NZNO:
Guideline – Code of Ethics
New Zealand Nurses Organisation PO Box 2128, Wellington 6140. www.nzno.org.nz
Page 2 of 23
Foreword
By NZNO President Grant Brookes and Kaiwhakahaere Kerri Nuku
The need for knowledge about ethics, ethical issues and ethical decision-making has never
been greater. Nursing is undertaken in increasingly complex professional practice
environments. Nurses face situations daily where they are challenged by inequities, unmet
needs and under-resourced communities.
That may be why the Code of Ethics is one of the most sought-after publications by the
New Zealand Nurses Organisation Tōpūtanga Tapuhi Kaitiaki o Aotearoa (NZNO). We are
proud of its wide circulation and usage.
NZNO’s Code of Ethics complements the Code of Conduct for Nurses, published by the
Nursing Council of New Zealand Te Kaunihera Tapuhi o Aotearoa. Whereas the latter sets
out the standards of behaviour nurses are expected to uphold in their professional
practice, this document is designed to help nurses examine and answer ethical questions.
Nurses with knowledge of ethics, and ethical frameworks and processes, are better
prepared for situations requiring ethical judgements.
A Code of Ethics for nurses was first adopted by the International Council of Nurses (ICN) in
1953. It was not until 1988 that our forerunner, the New Zealand Nurses Association,
produced a Code of Ethics specific to Aotearoa.
Over the last 30 years nurses from many cultural, ethnic, employment and practice
backgrounds have worked together to develop this Code, now in its sixth iteration. The
result is a publication produced by the nurses of Aotearoa, unique to Aotearoa, which
recognises our bicultural context. Cultural safety and partnership under te Tiriti of
Waitangi are integral to nursing practice and are now reflected in the Code. The nursing
profession continues to lead other health professions in these important aspects of health
care.
The most significant update to this edition is the work of Te Rūnanga to include a Māori
worldview. This gives the Code of Ethics a greater significance as NZNO works towards
bicultural partnership and to achieve an effective equity agenda.
We are confident the Code will be of value and provide nurses with the support they need
in the frequently difficult, complex, stressful, but also rewarding practice environments in
which they work.
Whakatauki
Whaea Taku toa I te toa takatahi taku toa takitini Taki Mano e
It’s not by my own self but by that of the many
NZNO:
Guideline – Code of Ethics
New Zealand Nurses Organisation PO Box 2128, Wellington 6140. www.nzno.org.nz
Page 3 of 23
Acknowledgements
NZNO would like to acknowledge the Public Health Association Kāhui Hauora
Tūmatanui for allowing us to adapt its Code of Ethics to reflect nursing in Aotearoa New
Zealand, and all those individuals and groups who have contributed to previous
editions.
This revision includes significant work by Te Rūnanga to embed a Māori worldview into
the document.
NZNO:
Guideline – Code of Ethics
New Zealand Nurses Organisation PO Box 2128, Wellington 6140. www.nzno.org.nz
Page 4 of 23
Introduction
The purpose of this Code of Ethics (the Code) is to guide nurses’ practice, and
communicate the nursing profession’s ethical values. It has been formulated and
updated in response to the need for a code that closely reflects the current context
of nursing practice. This new edition incorporates more strongly the bicultural
elements of ethical nursing practice in Aotearoa New Zealand.
The New Zealand Nurses Organisation Tōpūtanga Tapuhi Kaitiaki o Aotearoa
(NZNO) is the leading professional and industrial organisation for nurses in
Aotearoa New Zealand, representing more than 53,000 nurses and health workers
on a range of professional and employment-related issues across the public,
private and community sectors. Te Rūnanga o Aotearoa NZNO comprises our
Māori membership and is the arm through which our Tiriti o Waitangi partnership
is articulated.
Te Tiriti o Waitangi is the founding document of Aotearoa New Zealand and
underpins its economic and social development. This Code acknowledges the
principles of protection, participation and partnership between nursing and Māori.
