bioethics, Code of Ethics for Nurses, history, Nightingale Pledge, nursing, nursing ethics



  1. Fowler, Marsha D.
  2. Schoonover-Shoffner, Kathy


ABSTRACT: Modern nursing is supported by a rich ethical tradition dating back to the mid-19th century. Moving illustrations of nursing practice and "the highest morals" (McIsaac, 1901) relay the distinguished history and distinctives of nursing ethics from the 1860s to the present day. Of note is that nursing ethics is relationally focused, virtue-based, preventative, and central to the identity of nursing. A brief history of how bioethics emerged in the mid-20th century and an overview of the development of nursing ethics unveils differences between the two ethical paradigms.


Article Content

Unfortunately, too many people regard nursing as a mere occupation, not a profession, and such persons fail to recognize its ethical side, which should stand for the highest morals in human life.... No other class of people, not even the clergy or medical profession, has better opportunity to know life as it really is, stripped of all pretense and make believe, as we have. (McIsaac, 1901, pp. 483, 484)

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These words, penned over 120 years ago, strikingly reveal the profound and intimate work of nursing and the heart of ethical practice. McIsaac captured the essence of good nursing-rising to the highest morals. Nurses throughout history have faced extraordinary ethical demands in caring for people in the most difficult challenges of life. The nurses who first cared for COVID patients in Wuhan, Hubei Province, China, encountered frightening dilemmas and yet rose to the highest morals (Liu et al., 2022):


When I first came to the ward, I was worried that my protection was not good enough and I didn't dare get too close to the patient. But, when I saw the patient was in pain, I want to help him or her from the bottom of my heart. (p. 14)


Even [though] there are pressure ulcers and blisters on my face [from masks, goggles], I have to take protection properly and continue to finish my job. It is my responsibility to hold my ground. (p. 11)


The patient was so young, and his desire to live was so strong. We already know we couldn't save his life, but we try to because we knew there were his wife and child waiting for him. (p. 14)


Nurses in the United States also were challenged in caring for COVID patients and rose to the highest morals:


I'm barely upright. More than 80 hours in the last week. All our patients are on ventilators. I do this work to help people. Now we just help them die. The patients that are awake and understand cry when I hold their hands and pray aloud for them while they try to breathe. I do that with every single one of them. We're getting crushed physically and emotionally. Every day it gets worse. (ICU nurse, personal communication, 2020)


After Russia invaded Ukraine in 2022, nurses like Tetiana Freishyn working in Ivano-Frankivsk rose to the highest moral standards:


When the explosions first went off on 24 February, I turned up the volume of my children's TV cartoons, so that they wouldn't hear the noise. I was very much in doubt whether to stay or leave, but as a medical surgical nurse, I quickly realized that my skills were needed here. So, I stayed. (World Health Organization [WHO], 2022, para. 1)


These nurses' selfless actions not only reflect the highest morals, they vividly portray the essence of nursing ethics-relationship. Their words and McIsaac's reflections reveal the richness of nursing ethics, a relational ethics that developed long before the bioethics of today. What is our ethical heritage in nursing? How is it different from bioethics, and why does nursing ethics matter?



Since the 1970s, nurses have been taught biomedical ethics or bioethics and its four major principles: respect for autonomy (the right to make one's own choices); beneficence (acting with the best interest of the other); nonmaleficence (doing no harm); and justice (fairness and equality) (Beauchamp & Childress, 1979; Belmont Report, 1979). Nurses are educated to let these principles guide patient care, research, education, and policy. How bioethics and the four principles came to dominate clinical ethics is important to understand.


Bioethics is a recent development, born out of technological advances and calamities in medical treatments and research from the mid-20th century forward (see timeline). It is an applied ethical field dealing with medicine, the environment, and animals (Gordon, n.d.; Resnik, 2021). Bioethics studies the ethical, social, and legal issues that arise in biomedicine and biomedical research. Note that "medical ethics" focuses on proper physician conduct and the physician-patient relationship, dating back to the Oath of Hippocrates from the fifth century B.C.E. or even the Code of Hammurabi (1750 B.C.E.) (Gordon, n.d.).


