The new NMC Code of Conduct: a model (or is it a paradigm?) for stopping nurses reading important documents

Comment & Opinion

Brian Booth, RGN and Deborah Glover, BSc, RGN

Background reading

From March 31st, all registered nurses in this country are bound to a new Code of Conduct.

Out of interest, we compared it to previous versions and came to the conclusions herein. This is not an academic paper; it is not peppered with largely pointless references; it does not address issues of regulation.

Instead, it asks two simple questions:

  1. in its published format, how many nurses will flog their way through the new Code’s many pages?
  2. and of those who do, how many will feel ever so slightly patronised?

In years to come, it is likely that people will be asking ‘why did they once have to put up “no smoking” signs in confined places where people eat?’ It strikes us that future nurses, should they ever come across this version of a document meant to tell nurses what was expected and acceptable, will be equally puzzled at statements of the obvious; and the brighter ones may even say ‘but why didn’t they mention…?’

The United Kingdom Central Council (UKCC), which replaced the General Nursing Council (GNC), issued the first edition of ‘Code of Professional Practice’ in July 1983 [1]. On re-reading it, the first thing that strikes you is how short it is: the Code itself fits on one side of A4, and consists of 12 points, plus guidance notes (which are on that same page, not in an appendix).  The whole thing folded nicely into three - very pocket-friendly.

For readers who weren’t in practice at the time – in the UK, the 1980s were very different to today. ‘Diversity’ was not a word on everyone’s lips, for example; and albeit with a prefatory caveat, ‘the nurse’ in this document is assumed to be female.

This whole little document is full of nursing gold.  We urge you to go to the NMC site and download it; but here are some highlights:

  • CPD: ‘take every reasonable opportunity [to improve themselves]’
  • patient safety (a personal favourite): ‘ensure that by no action or omission on her part their condition or safety is placed at risk’ (i.e., whistle blowing was mandatory)
  • resources: ‘make known to the appropriate authorities if [shortages] endanger safe standards of practice’
  • teaching: ‘accept a responsibility…for assisting her peers and subordinates to develop professional competence’
  • staffing levels (another favourite): ‘Have due regard to the workload of and the pressure on colleagues and subordinates, and take appropriate action if these are seen to be such as to endanger safe standards of practice’.

In the guidance notes, they state clearly that whilst nurses should use ‘appropriate action’, they can expect protection if they have correctly invoked the Code.

We wish there were room here to run through later editions, as they grew in length and jargon; yet the third version [2] had still grown only to 16 points –the main points could still be edited to fit a single page - and that all-important ‘actions and omissions’ clause remained.

But let’s cut to the chase, and look at the Code we now work to [3]. As mentioned above, it’s not the 1980s any more; and perhaps people have got used to being battered with slogans. So our new Code kicks off on the cover with:

  • prioritise people
  • practice effectively
  • preserve safety
  • promote professionalism and trust

(and yes, they are all in lower case; i  double-checked, so i checked again; but I don’t think ee cummings wrote it…)

It runs to over 20 pages (good luck with getting that lot on a credit-card sized laminate for your purse or wallet). Let’s exclude all the introductory bits and attempts at justifying the NMC’s existence, and go with the numbers. From 12 points, we now have 25. But these have subsections, so the total is:

One hundred and five (105)

Not 12; 

and we’ll leave it to the NMC to explain what exactly has been added that is really necessary, if they believe that their oversight of nurse training has produced practitioners competent enough to not to need every ‘t’ and ‘i’ crossed and dotted.

It’s not all rubbish; 2.5 and 4.1, for example, address the right for patients to refuse any nursing interventions (although the probability of a mental capacity assessment for anyone refusing to have a wash seems high). But looking at continuous professional development (section 6.2), it is clear that you can use any old tat online; ‘maintain’ means, in our opinion, ‘having a record of some sort, without proof of competence’.

Teaching (9.4) is covered by weasel words such as ‘support’ and ‘help’.