Nurses acknowledge the unique relationship between Māori and the Crown in
applying this Code and nurses registered with the Nursing Council of New Zealand
Te Kaunihera Tapuhi o Aotearoa (NCNZ) are required by the NCNZ Code of
Conduct (2012) to honour these obligations. NCNZ’s
Guidelines for cultural safety:
the Treaty of Waitangi and Māori health in nursing education and practice
also
require nurses to practise in a culturally safe manner in compliance with te Tiriti o
Waitangi.
Values characteristic of Western ethical frameworks have traditionally been used
to develop value statements that guide nursing practice. These values inform the
development of the Code, with the addition of specific values that are important to
ethics and nursing practice in Aotearoa New Zealand. In this Code we also draw
specifically on values derived from a Māori worldview.
At this time of change, challenge and uncertainty in the health service, it is
important all nurses faced with an ethical dilemma are guided by ethical practice
principles (ICN 2012; WHO 2017). The nationwide use of the Code will signal to
other health professionals, managers and to the public that nurses are aware of
their moral responsibilities.
NZNO:
Guideline – Code of Ethics
New Zealand Nurses Organisation PO Box 2128, Wellington 6140. www.nzno.org.nz
Page 5 of 23
Using the Code of Ethics
The Code has been written as a basis for nurses to explore ethical beliefs, and
as a guide to explore individual situations arising in nursing practice.
Each situation is unique and exists in its own context, so the most important
values from the framework will vary according to the particular situation. Any one
value is not always an overriding value; the balance of values and their inter-
relationships may change, not only with each situation, but also within each
situation.
The Code does not seek to provide answers to situations encountered in
practice. Ethical concerns and situations are resolved using an approach that
incorporates exploring values applicable to the context and a process of logical
thinking and action. A number of decision-making models feature at the end of
the document which may help nurses as they seek clarity around ethical
questions.
Underlying philosophy
Nursing was founded on the moral premise of caring and the belief that nurses
have a commitment to do good. Society’s expectation is that nurses are moral
agents in their provision of care, and that they have a responsibility to conduct
themselves ethically in what they do and in how they interact with people
receiving care, their whānau and others (ICN 2012; WHO 2017).
Morality refers to the personal values, character and conduct of individuals or
groups within society (American Nurses Association, 2015). Ethics refers to the
various ways people think about, understand and examine how best to live a
moral life (Johnstone, 2019). The two terms can be used interchangeably with
the study of ethics often called moral philosophy or moral theology (American
Nurses Association, 2015).
Nursing ethics is defined as “the examination of all kinds of ethical and bioethical
issues from the perspective of nursing theory and practice” (Johnstone, 2016,
p.15). Nursing ethics recognises the distinct voice of nurses and the unique way
in which nursing practice is enacted (Fry & Johnstone, 2008; Johnstone, 2016).
Ethical nursing practice is based on a “commitment to do good, a sensitivity and
receptiveness to ethical matters, and a willingness to enter into relationships with
persons who have health-care needs and other problems” (Canadian Nurses
Association, 2017, p.4).
Nurses demonstrate ethical nursing practice when they advocate individually
and collectively for the elimination of social inequities. Nurses address social
NZNO:
Guideline – Code of Ethics
New Zealand Nurses Organisation PO Box 2128, Wellington 6140. www.nzno.org.nz
Page 6 of 23
inequities by: collaborating with other health-care professionals and
organisations for change in unethical health and social policies, legislation and
regulations; advocating for accessible, appropriate and affordable health-care
services that are available to all; recognising the significance of the socio-
economic determinants of health; understanding and including cultural safety in
their practice; and supporting environmental preservation and restoration.
Nurses are responsible for ensuring they achieve ethical nursing practice.
An ethical code supports nurses to achieve ethical nursing practice by describing
a set of values, principles and/or expectations that will guide ethical professional
conduct and assist nurses in their reflection and decision-making (Canadian
Nurses Association, 2017; Fry & Johnstone, 2008; Johnstone, 2019).
Assumptions
The way ethical issues are explored depends on the specific situation and its
context. Contextual determinants include cultural, whānau, professional,
religious and personal beliefs. This Code is based on several assumptions that
permeate nursing.
i) Relationships and interactions are based on mutual respect, including
respect for culture, religion, gender, sexual orientation, ethnicity and other
life-directing individual and group values. An example of this is providing
and working within the concept of cultural safety.
ii) Respect for the individual, whānau, group, iwi, hapū and community
encompasses partnership and collaboration; these are all encouraged to
engage in the process of nursing and their effort, knowledge and expertise
are acknowledged.
iii) Relationships and interactions seek to achieve an equitable outcome for
the individual, whānau, group, iwi, hapū and community. The purpose of
nursing is to uphold and improve the health of all of these.
