CHAPTER 1

Professional standards
and the requirement
to be ethical

Learning objectives
Upon the completion of this chapter and with further self-directed learning you
are expected to be able to:
n Locate the code of conduct, code of ethics and related standards of practice
developed by the relevant peak nursing organisations in the jurisdiction/
state/country of your practice, and which you are expected to uphold as
a professional nurse.
n Identify the ethical standards and ethical competencies expected of
professional nurses in the jurisdiction/state/country of your practice.
n Discuss why, if at all, nurses should uphold the standards of ethical conduct
prescribed by peak nursing organisations.
n Reflect critically on why, if at all, the practice of nursing is a moral
undertaking.
 
Keywords
n  ethicalcompetencies/ n  ethical safety n  professional
capabilities n  professional practice
n  ethical conduct boundaries n  professional
n  ethical practice n  professional conduct standards
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Introduction
From the moment a nurse enters into professional practice she or he is bound by
strict standards of professional conduct. The standards of conduct expected of
professional nurses are stated publicly in a range of documents including formally
endorsed professional codes of conduct, codes of ethics, competency standards,
and guidelines and position statements formulated on a range of issues relevant to
the profession and practice of nursing. For example, nurses in Australia are bound
by the standards of conduct expressed in the following documents published by
the Australian Nursing and Midwifery Council (ANMC):
n Code of Professional Conduct for Nurses in Australia (2008a)
n Code of Ethics for Nurses in Australia (2008b)

Johnstone, M. (2008). Bioethics : A nursing perspective. Elsevier Australia.

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 B ioethics : A N ursing P erspective

 ational Competency Standards for the Registered Nurse, 4th edn (2006a)
N
n
National Competency Standards for the Enrolled Nurse (2002)
n
n National Competency Standards for the Nurse Practitioner (2006b)
Note: These can be viewed at: http://www.anmc.org.au
Depending on the jurisdiction in which they are registered, nurses are also
obliged to follow various guidelines set down by their local nurse registering
authority. For example, nurses working in the Australian states of New South
Wales (NSW), Queensland (QLD), South Australia (SA), Tasmania (TAS), Victoria
(VIC) and Western Australia (WA), the Australian Capital Territory (ACT) and
the Northern Territory (NT) are bound respectively by the various standards,
policies and guidelines prescribed by those authorities (see Box 1.1).

Box 1.1  Australian Nurse Regulating Authorities

States

New South Wales

Nurses and Midwives Board NSW — http://www.nmb.nsw.gov.au/
Queensland
Queensland Nursing Council — http://www.qnc.qld.gov.au/
South Australia
Nurses Board of South Australia — http://www.nursesboard.sa.gov.au/
Tasmania
Nurses Board of Tasmania — http://www.nursingboardtas.org.au/
Victoria
Nurses Board of Victoria — http://www.nbv.org.au/
Western Australia
Nurses Board of Western Australia — http://www.nbwa.org.au/
Territories

Australian Capital Territory

Nurse and Midwifery Board of ACT — http://www.actnmb.act.gov.au/
Northern Territory
Health Professions Licensing Authority — http://www.nt.gov.au [follow the links]
Copyright © 2008. Elsevier Australia. All rights reserved.

A notable feature of the respective standards, policies and guidelines that

have been operationalised by local nurse registering authorities in Australia in
recent years is the increasing emphasis they have placed on the ‘establishment and
maintenance of appropriate professional behaviour in a therapeutic relationship
between a nurse and client in order to facilitate safe and effective care’ (Nurses
Board of SA 2002). These guidelines seek to alert and remind nurses of the serious
consequences that can and do occur when professional boundaries are crossed
both inadvertently and deliberately (see Box 1.2).
Nurses working in other countries are likewise bound by the standards of
conduct and related policies and guidelines developed, endorsed and published by
their respective peak nursing organisations (see Box 1.3).

Johnstone, M. (2008). Bioethics : A nursing perspective. Elsevier Australia.

