3.2 Blood Pressure Basics
Open Resources for Nursing (Open RN)
What is Blood Pressure?
A blood pressure reading is the measurement of the force of blood against the walls of the arteries as the heart pumps blood through the body. It is reported in millimeters of mercury (mmHg). This pressure changes in the arteries when the heart is contracting compared to when it is resting and filling with blood. Blood pressure is typically expressed as the reflection of two numbers, systolic pressure and diastolic pressure. The systolic blood pressure is the maximum pressure on the arteries during systole, the phase of the heartbeat when the ventricles contract. This is the top number of a blood pressure reading. Systole causes the ejection of blood out of the ventricles and into the aorta and pulmonary arteries. The diastolic blood pressure is the resting pressure on the arteries during diastole, the phase between each contraction of the heart when the ventricles are filling with blood. This is the bottom number of the blood pressure reading.[1] Therefore, 120/80 indicates the systolic blood pressure is 120 mm Hg and the diastolic blood pressure is 80 mm Hg.
Blood pressure measurements are obtained using a stethoscope and a sphygmomanometer, also called a blood pressure cuff. To obtain a manual blood pressure reading, the blood pressure cuff is placed around a patient’s extremity, and a stethoscope is placed over an artery. For most blood pressure readings, the cuff is usually placed around the upper arm, and the stethoscope is placed over the brachial artery. The cuff is inflated to constrict the artery until the pulse is no longer palpable, and then it is deflated slowly. The American Heart Association (AHA) recommends that the blood pressure cuff be inflated at least 30 mmHg above the point at which the radial pulse is no longer palpable. The first appearance of sounds, called Korotkoff sounds, are noted as the systolic blood pressure reading. Korotkoff sounds are named after Dr. Korotkoff, who first discovered the audible sounds of blood pressure when the arm is constricted.[2] The blood pressure cuff continues to be deflated until Korotkoff sounds disappear. The last Korotkoff sounds reflect the diastolic blood pressure reading.[3] It is important to deflate the cuff slowly at no more than 2-3 mmHg per second to ensure that the absence of pulse is noted promptly and that the reading is accurate. Blood pressure readings are documented as systolic blood pressure/diastolic pressure, for example, 120/80 mmHg.
Abnormal blood pressure readings can signify an area of concern and a need for intervention. Normal adult blood pressure is less than 120/80 mmHg. Hypertension is the medical term for elevated blood pressure readings of 130/80 mmHg or higher. See Table 3.2 for blood pressure categories according to the 2017 American College of Cardiology and American Heart Association Blood Pressure Guidelines.[4] Prior to diagnosing a person with hypertension, the health care provider will calculate an average blood pressure based on two or more blood pressure readings obtained on two or more occasions.
For more information about hypertension and blood pressure medications, visit the “Cardiovascular and Renal System” chapter in Open RN Nursing Pharmacology.
Hypotension is the medical term for low blood pressure readings less than 90/60 mmHg.[5] Hypotension can be caused by dehydration, bleeding, cardiac conditions, and the side effects of many medications. Hypotension can be of significant concern because of the potential lack of perfusion to critical organs when blood pressures are low. Orthostatic hypotension is a drop in blood pressure that occurs when moving from a lying down (supine) or seated position to a standing (upright) position. When measuring blood pressure, orthostatic hypotension is defined as a decrease in blood pressure by at least 20 mmHg systolic or 10 mmHg diastolic within three minutes of standing. When a person stands, gravity moves blood from the upper body to the lower limbs. As a result, there is a temporary reduction in the amount of blood in the upper body for the heart to pump, which decreases blood pressure. Normally, the body quickly counteracts the force of gravity and maintains stable blood pressure and blood flow. In most people, this transient drop in blood pressure goes unnoticed. However, some patients with orthostatic hypotension can experience light-headedness, dizziness, or fainting. This is a significant safety concern because of the increased risk of falls and injury, particularly in older adults.[6] Orthostatic hypotension is also commonly referred to a postural hypotension. When obtaining orthostatic vital signs, the pulse rate may also be collected. If the pulse increases by 30 beats/minute or more while the patient stands (or sits if unable to stand), this indicates a significant change.
Perform the following actions when obtaining orthostatic vital signs:
- Have the patient stand upright for 1 minute if able.
- Obtain the blood pressure measurement while the patient stands using the same arm and the same equipment as the previous measurement that was taken with patient lying or sitting.
- Obtain the radial pulse again.
- Repeat the blood pressure and radial pulse measurements again at 3 minutes. Waiting several minutes before repeating the measurements allows time for the autonomic nervous system to compensate for blood volume shifts after position change in the patient without orthostatic hypotension.
- If the patient has symptoms that suggest orthostatic hypotension but doesn’t have documented orthostatic hypotension, repeat blood pressure measurement.
Tip: Some patients may not demonstrate significant decreases in blood pressure until they stand for more than 3 minutes.
Table 3.2 Blood Pressure Categories[7]
| Blood Pressure Category | Systolic mm Hg | Diastolic mm Hg |
|---|---|---|
| Normal | Less than 120 | Less than80 |
| Elevated | 120-129 | Less than 80 |
| Stage 1 | 130-139 | 80-89 |
| Stage 2 | 140 or higher | Greater or equal to 90 |
| Hypertensive Crisis | Greater than 180 | Greater than 120 |
View Ahmend Alzawi’s Korotkoff sounds video on YouTube.[8]
Equipment to Measure Blood Pressure
Manual Blood Pressure
A sphygmomanometer, commonly called a blood pressure cuff, is used to measure blood pressure while Korotkoff sounds are auscultated using a stethoscope. See Figure 3.1[9] for an image of a sphygmomanometer.
There are various sizes of blood pressure cuffs. It is crucial to select the appropriate size for the patient to obtain an accurate reading. An undersized cuff will cause an artificially high blood pressure reading, and an oversized cuff will produce an artificially low reading. See Figure 3.2[10] for an image of various sizes of blood pressure cuffs ranging in size for a large adult to an infant.