NZNO:
Guideline – Code of Ethics
New Zealand Nurses Organisation PO Box 2128, Wellington 6140. www.nzno.org.nz
Page 7 of 23
Māori worldview and ethics
Cultural groups are bound together by a tapestry of historically inherited ideas,
beliefs, values, knowledge and traditions, art, customs, habits, language, roles,
rules and shared meanings about the world (McMurray & Clendon, 2015).
Culture provides the lens through which we view and understand the world, and
each culture views the world differently. It is essential to understand that cultural
concepts such as values and ethics are not always translated accurately from
one language (or culture) to another (Berghan, 2007).
A Māori world-view is different from a Western world-view so Western ethical
principles may not be directly relevant to Māori and vice versa. Māori have their
own knowledge systems that link to the land and have their own ways of
acquiring and testing knowledge (Smith, 1999 as cited in Cram, 2007). Cram
adds: “Sometimes these ways are sourced within tradition and other times we
use ‘modern’ tools to explore issues that are important to us. Sometimes we
choose to work alone and other times we choose to work collaboratively with
non-Māori. What is important here is that the choice is ours” (Cram, 2007, p.5).
Māori have the right to be Māori on their own terms.
Tikanga reflects the traditional values, beliefs and practices of Māori which
enhance the relationships fundamental to the sustainability of life, and are
embedded as kawa (primary values) (Hudson, Milne, Reynolds, Russell, &
Smith, 2010). These kawa have developed over time and are deeply embedded
in the social context. Tikanga and its philosophical base of mātauranga Māori
provides a framework through which Māori can actively engage with ethical
issues (Hudson et al., 2010).
Whare Tapa Wha and Te Wheke (Durie, 1998) provide models of health that
help guide nursing practice. Ethical care includes establishing the person’s
priorities, values and choices to meet their taha tinana (physical health), taha
wairua (spiritual health), taha whānau (family health) and taha hinengaro (mental
health) needs. This may include their whakapapa, tīpuna and the wider whānau,
hapū and iwi.
This Code of Ethics outlines principles that can inform ethical nursing practice.
Although each of the principles will not directly translate into the Western or
Māori equivalent, the nurse will be able to identify with each in their own way and
use them in their decision-making. The principles draw on the United Nations
(UN) Declaration on the Rights of Indigenous Peoples (United Nations, 2008),
previous versions of the NZNO Code of Ethics, and the Public Health
Association’s Code of Ethics and supporting documents.
NZNO:
Guideline – Code of Ethics
New Zealand Nurses Organisation PO Box 2128, Wellington 6140. www.nzno.org.nz
Page 8 of 23
Principles/values
The principles are not listed in any particular order, nor does one have a greater
weight than any other. No one moral viewpoint dominates another and the
emphasis is on …”understanding difference rather than striving for uniformity”
(Johnstone, 2016, p.78). The diversity and intended inclusiveness of the
principles, and the way in which nurses enact them, will help ensure the ethical
decisions we make reflect the lived reality and experience of the individuals,
whānau, hapū, iwi and communities that make up our society.
This image depicts the interweaving of Māori and Western ethical values for the
new Code of Ethics.
NZNO:
Guideline – Code of Ethics
New Zealand Nurses Organisation PO Box 2128, Wellington 6140. www.nzno.org.nz
Page 9 of 23
Māori values are:
- Rangatiratanga
- Manaakitanga
- Tika
- Whanaungatanga
- Wairuatanga
- Kotahitanga
- Kaitiakitanga
Western values are:
- Autonomy
- Beneficence
- Non-maleficence
- Justice
- Confidentiality
- Veracity
- Fidelity
- Guardianship of the environment and its resources
- Being professional.
Information in this section is obtained from a variety of sources which are listed
in the References section.
Description of the principles (Māori worldview)
Rangatiratanga
> Māori have the right to self-determination and the right to determine their own
destiny.
