The Code of Conduct in Practice

The Code of Conduct in Practice

The professional standards that are required of nurses are given in the Nursing and Midwifery Council code of professional conduct: standards for conduct, performance and ethics (2004). The NMC Code states that nurses are personally accountable for their practice and it details values that are common to all health care regulatory bodies in the United Kingdom. These values are concerned with respect for the individual, obtaining consent, confidentiality, co-operation with other professionals, knowledge and competence, trustworthiness and minimising risk to patients (NMC, 2004 a). In this essay, I shall analyse in some detail the second clause from the Code, which requires that a nurse “respect the patient or client as an individual.” (NMC, 2004 b).

Fromm, (1962) defines respect as “a person’s reaching awareness of the unique individuality of the other person, with the desire that the person develop and unfold in his or her individuality.” I shall give examples from my own clinical practice, where I was able to see the importance of affording such respect to individual patients and I shall discuss several aspects of the theoretical background to the requirement for respect for the individual, which has been a focus for the attention of many authors of nursing journals and textbooks.

The NMC Code says that nurses must “respect the role of patients and clients as partners in their care and the contribution they can make to it…. identifying their preferences…. and respecting these within the limits of professional practice, existing legislation, resources and the goals of the therapeutic relationship.” (NMC, 2004 c). Although it may seem obvious, it is important for healthcare professionals to recognise that “the patient has a right to make personal decisions regarding healthcare.” (Ellis and Nowlis, 1994 a). Melanie Johnson MP, (2004) spoke of “….a legal requirement for health care organisations to involve patients and the public in decisions about how health care is delivered.” It is certainly reasonable that any patient should expect to be able to refuse a treatment because it is unpleasant, inconvenient, worrying or because they simply do not feel like it, even though a healthcare professional would consider it beneficial for them.

The concept of patients being partners and co-operating with healthcare professionals in the implementation of their own care is an important one. Faulkner, (1996) states that “if a patient is to have a role in planned care, he needs firstly to understand the rationale behind the care and secondly to agree that the care is necessary. Both aims may best be achieved by involving the patient wherever possible in discussions about care.” McQueen, (2000) echoes this, with more focus on the nurse-patient relationship: “If people are to work together amiably and achieve a therapeutic outcome, the relationship within which this takes place is crucial.” It should be “mutually satisfying to both patient and nurse.”

Partnerships, at the most basic level, involve patients effectively communicating their symptoms, feelings and their perceived responses to their treatment. However, patients who have to live with a chronic condition often have more knowledge than healthcare professionals, about the effect that it has on them and on their ability to go about their daily lives. McMurchy and Vujicic, (2000) say that “The rise in chronic illness has highlighted client expertise. Clients have sophisticated knowledge about managing symptoms and adapting their daily routines to accommodate illness.” The recognition that the patient knows best has led to the idea of the “expert patient”; someone whose knowledge of the effects of a condition and its treatment can be passed on to others with the same condition – for example multiple sclerosis. The experience of others can help patients to live with a disease and cope effectively with the limitations that it imposes on their lives. “When it comes to identifying individual problems and needs, the patient is the expert, not the nurse nor any other professional.” (Mullally, 2001). In my clinical practice, I encountered a patient with Parkinson’s disease, who was the expert on his own drug administration. He was in possession of a one-off prototype device, which none of the ward staff could operate without his instruction.

For patients to feel that they are equal partners in their own healthcare and that they can make a valuable contribution to their treatment, it is necessary that alternatives are explained to them and that their preferences are considered when treatment is given. As part of NHS policy: “Patients will be given as much choice and control as possible across all areas of healthcare. To help patients make decisions that are right for them, they need high quality information and support.” (DoH, 2004)

The NMC Code acknowledges that patients’ preferences must be limited by the boundaries that are necessarily required by professional practice. (NMC, 2004 d). Smoking must be discouraged in a no-smoking hospital and a patient who insists that cannabis is an effective analgesic for him cannot be allowed to use it on the ward. The resources available must also be considered; a patient who wants the privacy of a single room cannot be afforded that luxury when it is simply not available. Patients’ preferences must also be within the goals of a therapeutic relationship. If a patient’s wishes would positively impair his recovery, then healthcare professionals must discourage him from carrying them out, even though this would mean that his wishes were, effectively, vetoed.

The NMC Code says that nurses must “promote and protect the interests and dignity of patients and clients, irrespective of gender, age, race, ability, sexuality, economic status, lifestyle, culture and religious or political beliefs.” (NMC, 2004 e). All nurses would agree that the interests and dignity of patients in their care are paramount and often quote, as examples, that they ask the patient how they wish to be addressed and always draw the curtains to protect the patient’s dignity. Ellis and Nowlis, (1994 b) state: “The patient has a right to individualised care, related to his or her unique needs and lifestyle. To support this right, you must treat each person as a unique and important individual.” This idea is often used in the nursing philosophies put forward by healthcare organisations or areas of care within hospitals: “….we believe that you should benefit from care that is focused upon respect for you as an individual, taking into account your personal values, beliefs, customs and independence.” (KCH, 2004).

It is easy to imagine that some patients’ interests may not be held quite as dearly as others. Even though they know that they should be professional and not have favourites or least-favourites, most nurses will have known patients with whom spending time is either a pleasure or a challenge. In clinical practice, I found it difficult when first dealing with patients who were conscious but uncommunicative, as some in a neurosurgery ward are. I also saw the importance of an “unconditional positive regard” for patients whose ethics, beliefs and lifestyle may be far removed from my own. When caring for a drug user, an alleged drug dealer, and two patients who had attempted suicide, I gained a clear understanding that there is no place for being judgemental when providing nursing care.