The width of the cuff should be 40% of the person’s arm circumference, and the length of the cuff’s bladder should be 80–100% of the person’s arm circumference. Keep in mind that only about half of the blood pressure cuff is the bladder and the other half is cloth with a hook and loop fastener to secure it around the arm.
View Ryerson University’s accurate blood pressure cuff sizing video on YouTube.[11]
Automatic Blood Pressure Equipment
Automatic blood pressure monitors are often used in health care settings to efficiently measure blood pressure for multiple patients or to repeatedly measure a single patient’s blood pressure at a specific frequency such as every 15 minutes. See Figure 3.3[12] for an image of an automatic blood pressure monitor. To use an automatic blood pressure monitor, appropriately position the patient and place the correctly sized blood pressure cuff on their bare arm or other extremity. Press the start button on the monitor. The cuff will automatically inflate and then deflate at a rate of 2 mmHg per second. The monitor digitally displays the blood pressure reading when done. If the blood pressure reading is unexpected, it is important to follow up by obtaining a reading using a manual blood pressure cuff. Additionally, automatic blood pressure monitors should not be used if the patient has a rapid or irregular heart rhythm, such as atrial fibrillation, or has tremors as it may lead to an inaccurate reading.
Media Attributions
- Sphygmomanometer&Cuff
- BP-Multiple-Cuff-Sizes (1)
- Automatische_bloeddrukmeter_(0)
- This work is a derivative of Vital Sign Measurement Across the Lifespan - 1st Canadian Edition by Ryerson University licensed under CC BY 4.0 ↵
- This work is a derivative of StatPearls by Campbell and Pillarisetty licensed under CC BY 4.0 ↵
- This work is a derivative of Clinical Procedures for Safer Patient Care by British Columbia Institute of Technology licensed under CC BY 4.0 ↵
- American College of Cardiology. Whelton, P. K., Carey, R. M., Aronow, W. S.., et al. (2018, May 7). 2017 guidelines for high blood pressure in adults. https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2017/11/09/11/41/2017-guideline-for-high-blood-pressure-in-adults ↵
- National Heart, Lung, and Blood Institute. (n.d.). Low blood pressure. https://www.nhlbi.nih.gov/health-topics/low-blood-pressure ↵
- U.S. National Library of Medicine. (2020, June 23). Orthostatic hypotension. https://ghr.nlm.nih.gov/condition/orthostatic-hypotension ↵
- American College of Cardiology. Whelton, P. K., Carey, R. M., Aronow, W. S.., et al. (2018, May 7). 2017 guidelines for high blood pressure in adults. https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2017/11/09/11/41/2017-guideline-for-high-blood-pressure-in-adults ↵
- Alzawi, A. (2015, November 19). Korotkoff+blood+pressure+sights+and+sounds SD [Video]. YouTube. All rights reserved. https://youtu.be/UfCr_wUepxo ↵
- “Sphygmomanometer&Cuff.JPG” by ML5 is in the Public Domain. ↵
- “BP-Multiple-Cuff-Sizes.jpg” by British Columbia Institute of Technology (BCIT) is licensed under CC BY 4.0. Access for free at https://opentextbc.ca/vitalsign/chapter/how-is-blood-pressure-measured/ ↵
- Ryerson University. (2018, March 21). Blood pressure - Accurate cuff sizing [Video]. YouTube. All rights reserved. https://youtu.be/uNTMwoJTfFE ↵
- “Automatische bloeddrukmeter (0).jpg” by Harmid is in the Public Domain. ↵
The American Nurses Association (ANA) defines morality as “personal values, character, or conduct of individuals or groups within communities and societies,” whereas ethics is the formal study of morality from a wide range of perspectives.[1] Ethical behavior is considered to be such an important aspect of nursing the ANA has designated Ethics as the first Standard of Professional Performance. The ANA Standards of Professional Performance are "authoritative statements of the actions and behaviors that all registered nurses, regardless of role, population, specialty, and setting, are expected to perform competently." See the following box for the competencies associated with the ANA Ethics Standard of Professional Performance[2]:
Competencies of ANA's Ethics Standard of Professional Performance[3]
- Uses the Code of Ethics for Nurses With Interpretive Statements as a moral foundation to guide nursing practice and decision-making.
- Demonstrates that every person is worthy of nursing care through the provision of respectful, person-centered, compassionate care, regardless of personal history or characteristics (Beneficence).
- Advocates for health care consumer perspectives, preferences, and rights to informed decision-making and self-determination (Respect for autonomy).
- Demonstrates a primary commitment to the recipients of nursing and health care services in all settings and situations (Fidelity).
- Maintains therapeutic relationships and professional boundaries.
- Safeguards sensitive information within ethical, legal, and regulatory parameters (Nonmaleficence).
- Identifies ethics resources within the practice setting to assist and collaborate in addressing ethical issues.
- Integrates principles of social justice in all aspects of nursing practice (Justice).
- Refines ethical competence through continued professional education and personal self-development activities.
- Depicts one's professional nursing identity through demonstrated values and ethics, knowledge, leadership, and professional comportment.
- Engages in self-care and self-reflection practices to support and preserve personal health, well-being, and integrity.
- Contributes to the establishment and maintenance of an ethical environment that is conducive to safe, quality health care.
- Collaborates with other health professionals and the public to protect human rights, promote health diplomacy, enhance cultural sensitivity and congruence, and reduce health disparities.
- Represents the nursing perspective in clinic, institutional, community, or professional association ethics discussions.
Reflective Questions
- What Ethics competencies have you already demonstrated during your nursing education?
- What Ethics competencies are you most interested in mastering?
- What questions do you have about the ANA’s Ethics competencies?
The ANA's Code of Ethics for Nurses With Interpretive Statements is an ethical standard that guides nursing practice and ethical decision-making.[4] This section will review several basic ethical concepts related to the ANA's Ethics Standard of Professional Performance, such as values, morals, ethical theories, ethical principles, and the ANA Code of Ethics for Nurses.
Values
Values are individual beliefs that motivate people to act one way or another and serve as guides for behavior considered “right” and “wrong.” People tend to adopt the values with which they were raised and believe those values are “right” because they are the values of their culture. Some personal values are considered sacred and moral imperatives based on an individual’s religious beliefs.[5] See Figure 6.1[6] for an image depicting choosing right from wrong actions.