> Tino rangatiratanga is at its strongest when hapū and iwi are acknowledged as
tāngata whenua in their particular area or region – this is characterised by iwi
autonomy (Durie, 1998).
> Article 3 of the UN Declaration on the Rights of Indigenous Peoples states that
indigenous peoples have the right to self-determination. That means they freely
determine their political status and freely pursue their economic, social and cultural
development.
> Nursing* actions and outcomes will reflect the hopes and aspirations of Māori for
self-determination in respect of their own affairs.
NZNO:
Guideline – Code of Ethics
New Zealand Nurses Organisation PO Box 2128, Wellington 6140. www.nzno.org.nz
Page 10 of 23
Manaakitanga
> Manaakitanga is the way in which we make people feel welcome when they are in
our company and ensure their mana is maintained.
> Manaakitanga also means showing kindness, treating people with respect, caring
for others, nurturing relationships, reciprocity, cultural and social responsibility.
> Nursing* practice will demonstrate an ethic of care, support and reverence for all
peoples: “He aha te mea nui o te ao, he tangata, he tangata, he tangata”.
Tika
> Tika is used in various ways but in the context of ethics it can be associated with
the importance of truth, correctness, directness, justice, fairness, and rights.
> Tika tāngata describes human rights.
> The UN Declaration on the Rights of Indigenous Peoples outlines the fundamental
rights of indigenous peoples throughout the world.
> Nursing* practice will be based upon what is right and proper according to
circumstance and in accordance with common good.
Whanaungatanga
> Whakawhanaungatanga is the process of establishing relationships, which enables
connections between past and present to be made.
> Whānau connection, relationships with whānau both past and present, and kinship
are paramount.
> Whanaungatanga develops as a result of kinship rights and obligations, which also
serve to strengthen each member of the kin group. It also extends to others with
whom one develops a close familial, friendship or reciprocal relationship.
> Nursing* practice will focus on people and the relationships established and
maintained with others.
NZNO:
Guideline – Code of Ethics
New Zealand Nurses Organisation PO Box 2128, Wellington 6140. www.nzno.org.nz
Page 11 of 23
Wairuatanga
> Wairuatanga is about understanding and believing there is a spiritual existence in
addition to the physical.
> The wairua of a person requires nourishment as regularly as the tinana (body), and
forms of nourishment differ among people.
> Article 12 of the UN Declaration on the Rights of Indigenous Peoples gives
indigenous people the right to manifest, practise, develop and teach their spiritual
and religious traditions, customs and ceremonies.
> Nursing* practice will acknowledge and respect the right of all people to spiritual
freedom.
Kotahitanga
> Kotahitanga is about unity, togetherness, solidarity and collective action.
> All people are encouraged to have their say and be a part of collective approaches.
> Nurses* will seek to work in unity and harmony with each other and others.
Kaitiakitanga
> Kaitiakitanga means guardianship or stewardship.
> Article 25 of the UN Declaration on the Rights of Indigenous Peoples states that
“indigenous peoples have the right to maintain and strengthen their distinctive
spiritual relationship with their traditionally owned or otherwise occupied and used
lands, territories, waters and coastal seas and other resources and to uphold their
responsibilities to future generations in this regard”.
> Nursing* policies and practices will reflect the custodial role we have of this planet
on behalf of ourselves, our children and those generations yet to come. “Toitu he
whenua, whatungarongaro he tangata – the land endures while people disappear.”
* Taken from Public Health Association (2012) with permission and adapted for use with
nurses.
NZNO:
Guideline – Code of Ethics
New Zealand Nurses Organisation PO Box 2128, Wellington 6140. www.nzno.org.nz
Page 12 of 23
Description of the principles (Western)
Autonomy
> Individuals have the right to self-determination. This assumes that the individual or
group, or their client or agent, have the wisdom to make the best choice for that
individual or group.
> Particular attention should be paid to awareness and acceptance of cultural
differences in the provision of health care, to ensure cultural safety of clients and
nurses. (A situation is culturally safe when a client feels their cultural or spiritual
needs are included in care, or that they can ask and have those needs met without
prejudice.)
