Most people know about the U.S. Bill of Rights, the first 10 Amendments to the U.S. Constitution, guaranteeing American citizens certain freedoms, such as the right to free speech and assembly, and protection against unreasonable search and seizure. Bills of rights have been developed for patients, such as nursing home patients, dying patients and cancer patients, among others. Most nurses are aware of the Patients’ Bill of Rights. While these rights may vary by state and facility, they generally guarantee patients the right to privacy and confidentiality, and the right to make informed decisions about their own medical care.

However, not every nurse is familiar with the Nurses’ Bill of Rights (also called the Bill of Rights for Registered Nurses). The ANA held a nurs-ing staffing summit in Washington, D.C., in 2000. In a survey before the summit, 75% of nurses reported the quality of nursing care at their facili-ties had declined because of inad-equate staffing and decreased nurse satisfaction.1 More than 200 summit attendees called for a document to detail what nurses need and deserve to do the best for their patients.1 This led to the development of the Nurses’ Bill of Rights, which was approved by the ANA Board of Directors in 2001. Then-ANA President Mary E. Foley, MS, RN, stated, “The ANA Bill of Rights is a powerful statement of the rights that every registered nurse must have to provide high-quality pa-tient care in a safe work environment. This is a tangible reminder to employ-ers of what nurses should be able to expect in their workplaces.”1

“Registered nurses promote and restore health, prevent illness and protect the people entrusted to their care,” the ANA said in a statement on the Nurses’ Bill of Rights and workplace safety.2 “They work to alleviate the suffering experienced by individuals, families, groups and communities. In so doing, nurses provide services that maintain respect for human dignity and embrace the uniqueness of each patient and the nature of his or her health problems, without regard for social or economic status. To maximize the contributions nurses make to society, it is necessary to protect the dignity and autonomy of nurses in the workplace.”2 The Nurses’ Bill of Rights seeks to satisfy that need.

Professional Rights

The Nurses’ Bill of Rights, which lists seven rights, is a statement of professional rights rather than a legal document. It establishes an informal covenant between nurses and their employing institutions to help guide development of organizational policy and to focus discussions between nurses and employers on issues related to patient care and working conditions. Nurses can advocate more effectively for the rights of patients if they have critical information about their own professional rights.

The Nurses’ Bill of Rights supple-ments other ANA documents, such as the Code of Ethics for Nurses with Interpretive Statements, Nursing’s Social Policy Statement and Nursing: Scope and Standards of Practice.3 In addition, nurses and their employ-ers must be familiar with the nurse practice act and professional practice regulations for their own states, as these documents do set forth the legal requirements for nursing practice in a given state.

Nurses should also be familiar with the “2010 Future of Nursing Report,” developed by the Institute of Medi-cine in conjunction with the Robert Wood Johnson Foundation, as it also addresses some of the barriers nurses face in responding to today’s rapidly evolving complex adaptive health care systems. Overcoming these bar-riers will ensure nurses are well po-sitioned to lead change and advance health care through academia and clinical practice.

Read Me My Rights

The Nurses’ Bill of Rights can help nurses settle work-related issues with employers. The use of such widely recognized consensus documents adds credibility to nurses who need to discuss difficult situations, such as safety, staffing and workplace violence with administration. Nurse educators can refer to the ANA Bill of Rights when addressing important topics related to professional practice and when seeking guidance in devel-oping nursing school curriculum and continuing education programs inside and outside of hospitals. Employers can refer to the Nurses’ Bill of Rights to ascertain what nurses need to fully meet their professional responsibili-ties. Many of ANA’s policies and pub-lications are relevant to the Nurses’ Bill of Rights. Following are the seven rights that make up the Nurses’ Bill of Rights

1. Nurses Have the Right to Practice in a Manner That Fulfills Their Obligations to Society and to Those Who Receive Nursing Care

Two ANA publications delineate these obligations. The first, ANA’s Nursing’s Social Policy Statement, says the authority for the practice of nursing is based on a social contract that acknowledges professional rights and responsibilities. The second document, ANA’s Code of Ethics for Nurses with Interpretive State-ments, is a “… succinct statement of the ethical obligations and duties of every individual who enters the nursing profession; it is the profes-sion’s nonnegotiable ethical standard; it is an expression of nursing’s own understanding of its commitment to society.”4 (Nurses might reference this right if there is a dispute with the em-ployer about their obligations toward patients.)

2. Nurses Have the Right to Practice in Environments that Allow Them to Act in Accordance with Professional Standards and Legally Authorized Scopes of Practice

The ANA’s Nursing: Scope and Standards of Practice sets forth the professional standards that apply to the practice of all professional nurses. Nurses should have a copy of the practice act, the regulations and any other official documents governing nursing practice for each state where they are employed and/or licensed. These documents define the legal scope of nursing practice and guide and protect nurses in the perfor-mance of their duties. The ANA has also published or endorsed standards for specialty nurse practice.5 (Nurses might reference this right if the employer is reluctant to allow nurses to perform jobs for which they are legally authorized and fully trained to perform.)