In addition to personal values, organizations also establish values. The American Nurses Association (ANA) Professional Nursing Model states that nursing is based on values such as caring, compassion, presence, trustworthiness, diversity, acceptance, and accountability. These values emerge from nursing practice beliefs, such as the importance of relationships, service, respect, willingness to bear witness, self-determination, and the pursuit of health.[7] As a result of these traditional values and beliefs by nurses, Americans have ranked nursing as the most ethical and honest profession in Gallup polls since 1999, with the exception of 2001, when firefighters earned the honor after the attacks on September 11.[8]
The National League of Nursing (NLN) has also established four core values for nursing education: caring, integrity, diversity, and excellence[9]:
- Caring: Promoting health, healing, and hope in response to the human condition.
- Integrity: Respecting the dignity and moral wholeness of every person without conditions or limitations.
- Diversity: Affirming the uniqueness of and differences among persons, ideas, values, and ethnicities.
- Excellence: Cocreating and implementing transformative strategies with daring ingenuity.
Morals
Morals are the prevailing standards of behavior of a society that enable people to live cooperatively in groups. “Moral” refers to what societies sanction as right and acceptable. Most people tend to act morally and follow societal guidelines, and most laws are based on the morals of a society. Morality often requires that people sacrifice their own short-term interests for the benefit of society. People or entities that are indifferent to right and wrong are considered “amoral,” while those who do evil acts are considered “immoral.”[11]
Ethical Theories
There are two major types of ethical theories that guide values and moral behavior referred to as deontology and consequentialism.
Deontology is an ethical theory based on rules that distinguish right from wrong. See Figure 6.2[12] for a word cloud illustration of deontology. Deontology is based on the word deon that refers to “duty.” It is associated with philosopher Immanuel Kant. Kant believed that ethical actions follow universal moral laws, such as, “Don’t lie. Don’t steal. Don’t cheat.”[13] Deontology is simple to apply because it just requires people to follow the rules and do their duty. It doesn’t require weighing the costs and benefits of a situation, thus avoiding subjectivity and uncertainty.[14],[15],[16]
The nurse-patient relationship is deontological in nature because it is based on the ethical principles of beneficence and maleficence that drive clinicians to “do good” and “avoid harm.”[17] Ethical principles will be discussed further in this chapter.
Consequentialism is an ethical theory used to determine whether or not an action is right by the consequences of the action. See Figure 6.3[19] for an illustration of weighing the consequences of an action in consequentialism. For example, most people agree that lying is wrong, but if telling a lie would help save a person’s life, consequentialism says it’s the right thing to do. One type of consequentialism is utilitarianism. Utilitarianism determines whether or not actions are right based on their consequences with the standard being achieving the greatest good for the greatest number of people.[20],[21],[22] For this reason, utilitarianism tends to be society-centered. When applying utilitarian ethics to health care resources, money, time, and clinician energy are considered finite resources that should be appropriately allocated to achieve the best health care for society.[23]
Utilitarianism can be complicated when accounting for values such as justice and individual rights. For example, assume a hospital has four patients whose lives depend upon receiving four organ transplant surgeries for a heart, lung, kidney, and liver. If a healthy person without health insurance or family support experiences a life-threatening accident and is considered brain dead but is kept alive on life-sustaining equipment in the ICU, the utilitarian framework might suggest the organs be harvested to save four lives at the expense of one life.[24] This action could arguably produce the greatest good for the greatest number of people, but the deontological approach could argue this action would be unethical because it does not follow the rule of “do no harm.”
Read more about Decision making on organ donation: The dilemmas of relatives of potential brain dead donors.
Interestingly, deontological and utilitarian approaches to ethical issues may result in the same outcome, but the rationale for the outcome or decision is different because it is focused on duty (deontologic) versus consequences (utilitarian).
Societies and cultures have unique ethical frameworks that may be based upon either deontological or consequentialist ethical theory. Culturally derived deontological rules may apply to ethical issues in health care. For example, a traditional Chinese philosophy based on Confucianism results in a culturally acceptable practice of family members (rather than the client) receiving information from health care providers about life-threatening medical conditions and making treatment decisions. As a result, cancer diagnoses and end-of-life treatment options may not be disclosed to the client in an effort to alleviate the suffering that may arise from knowledge of their diagnosis. In this manner, a client’s family and the health care provider may ethically prioritize a client’s psychological well-being over their autonomy and self-determination.[26] However, in the United States, this ethical decision may conflict with HIPAA Privacy Rules and the ethical principle of patient autonomy. As a result, a nurse providing patient care in this type of situation may experience an ethical dilemma. Ethical dilemmas are further discussed in the "Ethical Dilemmas" section of this chapter.
See Table 6.2 comparing common ethical issues in health care viewed through the lens of deontological and consequential ethical frameworks.
Table 6.2. Ethical Issues Through the Lens of Deontological or Consequential Ethical Frameworks
| Ethical Issue | Deontological View | Consequential View |
|---|---|---|
| Abortion | Abortion is unacceptable based on the rule of preserving life. | Abortion may be acceptable in cases of an unwanted pregnancy, rape, incest, or risk to the mother. |
| Bombing an area with known civilians | Killing civilians is not acceptable due to the loss of innocent lives. | The loss of innocent lives may be acceptable if the bombing stops a war that could result in significantly more deaths than the civilian casualties. |
| Stealing | Taking something that is not yours is wrong. | Taking something to redistribute resources to others in need may be acceptable. |
| Killing | It is never acceptable to take another human being’s life. | It may be acceptable to take another human life in self-defense or to prevent additional harm they could cause others. |
| Euthanasia/physician- assisted suicide | It is never acceptable to assist another human to end their life prematurely. | End-of-life care can be expensive and emotionally upsetting for family members. If a competent, capable adult wishes to end their life, medically supported options should be available. |
| Vaccines | Vaccination is a personal choice based on religious practices or other beliefs. | Recommended vaccines should be mandatory for everyone (without a medical contraindication) because of its greater good for all of society. |
Ethical Principles and Obligations
Ethical principles are used to define nurses’ moral duties and aid in ethical analysis and decision-making.[27] Although there are many ethical principles that guide nursing practice, foundational ethical principles include autonomy (self-determination), beneficence (do good), nonmaleficence (do no harm), justice (fairness), fidelity (keep promises), and veracity (tell the truth).