> Many socio-cultural groups in Aotearoa New Zealand see the importance of the
collective as equal to the needs and rights of the individual. The right of both the
individual and the collective (whānau, hapū, iwi) must be respected.
Beneficence
> Beneficence is the performing of actions leading to outcomes that now, or in the
future, would be regarded as worthwhile; the concept of doing good.
> The meaning and value of good can vary according to context and this can influence
what we think and do when considering beneficence.
Non maleficence
> Non-maleficence is the avoidance of harm, the prevention of future harm, and
minimising harm in situations where it is unavoidable.
> The meaning and value of harm can vary according to context and this can influence
what we think and do when considering maleficence.
NZNO:
Guideline – Code of Ethics
New Zealand Nurses Organisation PO Box 2128, Wellington 6140. www.nzno.org.nz
Page 13 of 23
Justice
> Justice is based on the assumption that society has a responsibility to treat people
fairly. Justice can be further split into three categories: fair distribution of scarce
resources (distributive justice), respect for people’s rights (rights-based justice) and
respect for morally-acceptable laws (legal justice).
> Society confirms concepts of justice in its legal frameworks. There is an inter-
relationship between law and justice, which means that one does not automatically
override the other. Laws are modified over time as they are applied and this
increases justice in society. Different health circumstances may require different
resource allocation or entitlement to achieve equity.
Confidentiality
> Confidentiality means the privacy of written or spoken information, or of observed
body language, acquired through privileged access.
> The concept of privacy can vary according to the situation and what laws might
apply.
Veracity
> Veracity occurs when actions, speech and behaviour ensure communications
between individuals and/or groups are honest and truthful.
Fidelity
> Fidelity means the obligation to remain faithful to one’s commitments to others,
particularly promises and when information is given in confidence.
NZNO:
Guideline – Code of Ethics
New Zealand Nurses Organisation PO Box 2128, Wellington 6140. www.nzno.org.nz
Page 14 of 23
Guardianship of the environment and its resources
> This assumes that society has a responsibility to respect and protect the
environment and its resources.
> How we understand and value guardianship and the relationship between person
and environment can vary according to culture and context.
Being professional
> This involves the belief that nursing is a profession with a defined purpose. It has a
special relationship with society, having been established by society.
> There is a duty to provide health-related care for those members of society in need.
> Nursing possesses a distinct body of knowledge, its own area of independent
practice and is guided by the specific set of values identified here.
> Nurses are accountable for their nursing practice and accept responsibility for their
actions and decision-making.
NZNO:
Guideline – Code of Ethics
New Zealand Nurses Organisation PO Box 2128, Wellington 6140. www.nzno.org.nz
Page 15 of 23
Applying the principles in practice
Nursing takes place in a series of unique relationships with others: clients (including whānau), colleagues, organisations and society. The Code provides
a framework around these unique relationships and how they relate to the varying ethical principles used to guide nursing practice.
The framework of the Code is summarised in the matrix below.
Principles
Context
Nurse-client/whānau
relationship
Nurse-colleague
relationship
Nurse-organisation
relationship
Nurse-societal
relationship
Rangatiratanga
Practice supports whānau
to make own health
decisions.
Practice and
engagement are self-
determined.
Leadership empowers
individual practitioners
and others.
Actions
demonstrate
willingness to
stand-up against
adversity and harm.
Manaakitanga
Practice enables
maintenance of mana and
recognises the role of
kaumātua and kuia.
Action and conversation
demonstrate respect and
care.
Self-care enables care
of others and includes
reflection and
debriefing.
Depth of care for
society is unified
and overarching.
NZNO:
Guideline – Code of Ethics
New Zealand Nurses Organisation PO Box 2128, Wellington 6140. www.nzno.org.nz
Page 16 of 23
Principles
Context
Nurse-client/whānau
relationship
Nurse-colleague
relationship
Nurse-organisation
relationship
Nurse-societal
relationship
Tika
Self-awareness and
knowledge of whānau
traditions enables tikanga
(correct care).
Working relationships
are enhanced through
awareness of customs
and traditions.
Practising to the
highest level of
integrity is enabled.
Community safety
and protection is
ensured by
following the lead
of ancestors.
Whanaungatanga
Whānau are included in
planning care that
honours professional
boundaries.