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 1 • P rofessional S tandards and the R equirement to be E thical

Box 1.2  Australian nurses boards’ standards and guidelines on professional boundaries
and professional conduct

New South Wales

Nurses and Midwives Board NSW
– Boundaries of Professional Practice: Guidelines for Registered Nurses, Registered Midwives and Enrolled
Nurses (1999)
Queensland
Queensland Nursing Council
– Professional Standards Policy (2003)
– Queensland Nursing Council and Health Practitioners Boards’ Statement on Sexual Relationships
­between Health Practitioners and their Patients (2000)
South Australia
Nurses Board of South Australia
– Standard Therapeutic Relationships and Professional Boundaries (2002)
Tasmania
Nurses Board of Tasmania
– Professional Boundaries Standards for Nurses in Tasmania (2005)
Victoria
Nurses Board of Victoria
– Professional Boundaries Guidelines for Registered Nurses in Victoria (2007)
Western Australia
Nurses Board of Western Australia
– Code of Practice (2000)
– Boundaries for Therapeutic Relationships (2002)
– Ethical Dilemmas: a Framework for Decision Making (2004)

Box 1.3  Nursing codes of ethics pertaining to jurisdictions outside Australia

American Nurses Association (2001) Code of ethics for nurses with interpretive statements
Available at: www.nursingworld.org/ethics/ecode.htm
Canadian Nurses Association (2002) Code of ethics for registered nurses
Copyright © 2008. Elsevier Australia. All rights reserved.

Available at: www.cna-nurses.ca

Nursing Council of Hong Kong (nd) Code of professional conduct and code of ethics for nurses in Hong Kong
Available at: www.nchk. org.hk
Nursing Council of New Zealand (2005) Code of conduct for nurses
Available at: www.nursingcouncil.org.nz
Nursing and Midwifery Council (UK) (2004) The NMC code of professional conduct: standards for conduct, perfor-
mance and ethics
Available at: www.nmc-uk.org
Singapore Nurses Board (nd) Code of ethics and professional conduct
Available at: www.snb.gov.sg

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 B ioethics : A N ursing P erspective

In addition, in countries where national nursing organisations are also in

membership with the International Council of Nurses (ICN) (currently the ICN
represents nurses in more than 129 countries including Australia, Canada, Fiji,
Hong Kong, Indonesia, Malaysia, New Zealand, Singapore, the Solomon Islands,
the United Kingdom (UK), the United States (US), etc) nurses are also bound by
the codes, policy and position statements published and endorsed by the ICN
code. Of particular note are the ICN’s:
n Code of Ethics for Nurses (2006)
n Framework of Competencies for the Generalist Nurse (2003)
n Position and policy statements on a range of issues relating to:
• nursing roles in health care service
• nursing profession
• socio-economic welfare of nurses
• health care systems
• social issues.
Note: these can be viewed at: www.icn.ch
There are well over 50 specific position statements that have been devised in
relation to each of the above issues, which can all be viewed via the ICN web page,
cited above. (For a comprehensive examination of the ICN Code of Ethics for
Nurses and related position statements, and their application as a guide to ethical
decision-making in nursing, see Fry and Johnstone 2008.)
A central and important requirement of these and other codes and related policy
and position statements is the fundamental expectation that, when practising in
a professional capacity, nurses in all levels and areas of practice will uphold the
highest standards of ethics and indeed be ‘exemplars’ (models) of excellent ethical
behaviour in professional and related contexts.

The requirement to be ethical

The requirement for nurses to be ethical and to uphold the highest standards
of ethical conduct when practising in a professional capacity is not unique
to nursing. It is generally expected that when performing their duties and
conducting their affairs, professionals (of all fields) will uphold exemplary
standards of conduct — commonly taken to mean standards that are higher
than, and not generally expected of, lay people or of the ‘ordinary person on
the street’. A key reason underpinning this expectation relates to the potential
vulnerability of clients and an associated expected ‘special obligation’ on the
part of professionals to reduce this vulnerability by conforming to ‘particularly
high ethical standards both in their professional and non-professional lives’
Copyright © 2008. Elsevier Australia. All rights reserved.

