Code, through the seven primary values and their accompanying responsibility statements. The concept of the necessity of quality practice environments would be incorporated throughout the Code to acknowledge how crucial the practice environment is to ethical nursing practice.

Endeavours that nurses undertake to address social inequities as part of ethical practice would be outlined in part II. This two-part framework would allow the Code to remain a document to be used in nursing regulation while also permitting it to address the important aspirational aspects of ethical nursing practice. Initially, this separation of the Code into two parts created a sense of unease for this author. But on further reflection, placing the ethical endeavours (aspirations) in part II seemed to make the social justice aims of the Code more visible than in the 2002 version, and therefore carrying greater weight. Further, these bold statements provide nurses with a broader vision of their work and serve to ensure that nursing students understand the breadth and depth of their ethical commitments as nurses. As described in the Code, these ethical endeavours

are broad aspects of social justice that are associated with health and well-being. … Nurses should endeavor as much as possible, individually and collectively, to advocate for and work toward eliminating social inequities … . (CNA 2008)

The 13 statements in part II include utilizing principles of primary healthcare; recognizing the significance of the social determinants of health; taking action to overcome barriers to healthcare for vulnerable groups; maintaining awareness of major health concerns such as poverty, inadequate shelter, food insecurity and violence; maintaining awareness of global health; and working collaboratively to develop a moral community. None of these statements lends itself to regulatory action, yet all nurses should be committed to these goals.

The revision of the CNA Code of Ethics involved a rigorous consultative process. That process has given rise to both positive regard for the revised Code and differing viewpoints on its new format. The significant engagement of nurses clearly informs us that nurses take their Code of Ethics very seriously and feel strongly about it. It may be that this 2008 Code will be considered a transition, helpful for the next revision, which may well see the Code constructed quite differently.

However the CNA code may be revised in the future, the 2008 Code (like its predecessors) is designed to serve regulatory as well as aspirational purposes. In some other countries, the national nursing code stands solely as an aspirational statement, referred to but not utilized directly by states or provinces. In Canada, it has been the practice that each provincial and territorial jurisdiction adopts the CNA Code as its own. This adoption of the code considerably strengthens the CNA Code in terms of nurses' awareness of and adherence to it, and also affirms our intent - that is, to maintain public trust.

* The opinions expressed are those of the individual authors and are not necessarily those of the CNA Ethics Advisory Committee.

References

Canadian Nurses Association. 2008 (in press). Code of Ethics for Registered Nurses. Ottawa: Author.