Action and behaviour
demonstrate awareness
of the significance of
whānau.
The concept of
whānau is recognised
as the foundation of
well-being for clients,
self and colleagues.
Understanding of
whānau is reflected
in caring.
Wairuatanga
Practice creates
opportunities for spiritual
well-being practices.
There is recognition and
respect for others’
spirituality.
Spirituality is enabled
and supported.
Care recognises
communities’
spiritual dimension.
Kotahitanga
Reciprocal engagement
between
individual/whānau and
nurse enables joint
decision-making.
Positive practice
environments are
achieved by working in
unison.
Connection through
positive partnerships
enables potential to be
expressed.
Whānau health is
supported by the
collective strength
of nursing to create
change.
NZNO:
Guideline – Code of Ethics
New Zealand Nurses Organisation PO Box 2128, Wellington 6140. www.nzno.org.nz
Page 17 of 23
Principles
Context
Nurse-client/whānau
relationship
Nurse-colleague
relationship
Nurse-organisation
relationship
Nurse-societal
relationship
Kaitiakitanga
There is guardianship,
protection and
preservation of care
through relationships.
Providing guardianship,
protection and
preservation is a shared
responsibility.
Guardianship and
protection aligns with
care and nurturing.
Protection and
guidance are
provided at all
levels.
Autonomy
Nurses support clients to
make informed decisions,
individually or collectively.
Self-awareness
promotes understanding
of contributions of self
and others.
Nurses act individually
and collectively but
recognise autonomy
may be limited in large
organisations.
The concept of
autonomy is
communicated and
adapted
appropriately into
practice.
Beneficence
Partnerships are
developed that are
experienced by clients as
safe and beneficial and
from which ‘good’ results.
Sharing knowledge and
skill enhances
professional
relationships and
effective care.
Nurses participate in
the design, moderation
and review of services
that meet client care
needs and protect their
rights.
Research,
education and
innovation in
consultation with
the community
ensure practice and
standards are safe
and ethical.
NZNO:
Guideline – Code of Ethics
New Zealand Nurses Organisation PO Box 2128, Wellington 6140. www.nzno.org.nz
Page 18 of 23
Principles
Context
Nurse-client/whānau
relationship
Nurse-colleague
relationship
Nurse-organisation
relationship
Nurse-societal
relationship
Non-maleficence
Clients are safe –
culturally, physically,
emotionally, socially.
Quality of care and harm
minimisation is
enhanced by peer
monitoring.
Nurses contribute to
an environment that is
safe physically,
socially, spiritually,
culturally and
emotionally.
Safety and
protection of the
vulnerable occur
through monitoring
services and
practice.
Justice
Dignity, needs and values
of clients are respected.
The client defines
fairness and perception of
outcome.
There is awareness and
acceptance of rights,
values and beliefs of self
and colleagues.
Nurses advocate for
equitable systems and
services that meet the
needs of clients and
colleagues.
Advocacy for
accessibility to
services is
ensured, including
the right to
complain about a
service.
Confidentiality
Client information is
privileged and
Safe-guarded against
unwarranted intrusion.
Nurses protect
colleagues from
unwarranted intrusion –
physical, social and
emotional.
Nurses contribute to
the organisational
responsibility for
safeguarding
information.
A balance is
achieved between
legal requirements
for privacy and
protection from
harm.
NZNO:
Guideline – Code of Ethics
New Zealand Nurses Organisation PO Box 2128, Wellington 6140. www.nzno.org.nz
Page 19 of 23
Principles
Context
Nurse-client/whānau
relationship
Nurse-colleague
relationship
Nurse-organisation
relationship
Nurse-societal
relationship
Veracity
Communication is open,
honest and truthful.
Collegial relationships
are promoted by
openness, honesty,
truthfulness.
Communication with
colleagues and
employers fosters a
supportive and trustful
environment.
Community well-
being is promoted
by accountability,
transparency, and
openness.
Fidelity
Trust is promoted by
honouring commitments
and providing a rationale
for decisions.
Conflicting demands are
managed to balance
loyalties to colleagues
and clients.
Role(s) are performed
with commitment to
practice and loyalty.
