GCOE Provision 4-6

2015 American Nurses
PROVISIONS 4-6,
BOUNDARIES OF
DUTY AND
LOYALTY
Slide Deck 2
2015 American Nurses Association

Provisions 4-6, Boundaries of Duty
and Loyalty
What do we mean by boundaries of duty and
loyalty?
Provisions 4-6 focus on the individual nurses
responsibility and accountability in nursing practice,
as well as the promotion of safe, quality health care.
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.
Interpretive Statements
4.1 Authority, Accountability, and Responsibility
4.2 Accountability for Nursing Judgments, Decisions, and
Actions
4.3 Responsibility for Nursing Judgments, Decisions, and
Actions
4.4 Assignment and Delegation of Nursing Activities or
Tasks
4.1 Authority, Accountability and
Responsibility
Nurses are always accountable for their own actions,
maintaining their competence to ensure safe
practice.
Technological advancements require ongoing
learning.
Evidence-informed practice mandates continuous
learning.
Shifting patterns of health care delivery demand
orientation to changing lines of authority,

communication channels and multisystem policies.
APRNs adhere to scope of practice, as state nurse
practice acts vary and reform roles periodically.

4.2 Accountability for Nursing
Judgments, Decisions, and Actions
Fidelity (loyalty, including
keeping promises, honoring
agreements, performing
competently, etc.)
Veracity (truth-telling; non-
deception)
Beneficence (doing what
benefits the patient)
Nonmaleficence (non-
infliction of harm)
Beauchamp & Childress, 2013

Ethical Virtues of All Health
Professionals
Compassion
Discernment
Trustworthiness
Integrity
Conscientiousness
Beauchamp & Childress, 2013

Virtues Specific to Nursing
Wisdom
Patience
Compassion
Honesty
Altruism
Courage
4.3 Responsibility for Nursing
Judgments, Decisions and Actions
Adhere to Nursing: Scope and
Standards of Practice, including
APRN scope and standards
Maintain standards of practice
Participate in peer review,
credentialing
Engage in committees and other
mechanisms to make sound
decisions about quality and safety
of care
Refuse assignments beyond
competence
Seek consultation when in doubt
4.4 Assignment Delegation of
Nursing Activities or Tasks
Delegate tasks consistent with your states nurse
practice act
Assess qualifications and competence of those
whom you delegate or assign
Participate in orientation, skill development,
continuing education, competency verification
and staffing policies to ensure safe care
Engage in shared responsibility for educating
student nurses
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.
5.1 Duties to Self and Others
5.2 Promotion of Personal Health, Safety and Well-Being
5.3 Preservation of Wholeness of Character
5.4 Preservation of Integrity
5.5 Maintenance of Competence and Continuation of
Professional Growth
5.6 Continuation of Personal Growth
5.1 Duties to Self and Others
Nurses must take care of themselves before taking
care of others.
Self-regarding duties include health, safety,
integrity, competence and professional growth.
5.2 Promotion of Personal Health,
Safety and Well-Being
Nurses have a duty to model health promotion to
patients and the public.
Fatigue and compassion fatigue may be
occupational hazards for nurses in intense clinical
practice.
Balance in personal and professional life is
essential for well-being.

Good diet, exercise, healthy sleep patterns and
healthy relationships are all factors in maintaining
this balance.
5.3 Preservation of Wholeness of
Character
Nurses are moral agents in any setting, as they
embrace the values of the profession and display
them in their communication and actions.
Nurses should assess risks to integrity ahead of
employment decisions.
Nurses personal values merge with professional
values, creating an identity that is reflected in
practice and permeates private life.
Thieves, liars and cheats do not make good nurses!
Felonious record disqualifies a person from becoming a
nurse
Nurses can foster a community of moral discourse
where open dialogue about crucial health issues is
facilitated.
Undue Influence of Patients
Because nurses are respected and have authority,

