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April 3, 2015

Can the Nursing and Midwifery Council’s new Code restore public confidence in nursing? The NMC itself seems to have its doubts. We are told on page 3 that ‘the Code contains a series of statements that taken together signify what good nursing and midwifery practice looks like’. But while those statements that preface the first three subsections (‘Prioritise People’, ‘Practise Effectively’ and ‘Preserve Safety’) are couched in terse (and slightly odd) don’t-argue-with-me second person directives (‘You put the interests of people using or needing nursing or midwifery services first’…), the statement at the top of the final ‘Promote Professionalism and Trust’ section seems notably lacking in conviction.

‘You should display a personal commitment to the standards of practice…set out in the Code’ it informs registrants. ‘You should be a model of integrity and leadership…this should lead to trust and confidence in the profession’. It should. But will it? Are we getting the hint of an admission here that maybe it’s not always that simple?

The new Code gives a good idea of how many balls nurses have to keep in the air at once these days. Just for starters, they are expected to ‘deliver the fundamentals of care effectively’ (Article 1.2); ‘keep colleagues informed’ (Article 8.3); ‘support students’ and colleagues’ learning’ (Article 9.4); ‘complete all records at the time or as soon as possible after an event’ (Article 10.1); ‘accurately assess signs of normal or worsening physical and mental health in the person receiving care’ and refer appropriately (Article 13.1-2) and, as we already know, remain through it all ‘a model of integrity and leadership’ (p15).

One possible result of these many conflicting demands is crystallised in Article 16.1: ‘You must raise and, if necessary, escalate any concerns you may have about…the level of care people are receiving in your workplace’. Here, presumably, is the part of the code that could apply to staff numbers: if your staffing levels are insufficient to allow you to provide care that reaches the expectations set out in the Code, you have a duty to report it. But crucially, if you don’t report it, could you also be in breach of the Code?

Of course, the injunctions set out in Article 16.1 apply as much to managers who are also nurses as they do to stressed-out Band 5s struggling to get through a manic shift on the Acute Medical Unit. But unless robust systems for reporting and acting on staffing issues are in place, there is, potentially, a damned-if-you-do-damned-if-you-don’t element to this. You can envisage a situation where cries for help repeatedly fall on deaf ears because the ward is ‘fully staffed’ – even though establishments are not fit for purpose. But on the one occasion when a particular staff nurse doesn’t make the call – either because she’s sick of being ignored or because she simply hasn’t time – she lands up in trouble. Big trouble.

Issues around staffing also come into play in Article 14 of the new Code. Article 14 states that registered practitioners must ‘be open and candid with all service users about all aspects of care and treatment, including when any mistakes or harm have taken place’. Sub-clauses further explain that they must act promptly to put the situation right and explain to interested parties what has happened. The interesting loophole is that there is no requirement for them to give reasons why it happened.

In some ways, this is completely understandable. No service provider wants a future investigation to be compromised by disgruntled employees speaking out of turn before it’s even got off the ground. But Article 14 leaves it unclear whether staff are actively banned from discussing why Mum fell over on her way to the toilet (“We don’t have enough staff, and all the staff we do have were busy giving care to other patients”) or merely not required to discuss it. But as it can be safely assumed that few service providers are keen to see staff chewing over nursing shortages – or other management abuses – with service users, there is at least the potential for employers to refer to the NMC staff who do so. Duty of Candour? When it suits.

The NMC says that adherence to the Code ‘should lead to trust and confidence in the profession’. But how are nurses supposed to reply when relatives ask ‘why did Mum fall over’? ‘No comment’?; ‘Make a complaint, and an investigation will uncover the reasons’? At a time when the NHS is supposedly aspiring to openness and transparency, answers like this just make the speaker look shifty. Employers, the NMC might argue, should give guidance. But if even one section of the Code comes down to the interpretation of individual policies, how is it then a national standard?

Because it has found it necessary to spell out the meaning of ‘fundamental care’ the new Code has been derided in some quarters as ‘patronising’. Personally, I am quite relaxed about the ‘fundamental footnote’. If the point of the Code is to give nurses clarity, then why not go for crystal? What’s disappointing is that despite this – there is no clarity. Grey areas not only still persist but potentially leave nurses at the mercy of employer whim. So let’s just cross our fingers and hope that plenty of clear policies and in-depth staff training are out there, shall we?

  1. What is new in this Code of Practice? Not much, actually – the difference is that it is fleshed out in the written word rather than via a code that was generally understood and communicated osmotically. Whether it was implemented is another matter……

    I am puzzled as to why you conclude that Article 14 is unclear. If someone falls, an investigation/ assessment will be undertaken to establish the cause. If this investigation identifies that the faller stated they repeatedly called for help and no-one attended and that, in desperation they headed for the loo unaided, that is what should be relayed to anyone enquiring about the fall. Nothing equivocal about that.

