Nurses rely on core values to ensure quality care is provided to patients.
As nurses, we are taught in school and in the workplace the ideal of “beneficence,” which is, doing no harm to our patient and being kind, honest and ethical.
These become core values that we should uphold in our practice so that we provide the best quality of care to our patients and so that we know we are practicing with integrity.
The concept of integrity though, is broad and can be applied in many different contexts; take for example, personal integrity versus professional integrity.
When it comes to nursing, there are certain situations that may pose a concern as to whether or not a nurse is truly practicing with integrity. For example, some nurses are out of work because they chose not to receive the flu vaccine. But although these nurses may have been adhering to their personal integrity, were they upholding their professional integrity by refusing the vaccine and potentially placing their patients at risk?
In 1973, nursing theorist Myra Estrin Levine, PhD(h), MSN, published her Conservation Model for nursing.
The model incorporates aspects of integrity-structural (physical health); personal (patient in on decision-making); and social-with the principle of “conservation of energy.”1
In order to provide nursing that respects and maintains the patient’s integrity, Levines’s model calls for the nurse to become part of the patient’s environment; her skills, education, and caring help the client to overcome their illness while seeing the patient in their entirety.1This grand theory serves as an example to the importance of integrity in nursing and also shows that there are many different aspects of integrity to consider in nursing as it relates to a person’s being.
An integrated self (being whole, consistent with views and actions, resisting evil desires, self-reflection), a personal identity (things that one stands for, integrity is the core of that person’s identity), and morally clean hands (defines the “bottom line” of what a person is willing to do and not to do) are three components of integrity.2
Integrity is a “complex set of values that have to be considered as a whole, a relational framework of values that exist for defined communities and individuals.”3 A value is defined as “relative worth, merit or importance.”4 Values guide our decision making, how we live our lives, and shape our consciousness.5 A virtue is defined as “moral excellence, goodness, righteousness.”4
Integrity can also be viewed as a personal and social virtue, emphasizing the point that integrity is made up of different values. “Acting with the virtue of integrity does not threaten the respect for life, integrity, well-being, and flourishing of others.”6
Integrity is living up to one’s own standards and having character. “Integrity is a noun… One acts with integrity; integrity is distanced from the act in a way that honesty, truthfulness, courage and so on are not.”3
Integrity is seen as the reason behind an individual acting as they do, not the actual act itself, and personal integrity is often seen as the core value for delivering ethical healthcare. 3
Integrity is witnessed when an individual goes beyond what the codes and rules state and see’s that acting outside of these guidelines will better patient outcomes and safety, and in their view is the “right thing to do.”3
In order to practice with integrity, a person must know themselves and know others to give fully competent and just care; “be both self- regarding and other-regarding to balance interest in self and others.”7
Morality serves as a defining characteristic a healthcare professional must have in order to practice with integrity. Having morals can be defined by being respectful, caring, doing “the little things”, getting involved, showing love and concern, and taking time to do a good job. “Moral sense prompts people to be kind and considerate when encountering another human being in distress.”8
Morality and integrity seem almost inextricable when defining integrity in nursing. Integrity has also been defined as the “capacity to deliberate and reflect usefully in the light of context, knowledge, experience, and information (that of self and others) on complex and conflicting factors bearing on action or potential action.”9
Compromise is needed in healthcare when it comes to moral complexity in the professional environment.
From the literature, a new definition for integrity will be made to provide clarity: By understanding and knowing oneself entirely and completely (physically, mentally, spiritually, and emotionally), one can begin to know and relate to others in a holistic manner; this knowing and understanding serves as the basis for providing quality nursing care by being respectful, honest, ethical, and morally just.
Integrity is not a unitary concept in nursing and healthcare. An individual incorporates their personal, professional, and moral values to guide their practice.
Sticking to Your Values
Integrity and the importance of upholding the characteristics that embody integrity are incorporated into codes, practices, policies and guidelines created by individual hospitals and associations.
For example, the American Nurses Association created the Code of Ethics and the American Hospital Association created the Patient’s Bill of Rights.
The concept of integrity in healthcare appears when the nurse’s integrity is being questioned, the maintenance of a patient’s integrity is being questioned, when there is conflict between two or three different types of integrity, e.g., personal, moral, professional, and over “morally informed practice.”9 The conflict may be with another person, with the institution or “system,” or with oneself.