Prior to the passage of the Pure Food and Drug Act in 1906 (History, Art & Archives, n.d.), no regulations protected consumers from fraudulent foods, drugs, or for the most part, duplicitous healthcare. There was no Food and Drug Administration (FDA), no Federal Policy for the Protection of Human Subjects known as the "Common Rule" (Office for Human Research Protections [OHRP], 2016), no Institutional Review Boards to evaluate research. These all arose following the medical brutalities of World War II, the Helsinki Accords, leaps in medical technology, loss of medical prestige in the consumerist movement, and more.


Origins of Bioethics

At the end of World War II, atrocities committed by Nazi physicians against prisoners in concentration camps led to the international Nuremberg Code of 1947. The code laid out principles of voluntary participation and informed consent (autonomy) of research subjects (Shuster, 1997). In 1948, the World Medical Association (WMA, 2018) passed the Declaration of Geneva, a pledge for physicians to serve humanity, practice with conscience and dignity, make the patient's health a first consideration, and maintain anonymity of practice information. The pledge is updated regularly (last in 2017) and now includes patient autonomy, prohibition against discrimination, upholding civil rights and human liberties, and maintenance of self-care (WMA, 2018).


In the 1950s, thousands of babies were born with severe deformities after their mothers took thalidomide for nausea in pregnancy. The drug originated in Germany, was distributed worldwide, was not adequately tested, and, in the United States, did not receive FDA approval. This tragedy spurred the Kefauver-Harris Amendments of 1962 requiring manufacturers to prove efficacy as well as safety of products before release to the public (Greene & Podolsky, 2012). Ironically, the American Medical Association opposed regulation of drugs by a government body because "the only possible final determination as to the efficacy and ultimate use of a drug is the extensive clinical use of that drug by large numbers of the medical profession over a long period of time" (Greene & Podolsky, 2012, p. 1482).


Two years later in 1964, the WMA passed the Declaration of Helsinki to guide ethical medical research and research combined with clinical care (WMA, 2022). In its seventh revision (2013), the Declaration addresses issues of informed consent and benefit to research participants, requiring that risk should not outweigh benefit (autonomy, beneficence, nonmaleficence) (WMA, 2022).

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In 1966, physician Henry Beecher documented exploitation of human subjects in multiple prestigious hospital and government programs in a landmark paper in the New England Journal of Medicine. Beecher (1966) relayed 22 studies with deleterious effects and/or where the subject or guardian did not fully understand what was to be undertaken or the hazards of the experiment (one investigator had 15 deaths in his first 150 cardiac catheterizations). The paper was a cry for ethically designed studies where "the gain anticipated from an experiment must be commensurate with the risk involved" (p. 1360) and for better procedures for obtaining and reporting informed consent.


The most egregious ethical breach in medicine and research in U.S. history was the Tuskegee Study of Untreated Syphilis in the Negro Male (Centers for Disease Control and Prevention [CDC], 2021). From 1932 to 1972, the U.S. Public Health Service enrolled 600 African American men and monitored them to discover what untreated syphilis does to the body. While participation in the study was voluntary, informed consent was not obtained. The men (399 of 600) were not told they had syphilis, were not treated even though a cure (penicillin) became available in 1943, were not allowed treatment when other physicians diagnosed their syphilis, and many died. The study ended in 1972 when an Associated Press article exposed the project (CDC, 2021).

Figure. Pledge of Fl... - Click to enlarge in new windowFigure. Pledge of Florence Nightingale. Wellcome Collection. Used with permission.

