The Nursing and Midwifery Code: Making it work for you and your patients
Before you dismiss the new NMC Code as something you will read when you get around to it, it is worth reflecting on how it impacts on your day to day work – and what it might mean if you don’t adhere to it
By now, every practice nurse on the Register should have received their copy of the Nursing and Midwifery Council’s updated Code of conduct.1 It is vital that they should ensure that they are familiar with its contents, as failure to comply with the Code could result in action being taken by the NMC, which ultimately could result in suspension from the professional Register.
In this article, we examine the principles of the Code and consider how it can be used by general practice nurses to improve patient care.
By the end of this article you should:
- Be familiar with the role of the NMC and the key elements of the new code of conduct
- Understand how implementation of the Code can improve patient care
- Know how to use the Code to act as the patient’s advocate
- Recognise how the Code can help strengthen a patient-focused approach to care provision
THE NMC: FOR US OR AGAINST US?
The Nursing and Midwifery Council (NMC) is the regulatory body for nurses and midwives working in the UK. It sets our professional standards through the code of conduct. But in recent years, the NMC has faced criticism over increased fees and a perceived lack of benefit from those fees to UK nurses and midwives.2 At times, its role in protecting the public can makes it feel like Big Brother, ready to pounce on nurses if ever things go wrong. One look at the NMC’s website page entitled ‘What we do’ is enough to make any nurse quiver. The page explains that one of the roles of the NMC is to deal with any concerns or allegations that a nurse does not meet the standards for skills, education and behaviour set by the NMC. If a problem is identified, the NMC will investigate and, when necessary, remove the nurse from the register temporarily or even permanently. In 2012-2013, the NMC imposed 864 interim orders that restricted a nurse or midwife’s practice – or suspended her from practice – while a case was being investigated. The NMC also struck off 589 nurses or midwives and suspended the registration of a further 232. Another 160 nurses or midwives had conditions imposed on how they could practise, and 163 received a caution order.3 Little wonder then that not everyone sees the NMC as an organisation which facilitates best practice and supports nurses to provide the highest quality of care – and yet this is exactly what it does.
The ethos of the new Code sits side by side with the 6 Cs,4 by underlining the most important philosophies of nursing care: accountability, professionalism and compassion.5 It should be embraced, memorised and quoted verbatim, particularly by any nurse who sometimes feels like a puppet in some macabre NHS Punch and Judy show, being pulled this way or that by GP employees, prescribing advisors, guideline writers and health economists – when all we want to do is deliver high quality patient-centred care.
So what does the new Code say that can help nurses to deliver better care? Well, the code is divided into four key sections, which could be referred to as the four Ps:
Prioritise people
Practise effectively
Preserve safety and
Promote professionalism and trust
What this iteration of the Code gives us, then, is a mandate to be the patient’s advocate. We can do this as a direct result of these four key sections of the code, which, if summed up into one simple sentence could read:
Nurses (and midwives) should inspire trust and show professionalism by always putting patients first and ensuring that care is delivered safely and effectively.
If anything comes in the way of that simple premise then it stands in the way of us fulfilling our obligations as registered nurses.
Each of the 4 Ps comes with a set of key messages that help to explain how nurses can achieve them.
When explaining the need to prioritise people, for example, the Code reminds us of the importance of putting the patient’s interests first and ensuring that their needs are recognised, assessed and responded to. Nurses are advised to treat others with kindness, respect and compassion and to acknowledge each individual’s right to choose the care they receive, the way in which it is delivered and the level of contribution that they may want to make to decisions about their care. This involves listening to what people say so that shared decisions can be made in partnership with patients and their families or carers. In order to make this happen, nurses are expected to help people to access information and support and always to act as the patient’s advocate, being prepared to challenge poor practice and discriminatory attitudes which may jeopardise this.
When discussing the need to practise effectively, the Code explicitly states that nurses should use the best evidence available when caring for patients and that they should maintain the knowledge and skills needed for safe, effective and evidence based practice. The importance of strong written, verbal and non-verbal communication skills is also highlighted. Effective teamwork is essential and the role of the health care team extends to giving and receiving performance-related feedback; nurses should therefore be able to gather and reflect on feedback from a variety of sources, using it to improve their practice and performance. This renewed focus on reflection is important and will be the subject of a future article on how to reflect effectively.
The issue of accountability and delegation is also covered in the revised Code and nurses are reminded not only of their own accountability but also their accountability for any decisions to delegate tasks and duties to other people, for example health care assistants, within the team. To that end, nurses are expected to ensure that people who have tasks delegated to them are adequately supervised and supported to ensure that they are competent to carry out those tasks and reach the required standard of care.