    I don’t think this Code identifies a higher workload for nurses, as you seem to suggest:
    “The new Code gives a good idea of how many balls nurses have to keep in the air at once these days. Just for starters, they are expected to ‘deliver the fundamentals of care effectively, keep colleagues informed, support students’ and colleagues’ learning, complete all records at the time or as soon as possible after an event, accurately assess signs of normal or worsening physical and mental health in the person receiving care and refer appropriately’ and be a model of integrity and leadership”.

    All of these ‘balls’ are things that I understood to be within my province as a practicing nurse from the time I started training. Without any of these things, a nurse would be working as a one man band.

    One big difference is that of Article 12, regarding PII. It was always the case when I was in clinical practice that the organisation I worked for provided me with professional indemnity insurance. This clause seems to suggest that there may be limitations to that indemnity insurance now, which individuals should check.

    Personally, I’m fascinated by the footnote to 4.4 – the issue of conscientious objection being limited. I clearly remember as a first ward student nurse, refusing to give out Brompton’s Mixture to a patient on the drug round because I thought we were actively hastening a patient’s death. I remember the Staff Nurse being distinctly unhappy with my stance, as was I with her explanation as to why Brompton’s Mixture was prescribed. She tried to order me to give the offending medicine and I steadfastly refused. My obstinacy did me no favours on that ward and probably set the tone for the rest of my career – I have always put my head above the parapet. I did not – and do not – need a written code to remind me of my duty as a nurse: to prioritise people IN MY CARE, practice effectively and preserve safety. I can’t help but wonder whether my objection would be deemed inadmissible these days and what the consequences would be for me standing my ground.

    Likewise, I wonder how my challenge to a consultant general surgeon might be considered – when, as a Ward Sister, I suggested that he refer his patient on to a specialist rather than conduct a total cystectomy himself, for the sake of a patient’s chances of survival. He certainly wasn’t happy with my challenge and I certainly objected to what he intended to do. My challenge hit the spot and the patient was referred, but again, I didn’t make life easy for myself. That can happen when you prioritise people IN YOUR CARE.

    This ‘new’ Code reminds me of a modern Job Description. Once upon a time these were one or two pages long. Today, they are written in a lengthy pamphlet, trying to cover every single possibility that a job might entail, with a catch all phrase or two at the end, and still only to be out of date (or to bear no resemblance to the job) as soon as one takes up the post.

    Will it make a difference to patient and public confidence about the state of nursing? Of course not. It is what they experience that provides confidence and reassurance – the evidence of what is practiced, not what is written in a pamphlet.

  2. Hello Barbara. Thanks for your comments, as ever. If its purpose is to provide clear boundaries and standards against which professional behaviour can be measured, I have no problem with nursing having a written Code of Conduct. Problems inevitably arise when all we have is ‘common sense’ – which means different things to different people. ‘Osmotic transmission’ to me signifies something similar – how do you know what people understand when they absorb knowledge in this way? The Code, by its objectivity, is supposed to get us away from this and result in fairer treatment for everyone. And let’s not forget that the Code is there, first and foremost, to protect the public.

    The blog post, however, grew out of musings about how objective parts of the Code really are. For example, on page 7, nurses are enjoined to ‘assess need and deliver or advise on treatment…without too much delay’. But what would count as ‘too much delay’? Is it context-specific? Or is it an absolute?

    Similarly, with Article 14, what would happen if a nurse told a relative (perhaps in answer to a direct question) that their mother had fallen over ‘because we are short-staffed’ or ‘because the staff we have not had enough training’? Even if it is the truth, it may be something the organisation the nurse works for (not necessarily a hospital) does not wish to have generally known. Could punitive action be taken under the cover of Code – which gives no guidance on this? The primary purpose of the Code is not, as I have said, to protect nurses from unscrupulous employers. But it is legitimate to ask whose interests the various Articles might (possibly unconsciously or unintentionally) favour.

    Personally, I would like to think that public confidence in nursing will be increased if nurses would stand up for themselves more. We have allowed the likes of the Daily Mail, with its hatred of educated women, to set the agenda as far as our profession is concerned, and we have let the political expediency of fads such as Intentional Rounding (IR) override evidence-based practice; there is no proper evidence base for IR. What kind of professional basis is that?

  3. Oh, I completely agree with you. I, too, do not have issue with the need for a Code of Conduct and my comment regarding osmotic transmission was not intended to sound as though I agreed with such a state of affairs! As for IR, it leaves me cold……..

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