Iranian Journal of Public Health
Tehran University of Medical Sciences
The Code of Ethics for Nurses
F Zahedi, M Sanjari, [...], and M Vahid Dastgerdi

Additional article information

Abstract
Nurses are ever-increasingly confronted with complex concerns in their practice. Codes of ethics are fundamental guidance for nursing as many other professions. Although there are authentic international codes of ethics for nurses, the national code would be the additional assistance provided for clinical nurses in their complex roles in care of patients, education, research and management of some parts of health care system in the country. A national code can provide nurses with culturally-adapted guidance and help them to make ethical decisions more closely to the Iranian-Islamic background. Given the general acknowledgement of the need, the National Code of Ethics for Nurses was compiled as a joint project (2009–2011). The Code was approved by the Health Policy Council of the Ministry of Health and Medical Education and communicated to all universities, healthcare centers, hospitals and research centers early in 2011. The focus of this article is on the course of action through which the Code was compiled, amended and approved. The main concepts of the code will be also presented here. No doubt, development of the codes should be considered as an ongoing process. This is an overall responsibility to keep the codes current, updated with the new progresses of science and emerging challenges, and pertinent to the nursing practice.

Keywords: Nursing ethics, Ethical code, Healthcare ethics, Professionalism, Patient’s right
Introduction
Nurses are responsible to provide their clients/patients with the high-quality care. They are undoubtedly confronted with various ethical challenges in their professional practice, so they should be familiar with ethical codes of conduct and the essentials of ethical decision making.

The codes of ethics have been adopted for many professions in recent decades. In nursing, as one the most-trusted professions, the ethical codes have been also published by nearly every recognized professional group worldwide. The first international code of ethics for nurses was adopted by the International Council of Nurses (ICN) in 1953 (1). The two codes prepared by American Nurses Association (ANA) (2) and Canadian Nurse Association (CAN) (3) are the examples of national codes of ethics for nurses. The codes outline how the nurses should behave ethically as a profession, and how they should decide when encounter barriers preventing them from fulfilling their professional obligations. The codes can also support nurses in their practice and reduce their moral distress.

In Iran, studies have shown nurses’ weaknesses in the knowledge of ethics and its application in practice (4, 5). In a qualitative study carried out by Negarandeh et al, the nurses identified “lack of code of ethics” as a barrier to patient advocacy in Iran (6). Sanjari et al, also, reviewed nursing codes of ethics and emphasized the necessity of compiling a national code of ethics for nurses in healthcare setting in 2008 (7). They suggested an adapted code considering cultural context and Islamic background of the country.

Considering the growing activities in the field of medical and healthcare ethics in Iran (8,9), and in order to address the needs and help to fulfill goals of health care system in the country, the National Code of Ethics for Nurses was prepared under supervision of the Ministry of Health and Medical Education (MOHME). It is expected that the Code will serve the interests and needs of the profession more efficiently, since it illustrate moral and professional obligations of nurses for prevention of diseases, promoting health in the society, communicating with colleagues, management of health care systems, and research activities.

The goal of this paper is to provide the nurses with the information about the National Code and help them to apply the provisions in their profession. The manuscript will introduce the main concepts of the recently published codes.

Methods
The project of “Compiling the National Code of Ethics for Nurses” was initiated by the Ethics Group of the Endocrinology and Metabolism Research Center (EMRC) of Tehran University of Medical Sciences (TUMS) in 2009.A working group composed of 3 nurses and one general practitioner prepared the first draft of the code through a study including the wide search of international and national codes of ethics for nurses in other countries. After compiling the draft, the project was continued as a joint project with Medical Ethics and History of Medicine Research Center (MEHRC) of TUMS and the Secretariat of High Council for Medical Ethics of Health Policy Council of MOHME.

At first, the preliminary draft was presented at special discussion secession at MEHRC and was challenged by professors, researchers and PhD and MPH students of TUMS. According to the discussions held, the draft was revised. Then, a Task Force that was appointed by the Secretariat of High Council for Medical Ethics of Health Policy Council of MOHME actively engaged in the process of reviewing and modification of the second draft of the code. The Task Force was composed of invited supervisors or head-nurses from main hospitals of TUMS, professors of Faculty of Nursing and Midwifery of TUMS, specialists in different fields of ethics, law, religion, and the representatives of Iranian Nursing Organization (INO), Medical Council of Islamic Republic of Iran, Office of Nursing Advisor to MOHME, Academy of Medical Sciences and Nursing Board of MOHME.

Owing to the sincere cooperation of all members of the Task Force, the final code was prepared after some discussion sessions. Then, it was proposed to the Health Policy Council of MOHME for evaluation and approval. The code as the National Code of Ethics for Nurses was delivered in the country in early 2011.