Actions and
behaviours
demonstrate
commitment to
society. Nurses are
registered with the
Nursing Council of
New Zealand.
Guardianship of
environment
and resources
Practice supports
conservation of resources
and environment.
Practice supports
conservation of
resources and
environment.
Practice uses human,
technical, financial and
natural resources
efficiently and reduces
use of harmful
substances.
Practice conserves
resources, and
enhances
communities’
relationships with
the natural
environment.
NZNO:
Guideline – Code of Ethics
New Zealand Nurses Organisation PO Box 2128, Wellington 6140. www.nzno.org.nz
Page 20 of 23
Principles
Context
Nurse-client/whānau
relationship
Nurse-colleague
relationship
Nurse-organisation
relationship
Nurse-societal
relationship
Being professional
Sound judgment and
practice meets
professional standards.
Services for clients are
advocated.
Practice review and
innovation is evidence-
based.
Maintenance and
review of practice
standards are
achieved in co-
operation with
colleagues.
Actions and
behaviours foster
communities’ trust
in the profession.
NZNO:
Guideline – Code of Ethics
New Zealand Nurses Organisation PO Box 2128, Wellington 6140. www.nzno.org.nz
Page 21 of 23
Ethical decision-making
A number of different decision-making tools can help inform nurses facing ethical
decisions. Each has its own merits and differing situations may benefit from the
application of a different tool.
The four box method (Jonsen, Siegler, & Winslade, 2010)
This is useful for addressing clinical ethical issues by asking us to allocate specific items
of information within four boxes that each focus on different aspects of care planning.
The four-box method recognises that even after reflection we may still disagree on which
moral theory is ultimately correct. The alternative of not making a decision, is not morally
neutral and is itself open to moral appraisal. Therefore we must find a way to reach a
decision we can agree is rational and ethical. The four-box method is a tool which helps
us achieve this.
CLINICAL ISSUES
PATIENT PREFERENCES
The principles of beneficence and non-
The principle of respect for autonomy
maleficence
What are the patient’s expressed
What is the patient’s medical
history/diagnosis/prognosis?
preferences for treatment?
Is the patient competent?
What are the treatment options?
What would they want done?
What are the goals of treatment?
What is in their best interests?
What is the benefit to the patient?
QUALITY OF LIFE
CONTEXTUAL FEATURES
The principles of beneficence and non-
The principles of loyalty and fairness
maleficence and respect for autonomy
Prospects of survival with and without
How does this affect others:
family/whānau and team?
treatment?
Cost to health system?
Various effects on patient of treatment?
Cultural/religious issues?
What are the plans for comfort and
Law and policy?
palliative care?
Find out more at https://depts.washington.edu/bioethx/tools/4boxes.html
Johnstone’s moral decision-making model (Johnstone, 2019)
Megan-Jane Johnstone’s model resembles the nursing approach in that it is based
around a five-step decision-making process.
1. Assess the situation (consider the relevant facts and values associated with the
issue).
2. Diagnose or identify the moral problem(s).
3. Set moral goals and plan an appropriate moral course of action.
4. Implement the plan of moral action.
5. Evaluate the moral outcome of the action implemented.
NZNO:
Guideline – Code of Ethics
New Zealand Nurses Organisation PO Box 2128, Wellington 6140. www.nzno.org.nz
Page 22 of 23
Johnstone notes the importance of ensuring that deliberations appeal to reason, emotion,
intuition and life experience to inform the decision-making process as much as to the
facts. She also notes the need for reflection and imagining possible moral futures and
solutions to problems (Johnstone, 2019).
Māori ethical decision-making models
Guidance on ethical decision-making for Māori may be sought from local and/or
organisational kaumātua or kuia. The Health Research Council’s publication Te Ara Tika:
Guidelines for Māori research ethics (Hudson et al., 2010) also provides a useful
framework for decision-making for those who are engaged in research, are on ethics
committees, or who engage in consultation or advice about Māori ethical issues from a
local, regional, national or international perspective.
References
American Nurses Association. (2015). Code of ethics for nurses with interpretive
statements. Silver Spring, MD: Author.
Berghan, G. (2007). What does a collective identity mean from a Maori point of view?