Autonomy
The ethical principle of autonomy recognizes each individual’s right to self-determination and decision-making based on their unique values, beliefs, and preferences. See Figure 6.4[28] for an illustration of autonomy. The American Nurses Association (ANA) defines autonomy as the “capacity to determine one’s own actions through independent choice, including demonstration of competence.”[29] The nurse’s primary ethical obligation is client autonomy.[30] Based on autonomy, clients have the right to refuse nursing care and medical treatment. An example of autonomy in health care is advance directives. Advance directives allow clients to specify health care decisions if they become incapacitated and unable to do so.
Read more about advance directives and determining capacity and competency in the “Legal Implications” chapter.
Nurses as Advocates: Supporting Autonomy
Nurses have a responsibility to act in the interest of those under their care, referred to as advocacy. The American Nurses Association (ANA) defines advocacy as “the act or process of pleading for, supporting, or recommending a cause or course of action. Advocacy may be for persons (whether an individual, group, population, or society) or for an issue, such as potable water or global health.”[31] See Figure 6.5[32] for an illustration of advocacy.
Advocacy includes providing education regarding client rights, supporting autonomy and self-determination, and advocating for client preferences to health care team members and family members. Nurses do not make decisions for clients, but instead support them in making their own informed choices. At the core of making informed decisions is knowledge. Nurses serve an integral role in patient education. Clarifying unclear information, translating medical terminology, and making referrals to other health care team members (within their scope of practice) ensures that clients have the information needed to make treatment decisions aligned with their personal values.
At times, nurses may find themselves in a position of supporting a client’s decision they do not agree with and would not make for themselves or for the people they love. However, self-determination is a human right that honors the dignity and well-being of individuals. The nursing profession, rooted in caring relationships, demands that nurses have nonjudgmental attitudes and reflect “unconditional positive regard” for every client. Nurses must suspend personal judgement and beliefs when advocating for their clients’ preferences and decision-making.[33]
Beneficence
Beneficence is defined by the ANA as “the bioethical principle of benefiting others by preventing harm, removing harmful conditions, or affirmatively acting to benefit another or others, often going beyond what is required by law.”[34] See Figure 6.6[35] for an illustration of beneficence. Put simply, beneficence is acting for the good and welfare of others, guided by compassion. An example of beneficence in daily nursing care is when a nurse sits with a dying patient and holds their hand to provide presence.
Nursing advocacy extends beyond direct patient care to advocating for beneficence in communities. Vulnerable populations such as children, older adults, cultural minorities, and the homeless often benefit from nurse advocacy in promoting health equity. Cultural humility is a humble and respectful attitude towards individuals of other cultures and an approach to learning about other cultures as a lifelong goal and process.[36] Nurses, the largest segment of the health care community, have a powerful voice when addressing community beneficence issues, such as health disparities and social determinants of health, and can serve as the conduit for advocating for change.
Nonmaleficence
Nonmaleficence is defined by the ANA as “the bioethical principle that specifies a duty to do no harm and balances avoidable harm with benefits of good achieved.”[37] An example of doing no harm in nursing practice is reflected by nurses checking medication rights three times before administering medications. In this manner, medication errors can be avoided, and the duty to do no harm is met. Another example of nonmaleficence is when a nurse assists a client with a serious, life-threatening condition to participate in decision-making regarding their treatment plan. By balancing the potential harm with potential benefits of various treatment options, while also considering quality of life and comfort, the client can effectively make decisions based on their values and preferences.
Justice
Justice is defined by the ANA as “a moral obligation to act on the basis of equality and equity and a standard linked to fairness for all in society.”[38] The principle of justice requires health care to be provided in a fair and equitable way. Nurses provide quality care for all individuals with the same level of fairness despite many characteristics, such as the individual's financial status, culture, religion, gender, or sexual orientation. Nurses have a social contract to “provide compassionate care that addresses the individual’s needs for protection, advocacy, empowerment, optimization of health, prevention of illness and injury, alleviation of suffering, comfort, and well-being.”[39] An example of a nurse using the principle of justice in daily nursing practice is effective prioritization based on client needs.
Read more about prioritization models in the “Prioritization” chapter.
Other Ethical Principles
Additional ethical principles commonly applied to health care include fidelity (keeping promises) and veracity (telling the truth). An example of fidelity in daily nursing practice is when a nurse tells a client, “I will be back in an hour to check on your pain level.” This promise is kept. An example of veracity in nursing practice is when a nurse honestly explains potentially uncomfortable side effects of prescribed medications. Determining how truthfulness will benefit the client and support their autonomy is dependent on a nurse’s clinical judgment, self-reflection, knowledge of the patient and their cultural beliefs, and other factors.[40]
A principle historically associated with health care is paternalism. Paternalism is defined as the interference by the state or an individual with another person, defended by the claim that the person interfered with will be better off or protected from harm.[41] Paternalism is the basis for legislation related to drug enforcement and compulsory wearing of seatbelts.
In health care, paternalism has been used as rationale for performing treatment based on what the provider believes is in the client’s best interest. In some situations, paternalism may be appropriate for individuals who are unable to comprehend information in a way that supports their informed decision-making, but it must be used cautiously to ensure vulnerable individuals are not misused and their autonomy is not violated.
Nurses may find themselves acting paternalistically when performing nursing care to ensure client health and safety. For example, repositioning clients to prevent skin breakdown is a preventative intervention commonly declined by clients when they prefer a specific position for comfort. In this situation, the nurse should explain the benefits of the preventative intervention and the risks if the intervention is not completed. If the client continues to decline the intervention despite receiving this information, the nurse should document the education provided and the client’s decision to decline the intervention. The process of reeducating the client and reminding them of the importance of the preventative intervention should be continued at regular intervals and documented.
