Can the new NMC Code improve standards of care delivery?
O
n 29 January 2015, the Nursing and Midwifery Council (NMC) published its revised Code of professional standards for nurses and midwives. The new Code has been developed after consultation, held over the summer of 2014, and is linked to the new process of revalidation, which is also scheduled to begin in 2015 (Glasper, 2015). After consultation with a number of external advisory groups, which included seeking evidence from a patient and public-engagement forum, the NMC has revised its to reflect more appropriately the contemporary nursing and midwifery professions, and the enhanced public expectations of health care in society (NMC, 2014a). In addition to public consultation, the NMC also examined the professional codes of practice of the other UK healthcare regulators and scrutinised a range of pertinent published reports. Principally, the NMC took cognisance of the public inquiry into the now wellpublicised events at the Mid Staffordshire NHS Foundation Trust, the Cavendish report on the preparation of healthcare assistants, (Cavendish, 2013) and the report into the Liverpool Care Pathway.
Background Codes of professional practice for nurses are as old as the profession itself and Esterhuizen (1995) believes that up until the 1970s, such codes fostered a profession that was inherently deferential to members of the medical profession. When the Central Midwives Board and The General Nursing Council were replaced with one national body, the United Kingdom Central Council for Nursing Midwifery and Health Visiting (UKCC) in 1983, a new Code of professional conduct was developed (Hinchliffe et al, 2008). This allowed the regulatory body to provide guidance to nurses and midwives and, importantly, to address cases of professional misconduct. This situation continued until 2002, when the UKCC was abolished and replaced with a new regulator, the NMC. To
238
underscore its new position, the NMC approved a new Code of Professional Conduct (NMC, 2002) This was timely, as there were voices of criticism. For example, Tadd (1994) questioned whether the Code was placing nurses in an invidious position in asking them to report unprofessional conduct; Shields and Watson (2007) were critical of its lack of emphasis on the value of research for nurses. To reflect these criticisms, in April 2008 the NMC launched a new Code to replace its existing Code of Professional Conduct. The new Code was designed explicitly to articulate the standards of conduct, performance and ethics required of nurses and midwives if they were to be considered fit for practice. The world of UK nursing has changed fundamentally since the publication of the Code in 2008. More and more nurses in the UK trained in other parts of Europe and the world. After 6 years and many reports of failures in the NHS, the first draft of a new revised Code was issued in May 2014 and featured eight key changes from the previous Code: 1. Patient and public expectations: The NMC proposed putting patients at the very heart of its activities with public protection as its primary raison d’être. 2. Prescribing and medicines management: The NMC recognised that many incidents in clinical practice reported via Datix (2015), the incident and adverse events reporting system, are medicines-related, and that there has been an increased incidence of fitnessto-practise referrals in this domain. After consultation, the NMC wanted to link this section of the new Code to the up-to-date advice provided by organisations such the British National Formulary. 3. Fundamentals of care: Following the criticisms from Robert Francis and Baroness Neuberger of the standards and level of care delivery, the NMC wanted to be very explicit in emphasising that fundamentals of care are pivotal to nursing practice. 4. The ‘duty of candour’ in professional accountability: Unlike the previous Code, this change would
highlight the importance of maintaining openness and honesty in clinical practice where any concerns or complaints about care delivery are shared with staff, service users, the public and healthcare regulators. 5. The conduct of nurses and midwives via social media channels:This has arisen after recognition by the NMC of the volume of social media-related fitness-to-practise referrals it has received in recent years. The improper use of Facebook in particular has already led the NMC to issue advice to nurses and midwives never to upload confidential or sensitive information on such sites, especially if it identifies patients (NMC, 2011). 6. Taking emergency action: The NMC has updated this section, which was part of the 2008 Code. It states that a nurse or midwife should only practise within their limits in an emergency—i.e. intervening if an emergency occurs outside their place of work, so as not to put the patient at any risk. 7. Raising concerns: Raising or escalating concerns has been given greater impetus in the drafting of the new Code.This is because of the concerns about whistleblowing, which have been uncovered after a range of NHS scandals where patient safety and care have been compromised. For example, at Winterbourne View, the hospital for patients with learning difficulties near Bristol, some members of staff actually committed criminal acts, and six were imprisoned as a result (Department of Health (DH), 2012). 8. Maintaining clear professional boundaries: This section of the draft Code has been strengthened to give clearer guidance to registrants about professional boundaries. This is exemplified by, for example, the case of one registrant who breached fundamental aspects of the 2008 Code, leading to his referral to a fitness-to-practise hearing. He was eventually struck off the register after the NMC panel found that his actions towards an 83-year-old widow were financially and sexually motivated (NMC, 2014b).