The Tuskegee tragedy led to passage of the 1974 National Research Act and formation of the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. The Commission created the famous Belmont Report of 1979 (OHRP, 1979), once again establishing specific ethical principles as cornerstones for research involving human participants. Furthermore, the Commission differentiated between research, an "activity designed to test an hypothesis, permit conclusions to be drawn, and thereby to develop or contribute to generalizable knowledge" (OHRP, 1979, Part A), and medical practice, "interventions that are designed solely to enhance the well-being of an individual patient or client and that have a reasonable expectation of provide diagnosis, preventive treatment or therapy to particular individuals" (OHRP, 1979, Part A). Later in 1979, philosophers Tom Beauchamp and James Childress published Principles of Biomedical Ethics. They differentiated between beneficence, that is maximizing good, and nonmaleficence, or doing no harm. Thus, 32 years after the Nuremberg Code, philosophers and now the government called for these same ethical principles-autonomy, beneficence, justice, non-maleficence-for human subjects research and medical practice. By the early 1980s, the principles for biomedical ethics were imported into nursing.


Of note is that bioethics grew out of medical concerns-medical experiments, medical treatments, medical problems. The four principles and the field of bioethics were created to guide medical research and medical practice. Although nurses carry out medical orders, unless they are in advanced practice, nurses do not order or discontinue medical treatments. Nurses benefit from bioethics, especially in relation to supporting medical care and in nursing research; however, nurses do not practice medicine.

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The question arises: If bioethics is the foundation of ethical medicine, is there a foundational ethics for nursing? First, it is important to distinguish between medicine and nursing.



Although nursing and medicine have overlapping practice, conceptually, nursing and medicine are different. Medicine is the science and practice of the diagnosis, prognosis, treatment, and prevention of disease, derived from the Latin medicus, meaning "a physician" (Oxford English Dictionary, 2022). Medicine is about healing illness, as noted in The Origin of Medical Terms (Skinner, 1949, p. 288), "Medicina, the art of healing, or the means of healing, from medicinus, relating to healing... Medicus the adjective meant healing or wholesome [and] ... doctor or physician." Medicine has been and continues to be about the work of alleviation of illness and pathology (Charen, 1951; Quain, 1885).


Nursing carries out medical orders but is not medicine. Florence Nightingale, founder of modern nursing, emphasized that nursing focuses on health. Nightingale stated,


Nursing is putting us in the best possible condition for Nature to restore or to preserve health-to prevent or to cure disease or injury. Health is not only to be well, but to be able to use well every power we have to use. Sickness or disease is Nature's way of getting rid of the effects of conditions which have interfered with health. It is Nature's attempt to cure-we have to help her. Partly, perhaps mainly, upon nursing must depend whether Nature succeeds or fails in her attempt to cure by sickness. Nursing is therefore to help the patient to live. (1885, p. 1043)


Nightingale (1885) continued the emphasis on health in describing "nurse training":


Nursing needs its instruments nearly as much as surgery, and yet more than medicine. The physician prescribes for supplying the vital force-but the nurse applies it. Training is to teach the nurse how God makes health and how He makes disease. Training is to teach a nurse to know her business, that is, to observe exactly, to understand, to know exactly, to do, to tell exactly, in such stupendous issues as life and death, health and disease.... Training is to teach the nurse how to handle the agencies within our control which restore health and life... how to keep the health-mechanism prescribed to her in gear. (p. 1043)


Throughout the last century and a half, nursing has continued its focus on health. The International Council of Nurses (2022, para. 2-3) states within its "long definition" of nursing,


Nursing...encompasses the promotion of health, prevention of illness, and care of ... people of all ages, in all health care and other community settings. Within this broad spectrum of health care, the phenomena of particular concern to nurses are individual, family, and group "responses to actual or potential health problems" [from ANA, 1980 Code of Ethics for Nurses, p. 9].... The unique function of nurses in caring for individuals, sick or well, is to assess their responses to their health status and to assist them in the performance of those activities contributing to health or recovery or to dignified death that they would perform unaided if they had the necessary strength, will, or knowledge and to do this in such a way as to help them gain full or partial independence as rapidly as possible.


The American Nurses Association (ANA) Code of Ethics for Nurses with Interpretive Statements (2015) similarly states,


Nursing encompasses the protection, promotion, and restoration of health and well-being; the prevention of illness and injury; and the alleviation of suffering, in the care of individuals, families, groups, communities, and populations.... Nurses act to change those aspects of social structures that detract from health and well-being. (p. vi)


In summary, nursing is about engaging in relationship with individuals, families, and communities to promote, maintain, and restore health. Nurses attend to the biopsychosocial and spiritual health of those we serve as we have "opportunity to know life as it really is, stripped of all pretense and make believe" (McIsaac, 1901, p. 438).



