Chapter 2. Nursing and the NMC Code

Introduction

This chapter explores the professional standards of nursing practice, as defined in the NMC Code (2015). It is vital that all nurses practising in the UK adhere to the standards and responsibilities presented in this document, in order to ensure safe, fair and ethical patient treatment. This chapter will provide a detailed overview of the core features of the NMC Code (2015), with a focused analysis of the expectations and responsibilities of nurses in the UK. Concepts such as accountability, mentorship and delegation will be discussed and related to practice in order to provide students and nurses with a clear insight into how the NMC Code (2015) relates to their practice setting and daily experiences.

Learning objectives

By the end of this chapter, you should be able to:

- Understand the purpose and content of the NMC Code (2015)

- Appreciate the value of professional standards in practice

- Identify professional actions and behaviours suitable for nurses

- Critically review your own professional practice compared to national standards

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The NMC Code

As noted in the previous chapter, the NMC Code (2015) is the most recent version of the professional practices and standards for nurses and midwives practising in the UK. The publication details the duties and responsibilities of nurses in routine practice and illustrates the professional attitudes and actions that should be carried out to achieve good patient care. Although the ethical dimensions of nursing practice were discussed in the previous chapter, the NMC Code (2015) also focuses on professional and practical aspects of nursing care.

The scope of the NMC Code is not limited to direct patient care, but also encompasses a range of activities that nurses are engaged in during routine practice. These activities include interactions with groups or communities, education, leadership, and research. The application of the values and principles noted within the Code may be interpreted and analysed with respect to each of these activities. However, although interpretation is advised, the values and standards noted in the Code are not optional or negotiable, but rather form an essential set of components that are demanded of contemporary nurses. These components will be the focus of the present chapter.

The NMC Code (2015) is divided into four different sections, based on the core professional values of nursing. These are as follows:

  • Prioritise people
  • Practise effectively
  • Preserve safety
  • Promote professionalism and trust (NMC, 2015).

Each of these domains will be considered separately to provide an insight into their value and implications for the nursing profession.

Prioritise people

The ability to prioritise people is key to being an effective nurse and involves putting the interests of service users first. Ethical and professional treatment of service users (patients) is necessary to maintain dignity and ensure that the needs of the individual are recognised, assessed, and managed appropriately. Treating patients with respect is a key aspect of the care process and the rights of patients should be upheld above all else. This means that nurses should not be discriminatory, judgemental or disrespectful to patients, regardless of personal views or patient behaviour.

Practise effectively

The ability to practise as a nurse in an effective manner relies on a multitude of factors. These factors include the ability to assess the needs of patients, interpret results of tests, advise on treatment courses, and to adhere to the evidence base. Furthermore, nurses need to be able to deliver optimal care within a swift timeframe, while clearly communicating with patients and maintaining professional standards of record keeping and knowledge sharing. The NMC Code outlines a number of aspects of practice that should be adhered to in order to be an effective nurse.

Preserve safety

In addition to delivering swift and effective care to patients, the NMC Code recognises that patient safety must be at the heart of all nurse decision-making. Ensuring the safety of an individual patient, group of patients, or the broader population requires nurses to understand multiple facets of their role. Firstly, you must be aware of your limitations and skill set, knowing when you are out of your depth and require help when delivering patient care. Attempting to manage patients when you are doubtful or lack the necessary skills or knowledge is not safe. You must also be aware of the care processes of others and be alert to the possibility of lapses in safe care, which may otherwise have adverse effects on patient wellbeing. Not only do nurses need to be able to identify safe and unsafe practice, but they should also be confident in reporting and addressing safety concerns in a timely manner.

Promote professionalism and trust

The final domain of the NMC Code (2015) is the promotion of professionalism and trust. The reputation of nurses needs to be defended, and from a professional perspective, an individual must uphold the values of the profession to ensure that nurses remain respected and valuable members of the healthcare team. As a nurse, you should adopt all of the necessary behaviours and attitudes that are outlined in the NMC Code and lead by example. By ensuring professionalism in everyday practice, patients are more likely to trust you and will be more confident in your abilities.