3. Nurses Have theRight to a Work Environment That Supports and Facilitates Ethical Practice in Accordance with Code of Ethics For Nurses With Interpretive Statements

For Nurses with Interpretive Statements

The Code of Ethics for Nurses and its interpretive statements establish ethical standards for the nursing profession and help nurses determine whether their workplaces support ethical practice. (Nurses might refer-ence this right if they believe they are being forced into an unethical plan of care.)

4. Nurses have the Right to Freely and Openly Advocate for Themselves and Their Patients Without Fear of Retribution

The ANA’s Code of Ethics for Nurses states the nurse promotes, advocates for and strives to protect the health, safety and rights of the patient as one of its nonnegotiable tenets. Some nurses have experienced adverse con-sequences for stepping forward with concerns. Some states have enacted whistle-blower laws to protect em-ployees who report unsafe or unethi-cal situations. State nurse practice acts include mandatory reporting provisions that hold nurses account-able for implementing state hospital laws and regulations as advocates for their patients. (Nurses might refer-ence this right if they believe they are being punished for trying to advocate for vulnerable patients or if the safety of a patient is in jeopardy.)

5. Nurses have the Right to Fair Compensation for Their Work Consistent with Their Educational Preparation, Knowledge, Experience and Professional Responsibilities

While there are no laws that define fair compensation (other than federal and state minimum wage require-ments), nurses are in an enviable position compared with many other professions. Nurses who do not believe their employer is paying them a wage commensurate with their experience, knowledge and educational preparation can often seek employment elsewhere. Nurses should familiarize themselves with current market wages in their re-gion, as salaries vary greatly from state to state. For example, RNs in California averaged $96,980 annually in 2013, compared with $56,030 in North Da-kota for the same year.6,7 It is illegal for employers to artificially control wages by collaborating with other employers in their region. (Nurses might refer-ence this right as they negotiate with employers about salary or benefits.)

6. Nurses Have the Right to a Work Environment that is Safe for Themselves and Their Patients

The Occupational Safety and Health Act of 1970 requires employers to pro-vide workplaces free from recognized hazards that could cause harm or death to employees.8 Some states have requirements that exceed federal standards. The right to a safe work environment includes many factors, such as sufficient staffing to ensure patient safety, programs to protect staff against infection and needle-sticks, protection against workplace violence, adequate training to ensure safe performance of assigned duties, and recognition of the inherent dan-ger of nurses working while overly fa-tigued. The ANA has even developed a position statement relating patient safety to nurse fatigue.9 Numerous studies over the past few years have shown a strong correlation between better nurse staffing and improved patient outcomes.10, 11, 12 (Nurses might reference this right whenever they believe a patient safety issue or a workplace safety issue arises, includ-ing mandatory overtime.)

7. Nurses in All Practice Settings Have the Right to Negotiate, Either as Individuals or Collectively, the Conditios of their Employment

Not only do nurses have the right

to negotiate terms of employment; they have the right to receive written descriptions setting forth wages, work schedules and how their performance will be evaluated. Under the National Labor Relations Act, employees — including registered nurses — may form, join or assist labor organizations and engage in collective bargaining over wages, hours and other terms and conditions of employment.13 Com-pared with other occupations (such as manufacturing and industry), nurses came relatively late to collective bar-gaining and unionization. Many nurses still have mixed feelings about union-ization: In 2010 about 23% of RNs reported they belonged to unions.14 Studies have shown that hospitals with RN unions have higher nurse retention rates, but report greater job dissatisfaction, possibly because unionized nurses may be more vocal and less fearful about voicing con-cerns.15 (Nurses might reference this right if their employer seems reluctant to allow for unionization and collective bargaining.)

The Pioneer

The ANA Nurses’ Bill of Rights was not the first such document. The National Student Nurses’ Association (NSNA) developed its Bill of Rights and Responsibilities for Students of Nursing in 1975 and last updated it in 2006.16 As with the ANA Bill of Rights, the rights for student nurses can serve as a basis to resolve issues of concern and to clarify expectations of all par-ties. The National Student Nurses’ As-sociation also suggests state student nursing associations use their bills of rights when developing policy and procedure manuals.

The first three of the 21 rights and responsibilities set forth in the National Student Nurses’ Associa-tion Bill of Rights for Students of Nursing are:

1. Students should be encouraged to develop the capacity for critical judgment and engage in a sus-tained and independent search for truth.

2. The freedom to teach and the freedom to learn are inseparable facets of academic freedom. Students should exercise their freedom in a responsible manner.

3. Each institution has a duty to develop policies and procedures that provide and safeguard the students’ freedom to learn.

The list of rights is augmented with a detailed grievance procedure for use among educational institu-tions that have adopted the rights.16 Such documents can help nurses learn to advocate for themselves early in their careers.