One hundred years before the emergence of bioethics in the mid-1960s, nursing ethics began to be articulated as modern nursing coalesced as a profession. In the earlier 1800s, nurses were men or unseemly women who cared for patients mainly in homes or institutions for the sick poor. Of significance to the development of nursing was that in the second half of the 1800s, women were hearing the call to learn, to grow, and to serve from highly recommended books like Nightingale's 1859 Notes on Nursing: What it Is and What it is Not (Coddington, 2020).


Nightingale and other nurse leaders demanded that nurses be intelligent women of exceptionally good character and moral training. Nightingale noted, "A good nurse should be the 'Sermon on the Mount' in herself" (1882, p. 1048). Nurses were to be chaste, sober, honest, truthful, trustworthy in the unseen as well as the seen, punctual, orderly, quiet, quick, gentle, cheerful, hopeful, clean, thinking of her patient and not of herself (Maxwell & Pope, 1910; Nightingale, 1882; Robb, 1894).


Civil War Ethics: Care for All

Nursing grew as a profession during the Civil War (1860-1865) (Fowler, 2017). Wealthy gentlewomen sponsored nurses in military hospitals to support soldier survival rates (Fowler, 2017). The Union Army acknowledged that nurses were needed to care for wounded soldiers and on June 10, 1861, appointed Dorothea Dix as its first superintendent of nurses (Wood, 2000). Dix, a national champion for care of the poor mentally ill and disabled (Parry, 2006), established strict standards of nurse training and care (feeding, dressing wounds, sanitation, demeanor, decorum), creating 3-month assignments for volunteers ("plain-looking" healthy women between 35 and 50). Women of patriotic zeal looking for more in life flocked to nursing (Little, 2021; Wood, 2000). This expansion paralleled the growth of nursing in England in the late 1800s where women were called to the vocation (Fowler, 2021).


Of note is that Civil War nurses cared for soldiers on both sides of the conflict, enduring great hardship not only from war conditions, but from gender discrimination against women in general and specifically by soldiers and Army physicians. Civil War nurse and historian Georgeanna Muirson Woolsey Bacon (1833-1906) observed, "No one knows, who did not watch the thing from beginning to end, how much opposition, how much ill-will, how much unfeeling want of thought, these women nurses endured" (Coddington, 2020, p. xiv). She added a profound insight about the nurses' sense of the highest morals of care, responsibility, and relationship with their patients:


These annoyances could not have been endured by the nurses but for the knowledge that they were pioneers.... This, and the infinite satisfaction of seeing from day to day sick and dying men comforted in their weary and dark hours, comforted as they never would have been but for these brave women, was enough to carry them through all and even more than they endured... the surgeons were most unwilling to see it [discrimination] fall, but the knowledge that the faithful, gentle care of the women-nurses had saved the lives of many of their patients, and that the small rate of mortality, or remarkable recoveries in their hospitals, reflected credit immediately upon themselves. (Coddington, 2020, p. xv)


Civil War nurse Clara Barton went on to establish the American Red Cross, another venue for high-quality service for women in nursing (Little, 2021). Nursing emerged from the war as a respectable, specialized, and professional service for women of high character.