Reflection

The four main domains of the NMC Code (2015) are used to guide nursing practice in a variety of contexts. Think about a care situation you have engaged in, or imagine one based on your own reading. When delivering care to a patient, what activities can you undertake to ensure you meet all four of these domains? Are some domains more important than others? Do you see any overlap between the domains?

What is expected of nurses?

Nurses are an important professional group in the healthcare system of the UK. They provide fundamental care and assistance to patients in primary, secondary and tertiary care settings, and the nurse role has become increasingly diverse over time. Contemporary nurses have a wide range of clinical duties and may specialise in specific care areas, driving expertise and evidence-based care. Along with the development of the role of the nurse in healthcare, the expectations of nurses have also changed over time. Patients have high expectations of nurses and demand excellence from nursing care. These expectations include representing the best interests of the patient, professional conduct at all times, caring and compassionate interactions, and advocacy on behalf of the patient.

Within the NMC Code (2015), it is apparent that the expectations of nurses do not just fall within the domain of providing patient care. Nurses are increasingly expected to engage in other professional activities intended to promote knowledge, optimal practice and societal values. This means that nurses are expected to act as leaders, educators and researchers, as well as care providers. All of these roles demand individual skillsets and knowledge, but at the same time there is some overlap between the roles. It is essential that nurses act as leaders in order to advocate for the needs of their patients, while this advocacy demonstrates a caring role at the same time. Nurses who discuss treatment options with patients and then decide on a mutually agreeable course of action serve as both carers and educators. Therefore, although distinct, multiple roles are often fulfilled by nurses unintentionally during a single episode of care.

Nursing responsibilities

Having considered the expectations placed on the nursing profession, it is also important to consider how these expectations translate into responsibilities. Nursing responsibilities can be defined as a set of actions or behaviours that should be completed in order to promote professional practice specific to the nursing profession. The responsibilities you have as a nurse are varied and are covered within the four main domains of the NMC Code (2015). However, it is worth considering specific responsibilities that nurses have in relation to patients, colleagues, their profession and their organisation. The following sections will focus on some of the most important responsibilities of nurses in all care contexts.

Accountability

Accountability is important for both patient care and professionalism in nursing, and is defined as a state of accepting responsibility for one's actions (Royal College of Nursing, 2016). A nurse is accountable only when they fulfil three conditions: the ability to perform an activity of intervention; accepting responsibility for the activity; and, having the authority to perform the activity (RCN, 2016). Therefore, accountability in practice not only means that one should only engage in activities one is qualified to perform, but also that nurses have been suitably delegated to perform the task and accept responsibility during task completion (Griffith, 2015).

Accountability can apply at multiple levels, as a nurse has to be accountable to him or herself, as well as colleagues, professional bodies and criminal or civil courts (NMC, 2015). Nurses must be accountable for their actions - even when performing the smallest tasks, as the implications of mistakes in practice may be vast. When you are not confident in completing a task, it is necessary to contact a senior member of staff or consult local guidelines and policies to determine the suitability of the task for your skill set and knowledge base.

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Delegation

Delegation of tasks is an important part of managing a busy workload and ensuring that patient care can be delivered in a timely and effective manner. Nurses have a duty to ensure quality care to patients and therefore it is crucial to ensure appropriate delegation of tasks to junior colleagues or associated healthcare professionals (RCN, 2016). Nurses should be accountable for delegation decisions made in practice and should be able to justify the suitability of the individual for the task, based on policies, guidelines and experience. When delegating, the skill set of the individual should be carefully considered and support provided when necessary. It is not acceptable to delegate tasks to another person where they are not trained to perform those tasks. Ultimately, the person who delegates the task needs to justify their decision and remains partly accountable for the outcomes of any intervention.

