Ethical Issues and Impact of Nurse-Patient Ratios

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HomeANA PeriodicalsOJINColumnsEthicsInterstate Nursing Practice and Regulation Ethics: Interstate Nursing Practice and Regulation: Ethical Issues for the 21st Century

Mary Cipriano Silva, PhD, RN, FAAN
Ruth Ludwick, PhD, RN,C

"The ethics incorporated into good nursing practice are more important than knowledge of the law; practicing ethically saves the effort of trying to know all the laws." (Hall, 1996, p.2)

In OJIN topic Multistate Licensure: Who Owns Your Care?, we weighed the pros and cons of interstate practice laws for nursing in the United States and its territories as we embark on a new era of licensure regulation. It is incumbent on us as nurses, both nationally and internationally, to dialogue about ethical issues that may come from entering into practice without traditional time and space boundaries.

The predominant model in the United States is that nurses are licensed in the state they practice. Nurses who hold dual or more licenses have successfully passed the licensure exam in one state and applied for reciprocity in one or more other states. In contrast to the predominant model, Utah and Arkansas are the only states that have changed state laws to encompass an interstate compact. Six other states are currently in process toward making state law changes (Hutcherson & Williamson, 1999). In addition, some countries like the United Kingdom ( and Australia ( have models for regulating licensure across boundaries.

As travel and electronic communication erode geographical barriers between patient and provider, new models for care delivery are emerging. As care models change, nurses must reflect on their practice and be vigilant about new and developing ethical issues. We will explore potential ethical issues related to interstate practice using the ethical principles of nonmaleficence, beneficence, autonomy, justice, and privacy/confidentiality.


The first principle, nonmaleficence, or do no harm, is directly tied to the nurse's duty to protect the patient's safety. Born out of the Hippocratic Oath, this principle dictates that we do not cause injury to our patients.

How do interstate practice and nonmaleficence interrelate? With interstate practice, it may not seem self-evident how nurses can injure patients with whom they have no physical contact. Consider the interstate nurse, however, who does not return a phone call to a patient who is considered a malingerer. In refusing to return the call, perhaps the patient suffers needless physical or emotional trauma. Therefore, a way that harm can occur to patients is through communication failures. These failures can be intentional as just described or as a result of electronic or human error. Failing to convey accurate information, giving wrong messages, and breaking down of equipment, can cause harm to patients. This harm could be life-threatening such as in cases of strokes and heart attacks.

Some of these communication problems may certainly occur whether a patient is at a neighborhood clinic...
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