National Code of Ethics for Nurses
The Code is an entirely new document produced for nursing ethics in the country, which was published in Farsi (10). It is also available through the website of MOHME (11). The English version is enclosed here as annex1. The target audience includes all nurses in the fields of nursing education, research, administrative, and clinical care, in the whole.

The National Code defines the values which are comprehensive and culturally-adapted. Then, it classify the ethical responsibilities as five main parts of “Nurses and People”, “Nurses and the Profession”, “Nurses and Practice”, “Nurses and Co-workers”, and “Nursing, Education and Research”, including 71 provisions in total.

The code sets out the required elements for ethical conduct and empowers nurses to make ethical decisions more perfectly as they perform as clinical nurses, researchers, administrators and policy-makers. It also reminds the nurses of the valuable state of their profession and what they should attempt to uphold as a nurse in providing direct care to clients/patients, teaching nursing students, performing research, and the supervision and management.

As a main general conceptual background of the National code, the patients are not considered as only people who receive the nursing care, and others including the patients’ family and healthy people in the society are considered in the plans and services. Another essence of the Code is that the individual dignity should be respected, regardless of who is receiving the care, or from which nationality, ethnicity, religion, culture, socio-economic class, gender, etc the patient/client is. Meanwhile, under the provisions of the National Code, nurses must recognize and respect cultural sensitivity in everyday practice, even in this era of globalization.

According the Code, the nurses should be sensitive to the ethical challenges and do their best to fulfill their moral duties. It also emphasizes the importance of informed consent, and addresses main ethical issues in everyday practice such as respect to privacy and confidentiality of patients/clients, relationship with colleagues, efficient performance of the professional duties, conflicts of interests, ethics in educational activities and protection of participants in research.

The Code also deals with the administrative duties of nurses. Moreover, it elucidates the concern of how the nurses should communicate with the hospital ethics committee for decision-making when are confronted with ethical cases.

Conclusion
Considering the experiences in compiling national ethical codes and guidelines (12–18), the National Code of Ethics for Nurses is developed as a guide for performing nursing responsibilities and the ethical obligations of the profession. Although there are authentic international codes of ethics for nurses, the national code would be the additional assistance provided for clinical nurses in their complex roles in care of patients, education, research and management of some parts of health care system in the country. Most nurses may be either too busy or exhausted to think about their behavior in practice. However, accountability through meeting the obligations is essential in nursing which is one the most-trusted professions in all societies.

Development of the codes should be considered as an ongoing process, so it is expected that nurses reflect their ideas when they deal with the shortcomings of the codes in their practice. The inputs will enable authorities to improve the code and pave the way for its effective implementation. The codes should be revised and updated in regular intervals considering reflections from nurses across the country. This is an overall responsibility to keep the codes current, updated with the new progresses of science and emerging challenges, and pertinent to the nursing practice.

Ethical considerations
Ethical issues (Including plagiarism, Informed Consent, misconduct, data fabrication and/or falsification, double publication and/or submission, redundancy, etc) have been completely observed by the authors.

Acknowledgments
It is noteworthy that, this could not be accomplished without dedication and sincere contribution of university lecturers, researchers, and experts in the field. The collaborators (excluding the authors) and members of the Task Force are listed (in alphabetical order) as follows: Adibzade A, Ajali A, Alipor A Z, AzimiLolati H, Bararpour F, Biabangardi Z, DehghanNayeri N, Eesazadeh N, Ghadyani MH, Ghasemzadeh N, Ghorbanpour M, Hashemi F, Heidari A, Joudaki K, Joulaie S, Karimi M, Kashaninia Z, Kazemian M, Milanifar AR, Mobasher M, Namazi HR, NazariEshtehardi M, Parsayekta Z, Saber S, Sahebjam S, Salemi S, Shojaee AA, Soufizadeh M, Tafti F, VaskooeKh, YadavarNikravesh M.

The representatives of Health Policy council of MOHME, The Institution (Nahad) of Representative of the Supreme Leaderin TUMS, Medical Ethics and History of Medicine Research Center of TUMS, Iranian Nursing Organization, Medical Council of Islamic Republic of Iran, Office of Nursing Advisors to MOHME, Academy of Medical Sciences and also Nursing Board of Ministry of Health and Medical Education were among the members of the Task Force. The authors declare that there is no conflict of interest.