(Freckelton 1996: 142; Johnstone 1998). Such is this expectation that exemplary
standards of ethical conduct have historically been cited as one of the key
hallmarks of professionalism and indeed as a necessary feature of professions
generally (Bayles 1981).

Questioning the requirement

to be ethical
The demand placed on nurses to be ethical and to uphold exemplary ethical
standards of conduct is not without controversy. One reason for this is that
the expectation to be ethical seems to assume (without supporting evidence)

Johnstone, M. (2008). Bioethics : A nursing perspective. Elsevier Australia.

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 1 • P rofessional S tandards and the R equirement to be E thical

that nurses, like other professionals, should as a matter of fact be ethical. This
assumption raises a number of important questions, such as:
n What is ethics and ethical professional conduct?
n Is it the case that nurses should be ethical?
n What does it mean to be an ‘ethical practitioner’?
n Is it possible to be an ethical professional in health care environments,
situations, and circumstances that are not supportive of ethical conduct?
n How should ethics be practised in professional (e.g. nursing and health care)
contexts?
n What ethical ‘competencies’ and ‘capabilities’ does a professional person need
in order to be able to practise ethics safely and effectively as an accountable
and responsible professional?
Whatever the possible answers to these and related questions (and there are many),
one thing is clear: nurses may be able to accept or reject the different viewpoints
expressed, but they cannot ignore them. This is because, so long as nurses continue
to work with and care for people — and strive to promote the health and wellbeing
of people (a core purpose of nursing practice) — they will not be able to avoid the
many and complex moral problems that will inevitably arise during the course of
their work. Neither will nurses be able to avoid making decisions and taking action
(including the ‘action’ of deliberately not taking action) in response to the problems
they encounter. As Hinman (1994: 1–2) explains in another context:
We cannot avoid confronting moral problems, because acting in ways that affect
the wellbeing of ourselves and others is as unavoidable as acting in ways that affect
the physical health of our own bodies. We inevitably face choices that hurt or help
people, choices that may infringe on their rights or violate their dignity or use them as
mere tools to our own ends. We may choose not to pay attention to the concerns of
morality such as compassion or justice or respect, just as we may choose to ignore the
concerns of nutrition. However, that does not mean we can avoid making decisions
about morality any more than we can evade deciding what foods to eat. We can
ignore morality, but we cannot sidestep the choices to which morality is relevant, just
as we cannot avoid decisions to which nutrition is pertinent even when we ignore the
information that nutritionists provide for us. Morality is about living, and as long as
we continue living, we will inevitably be confronted with moral questions — and if we
choose to stop living that too is a moral issue.

Nursing as a moral project

Nursing is, without question, a moral undertaking. Its practice never occurs in
Copyright © 2008. Elsevier Australia. All rights reserved.

a moral vacuum and is never free of moral risk. Even nursing care practices and
procedures that might seem ‘simple’, ‘basic’ or ‘trivial’ (e.g. placing a person on a
bedpan; administering an aspirin tablet) could, potentially, have morally significant,
harmful consequences. It is because of the potential to cause morally significant harm
to others — not to mention the breach of trust that could occur as a consequence of
such harm being caused — that nursing practice and the conduct of nurses warrants
attention from an ethical point of view. It is the purpose of this book to provide such
attention and to advance a critical examination of the moral role, responsibilities and
rights of nurses as accountable and responsible health care professionals. To this end,
in the chapters to follow, particular attention will be given to explaining what ethics
is and why nurses ‘should’ be ethical — even in contexts which are not supportive
of ethical conduct and where being ethical may be difficult. Issues and examples will

Johnstone, M. (2008). Bioethics : A nursing perspective. Elsevier Australia.