The section on preserving safety focuses on the importance of raising concerns whenever any situation that puts patients at risk is identified. It also refers to the issue of competence and the importance of nurses working within their individual competence levels along with the need to refer on when moving into areas that are outside of their competence. To be able to demonstrate competence, nurses are reminded of the importance of accessing and completing the necessary training before carrying out any new role and that if they are asked to act without appropriate training they should swiftly raise and if necessary escalate their concerns. Without appropriate training, nurses would be working outside their code of conduct and could therefore be considered to be in breach, putting their registration at risk.
Finally, the section on promoting professionalism and trust explains that nurses should act with honesty and integrity at all times. This is why off duty behaviour is as important as on duty behaviour. The specific recommendation that nurses refrain from expressing any personal beliefs (including political, religious or moral beliefs) to others in an inappropriate way is a reminder of the need to use all forms of communication – including social media – with care. Criticism of colleagues on Facebook or Twitter, for example, could constitute a breach of the code of conduct.6
Professionalism also requires that nurses fulfil the requirements for registration, including meeting the specified hours of practice and continuing professional development demanded by the NMC, by taking part in appropriate and regular learning and professional development activities that aim to maintain and develop competence and improve performance.7
Nurses must always have appropriate indemnity cover in place as a condition of continued registration.
Leadership is considered to be a key feature of professionalism and nurses are encouraged to demonstrate leadership skills that improve people’s experience of using healthcare services. These skills include identifying priorities, managing resources and dealing with risk to ensure the delivery of high quality care that puts patients first.
DO YOU MEET THE STANDARDS?
Here are some questions to enable you to reflect on whether you are able to meet the standards set within the 4 Ps of the NMC code:
1. Prioritising people: do you ever feel that your role is compromised by a ‘one size fits all’ approach, whether through template-based care, the use of formularies or guidelines which appear to restrict your ability to offer individualised patient-centred care? If so, does this element of the new Code empower you to challenge this situation? How could you develop a process which ensures that you act as the patient’s advocate, encourage shared decision making and feel able to challenge poor practice and discriminatory attitudes? The NMC code of conduct can support you to do this.
2. Practising effectively: do you feel that you are given adequate protected time for education and development? Have you been able to take a formal approach to reflective practice, as advised by the NMC in preparation for revalidation and by professional bodies such as the Royal College of General Practitioners in the General Practice Nursing Competencies framework?8,9 Do you have protected time to facilitate access to a clinical supervision network in your area, as recommended by the Care Quality Commission?10 Do you feel that you have enough time to support and develop anyone in the practice to whom nursing tasks are delegated? If not, does this element of the new Code empower you to challenge this situation?
3. Preserving safety: do you feel competent to challenge standards of care that threaten patient safety? If you feel you are being asked to deliver sub-standard care, are you able to address the situation, and if necessary, override it? For example, do you feel you have enough time with patients to be able to practise safely, ensuring that all relevant information has been discussed and informed consent has been gained? If not, does this element of the new Code empower you to do so?
4. Promoting professionalism and trust: do you feel that you are able, in most cases, to put the needs of the patient first and foremost while continuing to practise professionally at all times? Do you practise in a way that inspires others and demonstrates sound leadership skills to others within your area of practice? If not, does this section of the new Code help you in any way?
PUTTING IT INTO PRACTICE: MANAGING DIABETES USING THE NMC CODE
So what does this Code and the 4 Ps actually mean in practice? Well, here is a somewhat controversial example. NICE has recently published its updated draft guidelines for type 2 diabetes.11 The guidelines group was made up of a wide range of health care professionals including doctors, pharmacists, psychiatrists and nurses. There are several sections, and topics such as lifestyle management are dealt with very effectively, with a clear understanding of the challenges of lifestyle interventions for people with type 2 diabetes. However, the proposed changes to the pharmacological approach to managing type 2 diabetes have provoked a storm of protest, and have been described as ‘lacking in commonsense’.12,13 The resurrection of a drug with which few clinicians are familiar, repaglinide, has been met with disbelief – the drug has to be taken three times a day with meals and has been shown to have a higher risk of hypoglycaemia and weight gain than other therapies on the market.13 Many clinicians are concerned that compliance may be compromised and outcomes may be impaired as a result.13 However, if these guidelines are allowed to go through, the NMC code could protect any clinician who decides, after discussion with the patient, that a different therapy choice should be made. Here’s how:
- Prioritise people: the nurse has a duty to discuss the therapy options available along with the pros and cons of each option such as benefits, side effects, risk factors, the need for home blood glucose monitoring and, arguably, what the drug costs the NHS – although cost efficacy might be a better argument than how much the drug actually costs. For example, drugs which cause hypoglycaemia will require the patient to carry out home blood glucose monitoring and that cost needs to be factored in. It may be difficult for some people (workers, the elderly, people who need to move in and out of their home and/or workplace during the day) to remember to take their medication three times a day with meals and this could put them at unnecessary risk of macrovascular and microvascular complications from their diabetes.14
- Practise effectively: the nurse needs to have some knowledge of the elements described above, or be able to access information about them, and make them accessible to the patient too; this requires protected time for education, reflection and supervision to ensure that practice remains evidence-based at a time when evidence is constantly changing. This ensures that the nurse has the ability to question and challenge poor practice that might leave the patient at risk.