Multidisciplinary working

Managing a patient is a complex process, often involving more than one healthcare professional. Patients may have complex needs, where nurses, doctors, physiotherapists and allied healthcare professionals work together to meet those needs. This is called multidisciplinary working, and is a fundamental form of teamwork that underpins the values of the National Health Service (NHS, 2015). By addressing the needs of the patient in a collaborative and cooperative way, the chances for patient recovery are maximised (Scaria, 2016).

Multidisciplinary working has been shown to be effective in managing patients and therefore it is a professional duty of nurses to engage successfully with other health professionals when delivering patient care. This involves recognising the need for input from other professions, communicating effectively with those professionals, and making joint decisions on the care processes affecting the patient. If nurses do not work well within a team, then patient care can be disjointed, leading to poorer patient outcomes. Therefore, multidisciplinary working is a key ethical and professional responsibility of the nurse.

Leadership

In order for nurses to work successfully in a multidisciplinary team, they should be able to demonstrate qualities of leadership. Leadership in nursing is an important concept that describes the ways nurses motivate others to achieve a common goal (Sherring, 2012; NMC, 2015). Nurses can provide leadership in many different ways, including by advocating for the patient's point of view, by leading the multidisciplinary team, or by guiding junior members of staff. Regardless of the way leadership is put into action, nurses have a professional duty to take control of their profession and provide leadership in patient care, including the delivery of ethical and professional practice.

Leadership is also considered an important feature of nursing when considering processes outside of patient care, including the professional regulation of the nursing profession and the research setting. Nurses should be able to govern their own profession by contributing to the development of policy and providing strong leadership to other nurses. When engaging in research, strong leadership can focus investigations on specific clinical topics or areas. Leadership is also seen in educating other members of staff and supporting the use of policies and practices on the ward. Therefore, nurses should be able to engage with others, justify their own opinions, and guide the course of clinical practice.

Record keeping

When nurses interact with patients, they often do so verbally - either seeking the permission of the patient to act or making joint decisions regarding care processes. Talking to patients and colleagues is an effective way of imparting and gathering information, but this is not the only way that communication occurs in the healthcare setting. Nurses also have the responsibility to provide a more permanent record of the patient care process, through accurate and detailed record keeping. Record keeping may incorporate a number of resources and tools, including patient notes (both physical and electronic), letters, interprofessional correspondence, and the results of interventions or investigations. All of these documents illustrate the care decisions that have been made for a specific patient and provide a record of the outcomes of those decisions. Therefore, nurses should maintain these documents and ensure their accuracy to guarantee that care is being performed appropriately (NMC, 2009).

Documentation should be as detailed as possible and should record all of the necessary factual information for a care decision. This includes noting observations and vital signs of patients on a routine basis, as sudden changes that are not recorded may lead to poor outcomes. This also includes maintaining a record of written consent for procedures and documentation of discussions of these procedures with the patient. Records not only provide a clear outline of the patient's care plan to other professionals, but may also provide legal protection against wrongdoing. When a patient complains, or dies as a result of a specific course of treatment, records should be able to show the logic and reasoning behind the decisions that went into their care. If records are poorly kept or incomplete, then nurses are liable to being professionally or legally investigated, even if they performed care in an ethical and professional manner. Therefore, you should get into a habit of documenting every conversation and decision made with a patient in their notes from an early stage of your career to avoid such situations in the future. Unless it is written down formally, there is no evidence that a conversation took place!

Student-mentor relationship

One of the responsibilities of the nurse is to guide junior members of staff and provide mentorship in the clinical setting. A mentor is a senior staff member who can provide support to students and trainees, including education support and psychological support (Butterworth & Faugier, 2013). It is important that nurses engage in mentorship in order to promote the learning experiences of junior staff members. The skillset and knowledge base of the entire clinical team depend on a process of information sharing and critical feedback to ensure standards are met consistently.

The nature of the relationship between student and mentor should be considered fundamental to promoting education in nursing. Patience, understanding and guidance are all needed in order to be an effective mentor and to ensure that students have the chance to learn in a safe and nurturing environment. All nurses are expected to be able to provide mentorship to others and it is a professional responsibility for nurses to support the learning and training of their colleagues.