© 2015 MA Healthcare Ltd
Professor Alan Glasper from the University of Southampton discusses the recently published revised NMC Code
British Journal of Nursing, 2015, Vol 24, No 4
British Journal of Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on November 29, 2015. For personal use only. No other uses without permission. . All rights reserved.
HEALTHCARE POLICY The breadth of the new Code The new Code was finally approved by the NMC council in December 2014 and will become operational in March 2015, with all current registrants receiving a copy in the post. The new NMC Code now gives greater clarity to all registered nurses about their expected behaviour and the carrying out of their professional standards of practice. The NMC is confident that the new Code is more aligned with public expectations of a nurse, and that it is more reflective of contemporary nursing, with all its complexities in the fast-changing arena of health care. The chief objective of the NMC in issuing the new Code is to make it part of every nurse’s raison d’être and it is inherently linked to the new process of revalidation that will be introduced for all registrants in December 2015. The actual process of revalidation will ensure that all registrants have to consider how they have worked within the parameters of the Code in fulfilling their duties, irrespective of where they work or their position in an organisation. This applies equally, for example, to nurses or midwives who are annotated on the NMC register as teachers. The new Code will dovetail into new guidance being prepared by the NMC on the duty of candour and use of social media, which it intends to publish in March 2015. The eight change areas identified in the draft Code have now been assimilated into the final 2015 Code. This consists of 25 discrete areas organised around four specific themes where the intention is to illuminate what good nursing and midwifery practice are: prioritise people, practise effectively, preserve safety and promote professionalism and trust (NMC, 2015). It is beyond the scope of this article to present the details of the new Code’s 25 elements, since each has several explanatory sub-components. But the broad elements are as follows:
Prioritise people
© 2015 MA Healthcare Ltd
1. Treat people as individuals and uphold their dignity 2. Listen to people and respond to their preferences and concerns 3. Make sure that people’s physical, social and psychological needs are assessed and responded to 4. Act in the best interests of people at all times 5. Respect people’s right to privacy and confidentiality.
Practise effectively 6. Always practise in line with the best available evidence 7. Communicate clearly 8. Work cooperatively
British Journal of Nursing, 2015, Vol 24, No 4
9. Share your skills, knowledge and experience for the benefit of people receiving care and your colleagues 10. Keep clear and accurate records relevant to your practice 11. Be accountable for your decisions to delegate tasks and duties to other people 12. Have an indemnity arrangement in place that provides appropriate cover for any practice you take on as a nurse or midwife in the UK.
Preserve safety 13. Recognise and work within the limits of your competence 14. Be open and candid with all service users about all aspects of care and treatment, including when any mistakes or harm have taken place 15. Always offer help if an emergency arises in your practice setting or anywhere else 16. Act without delay if you believe that there is a risk to patient safety or public protection 17. Raise concerns immediately if you believe a person is vulnerable or at risk and needs extra support and protection 18. Advise on, prescribe, supply, dispense or administer medicines within the limits of your training and competence, the law, NMC guidance and other relevant policies, guidance and regulations 19. Be aware of, and reduce as far as possible, any potential for harm in your practice.
