The Ethical Comportment and Formation Apprenticeship Part 3: “Nursing Ethics as Evident in Early Writings on Ethics for Nursing Education”



Patricia Benner, R.N. Ph.D., FAAN

Copyright September 20, 2021

Provisions of the 2015 ANA CODE OF ETHICS:  American Nurses Association, Code of Ethics for Nurses with Interpretive Statements 2015. Marsha Fowler, Lead Co-Writer, committee “Historian and Code Scholar”

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 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.


This is our second installment on the Third Professional Apprenticeship, “Ethical Comportment and Formation,”the first was with Sara Shannon talking about professional ethics and bioethics (July 27, 2021). We begin with the Provisions of the 2015 ANA Code of Ethics for Nurses with Interpretive Statements. Marsha Fowler, Lead Co-writer of the 2015 revision of the ANA Code of Ethics for Nurses with Interpretive Statements, and designated “Historian and Code Scholar” presents a 20-minute lecture on Nursing Ethics based upon early ethics writings from the late 1800s to 1965. This body of literature on ethics, and the Code of Ethics itself, as Fowler points out, considerably predates the emergence of bioethics as a discipline (Beauchamp and Childress, 2019), which is a principles-based ethics seeking to assist with resolving breakdowns in ethical practice and dilemmas and conflicts related to ethical issues in clinical practice. Note that the provisions of the Code of Ethics do not employ the language or concepts of bioethics. In the National Carnegie Foundation for the Advancement of Teaching Study of Nursing, (Benner, et. al., 2010) it was found that both faculty and students responded to questions about where nursing ethics is taught in the curriculum and what the ethical content consists of, with answers that reflected the principle-based ethics of bioethics. This indicated that faculty and students considered the official ethical content in the nursing curriculum to be bioethics. Despite these assumptions, a strong practice-based ethical content was evident in the clinical practice segment of nursing curricula. Senior nursing students identified the following ethical concerns/notions of good in their clinical narratives about what they considered important instances of good practice:

Examples of student nurses’ ethical concerns:

  •  Meeting the patient as a person: Many clinical examples were given about breaking through the impersonal bureaucratic environment of caring for the many to the individualized attention, getting to know the patient as a person rather than a disease, injury, or condition.
  • Preserving the dignity and personhood of the patient: The anonymity and depersonalization of the individual erode a sense of self and dignity, and nurses had many practices for discovering and preserving the sense of self and dignity in the context of the institutionalizing and depersonalization of the hospital.
  • Responding to sub-standard practice: Senior nursing students found it essential to good ethical practice to correct and respond with efforts to improve substandard nursing care.
  • Advocating for patients: The most frequent narratives exemplifying a strong notion of good practice had to do with “advocating for patients,” which had a broad range of practical meanings, such as “standing alongside in support and strengthening the patient;” “giving the silent patient their voice…their right to be represented and heard.” Advocating for patients was heavily dependent upon the first three notions of good: a) meeting the patient as a person; b) preserving dignity and personhood of the patient, c) responding to sub-standard practice.
  • Engaging fully in learning to do “good” nursing practice: (Taken from students’ responses in The Carnegie Study, Benner,, 2010.)  Engaging in a self-improving practice, which is a central notion of good essential for the integrity of professional practice (MacIntyre, A., 2007), was also a frequently mentioned theme of senior nursing students in the examples they gave of the “best of their practice” or clinical situations that “taught them something new or important”.

It seemed worthy to mention these practice-based sources of notions of good, or ethical concerns, pervasive in Senior Nursing Students Clinical Practice Narratives, because they are highly relational, with great concern for the patient as a person, and concern for the safety and personal and social well-being of the patient (Benner,, 2010). The practice-based ethical concerns were broader than a principle-based, practice-breakdown and repair approach taken in Bioethics (Beauchamp and Childress, 2019). These notions of good practice in nursing expressed in senior clinical narratives exemplify the nine major Provisions of the ANA Code of Ethics. They resonate with the early writings on nursing ethics in the nursing literature from the late 1800s to 1965 studied by Dr. Marsha Fowler and discussed in her presentation on Nursing Ethics. Dr. Marsha Fowler closes her presentation with an eloquent mandate to take seriously nursing’s early ethical statements and commitments. Despite the formal claims made in nursing content on ethics being focused on bioethics (ethics taught in clinical practice), it is heartening to see relational ethics related to the personal and social well-being of the patient are alive and well in actual clinical narratives from actual practice.



ANA Code of Ethics for Nurses, with Interpretive Statements. (2015) American Nurses’ Association. Silver Spring, MD.

Beauchamp, T.F., Childress, (2019) Principles of Bioethics. Eighth Edition. Oxford University Press. 

Benner, P., Sutphen, M., Leonard-Kahn, V., Day, L. (2010) Educating Nurses: A Call for Radical Transformation. Jossey-Bass, Carnegie Foundation for Advancement of TeachingStanford.

Fowler, Marsha. Fowler, Marsha (2017).  “Why the history of nursing ethics matters,” Nursing Ethics, 2017, 24(3), 292-304.

MacIntyre, A., (2007) After Virtue. Third Edition. Notre Dame University Press.



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