Health Promotion Forum of New Zealand.
Canadian Nurses Association. (2017). Code of ethics for registered nurses. Ottawa,
Canada: Author. Retrieved from https://www.cna-aiic.ca/en/nursing-practice/nursing-
ethics
Cram, F. (2007). Māori and public health: Ethics. A discussion paper. Prepared for the
Public Health Association. Wellington: Katoa Ltd.
Durie, M. (1998). Whaiora: Māori health development (2
nd
ed). Auckland: Oxford
University Press.
Fry, S. T., & Johnstone, M. J. (2008). Ethics in Nursing Practice. A guide to ethical
decision-making (3
rd
ed). Chichester: Wiley-Blackwell.
Hudson, M., Smith, B., Milne, M., Reynolds, P., & Russell, K. (2010). Te Ara Tika:
Guidelines for Maori research ethics: A framework for researchers and ethics
committee members. Health Research Council of New Zealand: Auckland. Retrieved
from
http://www.hrc.govt.nz/sites/default/files/Te%20Ara%20Tika%20Guidelines%20for%20
Maori%20Research%20Ethics.pdf
International Council of Nurses. (2012). The ICN code of ethics for nurses. Geneva,
Switzerland: Author. Retrieved from https://www.icn.ch/sites/default/files/inline-
files/2012_ICN_Codeofethicsfornurses_%20eng.pdf
Johnstone, M.J. (2019). Bioethics: A nursing perpective (7
th
ed). Melbourne: Elsevier.
Jonsen, A., Siegler, M., & Winslade, W. (2010). A practical approach to ethical decisions
in clinical medicine (7
th
ed). New York: McGraw Hill.
McMurray, A., & Clendon, J. (2015). Community Health and Wellness: Primary health
care in practice (5
th
ed). Melbourne: Elsevier.
NZNO:
Guideline – Code of Ethics
New Zealand Nurses Organisation PO Box 2128, Wellington 6140. www.nzno.org.nz
Page 23 of 23
Nursing Council of New Zealand. (2011). Guidelines for cultural safety, the Treaty of
Waitangi and Māori health in nursing education and practice. Wellington, New Zealand:
Author. Retrieved from
http://www.nursingcouncil.org.nz/content/download/721/2871/file/Guidelines%20for%20
cultural%20safety,%20the%20Treaty%20of%20Waitangi,%20and%20Maori%20health
%20in%20nursing%20education%20and%20practice.pdf
Nursing Council of New Zealand. (2012). Code of conduct for nurses. Wellington, New
Zealand: Author. Retrieved from
http://www.nursingcouncil.org.nz/Nurses/Code-of-Conduct
Public Health Association of New Zealand. (2012). Te Ture Whakaruruhau Code of
ethical principles for public health in Aotearoa New Zealand. Wellington, New Zealand:
Author. https://app.box.com/s/62474kdlaxyq3t406sdck4j67bh6s40e
United Nations. (2008). United Nations declaration on the rights of indigenous peoples.
New York, USA: Author. Retrieved from
http://www.un.org/esa/socdev/unpfii/documents/DRIPS_en.pdf
World Health Organization. (2017). Code of ethics and professional conduct. Geneva,
Switzerland: Author. Retrieved from
http://www.who.int/about/ethics/code_of_ethics_full_version.pdf
Date adopted: 1995, 2001, 2010, 2013. Reviewed: 2019
Review date: 2024 Correspondence to: nurses@nzno.org.nz
Principal authors: Te Rūnanga o Aotearoa NZNO; Dr Jill Clendon
Mission statement
NZNO is committed to the representation of members and the promotion of nursing and midwifery.
NZNO embraces Te Tiriti o Waitangi and works to improve the health status of all peoples of Aotearoa
New Zealand through participation in health and social policy development.
© 2019 This material is copyright to the New Zealand Nurses Organisation.
Apart from any fair dealing for the purpose of private study, research, criticism or review, as permitted
under the Copyright Act, no part of this publication may be reproduced by any process, stored in a
retrieval system or transmitted in any form without the written permission of the Chief Executive of the
New Zealand Nurses Organisation (NZNO), PO Box 2128, Wellington 6140.
ISBN: 978-1-98-856006-9