Examples are wide ranging:
The National Health Services provide abortions on therapeutic grounds, but individual professionals may not want to participate in such a procedure because of their morals and beliefs.9
A new graduate nurse feeling pressured with time, was able to give out all her due medications, but could only feed two of her patients (having to send back a tray), she knew it was wrong but also knew there would be pressure to finish on time from her nurse manager.7
An operating room nurse blowing the whistle on two surgeons who were demonstrating incompetent practice which caused her three years of conflict and insults to her personal integrity and professional competence.10
Preserving Integrity in Nursing
The community serves as a setting for integrity; in this case, the nurse’s work environment is the community setting and the patient is the person we are interacting with.
In defining and understanding integrity in healthcare, one cannot only look at the integrity of the nurse; in practicing with integrity, the patient’s integrity is being maintained and is of utmost importance to providing ethical, moral, safe patient care.
Provision Five in the ANA’s Code of Ethics describes the “responsibility to preserve integrity and safety, to maintain competence” to self and to others.11
Within this domain, moral self-respect is needed to preserve wholeness of one’s character and personal integrity; personal and professional identities are not entirely separate or entirely fused, they are seen as integrated, according to ANA. The nurse’s wholeness of character includes the relationship with patients. If a nurse wants to preserve integrity, that is a self-concern of the individual nurse.11
It is essential for nurses to understand the meaning of integrity in nursing practice so that they may then practice with integrity; this leads to an optimal nurse-patient relationship. It is of utmost importance to comprehend the necessity of maintaining integrity in one’s practice so that the nurse and the patient’s sense of self (wholeness) is preserved, and that practice is based on respect, with moral and ethical soundness.
Levine’s Conservation theory acknowledged three types of integrity in nursing practice: structural, personal, social. But it is evident that integrity has many other “faces” with moral, ethical, and professional being major ones.
It is very difficult to separate one aspect of integrity from another when understood in the context of nursing practice because integrity encompasses different aspects of one’s being.
The barriers to adhering to integrity in nursing, e.g., time, group norms, personal values, and the intricacies involved with adhering to one type of integrity, e.g., personal integrity, while comprising another type, such as professional integrity, serve as areas of further research.
Integrity within healthcare needs to be a topic that is open for discussion. Continuing education courses, nursing graduate programs and staff meetings are some settings where this can take place.
Also, it is the role of nurse managers and nursing leaders to promote an environment that is trusting, respectful and safe, where nurses can feel comfortable expressing thoughts and feelings about situations that may arise regarding integrity.
Building a moral community within the workplace “in which there is coherence between what a healthcare organization publicly professes to be, and what employees, patients and others both witness and participate in,” should be the goal.12 Then we as nurses can be proud and sure we are practicing with integrity.
1. McEwen, M. & Wills, E.M. (2011). Theoretical Basis for Nursing. Philadelphia, PA: Lippincott, Williams, & Wilkins.
2. Calhoun, C. (1995). Standing for Something. The Journal of Philosophy, 92(5), 235-260.
3. Tyreman, S. (2011). Integrity: Is It Still Relevant to Modern Healthcare? Nursing Philosophy, 12(2), 107-118.
4. Value. (nd). Collins English Dictionary – Complete & Unabridged 10th Edition. Retrieved October 10, 2012 from http://dictionary.reference.com/browse/Value5
5. Koerner, J.G. (1996). Congruency Between Nurses’ Values and Job Requirements: A Call For Integrity. Holistic Nursing Practice, 10(2), 69-77.
6. Ekeberg, V. (2011). Mature Care and the Virtue of Integrity. Nursing Philosophy, 12(2), 128-138.
7. Petterson, T. (2008). Comprehending Care – Problems and Possibilities in the Ethics of Care. Lanham, MD: Lexington Books.
8. Kelly, B. (1998). Preserving Moral Integrity: A Follow-Up Study with New Graduate Nurses. Journal of Advanced Nursing, 28(5), 1134-1145.
9. Edgar, A., & Pattison, S. (2011). Integrity and the Moral Complexity of Professional Practice. Nursing Philosophy, 12(2), 94-106.
10. Lifeline: Blowing the Whistle on Incompetence. Nursing89, 19(7), 47-50.
11. American Nurses Association (2001). Code of Ethics for Nurses with Interpretive Statements. Retrieved October 5, 2012 from http://www.nursingworld.org.
12. Hardingham, L.B. (2004). Integrity and moral residue: nurses as participants in a moral community. Nursing Philosophy, 5(2), 127-134.