Rights of Nurses, Rights for Patients

The ANA Nurses’ Bill of Rights helps to protect both the rights of nurses and the right for patients to receive quality nursing care. These rights naturally flow into and enhance standards established by specialty nursing organizations, such as the American Association of Critical-Care Nurses. Implementation of the AACN Standards for Establishing and Sus-taining Healthy Work Environments ensures that acute care and critical care nurses have the skills, resources, accountability and authority to make decisions that lead to excellent pro-fessional practice and optimal care for patients and families.17 The six AACN standards are skilled commu-nication, true collaboration, effective decision making, appropriate staffing, meaningful recognition and authentic leadership.17

Some state nursing associations have incorporated ANA’s Nurses’ Bill of Rights into their own pro-fessional practice documents. For example, the New York State Nurses Association says on its website that the organization believes the rights must be afforded to registered nurses and they must know those rights. In addition, the association states that to exercise these rights, RNs must assess the assignment, clarify the facts and assess their own knowl-edge, ability and experience. After evaluating and choosing an option, the nurse must notify the appropri-ate people of the chosen option in a timely manner.18 These actions, for example, would provide an ethical and professional way in which to handle staffing disparities.

The Maryland Nurses Association recommends using the ANA Nurses’ Bill of Rights as a “decision tree” when accepting or rejecting an as-signment that appears to preclude safe care or that requires nurses

to practice beyond their scope.19 Maryland reminds nurses they open themselves to disciplinary action by accepting an assignment they are not qualified to perform.19 Using the bill of rights in this way may mitigate adverse outcomes for both patient and nurse.

Other organizations, such as the Academy of Medical/Surgical Nurses, support the Nurses’ Bill of Rights as a foundation for discussion of patient and worker safety concerns by the nurse and health care employer, while the American Academy of Ambula-tory Care Nursing has developed a similar but not identical list of rights Bill of Rights as well.

Attractive Magnets

Hospitals achieving or seeking Magnet designation recognize the importance of the Nurses’ Bill of Rights in fostering a positive work en-vironment. Developed by the ANCC, the Magnet Recognition Program recognizes health care organizations for quality patient care, nursing excel-lence and innovations in professional nursing practice.21

Hospitals seek Magnet status to help them attract and retain top talent; to improve care, safety and satisfaction; to foster a collaborative culture; to advance nursing standards and practice; and to grow business and financial success.22 According to the ANCC, about 390 hospitals had achieved Magnet status as of Febru-ary 2012. Eight out of 10 of the top-rated medical centers in the U.S. are Magnet facilities.22

The Magnet Recognition Program advances three goals within health care organizations: (a) promote qual-ity in a setting that supports profes-sional practice; (b) identify excellence in the delivery of nursing services to patients; and (c) disseminate best practices in nursing services.22,23

One study of more than 26,250 RNs showed that Magnet hospitals have better work environments, a more highly educated nursing staff, better nurse-to-patient staffing ratios and overall higher nurse satisfaction than do non-Magnet hospitals.24 Hospitals must address five Magnet compo-nents in the application process:

• Transformational leadership

• Structural empowerment

• Exemplary professional practice

• New knowledge, innovation and improvements

• Empirical quality

The section on structural empow-erment references the Nurses’ Bill of Rights. To fully meet the criteria of that section, hospitals must provide a list of continuing education programs and the number of nurses complet-ing the programs over the past 24 months. A program designed to ensure nurses understand the Nurses’ Bill of Rights must be among the program topics.22 A study showed that structural empowerment is positively correlated with nursing job satisfac-tion and high-quality patient care.24

Studies of attributes of Magnet hospitals — which by definition in-corporate the Nurses’ Bill of Rights into their cultures — are measur-ably correlated with improved outcomes in a number of areas. Studies of Magnet hospitals have provided evidence of improved patient care outcomes and in-creased patient satisfaction, as well as improved nurse satisfaction and nurse retention.24 The best example of environments supporting profes-sional nurse practice are Magnet hospitals.25 Patients in such opti-mized environments have lower risks of death and fewer episodes of failure to rescue. Nurses work-ing in healthy work environments rate patient care more highly, with Magnet hospitals being markedly skewed toward excellence.26

A Standardized Structure

The Nurses’ Bill of Rights provides a standardized and recognized struc-ture within which nurses can advo-cate for themselves, a fundamental right for any profession. While nurs-es have always vigorously advocated for their patients, they have not al-ways done so for themselves. Today, nurses are independent practicing professionals with well-defined roles and responsibilities, and account-ability and authority for the care and safety of their patients. They work collaboratively with other health care professionals. They advocate for themselves and their patients.

Are copies of the Nurses’ Bill of Rights prominently posted where they are readily viewable by staff, such as in nursing stations, the human relations department and nursing administration offices? If not, why not? Do nurses at your facility know about the ANA Nurses’ Bill of Rights and how the rights relate to their professional practice? If not, ask your education department or administra-tion to provide appropriate training as needed. Nurses can more effectively advocate for their patients’ rights if they are familiar with their own rights.