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. 2021 Oct 8;62:151508. doi: 10.1016/j.apnr.2021.151508

Table 2.

Code of ethics provisions with exemplars.

The following provisions were specifically identified by one or more participant as being “most relevant.” The selections are presented as described by the participant, even when they might not align with the Interpretive Statement of the ANA Code of Ethics (ANA, 2015).
Provision Endorsed Exemplar statements
Provision 1. The nurse practices with compassion and respect for the inherent dignity, worth, and personal attributes of every person, without prejudice. This provision was not selected; however, nurses spoke of compassion and respect.
Provision 2. The nurse's primary commitment is to the patient, whether an individual, family, group, community, or population. One nurse chose both Provision 2 and Provision 3, with this rationale: “When the pandemic hit, we are thinking about our patients but also thinking about how their care affects the whole family and our community and the population…I struggle with advocating for a family (who) can't get childcare. It's a single mom and they can't get childcare, but they're able to make it to this appointment but the clinic won't let them in because there's more than one person accompanying this patient” (G3, P1)
Provision 3. The nurse promotes, advocates for, and protects the rights, health and safety of the patient. One nurse identified Provision 3 directly: however, many across and within groups spoke about being an advocate for patients. Several nurses confessed to internal struggles over limiting visitors for frail older patients and those who were isolated. “I think we've all been, as nurses, traumatized by the restricted visitation at various points. And then just helping even using our own devices to make sure that the patients can talk to their family members via technology has been huge and really helpful…And now visitation has eased up a little bit. Certainly been less distressing for some of us nurses, because having that support person at the bedside is just huge.” (G4, P4)
“You know that really impacted the way we practice…It impacted them and us. You know of course our team is always supportive and caring and just going above and beyond. But during these scary times, you know our patients are already quarantining and already isolated and then you throw this in the mix. They're terrified and they don't have the same supports that they usually had within the treatment room, within the treatment center and that's impacted us as well.” (G4, P3)
Provision 4. The nurse has authority, accountability, and responsibility for nursing practice, makes decisions, and takes action consistent with the obligation to provide optimal care. Nurses were acutely aware of their responsibility to provide optimal care as well as the tensions that arose in trying to do so. “You're right, I think we had a lot of people say ‘Yes, I'm ready, I can do it. We can take action.’ There was a lot of involvement in making sure we were doing the right things by ourselves to mitigate our own risk in order to continue to take care of our patient population.” (G1, P6)
Another nurse agreed describing the way they acclimated to different units or patient populations. “So we were challenged with taking care of a lot of SICU patients and medical ICU patients that we aren't used to the care of. Getting to know new teams, their way of doing things, caring for patients and learning about diagnoses we haven't talked about—some of us—in 10–20 years…” (G1, P7)
Others echoed these beliefs with the inability to provide “optimal care.” They also cited the rewards in finding creative ways to communicate with families. “They need us, I would hope they would need us more now than they ever would… there's a lot of things that are still happening besides COVID out there that we still need to consider in our everyday lives. Appointments were being put on hold and now we have patients coming in that are flaring, can't control their pain because they were afraid to come out and seek care because of COVID.” (G3, P1)
“… every one's coming together and keeping positive and trying to do the best we can. Even some pride in my immediate family, I almost feel like they're helping me take care of you know the community by helping educate a little bit. Yeah, just pride I would say.” (G4, P4)
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. Only one nurse chose Provision 5, but it prompted others in the group to validate the importance of self-care. “So I think it was #5 up on the code but [it] was the self-care. That's well you know, we'll just call it self-care for now. You know it's not only my employees but the vulnerable populations that we're taking care of. And you know kind of what all that meant and implementing all those safety standards and so on going forth.” (G4, P3)
“I will say I did take my vacation that I had planned…but there was a part of me that felt guilty going away.” (G4, P1)
“I think as a group, you know, it was mentioned earlier that we take care of everyone and leave ourselves for last. I think that we have to be reminded that it's ok for us to take some time for ourselves. Because you know you just keep going, going, going in this crisis pandemic situation and you really do need to step back and reset. And sometimes, you know you should and sometimes having someone remind you or make you do it is a good thing.” (G6, P1)
Provision 6. The nurse, through individual and collective action, establishes, maintains, and improves the moral environment of the work setting and the conditions of employment, conducive to quality health care. One nurse was clear that this provision was very relevant. “Quality care. I think we all experienced – we went from hand washing, was the big focus to handwashing, masks, gloves, gowns, fit testing, PPE, you know and learning so many new guidelines that changed so frequently…my cardiac rehab nurse went to the testing site. So a huge eye opener for her…You hugged everybody, you were friends with them, to being covered up and swabbing people, you know, watching your distance, maintaining your social distance, going home and showering, changing and washing your clothes.” (G1, P4)
Another spoke about the importance of science as a guiding principle. “I think there's this division in the country, there's a lack of the science and the evidence being shared to really protect people and I think that puts nurses in a really challenging position ethically and it eats away at your moral compass. Because you know the right things to do and what we should be doing, and yet they're not being done.” (G2, P5)
Provision 7. The nurse, whether in research, practice, education, or administration, contributes to the advancement of the profession through research and scholarly inquiry, professional standards development, and generation of nursing and health policies. This provision was not selected although the nurse's role as “scientist” and “educator” was described.
Provision 8. The nurse collaborates with other health professionals and the public to protect and promote human rights, health diplomacy, and health initiatives. Two nurses commented on the role of nurses as community ambassadors who were resources for both their colleagues, families, and the larger community. “And then #8, I think we all do. The nurse collaborates with other healthcare professionals and the public, community, national, international. I'm sure as nurses, we get all of our families reaching out to us for all of their medical questions, guidance, what do you think. I think we all get those calls. And it's been an eye opener. I think it's made me educate myself even more. What should I be telling people, what should I be practicing, what should I be promoting?” (G1, P4)
Other nurses noted that the reframing of the practice environment also led to interpersonal challenges related to team collaboration. “I think for me, Provision 8. Collaborating with other health professionals and the public has been really integral to what I've been doing. I've had to find new ways to connect with the staff in XXX, our schedulers, our providers who have also been working remotely and then relay all this information to our patients and you know keep everybody connected without seeing anyone for months at a time.” (G6, P4)
“I think people came together pretty well especially at the beginning. It was kind of like have each other's back. But then there were definitely people that there was ruffled feathers and talking among (themselves) that they felt like different people were taking advantage of the system…. So then I think there was some angst towards specific people. I didn't really care about that. I just do what I want to do and go to work but that's like lunchroom conversation that you would hear.” (G4, P1)
“…I just feel like there's 19 different paths and it's so uncertain which was it's going to go that you almost, you can't wrap your head around it to make a good solid plan moving forward other than to just prepare for all 19 paths and then like you said before about the conflict and how other people feel about it and the dissent.” (G1, P6)
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. Although no one identified Provision 9 as most relevant, there were discussions around the role of nurses given the current political climate and need for social justice.