Relationships as Foundational

In 1873, New York City's Bellevue Hospital opened one of the first American nursing schools based on standards developed by Nightingale. That year, hospitals in New Haven and Boston opened similar schools. Nursing ethics began to emerge in nursing literature. In 1889, nurse "HCC" (identified only by initials) wrote a series of articles on ethics in The Trained Nurse and Hospital Review, a pioneer publication from 1893 to 1950. HCC delineated seven classes of nursing relationships:


For convenience sake I will divide the duties of a nurse into seven classes: 1st. Those she owes to the family. 2nd. Those she owes to the doctor. 3rd. Those owing the family, friends, and servants of the patient. 4th. To herself. 5th. To her own friends. 6th. To her own hospital or school. 7th. To other nurses. (HCC, 1889, p. 179; Fowler, 1984)


The first relationship referred to the nurse patient/family relationship, as nursing took place in homes and nurses were hired by the family (Fowler, 2017). HCC went on to discuss each of these relationships in detail in subsequent Trained Nurse articles. Fowler (1984) identified HCC as nursing leader and educator Harriet C. Camp. In 1912, HCC, writing as the now married Harriet Camp Lounsbery, published Making Good on Private Duty: Practical Hints to Graduate Nurses. She explicated the sacred trust of the nurse/patient relationship:


The relation between nurse and patient should, from the first, be a more than amicable one. You have come to bestow the priceless blessing of unwearied, skillful care upon one who should thankfully receive it, and believe me, if you do not go to your patient with a feeling of thankfulness to God for allowing you to assume such a sacred trust as the care of a human life, you are in no condition to undertake the work. Your nursing should be, in a way, an exponent of your own spiritual state; looking at it in its highest aspect, an outward and visible sign of an inward and spiritual grace. (Lounsbery, 1912, p. 17)


Later, Camp Lounsbery's seven nursing relationships were recombined by others and reduced to five: (a) nurse-to-patient/family, (b) nurse-to-other health professionals, (c) nurse-to-self, (d) nurse-to-profession, and (e) nurse-to-society (Fowler, 2017), and sometimes as three umbrella relationships. This basis of relational ethics continues in today's Code of Ethics for Nurses with Interpretive Statements (ANA, 2015).


In 1893, Lystra Gretter and a Committee for the Farrand Training School for Nurses in Detroit, Michigan, created The Nightingale Pledge, a moral oath for nurses administered at commencement (Crathern, 1953; Fowler, 1997; Maxwell & Pope, 1910; see Figure 1). Though now dated, the Pledge has been taken by hundreds of thousands of nurses and is considered the first ethical code. Gretter added the concepts of health promotion and social justice to the pledge in 1935 with this statement, "With loyalty will I aid the physician in his work, and as a missioner of health, I will dedicate myself to devoted service for human welfare" (Crathern, 1953, p. 80).


The Centrality of Ethics

In 1900, influential nurse leader Isabel Hampton Robb (1860-1910) began her treatise on Nursing Ethics: For Hospital and Private Use, quoting Scripture, "All things whatsoever ye would that men should do to you, do ye even so to them.- Matthew vii, 12." Robb, an 1882 graduate of Bellevue Hospital and superintendent of nurses and principal of the Training School for Nurses at Johns Hopkins Hospital and later the Illinois Training School for Nurses, defined ethics this way:


By ethics is meant the science that treats of human actions from a standpoint of right and wrong. This capability of discriminating between right and wrong is based on a knowledge of human nature and of the various relations in which man as a moral or social being is or may be placed. (Robb, 1900, p. 16)


She elaborated upon the need for an "adopted" moral code of ethics for the entire profession:


Any ideas of special moral responsibilities have been vague and indefinite to the many, while the few have evolved them for themselves as a result of observation and experience. Now, however, not only as individuals, but as a profession, we are beginning to feel an increasing necessity for some such definite moral force or laws that shall bind us more closely together in this work of nursing, and that will bring us into more uniform and harmonious relations. I know of no other body of workers outside of physicians who need just such strength and stimulus as come from unity of purpose than do trained nurses, accustomed as they must become to deal with all sorts and conditions of men and circumstances. (Robb, 1900, pp. 11-12)


About the critical importance of instantiating ethics in the nursing student, Robb (1900) emphasized,


As the standard of education and requirements become of a higher character and the training more efficient, the trained nurses will draw nearer to science and its demands and take a greater share as a social factor in solving the world's needs. But there is another side to nursing-the ethical-without which all the work accomplished would be dead and spiritless.... From this standpoint the nurse's work is a ministry; it should represent a consecrated service, performed in the spirit of Christ, who made himself of no account but went about doing good. (pp. 37-38)