Care-Based Ethics
Nurses use a client-centered, care-based ethical approach to patient care that focuses on the specific circumstances of each situation. This approach aligns with nursing concepts such as caring, holism, and a nurse-client relationship rooted in dignity and respect through virtues such as kindness and compassion.[42],[43] This care-based approach to ethics uses a holistic, individualized analysis of situations rather than the prescriptive application of ethical principles to define ethical nursing practice. This care-based approach asserts that ethical issues cannot be handled deductively by applying concrete and prefabricated rules, but instead require social processes that respect the multidimensionality of problems.[44] Frameworks for resolving ethical situations are discussed in the “Ethical Dilemmas” section of this chapter.
Nursing Code of Ethics
Many professions and institutions have their own set of ethical principles, referred to as a code of ethics, designed to govern decision-making and assist individuals to distinguish right from wrong. The American Nurses Association (ANA) provides a framework for ethical nursing care and guides nurses during decision-making in its formal document titled Code of Ethics for Nurses With Interpretive Statements (Nursing Code of Ethics). The Nursing Code of Ethics serves the following purposes[45]:
- It is a succinct statement of the ethical values, obligations, duties, and professional ideals of nurses individually and collectively.
- It is the profession’s nonnegotiable ethical standard.
- It is an expression of nursing’s own understanding of its commitment to society.
The preface of the ANA’s Nursing Code of Ethics states, “Individuals who become nurses are expected to adhere to the ideals and moral norms of the profession and also to embrace them as a part of what it means to be a nurse. The ethical tradition of nursing is self-reflective, enduring, and distinctive. A code of ethics makes explicit the primary goals, values, and obligations of the profession.”[46]
The Nursing Code of Ethics contains nine provisions. Each provision contains several clarifying or “interpretive” statements. Read a summary of the nine provisions in the following box.
Nine Provisions of the ANA Nursing Code of Ethics
- 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 action consistent with the obligation to promote health and to 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 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.
Read the free, online full version of the ANA's Code of Ethics for Nurses With Interpretive Statements.
In addition to the Nursing Code of Ethics, the ANA established the Center for Ethics and Human Rights to help nurses navigate ethical conflicts and life-and-death decisions common to everyday nursing practice.
Read more about the ANA Center for Ethics and Human Rights.
Specialty Organization Code of Ethics
Many specialty nursing organizations have additional codes of ethics to guide nurses practicing in settings such as the emergency department, home care, or hospice care. These documents are unique to the specialty discipline but mirror the statements from the ANA’s Nursing Code of Ethics. View ethical statements of various specialty nursing organizations using the information in the following box.
Ethical Statements of Selected Specialty Nursing Organizations
Nurses frequently find themselves involved in conflicts during patient care related to opposing values and ethical principles. These conflicts are referred to as ethical dilemmas. An ethical dilemma results from conflict of competing values and requires a decision to be made from equally desirable or undesirable options.
An ethical dilemma can involve conflicting patient’s values, nurse values, health care provider’s values, organizational values, and societal values associated with unique facts of a specific situation. For this reason, it can be challenging to arrive at a clearly superior solution for all stakeholders involved in an ethical dilemma. Nurses may also encounter moral dilemmas where the right course of action is known but the nurse is limited by forces outside their control. See Table 6.3a for an example of ethical dilemmas a nurse may experience in their nursing practice.
Table 6.3a. Examples of Ethical Issues Involving Nurses
| Workplace | Organizational Processes | Client Care |
|---|---|---|
|
|
|
Read more about Ethics Topics and Articles on the ANA website.
According to the American Nurses Association (ANA), a nurse’s ethical competence depends on several factors[47]:
- Continuous appraisal of personal and professional values and how they may impact interpretation of an issue and decision-making
- An awareness of ethical obligations as mandated in the Code of Ethics for Nurses With Interpretive Statements[48]
- Knowledge of ethical principles and their application to ethical decision-making
- Motivation and skills to implement an ethical decision
Nurses and nursing students must have moral courage to address the conflicts involved in ethical dilemmas with “the willingness to speak out and do what is right in the face of forces that would lead us to act in some other way.”[49] See Figure 6.7[50] for an illustration of nurses’ moral courage.
Nurse leaders and organizations can support moral courage by creating environments where nurses feel safe and supported to speak up.[51] Nurses may experience moral conflict when they are uncertain about what values or principles should be applied to an ethical issue that arises during patient care. Moral conflict can progress to moral distress when the nurse identifies the correct ethical action but feels constrained by competing values of an organization or other individuals. Nurses may also feel moral outrage when witnessing immoral acts or practices they feel powerless to change. For this reason, it is essential for nurses and nursing students to be aware of frameworks for solving ethical dilemmas that consider ethical theories, ethical principles, personal values, societal values, and professionally sanctioned guidelines such as the ANA Nursing Code of Ethics.
Moral injury felt by nurses and other health care workers in response to the COVID-19 pandemic has gained recent public attention. Moral injury refers to the distressing psychological, behavioral, social, and sometimes spiritual aftermath of exposure to events that contradict deeply held moral beliefs and expectations.[52] Health care workers may not have the time or resources to process their feelings of moral injury caused by the pandemic, which can result in burnout. Organizations can assist employees in processing these feelings of moral injury with expanded employee assistance programs or other structured support programs.[53] Read more about self-care strategies to address feelings of burnout in the "Burnout and Self-Care" chapter.
Frameworks for Solving Ethical Dilemmas
Systematically working through an ethical dilemma is key to identifying a solution. Many frameworks exist for solving an ethical dilemma, including the nursing process, four-quadrant approach, the MORAL model, and the organization-focused PLUS Ethical Decision-Making model.[54] When nurses use a structured, systematic approach to resolving ethical dilemmas with appropriate data collection, identification and analysis of options, and inclusion of stakeholders, they have met their legal, ethical, and moral responsibilities, even if the outcome is less than ideal.