The NMC Code says that nurses must “maintain appropriate professional boundaries…. with patients…. and focus exclusively upon the needs of the patient.” (NMC, 2004 f). However, this may have different interpretations, depending on the patient and the situation. Barry, (1996) states: “While caring is an essential ingredient of healing, over-identification with patients and their families can compromise judgement and the limits between professional and personal boundaries can become blurred.” In contrast, Duxbury, (2000) argues that: “Professional intimacy is the result of patience and respect.” and that: “Nurses are … increasingly beginning to recognise the importance of the development of a degree of rapport with patients before close contact can be expected.”

In my clinical placements, I found that patients often wanted to talk. What they said was sometimes quite revealing, giving an insight into their medical history, personal circumstances and their immediate needs. One patient was very worried about his partner, also in hospital, who he had been unable to visit for three months. By ensuring that his mobile phone was charged so that he could talk to her every day, I was focusing upon a very real need of his, which was likely to assist his post-operative recovery.

The NMC Code says that nurses must “promote the interests of patients”, including helping them to “gain access to…. information and support relevant to their needs.” (NMC, 2004 g). For some patients, in particular those from ethnic minorities, this kind of help is most important. Hinchliff et al, (2003) have gathered evidence that “individuals from ethnic minorities are less likely to access cardiac rehabilitation programmes.” and that “the lack of interpreter services means that the needs of patients from some ethnic minorities are not fully met.” Whilst attending a cardiac rehabilitation session as part of my clinical placement, it was noticeable that eleven out of the twelve patients were white.

In another clinical placement, I attended interviews with patients, their families and a specialist nurse, who showed outstanding professionalism when she had to present shockingly bad news. She provided information and support and offered the patients hope and a degree of control and involvement in the therapy that was to come. She also correctly assessed of the amount of information that the patients and their families could take in at such a difficult time. She stopped before they were overloaded with information but reassured them that help was there for them and that she would be available with more support when they felt that they needed it.

The NMC Code says that nurses must report “any conscientious objection that may be relevant to their professional practice” and “continue to provide care…. until alternative arrangements are implemented.” (NMC, 2004 h). Rubenfeld and Scheffer, (1999) write: “Sometimes a nurse’s values and beliefs are in conflict with an area of patient need. Nurses cannot simply refuse to care for people they do not like, however, when they honestly believe that their values and beliefs could interfere with the quality of care in any given situation…. they should refer patients to other healthcare providers.”

In my clinical practice, I did not witness any occurrence of conscientious objection by staff, nor do I feel that I have any conscientious objections to a patient’s choice of treatment. I do understand, however, that others may have such objections. In that case, I may have a role in covering for other members of staff who cannot allow themselves to be involved in the care of a particular patient. It is easy to imagine a situation where one would not wish to care for a patient because of what they had done. If such a situation arose, one would have to adhere to the NMC Code by making one’s objections known to the nurse in charge, but continuing to provide professional care unless or until it were possible to be relieved.

In this essay, I have discussed the importance of respect for the patient as an individual, as it is described in each part of the second clause of the NMC Code. I have been particularly concerned with the development of the patient as a partner in his or her own care, contributing to that care, expressing preferences and making choices. I have described my own experiences of interactions with patients in my clinical practice, where I feel that I have consistently shown due respect for each patient as an individual. I have also examined a selection of ideas put forward by experienced nursing practitioners and authors, in an attempt to explain or support an argument or to provide a different view. Their theoretical descriptions of the reasons for, and the effects of our interactions with patients have reinforced my understanding of why nurses should respect each patient as an individual, going beyond simple courtesies which are desirable in all professional or social relationships.

References:

Barry, Patricia D (1996)

Psychosocial Nursing. Care of physically ill patients and their families. 3rd Edition.

Philadelphia: Lippincott: p573

DoH (2004)

About a patient-led NHS. Department of Health – P&G Org policy Modernisation.

http://www.dh.gov.uk/PolicyAndGuidance/OrganisationPolicy/Modernisation/SystemReform/SystemReformArticle/fs/en?CONTENT_ID=4106610&chk=1yG26S

(accessed on 30 November 2005)

Duxbury, Joy (2000)

Difficult Patients.

Oxford: Butterworth-Heineman: p146

Ellis, Janice Rider and Nowlis, Elizabeth Ann (1994 a)

Nursing. A Human Needs Approach. 5th Edition

Philadelphia: Lippincott: p181

Ellis, Janice Rider and Nowlis, Elizabeth Ann (1994 b)

Nursing. A Human Needs Approach. 5th Edition

Philadelphia: Lippincott: p181

Faulkner, Ann (1996)

Nursing. The reflective approach to adult nursing practice. 2nd Edition

London: Chapman and Hall: p163

Fromm E (1962)

The Art of Loving.

New York: Harper Colophon Books: cited in Orem:

Orem, Dorothea E (1995)

Nursing. Concepts of Practice. 5th Edition.

St Louis: Mosby: p26

Hinchliff S, Norman S and Schober J (2003)

Nursing Practice and Health Care. 4th Edition.

London: Arnold: p232

Johnson, Melanie MP (2004)

Speech on 26th April 2004: The Expert Patient Programme.

http://www.dh.gov.uk/NewsHome/Speeches/SpeechesList/SpeechesArticle/fs/en?CONTENT_ID=4082345&chk=G3K07Q