In addition to Camp and Robb, hundreds of articles and approximately 100 nursing ethics textbooks and editions were published by nurses between the late 1800s and 1965 (Fowler, 1984). Annie Warburton Goodrich, in her 1932 book, The Social and Ethical Significance of Nursing, wrote, "So much is nursing of the essence of ethics that it is consistent to assert that the terms good and ethical as applied to nursing practice are synonymous" (p. 5). Fowler noted that up until the mid-1960s, when nursing education moved out of hospitals and into university settings, ethics was as integral to the training of nurses as technical and medical training, where "nursing viewed ethics not as the frosting on the cake but as the cake itself" (2017, p. 297).


Influential Leadership

Nursing ethics was developed by the nursing leadership and educator elite. Robb was the first president of the Nurses Associated Alumnae of the United States and Canada (now ANA), helped organize with Lavinia Dock the Society of Superintendents of Training Schools (later the National League for Nursing Education [NLNE, later the NLN]), helped create the International Council of Nurses, and helped found the American Journal of Nursing (AJN). She revolutionized nursing with her 1893 publication of Nursing: Its Principles and Practices that went on to three editions; published Nursing Ethics in 1900 and Educational Standards for Nursing in 1907 (American Association for the History of Nursing, 2018).


Isabel McIsaac (1858-1914) was an 1888 graduate and later administrator of the Illinois Training School for Nurses. She was an incredible innovator in nursing education, president of the AJN Company, president of the ANA, president of the American Society of Superintendents of Training Schools for Nurses (NLN), third superintendent of the U.S. Army Nurse Corps, and served as Interstate Secretary of the American Red Cross Nursing Service. She, too, wrote a number of influential nursing textbooks (Sarnecky, n.d.).


Other nurse leaders like Dorothea Dix (1802-1887), Clara Barton (1821-1912), Linda Richards (1841-1930), Lavinia Dock (1858-1956), Lilian Wald (1867-1940), and Charlotte Aikens (1868-1949) contributed to the development of nursing's rich ethical heritage through their work and extensive writings. One sees in Nightingale's, Robb's, Camp's, McIsaac's, and other leaders' writings (i.e., Aikens, 1916; Talley, 1925) the ethical commitment, termed devotion to the patient, of keeping not only professional secrets (similar to confidentiality) but patients' life secrets (fidelity). In their writings, we find loyalty to the physician, to colleagues, and to nursing (pride of profession); fairness (social justice); adequate training and growing knowledge to provide the best care (virtue as excellence); and the call to serve the poor or anyone who needed the nurse's help. There was massive emphasis on moral character, moral formation, and moral courage.



The ANA, founded in 1896 as the Nurses Associated Alumnae of the United States of America, stated,


The object of the Association shall be: to establish and maintain a code of ethics, to the end that the standard of nursing education be elevated; the usefulness, honor, and interests of the nursing profession be promoted; public opinion in regard to duties, responsibilities, and requirements of nurses be enlightened; emulation and concert of action in the profession be stimulated; professional loyalty be fostered, and friendly intercourse between nurses be facilitated. (ANA, 2015, p. 38)


Although the ANA, Robb, and others called for an official code of ethics, no profession-wide code was adopted until 1950. In August 1926, the ANA published in AJN but never adopted a "Suggested Code of Ethics" (ANA, 1926). Another "Tentative Code for the Nursing Profession" was published in 1940 but again, not adopted by the ANA (1940). Why? The ANA Committee on Ethical Standards wrote it was at work on a comprehensive study on formulating the proposed principles (ANA, 1940, p. 977).