Nursing Process Model
The nursing process is a structured problem-solving approach that nurses may apply in ethical decision-making to guide data collection and analysis. See Table 6.3b for suggestions on how to use the nursing process model during an ethical dilemma.[55]
Table 6.3b. Using the Nursing Process in Ethical Situations[56]
| Nursing Process Stage | Considerations |
|---|---|
| Assessment/Data Collection |
|
| Assessment/Analysis |
|
| Diagnosis |
|
| Outcome Identification |
|
| Planning |
|
| Implementation |
|
| Evaluation |
|
Four-Quadrant Approach
The four-quadrant approach integrates ethical principles (e.g., beneficence, nonmaleficence, autonomy, and justice) in conjunction with health care indications, individual and family preferences, quality of life, and contextual features.[57] See Table 6.3c for sample questions used during the four-quadrant approach.
Table 6.3c. Four-Quadrant Approach[58]
| Health Care Indications
(Beneficence and Nonmaleficence)
|
Individual and Family Preferences
(Respect for Autonomy)
|
| Quality of Life
(Beneficence, Nonmaleficence, and Respect for Autonomy)
|
Contextual Features
(Justice and Fairness)
|
MORAL Model
The MORAL model is a nurse-generated, decision-making model originating from research on nursing-specific moral dilemmas involving client autonomy, quality of life, distributing resources, and maintaining professional standards. The model provides guidance for nurses to systematically analyze and address real-life ethical dilemmas. The steps in the process may be remembered by using the mnemonic MORAL. See Table 6.3d for a description of each step of the MORAL model.[59],[60]
Table 6.3d. MORAL Model
| M: Massage the dilemma | Collect data by identifying the interests and perceptions of those involved, defining the dilemma, and describing conflicts. Establish a goal. |
|---|---|
| O: Outline options | Generate several effective alternatives to reach the goal. |
| R: Review criteria and resolve | Identify moral criteria and select the course of action. |
| A: Affirm position and act | Implement action based on knowledge from the previous steps (M-O-R). |
| L: Look back | Evaluate each step and the decision made. |
PLUS Ethical Decision-Making Model
The PLUS Ethical Decision-Making model was created by the Ethics and Compliance Initiative to help organizations empower employees to make ethical decisions in the workplace. This model uses four filters throughout the ethical decision-making process, referred to by the mnemonic PLUS:
- P: Policies, procedures, and guidelines of an organization
- L: Laws and regulations
- U: Universal values and principles of an organization
- S: Self-identification of what is good, right, fair, and equitable[61]
The seven steps of the PLUS Ethical Decision-Making model are as follows[62]:
- Define the problem using PLUS filters
- Seek relevant assistance, guidance, and support
- Identify available alternatives
- Evaluate the alternatives using PLUS to identify their impact
- Make the decision
- Implement the decision
- Evaluate the decision using PLUS filters
As discussed previously, the American Nurses Association (ANA) defines advocacy at the individual level as educating health care consumers so they can consider actions, interventions, or choices related to their own personal beliefs, attitudes, and knowledge to achieve the desired outcome. In this way, the health care consumer learns self-management and decision-making.[63] Advocacy at the interpersonal level is defined as empowering health care consumers by providing emotional support, assistance in obtaining resources, and necessary help through interactions with families and significant others in their social support network.[64]
What does advocacy look like in a nurse’s daily practice? The following are some examples provided by an oncology nurse[65]:
- Ensure Safety. Ensure the client is safe when being treated in a health care facility and when they are discharged by communicating with case managers or social workers about the client’s need for home health or assistance after discharge so it is arranged before they go home.
- Give Clients a Voice. Give clients a voice when they are vulnerable by staying in the room with them while the doctor explains their diagnosis and treatment options to help them ask questions, get answers, and translate information from medical jargon.
- Educate. Educate clients on how to manage their current or chronic conditions to improve the quality of their everyday life. For example, clients undergoing chemotherapy can benefit from the nurse teaching them how to take their anti-nausea medication in a way that will be most effective for them and will allow them to feel better between treatments.
- Protect Patient Rights. Know clients’ wishes for their care. Advocacy may include therapeutically communicating a client’s wishes to an upset family member who disagrees with their choices. In this manner, the client’s rights are protected and a healing environment is established.
- Double-Check for Errors. Know that everyone makes mistakes. Nurses often identify, stop, and fix errors made by interprofessional team members. They flag conflicting orders from multiple providers and notice oversights. Nurses should read provider orders and carefully compare new orders to previous documentation. If an order is unclear or raises concerns, a nurse should discuss their concerns with another nurse, a charge nurse, a pharmacist, or the provider before implementing it to ensure patient safety.
- Connect Clients to Resources. Help clients find resources inside and outside the hospital to support their well-being. Know resources in your agency, such as case managers or social workers who can assist with financial concerns, advance directives, health insurance, or transportation concerns. Request assistance from agency chaplains to support spiritual concerns. Promote community resources, such as patient or caregiver support networks, Meals on Wheels, or other resources to meet their needs.
Nurses must recognize their unique position in client advocacy to empower individuals to provide them with the support and resources to make their best judgment. The intimate and continuous nature of the nurse-patient relationship places nurses in a prime position to identify and address the needs and concerns of their patients. This relationship is built on trust, empathy, and consistent interaction, which allows nurses to gain a deep understanding of their patients' values, preferences, and personal circumstances. By leveraging this close proximity and strong rapport, nurses can effectively advocate for their patients, ensuring that their voices are heard, and their wishes are respected in all aspects of care.[66]
The power of the nurse-patient relationship extends beyond the immediate clinical environment. Nurses often act as liaisons between patients and the broader health care team, facilitating communication and ensuring that patient preferences are integrated into care plans. This advocacy role is crucial in navigating complex health care systems where patients may feel overwhelmed or marginalized. Nurses can help demystify medical jargon, explain treatment options, and support patients in making informed decisions that align with their values and goals. Through education and emotional support, nurses empower patients to take an active role in their own care, enhancing patient autonomy and satisfaction.[67]
In addition to direct patient care, nurses play a pivotal role in identifying systemic issues that affect patient outcomes. Their frontline perspective provides valuable insights into the barriers patients face in accessing quality care, such as socioeconomic challenges, cultural barriers, and institutional policies. By advocating for policy changes and improvements in health care delivery, nurses contribute to creating a more equitable and patient-centered health care system. Their advocacy efforts can lead to the implementation of practices and policies that better address the needs of diverse patient populations, ultimately improving health outcomes on a broader scale.[68]
Nurses' advocacy is also essential in situations where patients are unable to speak for themselves, such as in cases of severe illness, disability, or end-of-life care. In these instances, nurses must be vigilant in recognizing and addressing the needs of vulnerable patients, ensuring that their rights and dignity are upheld. This may involve working closely with families and caregivers, coordinating with interdisciplinary teams, and navigating ethical dilemmas to provide the best possible care for the patient.