Section 11.2, delegation, makes it clear that if someone has conned you into thinking they are competent, you will carry the can if it goes wrong. Now, we know that we always, rightly, remain accountable; but point 11.3 suggests that once you’ve delegated, you then have to check up on what’s been done. This seems like a dangerous move towards the United States  ‘RN as supervisor, not practitioner’ model. (I would also ask this; if I feel I have assessed someone as competent to undertake a task, but then I have to go and check they have done it competently, why not do it myself to both save time and to prevent the delegatee feeling worthless as they are being checked up on every time they do somethingDeborah)

Staffing: the whole of section 16 was probably only written because they couldn’t find an emoticon representing a shrug of the shoulders. Now jump to section 25 – a complete rewording of the same stuff. In short: - in the first instance, if you have concerns about understaffing, raise them with very people who are responsible for that understaffing. If you think someone has been taken on without the necessary skills and experience, discuss it with the people who employed them. That sounds like a good career move.

Deborah’s view

I admit, I haven’t yet had the text of this new document engraved on my heart à la Queen Mary and Calais, mainly because the man who writes the Lord’s Prayer on a grain of rice is busy. But I also feel a sense of bewilderment at the size and content of this document. I took a look at the frequently asked questions on the NMC site (less frequently asked questions, more, ‘we are justifying this by pretending that these questions are asked – frequently’). Professionalism figured a lot in the answers. So I had a look at some other professional codes of conduct to see if they felt the need to keep repeating it. The Teachers Code [4] runs to 10 pages, only six of which relate to the Code. It goes like this

  • Section 1 – Unacceptable professional conduct - “conduct which falls short of the standard expected of a registered teacher ... and is behaviour which involves a breach of the standards of propriety expected of the profession”.
  • Section 2 – convicted of a relevant offence
  • Section 3- serious professional incompetence

A further three pages have explanatory notes. Short, simple, to the point, easy to read, easy to take note of, and pretty much could cover nurses and midwives.

Even pilots only have one page to deal with (and to be honest, if you substituted the word ‘nurse’ for pilot and ‘patient’ for passenger, it would apply very well – except for the ‘chicken or beef’ bit…) Box 1 shows some examples from their Code [5] – do these concepts look familiar to you at all?

Box 1: Example content from the Air Line Pilots Association Code of Conduct

  • An Air Line Pilot will keep uppermost in his mind that the safety, comfort, and well-being of the passengers who entrust their lives to him are his first and greatest responsibility
  • He will remember that an act of omission can be as hazardous as a deliberate act of commission, and he will not neglect any detail that contributes to the safety of his flight, or perform any operation in a negligent or careless manner
  • He will faithfully obey all lawful directives given by his supervisors, but will insist and, if necessary, refuse to obey any directives that, in his considered judgment, are not lawful or will adversely affect flight safety. He will remember that in the final analysis the responsibility for safe completion of the flight rests upon his shoulders
  • He will not knowingly falsify any log or record, nor will he condone such action by other crew members
  • He will regard himself as a debtor to his profession and ALPA, and will dedicate himself to their advancement. He will cooperate in the upholding of the profession by exchanging information and experience with his fellow pilots and by actively contributing to the work of professional groups and the technical press
  • He will continue to keep abreast of aviation developments so that his skill and judgment, which heavily depend on such knowledge, may be of the highest order

And accountants, the most process driven 'cover-our-back' professions in the world only have a one page Code (five principles – integrity, objectivity, professional competence and due care, confidentiality, and professional behaviour) [6]

So why do nurses and midwives need such a weighty tome? If we take a look at the International Council’s definition of nursing, you’ll see that the word professional doesn’t appear. It is implied. And it succinctly outlines what is expected of a nurse [7]:

‘Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles’.

The NMC and others argue that this level of detail is required because of well-publicised failings in care and the rise of social media. But this is patronising, surely? The word confidentiality would cover the latter – I knew I shouldn’t discuss my patients on public transport long before I learnt how to Tweet, and I am old enough (and professional enough) to know that the same rule would apply no matter which media I used to communicate with friends and colleagues.

In summary

We find it hard to believe that many nurses are going to sit down and absorb this mini-novel – rather, we believe that a nice, glossy and doubtless expensively produced document telling you that kicking patients and making fun of their spiritual beliefs is, on the whole, not good practice, will end up as cat litter or landfill.