Promote professionalism and trust 20. Uphold the reputation of your profession at all times 21. Uphold your position as a registered nurse or midwife 22. Fulfil all registration requirements 23. Cooperate with all investigations and audits 24. Respond to any complaints made against you professionally 25. Provide leadership to make sure people’s wellbeing is protected and to improve their experiences of the healthcare system. (NMC, 2015)
Discussion The new Code is closely aligned with many of the key lines of enquiry used by the Care Quality Commission when inspecting healthcare organisations. In addition, the new Code, being in the public domain, will help service users more clearly understand just what to expect when receiving care from nurses and midwives. The inclusion of service users in the assessment of student practice is already commonplace in many universities and they will now be able to use the Code to give feedback to these students about the care they receive from them. Nurse educators will also find the new Code invaluable in orientating the curriculum and their teaching towards preparing students to join the register, fully aware that a commitment to professional standards is absolutely pivotal to belonging to the profession. Ultimately, the vision of the new Code is to drive up patient care delivery. Further details can be found at www.nmcBJN uk.org/code. Cavendish (2013) The Cavendish Review. An Independent Review into Healthcare Assistants and Support Workers in the NHS and social care settings. http://tinyurl.com/m3zr7pe (accessed 19 February 2015) Datix (2015) Incident reporting system and adverse events reporting. http://tinyurl.com/q88g36j (accessed 16 February 2015) Department of Health (2012) Transforming care: A national response to Winterbourne View Hospital. http://tinyurl.com/kpwrver (accessed 19 February 2015) Esterhuizen P (1995) Is the professional code still the cornerstone of clinical nursing practice? J Adv Nurs 23(1): 25–31 Glasper A (2014) Revalidation proposals: a chance to have your say. Br J Nurs 25(5): 1172–3 Hinchliffe S, Norman S, Schober J (2008) Nursing Practice and Health Care 5E: a Foundation Text 5th edn. Hodder, London Nursing and Midwifery Council (2002) The Code: Standards of conduct, performance and ethics for nurses and midwives. NMC, London Nursing and Midwifery Council (2011) Regulator acts to prevent nurses and midwives getting into trouble on Facebook. http:// tinyurl.com/prtfzs8 (accessed 16 February 2015) Nursing and Midwifery Council (2014a) Code evidence report. http:// tinyurl.com/kcf4btr (accessed 19 February 2015) Nursing and Midwifery Council (2014b) Former Mid Staffs Director of Nursing struck off. http://tinyurl.com/pvttx3y (accessed 16 February 2015) Nursing and Midwifery Council (2015) The Code: Professional standards of practice and behaviour for nurses and midwives. http:// tinyurl.com/mquhnt3 (accessed 19 February 2015) Shields L, Watson R (2007) The demise of nursing in the United Kingdom: a warning for medicine. J R Soc Med 100(2): 70–4. Tadd V (1994) Professional codes: an exercise in tokenism? Nurs Ethics 1(1): 15–23
KEY POINTS n The Nursing and Midwifery Council (NMC) has published a new Code, which will become operational in March 2015 n The old 2008 NMC Code was no longer fit for purpose and did not adequately reflect contemporary nursing n The 2015 Code consists of 25 discrete areas organised around four specific themes whose purpose is to illuminate precisely the parameters of good nursing and midwifery practice n The launch of the new Code is inherently linked to the new process of nurse revalidation that will be introduced for all registrants in December 2015
239
British Journal of Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on November 29, 2015. For personal use only. No other uses without permission. . All rights reserved.
O
n 29 January 2015, the Nursing and Midwifery Council (NMC) published its revised Code of professional standards for nurses and midwives. The new Code has been developed after consultation, held over the summer of 2014, and is linked to the new process of revalidation, which is also scheduled to begin in 2015 (Glasper, 2015). After consultation with a number of external advisory groups, which included seeking evidence from a patient and public-engagement forum, the NMC has revised its to reflect more appropriately the contemporary nursing and midwifery professions, and the enhanced public expectations of health care in society (NMC, 2014a). In addition to public consultation, the NMC also examined the professional codes of practice of the other UK healthcare regulators and scrutinised a range of pertinent published reports. Principally, the NMC took cognisance of the public inquiry into the now wellpublicised events at the Mid Staffordshire NHS Foundation Trust, the Cavendish report on the preparation of healthcare assistants, (Cavendish, 2013) and the report into the Liverpool Care Pathway.