Nurses frequently find themselves involved in conflicts during patient care related to opposing values and ethical principles. These conflicts are referred to as ethical dilemmas. An ethical dilemma results from conflict of competing values and requires a decision to be made from equally desirable or undesirable options.
An ethical dilemma can involve conflicting patient’s values, nurse values, health care provider’s values, organizational values, and societal values associated with unique facts of a specific situation. For this reason, it can be challenging to arrive at a clearly superior solution for all stakeholders involved in an ethical dilemma. Nurses may also encounter moral dilemmas where the right course of action is known but the nurse is limited by forces outside their control. See Table 6.3a for an example of ethical dilemmas a nurse may experience in their nursing practice.
Table 6.3a. Examples of Ethical Issues Involving Nurses
| Workplace | Organizational Processes | Client Care |
|---|---|---|
|
|
|
Read more about Ethics Topics and Articles on the ANA website.
According to the American Nurses Association (ANA), a nurse’s ethical competence depends on several factors[69]:
- Continuous appraisal of personal and professional values and how they may impact interpretation of an issue and decision-making
- An awareness of ethical obligations as mandated in the Code of Ethics for Nurses With Interpretive Statements[70]
- Knowledge of ethical principles and their application to ethical decision-making
- Motivation and skills to implement an ethical decision
Nurses and nursing students must have moral courage to address the conflicts involved in ethical dilemmas with “the willingness to speak out and do what is right in the face of forces that would lead us to act in some other way.”[71] See Figure 6.7[72] for an illustration of nurses’ moral courage.
Nurse leaders and organizations can support moral courage by creating environments where nurses feel safe and supported to speak up.[73] Nurses may experience moral conflict when they are uncertain about what values or principles should be applied to an ethical issue that arises during patient care. Moral conflict can progress to moral distress when the nurse identifies the correct ethical action but feels constrained by competing values of an organization or other individuals. Nurses may also feel moral outrage when witnessing immoral acts or practices they feel powerless to change. For this reason, it is essential for nurses and nursing students to be aware of frameworks for solving ethical dilemmas that consider ethical theories, ethical principles, personal values, societal values, and professionally sanctioned guidelines such as the ANA Nursing Code of Ethics.
Moral injury felt by nurses and other health care workers in response to the COVID-19 pandemic has gained recent public attention. Moral injury refers to the distressing psychological, behavioral, social, and sometimes spiritual aftermath of exposure to events that contradict deeply held moral beliefs and expectations.[74] Health care workers may not have the time or resources to process their feelings of moral injury caused by the pandemic, which can result in burnout. Organizations can assist employees in processing these feelings of moral injury with expanded employee assistance programs or other structured support programs.[75] Read more about self-care strategies to address feelings of burnout in the "Burnout and Self-Care" chapter.
Frameworks for Solving Ethical Dilemmas
Systematically working through an ethical dilemma is key to identifying a solution. Many frameworks exist for solving an ethical dilemma, including the nursing process, four-quadrant approach, the MORAL model, and the organization-focused PLUS Ethical Decision-Making model.[76] When nurses use a structured, systematic approach to resolving ethical dilemmas with appropriate data collection, identification and analysis of options, and inclusion of stakeholders, they have met their legal, ethical, and moral responsibilities, even if the outcome is less than ideal.
Nursing Process Model
The nursing process is a structured problem-solving approach that nurses may apply in ethical decision-making to guide data collection and analysis. See Table 6.3b for suggestions on how to use the nursing process model during an ethical dilemma.[77]
Table 6.3b. Using the Nursing Process in Ethical Situations[78]
| Nursing Process Stage | Considerations |
|---|---|
| Assessment/Data Collection |
|
| Assessment/Analysis |
|
| Diagnosis |
|
| Outcome Identification |
|
| Planning |
|
| Implementation |
|
| Evaluation |
|
Four-Quadrant Approach
The four-quadrant approach integrates ethical principles (e.g., beneficence, nonmaleficence, autonomy, and justice) in conjunction with health care indications, individual and family preferences, quality of life, and contextual features.[79] See Table 6.3c for sample questions used during the four-quadrant approach.
Table 6.3c. Four-Quadrant Approach[80]
| Health Care Indications
(Beneficence and Nonmaleficence)
|
Individual and Family Preferences
(Respect for Autonomy)
|
| Quality of Life
(Beneficence, Nonmaleficence, and Respect for Autonomy)
|
Contextual Features
(Justice and Fairness)
|
MORAL Model
The MORAL model is a nurse-generated, decision-making model originating from research on nursing-specific moral dilemmas involving client autonomy, quality of life, distributing resources, and maintaining professional standards. The model provides guidance for nurses to systematically analyze and address real-life ethical dilemmas. The steps in the process may be remembered by using the mnemonic MORAL. See Table 6.3d for a description of each step of the MORAL model.[81],[82]
Table 6.3d. MORAL Model
| M: Massage the dilemma | Collect data by identifying the interests and perceptions of those involved, defining the dilemma, and describing conflicts. Establish a goal. |
|---|---|
| O: Outline options | Generate several effective alternatives to reach the goal. |
| R: Review criteria and resolve | Identify moral criteria and select the course of action. |
| A: Affirm position and act | Implement action based on knowledge from the previous steps (M-O-R). |
| L: Look back | Evaluate each step and the decision made. |
PLUS Ethical Decision-Making Model
The PLUS Ethical Decision-Making model was created by the Ethics and Compliance Initiative to help organizations empower employees to make ethical decisions in the workplace. This model uses four filters throughout the ethical decision-making process, referred to by the mnemonic PLUS:
- P: Policies, procedures, and guidelines of an organization
- L: Laws and regulations
- U: Universal values and principles of an organization
- S: Self-identification of what is good, right, fair, and equitable[83]
The seven steps of the PLUS Ethical Decision-Making model are as follows[84]:
- Define the problem using PLUS filters
- Seek relevant assistance, guidance, and support
- Identify available alternatives
- Evaluate the alternatives using PLUS to identify their impact
- Make the decision
- Implement the decision
- Evaluate the decision using PLUS filters
In addition to using established frameworks to resolve ethical dilemmas, nurses can also consult their organization’s ethics committee for ethical guidance in the workplace. Ethics committees are typically composed of interdisciplinary team members such as physicians, nurses, allied health professionals, administrators, social workers, and clergy to problem-solve ethical dilemmas. See Figure 6.8[85] for an illustration of an ethics committee. Hospital ethics committees were created in response to legal controversies regarding the refusal of life-sustaining treatment, such as the Karen Quinlan case.[86] Read more about the Karen Quinlan case and controversies surrounding life-sustaining treatment in the “Legal Implications” chapter.