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 B ioethics : A N ursing P erspective

be discussed critically to show that it is not enough just to be ‘sensitive’ to and have
knowledge of certain ethical issues, but also to have the skills and wisdom (the ‘know-
how’) to deal with them safely, competently and effectively and, equally important,
to have the capacity to act in order to achieve morally desirable outcomes.

Conclusion
Nurses in all levels and areas of practice are bound by strict standards of professional
conduct and are expected publicly to uphold the highest ideals of ethical professional
practice. However, just why nurses should uphold the standards expected of them
and how best to do so remains an open question. It is important, therefore, for
nurses (whatever their level and area of practice, and whether working in clinical,
managerial, administration, education, research and/or other related domains) to
critically examine and reflect on such questions as:
n What is ethics?
n What is ethical professional conduct?
n Why should I be ethical?
n What should I do in situations where I know what the ‘right’ thing to do is,
but I have no support to act on my judgment?
n Do I know enough about ethics in order to practise ethics safely and effectively
as an accountable and responsible professional?
n What ethical ‘competencies’ and ‘capabilities’ do I need to develop in order to
fulfil my responsibilities as an ethical nurse?

C a s e s ce n a r i o 1
While undergoing treatment in a public hospital over a 6-week period an 81-year-old man was
robbed of $33 000 by a nurse working at the hospital. The robbery took place after the nurse in
question allegedly stole the man’s bank keycard and personal identification number (PIN) from his
wallet on the night that he was admitted to the hospital (Rogers 2000: 3). The money was stolen
from the man’s bank account in ‘59 separate transactions over a six-week period’. It was reported
that the man ‘only realised that the money was missing from his account when he received a
letter from his bank advising him that his account was overdrawn’ (Rogers 2000: 3). The nurse,
who subsequently resigned from the hospital and moved interstate, was later summonsed on ‘59
counts of obtaining a benefit by deception’ and arrested to face charges in the local court of the
town where the offences allegedly took place.
Copyright © 2008. Elsevier Australia. All rights reserved.

C a s e s ce n a r i o 2
While on duty in a neuroscience ward of a metropolitan hospital, Nurse A stole medication from
the drug cupboard. While on duty, Nurse A had also engaged in a range of other unacceptable
behaviours that included: taunting a stroke patient by making ‘inappropriate comments that
related to the patient’; writing offensive descriptions of patients on their care plans (which were in
full view of other staff working on the ward); giving patients offensive and derogatory names; and
acting in a ‘sexually suggestive and provocative way by dancing in full view of the staff’ (Nurses
Board of Victoria [NBV] 2005: 15). In addition, Nurse A had administered an excessive amount of
medication to a patient ‘to keep the patient quiet’ (NBV 2005: 15).

Johnstone, M. (2008). Bioethics : A nursing perspective. Elsevier Australia.

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 1 • P rofessional S tandards and the R equirement to be E thical

Following an internal investigation into Nurse A’s conduct by her employer hospital, Nurse A
was reported to the state’s nurse registering authority. At the formal hearing of the allegations of
unprofessional conduct made against Nurse A, the nurse registering authority took into account
the seriousness of the findings made against the nurse and, in keeping with the principle of
protecting the public interest, cancelled her registration (NBV 2005: 15).

Critical questions
1. What standards of ethical professional conduct did the nurses breach in these scenarios?
2. If you were a nurse working in a hospital or a residential home care setting and you suspected
or knew that a nurse was abusing, defrauding or derogating a patient or resident, what, if
any, action would you take?
3. Upon what basis would you justify your actions (or non-actions, as the case may be)?
4. What might be the consequences both to the patients/residents and to yourself, in either
case, of you taking action or not taking action?
Copyright © 2008. Elsevier Australia. All rights reserved.

Johnstone, M. (2008). Bioethics : A nursing perspective. Elsevier Australia.

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Copyright © 2008. Elsevier Australia. All rights reserved.

Johnstone, M. (2008). Bioethics : A nursing perspective. Elsevier Australia.

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