their influence on patient decision-making may be
unduly influential; nurses should avoid coercion or
unintentional pressure in helping patients articulate
their own values and preferences.
How do you respond?
An elderly patient faces a
tough decision about
whether to undergo
chemotherapy to prolong
her life. The patient asks
you what you would do in
her shoes.
How do you respond?
How does the Code

guide you?
5.4 Preservation of Integrity
When integrity is eroded, nurses may experience moral
distress.
Threats to integrity may be encountered in practice.
Nurses may be asked to take action in conflict with personal or
professional values or the Code.
Nurses have a right and duty to express their opposition and only
compromise if such a decision preserves their moral integrity.
Integrity-preserving
compromise is more likely in a safe
environment of mutual respect where open moral
dialogue is encouraged.

Conscientious Objection
Conscientious objection enables an individual to
refuse participation in an activity that violates
personal values or beliefs.
Select an employer whose values correspond with
your own, whose routine practices do not violate
your beliefs.
Timely appropriate communication to supervisors
is necessary to make alternate arrangements in
order to avoid neglect of care or patient
abandonment.
Conscientious Objection
When is it imperative to refuse to
participate in a practice that conflicts
with your values?
Thousand Shades of Grey
ethics isnt about choosing between
right and wrong; its about choosing
between grey and grey. Its about
choosing between two equally desirable,
but mutually exclusive courses of action.
Freedom or security? Courage or comfort?
Self-examination or blissful happiness?
-Will Ferguson,Happiness
Ethical Unloading
Moral distress
Cumulative moral residue
Crescendo effect
Burnout/rustout
Moral courage
5.5 Maintenance of Competence
and Continuation of Professional
Growth
5.6 Continuation of Personal
Growth
Evaluate performance periodically
using standards and peer review

Commit to lifelong learning and
advanced study
Broaden understanding of the
world, human beings and

themselves as moral agents in the
world
Provision 6
The nurse, through individual and collective effort,
establishes, maintains, and improves the ethical
environment of the work settings and conditions of
employment that are conducive to safe, quality
health care.
6.1 The Environment and Moral Virtue
6.2 The Environment and Ethical Obligation
6.3 Responsibility for the Health care Environment
6.1 The Environment and Moral
Virtue
Additional Virtues
Virtues Expected of All:Expected of All
Integrity Nurses:
Respect Knowledge
Moderation Skill
Industry Wisdom
Patience
Compassion
Honesty
Altruism
Courage
Moral Milieu
For virtues to flourish, the work climate should
foster:
Respect and trust
Mutual caring
Communication
Generosity
Kindness
Equality
Prudence
Transparency
6.2 The Environment and Ethical
Obligation
Create a culture of excellence
Formulate clear policies and procedures
Ensure all nurses have working knowledge of the
Code
Provide functional Ethics Committees
Treat employees fairly and with dignity
Facilitate mechanisms for grievances to be aired
in a fair and timely fashion
6.3 Responsibility for the Health
Care Environment
Ensure ongoing professional development and
evaluation of all staff
Participate in interprofessional workplace
advocacy to address unethical practice
Continue to express concerns over unacceptable
ethical practice, documenting these sequentially
Resign after repeated unsuccessful attempts to
change unjust or unethical practice in order to
preserve integrity, or risk being complicit in
unethical practice
Mutual Ethical Integrity
What can we do collaboratively to
shape a future for nursing that fosters
ethical integrity in all dimensions
of practice?
Ethical living requires coping well with
the lives fate has dealt us. Our lives
routinely demand that we choose well
from among myriad options for shaping
our common destinies. We are enlarged
by the magnitude of our responsibilities
for shaping the future. Every human life
takes on a singular majesty when
dedicated to the noble quest for ethical
living.
-Anita Allen, 2004

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2015 American Nurses

2015 American Nurses Association

orientation to changing lines of authority,

practice acts vary and reform roles periodically.

Beauchamp & Childress, 2013

Beauchamp & Childress, 2013

essential for well-being.

Because nurses are respected and have authority,

How does the Code

using standards and peer review

world, human beings and

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