After the passage of the Patient Self-Determination Act in 1991, all health care institutions receiving Medicare or Medicaid funding are required to form ethics committees. The Joint Commission (TJC) also requires organizations to have a formalized mechanism of dealing with ethical issues. Nurses should be aware of the process for requesting guidance and support from ethics committees at their workplace for ethical issues affecting patients or staff.[87]
Institutional Review Boards and Ethical Research
Other types of ethics committees have been formed to address the ethics of medical research on patients. Historically, there are examples of medical research causing harm to patients. For example, an infamous research study called the “Tuskegee Study” raised concern regarding ethical issues in research such as informed consent, paternalism, maleficence, truth-telling, and justice.
In 1932 the Tuskegee Study began a 40-year study looking at the long-term progression of syphilis. Over 600 Black men were told they were receiving free medical care, but researchers only treated men diagnosed with syphilis with aspirin, even after it was discovered that penicillin was a highly effective treatment for the disease. The institute allowed the study to go on, even when men developed long-stage neurological symptoms of the disease and some wives and children became infected with syphilis. In 1972 these consequences of the Tuskegee Study were leaked to the media and public outrage caused the study to shut down.[88]
Potential harm to patients participating in research studies like the Tuskegee Study was rationalized based on the utilitarian view that potential harm to individuals was outweighed by the benefit of new scientific knowledge resulting in greater good for society. As a result of public outrage over ethical concerns related to medical research, Congress recognized that an independent mechanism was needed to protect research subjects. In 1974 regulations were established requiring research with human subjects to undergo review by an institutional review board (IRB) to ensure it meets ethical criteria. An IRB is group that has been formally designated to review and monitor biomedical research involving human subjects.[89] The IRB review ensures the following criteria are met when research is performed:
- The benefits of the research study outweigh the potential risks.
- Individuals’ participation in the research is voluntary.
- Informed consent is obtained from research participants who have the ability to decline participation.
- Participants are aware of the potential risks of participating in the research.[90]
A True Story of a New Nurse’s Introduction to Ethical Dilemmas
A new nurse graduate meets Mary, a 70-year-old woman who was living alone at home with Amyotrophic Lateral Sclerosis (ALS or also referred to as “Lou Gehrig’s disease”). Mary’s husband died many years ago and they did not have children. She had a small support system, including relatives who lived out of state and friends with whom she had lost touch since her diagnosis. Mary was fiercely independent and maintained her nutrition and hydration through a gastrostomy tube to avoid aspiration.
As Mary’s disease progressed, the new nurse discussed several safety issues related to Mary living alone. As the new nurse shared several alternative options related to skilled nursing care with Mary, Mary shared her own plan. Mary said her plan included a combination of opioids, benzodiazepines, and a plastic bag to suffocate herself and be found by a nurse during a scheduled visit. In addition to safety issues and possible suicide ideation, the new nurse recognized she was in the midst of an ethical dilemma in terms of the treatment plan, her values and what she felt was best for Mary, and Mary’s preferences.
Applying the MORAL Ethical Decision-Making Model to Mary’s Case
| Massage the Dilemma | Data: Mary lives alone and does not want to go to a nursing home. She lacks social support. She has a progressive and incurable disease that affects her ability to swallow, talk, walk, and eventually breathe. She has made statements to staff indicating she prefers to die rather than leave her home to receive total care in a long-term care setting.
Ethical Conflicts: According to the deontological theory, suicide is always wrong. According to the consequentialism ethical theory, an action's morality depends on the consequences of that action. Mary has a progressive, incurable illness that requires total care that will force her to leave the home. She wishes to stay in her home until she dies. Ethical Goals: To honor Mary’s dignity and respect her autonomy in making treatment decisions. For Mary to experience a “good” death as she defines it, and neither hasten nor prolong her dying process through illegal or amoral interventions. |
|---|---|
| Outline the Options |
|
| Review Criteria and Resolve | Mary was assessed to be rational and capable of decision-making by a psychiatrist. Mary defined a “good” death as one occurring in her home and not in a hospital or long-term care setting. Mary did not want her life to be prolonged through the use of technology such as a ventilator.
Resolution: Mary elected to discontinue tube feeding and limit hydration to only that necessary for medication to provide comfort care and symptom management. |
| Affirm Position and Act | Although some health care members did not personally believe in discontinuing food and fluids through the g-tube based on their interpretation of the deontological ethical theory, Mary’s decision was acceptable both legally and ethically, based on the consequentialism ethical theory that the decision best supported Mary’s goals and respected her autonomy.
Daily visits were scheduled with hospice staff, including the nurse, nursing assistant, social worker, chaplain, and volunteers. Hired caregivers supplemented visits and in the last couple of days were scheduled around the clock. Mary died comfortably in her bed seven days after implementation of the agreed-upon plan. |
| Look Back | The health care team evaluated what happened during Mary’s situation and what could be learned from this ethical dilemma and applied to future patient-care scenarios. |