Professional development and research

A key component of the NMC Code (2015) is the wide range of responsibilities that nurses have in practice. All of these responsibilities reflect areas of professional expertise requiring specific knowledge and skills. Professional development, and continuing professional development (CPD) in particular, are terms widely used to describe the constant need for nurses to not only maintain their knowledge and skills, but also to engage in a lifelong process of learning (Royal College of Nursing, 2014). New discoveries are always being made, leading to new drug treatments, while the evidence base for some interventions may change on an annual basis. Unless nurses are able to keep up with these changes, they risk their own professionalism by engaging in out-dated or unsafe practices. It is a professional duty of the nurse to review research, local guidelines and national guidelines in order to make sure that they are up-to-date with the most current evidence. Furthermore, nurses need to continually reflect on their skillset and practice techniques to make sure that they can demonstrate competency in performing procedures ranging from patient lifting/handling to basic life support.

Finally, the need for nurses to become involved in the research setting is being recognised as increasingly important (Parahoo, 2014). Research is the foundation of knowledge gathering, and all scientific studies aim to increase knowledge and expertise in a given field. Nurses can utilise published research to guide their practice by appraising evidence and critically analysing how this may apply to their care setting. However, it is of the utmost importance that nurses are also actively involved in research in order to ensure that nursing priorities are addressed in the research setting, and to allow for further skill development. By becoming involved in research at any level, nurses expose themselves to the principles of critical analysis and can develop a deeper understanding of clinical topics. As a nurse, you are encouraged to develop your research interests and contribute to the expansion of the knowledge base for yourself and others.

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Conclusion

This chapter has provided an overview of the professional standards of nursing, as noted in the NMC Code (2015). Four key domains have been evaluated: prioritise people, practise effectively, preserve safety, and promote professionalism and trust. The details of each of these domains reflect the need for nurses to meet the challenges of performing multiple roles and having many responsibilities in the care setting. Nurses must act as educators, care providers, counsellors, researchers and leaders in modern practice. By using professional guidance and ensuring that you meet the criteria for effective professional nursing, all of these areas can be fulfilled in your own practice and future practice. It is vital that you utilise evidence and experience to continue to develop your knowledge and skills over time to meet the professional standards of the nursing profession.

Reflection

Now that we have reached the end of this chapter, it is important to reflect on the learning objectives and content covered. You should:

- Have a clear understanding of the purpose and value of the NMC Code

- Be able to identify and describe professional nursing standards

- Be able to appreciate the diversity of the professional role of nurses

Reference list

Butterworth, T., & Faugier, J. (2013). Clinical supervision and mentorship in nursing. London: Springer.

Griffith, R. (2015). Accountability in district nursing practice: key concepts. British Journal of Community Nursing, 20(3), 146-149

NHS (2015). About the NHS: NHS core principles. Available at: http://www.nhs.uk/NHSEngland/thenhs/about/Pages/nhscoreprinciples.aspx [accessed 6th November 2016]

Nursing and Midwifery Council (2009). Record keeping: guidance for nurses and midwives. London: NMC

Nursing and Midwifery Council (2015). The codes for nurses and midwives. London: NMC

Parahoo, K. (2014). Nursing research: principles, process and issues. London: Palgrave Macmillan.

Royal College of Nursing (2014). RCN factsheet: continuing professional development (CPD) for nurses working in the United Kingdom (UK). London: RCN

Royal College of Nursing (2016). Accountability and delegation. Available at: https://www.rcn.org.uk/professional-development/accountability-and-delegation [accessed 6th November 2016]

Scaria, M. K. (2016). Role of care pathways in interprofessional teamwork. Nursing Standard, 30(52), 42-47.

Sherring, S. (2012). Nursing leadership within the NHS: An evolutionary perspective. British Journal of Nursing, 21(8), 491-494


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