Provision 6

Nurses are responsible for contributing to an environment that demands respectful interactions among colleagues, mutual peer support, and open identification of difficult issues that may have potential ethical implications. This includes advocating for more substantial ethics content in nursing education programs as well as ongoing professional development in ethics. Nurses in leadership roles have a particular responsibility to ensure that nurses are treated fairly, safely, and justly, and that they are involved in decisions related to their practice and working conditions. Nurses in leadership roles must respond to concerns and work to resolve them in a way that preserves the integrity of nurses. They ought to seek to change enculturated activities or expectations in the practice setting that are morally objectionable. Nurses practicing in every area must play an active role in shaping professional practice environments to meet the expectations outlined by the Nursing Scope and Standards of Practice, recognizing that these environments directly or indirectly impact health outcomes.

Unsafe or inappropriate activities or practices must be rectified. Organizational changes are difficult to achieve and require persistent, collective efforts. Nurses throughout an organization should take steps to advocate for the recognition of problems at an institutional level and explore potential resolutions. Participation in collective and interprofessional efforts that strengthen the commitment to an ethical environment is appropriate.

Nurses should address concerns about the healthcare environment through appropriate channels and/or regulatory or accrediting bodies to ensure a safe and ethical environment. After repeated efforts to bring about change fail, nurses may feel a moral obligation to resign from healthcare facilities, agencies, or institutions where there are sustained patterns of violation of patients’ rights, where nurses are required to compromise standards of practice or personal integrity, or where the leadership is unresponsive to nurses’ expressions of concern. Given the possibility of organizational reprisal and financial hardship, if nurses choose to stay in an ethically compromised organization, they should continue to be vocal advocates for improving working conditions for nurses and improving unit and institutional practice for ethical patient care. By remaining in such an environment, even if due to financial necessity, nurses risk becoming complicit in ethically unacceptable practices and may suffer adverse personal and professional consequences. When nurses decide to resign or are terminated without just cause, they should pursue reasonable efforts to report and expose injurious actions that threaten nurses, patients, and the delivery of safe, high-quality care. Deciding to resign is often a challenging decision. If individual moral integrity is seriously compromised, or the nurse feels unable to act in accord with ethical values, or all attempts to pursue resolution have failed, resignation may be necessary. The needs of patients or external pressure may never be used to obligate nurses to remain in persistently morally unacceptable work environments. Despite its risk, nurses need to acknowledge the potential benefits of collective action, whether through bargaining, voting, and/or striking. Nurse-led entities should represent nurses in addressing unjust practices. Resumption of work after a collective action often requires intentionally rebuilding the ethical environment and nurses’ relationships with colleagues, the interprofessional team, the institution, and the community.

A working environment that prioritizes nurses’ professional fulfillment minimizes moral distress, strain, and dissonance. Nurses create an ethical environment and culture of civility and kindness, treating all people with dignity and respect. They collaborate to meet the shared goals of providing compassionate, transparent, and effective health services. Through advocacy and allyship, the collective power of the nursing profession, and collaboration with nursing organizations, nurses can help secure the just economic and general welfare of nurses, safe practice environments, and a balance of interests. These organizations advocate for nurses by supporting legislation; publishing position statements; maintaining standards of practice; maintaining the Code; and monitoring social, professional, and healthcare changes.