Background Codes of professional practice for nurses are as old as the profession itself and Esterhuizen (1995) believes that up until the 1970s, such codes fostered a profession that was inherently deferential to members of the medical profession. When the Central Midwives Board and The General Nursing Council were replaced with one national body, the United Kingdom Central Council for Nursing Midwifery and Health Visiting (UKCC) in 1983, a new Code of professional conduct was developed (Hinchliffe et al, 2008). This allowed the regulatory body to provide guidance to nurses and midwives and, importantly, to address cases of professional misconduct. This situation continued until 2002, when the UKCC was abolished and replaced with a new regulator, the NMC. To
238
underscore its new position, the NMC approved a new Code of Professional Conduct (NMC, 2002) This was timely, as there were voices of criticism. For example, Tadd (1994) questioned whether the Code was placing nurses in an invidious position in asking them to report unprofessional conduct; Shields and Watson (2007) were critical of its lack of emphasis on the value of research for nurses. To reflect these criticisms, in April 2008 the NMC launched a new Code to replace its existing Code of Professional Conduct. The new Code was designed explicitly to articulate the standards of conduct, performance and ethics required of nurses and midwives if they were to be considered fit for practice. The world of UK nursing has changed fundamentally since the publication of the Code in 2008. More and more nurses in the UK trained in other parts of Europe and the world. After 6 years and many reports of failures in the NHS, the first draft of a new revised Code was issued in May 2014 and featured eight key changes from the previous Code: 1. Patient and public expectations: The NMC proposed putting patients at the very heart of its activities with public protection as its primary raison d’être. 2. Prescribing and medicines management: The NMC recognised that many incidents in clinical practice reported via Datix (2015), the incident and adverse events reporting system, are medicines-related, and that there has been an increased incidence of fitnessto-practise referrals in this domain. After consultation, the NMC wanted to link this section of the new Code to the up-to-date advice provided by organisations such the British National Formulary. 3. Fundamentals of care: Following the criticisms from Robert Francis and Baroness Neuberger of the standards and level of care delivery, the NMC wanted to be very explicit in emphasising that fundamentals of care are pivotal to nursing practice. 4. The ‘duty of candour’ in professional accountability: Unlike the previous Code, this change would
highlight the importance of maintaining openness and honesty in clinical practice where any concerns or complaints about care delivery are shared with staff, service users, the public and healthcare regulators. 5. The conduct of nurses and midwives via social media channels:This has arisen after recognition by the NMC of the volume of social media-related fitness-to-practise referrals it has received in recent years. The improper use of Facebook in particular has already led the NMC to issue advice to nurses and midwives never to upload confidential or sensitive information on such sites, especially if it identifies patients (NMC, 2011). 6. Taking emergency action: The NMC has updated this section, which was part of the 2008 Code. It states that a nurse or midwife should only practise within their limits in an emergency—i.e. intervening if an emergency occurs outside their place of work, so as not to put the patient at any risk. 7. Raising concerns: Raising or escalating concerns has been given greater impetus in the drafting of the new Code.This is because of the concerns about whistleblowing, which have been uncovered after a range of NHS scandals where patient safety and care have been compromised. For example, at Winterbourne View, the hospital for patients with learning difficulties near Bristol, some members of staff actually committed criminal acts, and six were imprisoned as a result (Department of Health (DH), 2012). 8. Maintaining clear professional boundaries: This section of the draft Code has been strengthened to give clearer guidance to registrants about professional boundaries. This is exemplified by, for example, the case of one registrant who breached fundamental aspects of the 2008 Code, leading to his referral to a fitness-to-practise hearing. He was eventually struck off the register after the NMC panel found that his actions towards an 83-year-old widow were financially and sexually motivated (NMC, 2014b).
© 2015 MA Healthcare Ltd
Professor Alan Glasper from the University of Southampton discusses the recently published revised NMC Code
British Journal of Nursing, 2015, Vol 24, No 4
British Journal of Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on November 29, 2015. For personal use only. No other uses without permission. . All rights reserved.
HEALTHCARE POLICY The breadth of the new Code The new Code was finally approved by the NMC council in December 2014 and will become operational in March 2015, with all current registrants receiving a copy in the post. The new NMC Code now gives greater clarity to all registered nurses about their expected behaviour and the carrying out of their professional standards of practice. The NMC is confident that the new Code is more aligned with public expectations of a nurse, and that it is more reflective of contemporary nursing, with all its complexities in the fast-changing arena of health care. The chief objective of the NMC in issuing the new Code is to make it part of every nurse’s raison d’être and it is inherently linked to the new process of revalidation that will be introduced for all registrants in December 2015. The actual process of revalidation will ensure that all registrants have to consider how they have worked within the parameters of the Code in fulfilling their duties, irrespective of where they work or their position in an organisation. This applies equally, for example, to nurses or midwives who are annotated on the NMC register as teachers. The new Code will dovetail into new guidance being prepared by the NMC on the duty of candour and use of social media, which it intends to publish in March 2015. The eight change areas identified in the draft Code have now been assimilated into the final 2015 Code. This consists of 25 discrete areas organised around four specific themes where the intention is to illuminate what good nursing and midwifery practice are: prioritise people, practise effectively, preserve safety and promote professionalism and trust (NMC, 2015). It is beyond the scope of this article to present the details of the new Code’s 25 elements, since each has several explanatory sub-components. But the broad elements are as follows:
Prioritise people
© 2015 MA Healthcare Ltd
1. Treat people as individuals and uphold their dignity 2. Listen to people and respond to their preferences and concerns 3. Make sure that people’s physical, social and psychological needs are assessed and responded to 4. Act in the best interests of people at all times 5. Respect people’s right to privacy and confidentiality.
