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Code of Ethics and Conduct for European Nursing Loredana Sasso, Alessandro Stievano, Máximo González Jurado and Gennaro Rocco Nurs Ethics 2008 15: 821 DOI: 10.1177/0969733008095390 The online version of this article can be found at: http://nej.sagepub.com/content/15/6/821

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CODE

AND CONDUCT FOR EUROPEAN NURSING

OF

ETHICS

Loredana Sasso, Alessandro Stievano, Máximo González Jurado and Gennaro Rocco Key words: Code of Ethics and Conduct for European Nursing; codes of ethics; codes of professional conduct; European Federation of Nursing Regulators A main identifying factor of professions is professionals’ willingness to comply with ethical and professional standards, often defined in a code of ethics and conduct. In a period of intense nursing mobility, if the public are aware that health professionals have committed themselves to the drawing up of a code of ethics and conduct, they will have more trust in the health professional they choose, especially if this person comes from another European Member State. The Code of Ethics and Conduct for European Nursing is a programmatic document for the nursing profession constructed by the FEPI (European Federation of Nursing Regulators) according to Directive 2005/36/EC On recognition of professional qualifications, and Directive 2006/123/EC On services in the internal market, set out by the European Commission. This article describes the construction of the Code and gives an overview of some specific areas of importance. The main text of the Code is reproduced in Appendix 1.

Background When the FEPI (Federazione Europea delle Professioni Infermieristiche; European Federation of Nursing Regulators) was founded in 2004, it was evident that the establishment of ethical and deontological principles shared throughout Europe would give better protection to European citizens and enhance professional development. The FEPI’s main objective is to protect European citizens by guaranteeing excellence in:

• • • •

Nursing practice competences for safer mobility of nurses across the continent; Common professional standards for excellent quality of health care outcomes; Development and maintenance of professional competences; Codes of conduct based on common principles to improve the protection of European citizens.

Correspondence: Alessandro Stievano. Tel: ⫹39 3397634406; Fax: ⫹39 0645437034; E-mail: [email protected] [email protected]

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FEPI seeks to achieve public protection and patient safety by being:

• An advocate of patient safety to the European institutions; • A promoter of nursing excellence and public protection at both national and European levels;

• A source of information for nursing professionals, policy makers, consumers, educators and researchers;

• A networker with international organizations, academia and policy makers; • A point of reference for any interested party that is seeking reliable data on nursing regulations. The FEPI Working Group on Codes of Ethics was set up following a mandate by the FEPI General Assembly and included in the 2007 FEPI Action Plan, as a result of the European debate on the need to take joint action on codes of ethics in Europe. Such debates were triggered by the Lisbon Strategy, which seeks to make the European Union (EU) the most competitive and dynamic knowledge-based economy and society by 2010. Patient safety and public protection in an enlarged European internal market cannot be achieved without a common understanding of the values and codes of conduct that govern the nursing profession. The FEPI Working Group on Codes of Ethics offered a platform for reflection for nursing regulators, as well as for competent authorities and researchers, on the principles and values that would lead to the drafting of a European code of ethics and conduct for nursing. Such principles are crucial for the future of the profession and would bring substantial added value to the work being carried out on this matter at EU level. For this purpose, FEPI worked in close collaboration with CEPLIS, the European Council of Liberal Professions, which is the leading organization in the reflection on Common Values for the Liberal Professions in Europe. ‘Liberal professions’ are defined as ‘those practised on the basis of relevant professional qualifications in a personal, responsible and professionally independent capacity by those providing intellectual and conceptual services in the interest of the client and the public’.1

Introduction Directive 2005/36/EC of 7 September 20052 states that, when a service is provided across borders, the regulations on professional qualifications of the hosting Member State will be valid, particularly those regarding patient protection and safety. Concerning nursing, the Directive states that nurses have to have a clear knowledge of the basics and the ethics of the nursing profession: Training for nurses responsible for general care shall provide an assurance that the person in question has acquired the following knowledge and skills: sufficient knowledge of the nature and ethics of the profession and of the general principles of health and nursing.