Finally, in 1950 the ANA House of Delegates adopted A Code for Professional Nurses, with 17 enumerated provisions based on nursing's five relationships as Camp delineated in 1889. The Code has been amended, revised, and the number of provisions condensed multiple times, with interpretive statements added in 1976. Today, the structure of the nine provisions of the Code of Ethics for Nurses (ANA, 2015) continues to embed the relational nature of nursing ethics of (a) nurse-to-patient/family, (b) nurse-to-other health professionals, (c) nurse-to-self, (d) nurse-to-profession, and (e) nurse-to-society. Provisions 1 through 3 describe the most fundamental values and commitments of the nurse; Provisions 4 through 6 address the boundaries of duty and loyalty; and Provisions 7 through 9 speak to aspects of the nurses' duties beyond individual patient encounters (ANA, 2015).


What happened to the rich nursing ethics literature of the late 1800s and early 1900s? In 1965, the ANA recommended that nursing education move from the hospital to the university setting (ANA, 1965). Although in many ways this move was good for nursing academics, nursing's ethical heritage literature held in hospital libraries did not move into university libraries. Furthermore, ethics education changed from being taught primarily by nurse educators to philosophers and theologians who taught abstract European philosophies unrelated to nursing or nursing practice (Fowler, 2020). Nursing ethics-that is, moral character, moral formation, nursing relationships as essential to nursing practice-was no longer central to nursing education. Contemporaneously, technology exploded and led to ethical concerns that, in part, gave rise to the field of bioethics.



First and foremost, nursing ethics is relationally focused and character or virtue based. Nursing ethics was born out of a deep awareness of calling to serve the sick and injured, no matter who or where they were, to restore and improve health. It came from the sense of relationship that women of high virtues and noble character had with those for whom they cared and with whom they served. Nursing ethics continues today as relational and virtue-based in our Code of Ethics for Nurses (ANA, 2015).


Nursing ethics is central to nursing identity; it is not just something nurses think about in certain situations. Nursing ethics is inseparable from nursing action; it is the ground note of nursing care. It is not episodic in certain instances of problems; nursing ethics is constant. It is represented in every clinical action and each nurse interaction, affirming the good intrinsic to nursing. This includes being flexible, attuned, and responsive to changes in the patient's immediate situation and to meet patients where they are in the moment (Benner, 1984).


Nursing ethics reflects more than nursing duties; it is values, virtues, and ideals-in relationship. These are all instantiated in nursing students as they progressively become nurses, that is, as they interiorize a nursing identity. Nursing ethics means the nurse meets every patient relationally, where the person-of-the-nurse meets the person-of-the-patient in ways that respect, support, and affirm the patient's dignity, individuality, humanity, choices, and relational web of the patient and the instantiated norms and ends of the nursing profession in the nurse.


Finally, nursing ethics not only predates bioethics by over 100 years, it comes from and offers a different paradigm than bioethics. It was not born out of ethical dilemmas or problems (research, technology, informed consent, etc.), and is not problem, conflict, or medically focused. Rather, nursing's ethics is preventative, centering on averting ethical dilemmas before problems arise by fostering and preserving relationships (Fowler, 2020).


Perhaps nurses who have responded with the highest morals to recent ethical burdens best portray the centrality of nursing ethics to nursing. Nurses in Wuhan, China, treating COVID patients said, "Our country is in trouble, due to the responsibility and the sense of mission, I have to be a warrior, a front-line staff... I decided to postpone the wedding date" (Liu et al., 2022, p. 11), and "We have to make ourselves stronger before we comfort the patient" (Liu et al., 2022, p. 14).


Tetiana Freishyn, the Ukrainian nurse caught in war, noted (WHO, 2022, para 7, 12), "The recurrent air alarms mean that you never know when your work is interrupted... We quickly need to upgrade our skills," and, "My nursing profession is my life; it's what gets me out of bed every day; it's the state of my soul."


An American nurse also portrays this relational, virtue-based, contextual, in-the-moment nursing ethics:


In 16 hours, I helped someone die, rubbed her daughter's back while she sobbed and ached... helped my other patient reorient to a world after 2 months entering the hospital with COVID, held her hand and prayed to Jesus aloud after she asked me to pray. I weaned her sedation, comforted her, explained every detail, and just held her hand. All in a day's work, as they say. I would say that's the power of a nurse. (Personal communication to Nurse Christian Fellowship staff, 2021)




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