Practise effectively 6. Always practise in line with the best available evidence 7. Communicate clearly 8. Work cooperatively
British Journal of Nursing, 2015, Vol 24, No 4
9. Share your skills, knowledge and experience for the benefit of people receiving care and your colleagues 10. Keep clear and accurate records relevant to your practice 11. Be accountable for your decisions to delegate tasks and duties to other people 12. Have an indemnity arrangement in place that provides appropriate cover for any practice you take on as a nurse or midwife in the UK.
Preserve safety 13. Recognise and work within the limits of your competence 14. Be open and candid with all service users about all aspects of care and treatment, including when any mistakes or harm have taken place 15. Always offer help if an emergency arises in your practice setting or anywhere else 16. Act without delay if you believe that there is a risk to patient safety or public protection 17. Raise concerns immediately if you believe a person is vulnerable or at risk and needs extra support and protection 18. Advise on, prescribe, supply, dispense or administer medicines within the limits of your training and competence, the law, NMC guidance and other relevant policies, guidance and regulations 19. Be aware of, and reduce as far as possible, any potential for harm in your practice.
Promote professionalism and trust 20. Uphold the reputation of your profession at all times 21. Uphold your position as a registered nurse or midwife 22. Fulfil all registration requirements 23. Cooperate with all investigations and audits 24. Respond to any complaints made against you professionally 25. Provide leadership to make sure people’s wellbeing is protected and to improve their experiences of the healthcare system. (NMC, 2015)
Discussion The new Code is closely aligned with many of the key lines of enquiry used by the Care Quality Commission when inspecting healthcare organisations. In addition, the new Code, being in the public domain, will help service users more clearly understand just what to expect when receiving care from nurses and midwives. The inclusion of service users in the assessment of student practice is already commonplace in many universities and they will now be able to use the Code to give feedback to these students about the care they receive from them. Nurse educators will also find the new Code invaluable in orientating the curriculum and their teaching towards preparing students to join the register, fully aware that a commitment to professional standards is absolutely pivotal to belonging to the profession. Ultimately, the vision of the new Code is to drive up patient care delivery. Further details can be found at www.nmcBJN uk.org/code. Cavendish (2013) The Cavendish Review. An Independent Review into Healthcare Assistants and Support Workers in the NHS and social care settings. http://tinyurl.com/m3zr7pe (accessed 19 February 2015) Datix (2015) Incident reporting system and adverse events reporting. http://tinyurl.com/q88g36j (accessed 16 February 2015) Department of Health (2012) Transforming care: A national response to Winterbourne View Hospital. http://tinyurl.com/kpwrver (accessed 19 February 2015) Esterhuizen P (1995) Is the professional code still the cornerstone of clinical nursing practice? J Adv Nurs 23(1): 25–31 Glasper A (2014) Revalidation proposals: a chance to have your say. Br J Nurs 25(5): 1172–3 Hinchliffe S, Norman S, Schober J (2008) Nursing Practice and Health Care 5E: a Foundation Text 5th edn. Hodder, London Nursing and Midwifery Council (2002) The Code: Standards of conduct, performance and ethics for nurses and midwives. NMC, London Nursing and Midwifery Council (2011) Regulator acts to prevent nurses and midwives getting into trouble on Facebook. http:// tinyurl.com/prtfzs8 (accessed 16 February 2015) Nursing and Midwifery Council (2014a) Code evidence report. http:// tinyurl.com/kcf4btr (accessed 19 February 2015) Nursing and Midwifery Council (2014b) Former Mid Staffs Director of Nursing struck off. http://tinyurl.com/pvttx3y (accessed 16 February 2015) Nursing and Midwifery Council (2015) The Code: Professional standards of practice and behaviour for nurses and midwives. http:// tinyurl.com/mquhnt3 (accessed 19 February 2015) Shields L, Watson R (2007) The demise of nursing in the United Kingdom: a warning for medicine. J R Soc Med 100(2): 70–4. Tadd V (1994) Professional codes: an exercise in tokenism? Nurs Ethics 1(1): 15–23
KEY POINTS n The Nursing and Midwifery Council (NMC) has published a new Code, which will become operational in March 2015 n The old 2008 NMC Code was no longer fit for purpose and did not adequately reflect contemporary nursing n The 2015 Code consists of 25 discrete areas organised around four specific themes whose purpose is to illuminate precisely the parameters of good nursing and midwifery practice n The launch of the new Code is inherently linked to the new process of nurse revalidation that will be introduced for all registrants in December 2015
239
British Journal of Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on November 29, 2015. For personal use only. No other uses without permission. . All rights reserved.