- Preserve safety: the nurse should recognise that there may be safety issues with medication recommended within the guidelines for some patients and that other therapies may offer an improved safety profile, either as a direct result of the medication itself or as a result of the dosing structure which makes it simpler to take and improves compliance.
- Promote professionalism and trust: patients have said that being treated by a trustworthy and honest health care professional who treats them as an individual can have a significant effect on the quality of care.15 This illustrates how essential it is that patients and their families have confidence in their health care professional to achieve the best outcomes for them whenever possible. This may include standing firm when being criticised for taking a patient-centred care approach, which may differ from the standard approach advocated by those with a different agenda.
This is just one example of where the use of the code could influence patient care by allowing nurses to demonstrate the importance of adhering to the specific requirements of the 4 Ps.
CONCLUSION
The updated NMC code of conduct resonates well with other recent schemes aimed at facilitating the delivery of high quality care in practice such as the 6 Cs. Familiarity with the Code will ensure that nurses are well equipped to demonstrate fitness to practise and if required, are able to challenge inappropriate demands or requests from employers to work in an unsafe, non-patient-centred way or outside of their competency. Nurses can also use the Code to lobby for protected time for professional development and clinical supervision. Far from being a tool with which to beat nurses, the revised Code provides us with a useful set of guidelines which facilitate best practice and allow us to call time on poor standards of care, lack of training and patchy provision of clinical supervision.
REFERENCES
1. Nursing and Midwifery Council. Code of Conduct, 2015. http://www.nmc-uk.org/
2. Health Committee. 9th report 2012 accountability hearing with the NMC, 2013 http://www.publications.parliament.uk/pa/cm201213/cmselect/cmhealth/639/63902.htm
3. Nursing and Midwifery Council. What we do, 2015. http://www.nmc-uk.org/patients-public/What-the-NMC-does/
4. Chief Nursing Officer. Compassion in Practice, 2012 http://www.england.nhs.uk/wp-content/uploads/2012/12/compassion-in-practice.pdf
5. Kutin J. 3 attributes that make up a nurse’s philosophy, 2013. http://www.nursetogether.com/your-nursing-philosophy
6. NMC. Guidance on professional conduct, 2011. http://www.nmc-uk.org/Documents/NMC-Publications/NMC-Guidance-on-professional-conduct.pdf
7. NMC. Standards for competence for registered nurses, 2010 http://www.nmc-uk.org/Documents/Standards/Standards%20for%20competence.pdf
8. NMC. Revalidation, professionalism and the code, 2015. http://www.nmc-uk.org/Nurses-and-midwives/Revalidation/Revalidation-professionalism-and-the-Code/
9. RCGP General Practice Foundation. General Practice Nurse Competencies, 2012 http://www.rcgp.org.uk/membership/practice-team-resources/~/media/1E0765D171B44849876EA38FC97E96F1.ashx
10. Care Quality Commission. Supporting effective clinical supervision, 2013. http://www.cqc.org.uk/sites/default/files/documents/20130625_800734_v1_00_supporting_information-effective_clinical_supervision_for_publication.pdf
11. NICE. Type 2 diabetes in adults: draft guidance for consultation, 2015 http://www.nice.org.uk/guidance/gid-cgwave0612/documents/type-2-diabetes-draft-nice-guideline2
12. Price C. Are NICE guidelines becoming a laughing stock? Pulse 15 March 2015. http://www.pulsetoday.co.uk/clinical/prescribing/are-nice-guidelines-becoming-a-laughing-stock/20009342.article#.VRqHJkJh3m1
13. O’Hare JP et al. The new NICE guidelines for diabetes: a critical analysis, 2015 Available from http://bjdvd.co.uk/index.php/bjdvd/article/view/47/109
14. UK Prospective Diabetes Study Group (1998) Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). Lancet 1998;352:854–865
15. Health and Care Professions Council. Professionalism in healthcare professionals, 2014 Available from http://www.hpc-uk.org/assets/documents/10003771Professionalisminhealthcareprofessionals.pdf
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