ANNEX 1. The Code of Ethics for Nurses in Islamic Republic of Iran
VALUES Nurses have the responsibility that within their career limit, make decisions and act based on their professional values. Values are intrinsically valuable concepts, and can be defined as the basis by which an individual or community selects the criterion of right or wrong. Taking into account the exalted position of nursing, professional values are determined by qualified associations and organization. In our country, the limits and boundaries of the actions, in many cases, are determined by Islam and our Constitution. As much as the ethical values are in compliance with religious principles, they are universal and transnational.
The most important principles that should be considered in nursing profession are:

Respecting the patient/client and preserving human dignity
Altruism and sympathy
Devotion to professional obligations
Accountability, responsibility and conscience
Justice in services
Commitment to honesty and loyalty
Maintaining patient’s privacy, and commitment to confidentiality, and trust
Continuous improvement of scientific and practical competence
Promote the awareness of professional rules and ethical guidelines, and respecting them
Mutual respect and appropriate communication with other health care providers
Respecting autonomy of the patient/client
Compassion and kindness
ETHICAL GUIDELINES
1. Nurses and People
The Nurse should:

1-1. Make effort for: improvement of community health, prevention of diseases, restoration of health and alleviation of pain and suffering of patients; and consider these as her/his main mission.
1-2. Offer the nursing care regardless of race, nationality, religion, culture, gender, age, socioeconomic status, political conditions, physical or mental illness, or any other factor; and strive to eliminate injustice and inequality in society.
1-3. Provide the nursing care to client/patient with respect to the human rights while considering; to the extent it is possible; values, socio-cultural traditions, and religious beliefs of patient/client.
1-4. Educate the community in term of health promotion and disease prevention and consider it as one of his/her most important responsibilities. Nursing care and standard teaching must be presented in a way to fit the culture, beliefs, values and individual’s needs.
1-5. Be sensitive to the challenges and ethical issues, in both community and workplace, that could undermine the sanctity of the nursing profession; and offer the appropriate solution when is necessary.
1-6. While cooperating and coordinating with other individuals, groups and social institutions, try to address social needs and resolve ethical issues raised in the area of health care.
1-7. Pay special attention to vulnerable groups and individuals such as children, elderly, people with physical disability, mental illness, and so on.
1-8. While have attention to the medical health at the local level, endeavor to achieve the health goals in national and international levels.
1-9. Perform his/her responsibilities, in crises and natural disasters such as war, earthquake, flood, and disease epidemic, while taking the necessary precautions.
2. Nurses and the Profession
The Nurse should:

2-1. Take into account ethical responsibilities, as well as the legal and professional liabilities, when implementing the nursing interventions and making the clinical decisions.
2-2. 2-Whitin the limits of his/her power and duties, attempt to provide a safe and healthy environment for the client / patient.
2-3. Maintain the safety of the client / patient by: being on time, efficient performance of the professional duties, and accurate and complete recording of the performed care.
2-4. Provide the best care to the client / patient; based on professional standards which is resulted from valid research and reliable evidence.
2-5. Carry out all the nursing interventions with respect to the client / patient and his/her family.
2-6. Do his/her maximum effort to conserve patient’s confidentiality and privacy, and respect autonomy, and obtain the informed consent.
2-7. Prevent the probable damage to the client / patient by detecting and reporting the professional errors of medical team.
2-8. In case of mistake in nursing interventions, explain honestly to the client / patient, and proceed with truthfulness and fairness in any circumstances.
2-9. Maintain and enhance his/her physical, mental, social, and spiritual abilities.
2-10. Keep his /her knowledge and skills up to date, in order to maintain the professional competence.
2-11. Have the capability and knowledge of effective and safe nursing care, without direct supervision, and be accountable for his/her actions.
2-12. Perform in a way that nobody could question his/her professional credibility and dignity.
2-13. Be cautious about misuse of his/her name and position for commercial advertising of products.
2-14. Avoid the acceptance of any gift or benefit from the client / patient or their relatives, which may cause any limitation either now or in the future.
3. Nurses and Practice
The Nurse should:

3-1. Introduce him /herself with name, title and his/her professional role to the client / patient.
3-2. Provide all the nursing interventions with respect to the client / patient and preserving their dignity.
3-3. Consider the client / patient’s demands regardless of their age, sex, race, economic status, lifestyle, culture, religion, political beliefs and physical abilities.
3-4. Perform the nursing care based on current knowledge and common sense.
3-5. Produce a gentle behavioral and verbal communication, in a way that with attracting the client/ patient trust, their needs and concerns could be understood.
3-6. Before performing any nursing interventions, obtain the patient or his/her legal guardian consent. In this regard, the nurse should provide sufficient information about nursing intervention for the patient, so that she/he could have the possibility of well-informed acceptance or rejection of the service.
3-7. When presenting or applying a new product in clinical practice, have a complete knowledge of its risks. Moreover, provide the client / patient with the necessary information about benefits and disadvantages of the product, hence they could have the possibility of informed choice.
3-8. Be aware that no one has the right to consent in place of a competent adult. In case of children, giving the consent is one of the legal guardian’s responsibilities.
3-9. In order to empower the client / patient, educate him/her and their family; in frame of care plan and discharge program.
3-10. As an exception, in case of an emergency, when the immediate therapeutic action is mandatory for saving the client / patient’s life, start the necessary intervention without patient’s consent.
3-11. Perform the appropriate intervention based on existing standards and patient’s higher interests; when obtaining the informed consent or realizing the patient’s wishes is not possible.
3-12. Apply the safety measures to be sure that nursing interventions are harmless, and when is necessary, consult this matter with other health team members.
3-13. Consider all the information given or obtained during the care process as the professional secrets, and do not reveal them without client / patient’s permission except in legally permissible cases.
3-14. Employ the medical information of client / patient only for health related purposes (treatment, research) and in patient’s interest. Inform the client / patient that part of his/ her medical record might be disclosed to other team members for medical consultation.
3-15. Using the medical information of the client / patient in research or education should be with their permission. Presentation of the result must be done without mentioning the name, address or any other information that could lead to identification of the patient.
3-16. Respect the patient privacy when performing any nursing intervention.
3-17. When performing the ideal service is unfeasible, continue the health care, in best of his /her ability, until establishment of a new health care program.
3-18. Provide the care for injured or patients in emergency situations, even outside the workplace.
3-19. In case of dissatisfaction of the client / patient or other problem, respect their right to change the charged nurse or other health care providers, and as much as possible, try to satisfy the client / patient in this matter.
3-20. In case of noticing a violation of standards of care, inform the authorities who have sufficient power for improvement of condition.
3-21. Report any objection or problem of patient to the ward supervisor.
3-22. Avoid any action, even in patient’s request, that requires ethical, legal or religious violation.
3-23. Assist the patients who spend the last days of their life for accepting the reality and to appropriately planning of their demands, including performing the religious practices or recording their wills.
4. Nurses and Co-workers
The Nurse should

4-1. Cooperate with medical team members, the client / patient and their family, for more efficient presentation of nursing interventions.
4-2. Contribute the client / patient or legal guardian in making decision about nursing interventions.
4-3. Share his/her professional knowledge and experience with other colleagues.
4-4. Establish a good relation based on mutual trust, with medical team.
4-5. Have a respectable conduct with other nurses, professors and students.
4-6. In case of any conflict of interest in the care of the client / patient, discuss it with senior colleagues and the principals, while giving the priority to preserving the clients / patients’ rights.
4-7. Establish a respectful professional relationship with co-workers in various levels, including the head nurse, supervisor, nursing director and department heads
4-8. Confronting any ethical challenge, consult the hospital ethics committee for decision-making.
Nursing Director should:
4-9. Act as a role model for other nurses in all aspects of professional carrier.
4-10. Put his/her maximum efforts into the transfer of legal and ethical information to other nurses.
4-11. Provide the necessary conditions for participation of nurses in continuous training program.
4-12. When required, consult ethicists, in order to resolve the ethical problems occur during nursing interventions.
4-13. According to the hierarchy, collaborated with other colleagues, act in line with client / patient’s interest.
4-14. With the aim of improving the service quality, do his/her maximum effort to maintain a good working environment and increase professional motivation.
4-15. Behave fairly in the process of evaluation and promotion of nurses while considering the professional standards and nursing ethics code.
5. Nursing, Education and Research
5-1. Nursing professors should employ their maximum efforts to update their scientific knowledge, and to promote ethical knowledge and conduct.
5-2. The relationship between professors and students in scientific, educational and research environments should be based on professional ethics and mutual respect.
5-3. Nursing professors should make effort to improve students’ knowledge and skills, and promote their ethical and professional performance.
5-4. Consider carefully and accurately the patient’s rights and ethical concerns, in cases of using the patients for educational purposes.
5-5. Medical services should not be affected if client /patient or their family do not wish to-cooperate in education of the students.
5-6. To improve the healthcare services, the quality of nursing training courses, existing guidelines and standards must be continually reviewed and revised.
5-7. Nurses, who are involved in research, must pass the specific training courses, have knowledge about the research regulations, and be familiar with national, general, and specific ethical guidelines and be pledged to these regulations.
5-8. Nurses should not use their professional positions to convince the client / patient to participate in the research project.
5-9. Refusal of participation in the research project by the patient or his/her family should not influence the delivery of the nursing interventions.
5-10. Clinical nurses should make effort to enhance the expertise and clinical capacities of nursing and midwifery students.