The Directive On services in the internal market (points 113 and 114)3 invites Member States, in collaboration with the Commission, to encourage the creation of codes of ethics at European level and to ensure that such codes are available through the internet. Nursing Ethics 2008 15 (6)


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… Member States, in cooperation with the Commission, are to encourage interested parties to draw up codes of conduct at Community level, aimed, in particular, at promoting the quality of services and taking into account the specific nature of each profession. Those codes of conduct should comply with Community law, especially competition law. They should be compatible with legally binding rules governing professional ethics and conduct in the Member States … Member States should encourage the setting up of codes of conduct, in particular, by professional bodies, organisations and associations at Community level. These codes of conduct should include, as appropriate to the specific nature of each profession, rules for commercial communications relating to the regulated professions and rules of professional ethics and conduct of the regulated professions which aim, in particular, at ensuring independence, impartiality and professional secrecy …

In this framework, the FEPI Working Group on Codes of Ethics included FEPI member organizations from eight European countries (Croatia, Greece, Ireland, Italy, Portugal, Romania, Spain, UK) as well as non-FEPI members from France and Cyprus. This group analysed the relevant national nursing codes of conduct. Their work was supported by a group of experts in ethics, philosophy, law, and political and EU experts. They then drew up the first Code of Ethics and Conduct for European Nursing, which was presented at the FEPI conference ‘Placing the patient first – effective nursing regulation across Europe’, held in Dubrovnik, 25–28 September, 2007. This project was developed to:

• Ensure the safety and protection of the public who receive nursing services in • •

Europe by providing the nursing regulatory boards with the principles and inspiring values to develop the respective codes of ethics and conduct; Inform the public and nurses about the common values on ethics and conduct, with which all nurses practising in Europe should comply; Harmonize the principles of quality and equity in the provision of care to EU citizens.

The nursing profession was the first of the liberal professions in Europe to achieve this important goal, to the great satisfaction of the entire European nursing community. The main sources that allowed the Code to be drawn up were:

• • • • •

The Directives of the European Commission and the European Parliament;2,3 Legislation on human rights;4–7 Legislation on citizens’ rights throughout Europe;8–10 Common values of the liberal professions developed by CEPLIS;1 The codes of other important world nursing organizations.11

The main purpose of this project was to contribute to discussions and policies aimed at harmonizing the ethical standards of nursing practice and the nursing profession in Europe by identifying, clarifying and analyzing the moral values underlying codes of ethics in nursing and to draw up a new code whose ethical principles could be shared at least by all FEPI members and in general throughout Europe.

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Method used to construct the Code of Ethics and Conduct for European Nursing The Code was designed and developed by FEPI at the headquarters of the Consejo General de Enfermeria (CGE) in Madrid, Spain, with the working group chaired by Máximo González Jurado (CGE President). The Code was drawn up following an in-depth analysis of the current national codes of ethics and in consultation with national nursing regulators of the 10 participating countries. A group of experts and delegates from all the countries involved in the project, supported by Spanish experts in law, ethics and bioethics, contributed to the drafting of the Code. In 2004 CEPLIS circulated a questionnaire to various groups and organizations in Member States, seeking comments on specific values that all liberal professions should exhibit. The responses to the questionnaire resulted in the drafting of a document entitled Common values for liberal professionals in Europe.1 This document presents eight common values: Confidentiality This is the cornerstone for the building of trust between professionals and their clients or patients. Participation in Continuous Professional Development Codes of Conduct should make it clear that professionals have an unequivocal responsibility to maintain competency in their field of practice and to this end must participate in continuous professional development throughout their working lives. Independence and Impartiality Codes of Conduct should make it clear that liberal professionals have the right to exercise personal judgment in the frame of their responsibilities after taking into account all relevant circumstances, without any application of external influence. Honesty and Integrity Codes of Conduct should make it clear that professionals are required to act with courtesy, honesty and integrity in their relationships with clients and others, including professional colleagues. Supervision of Support Staff Codes of Conduct should make it clear that professionals are required to ensure that any member of support staff to whom a task is delegated has the knowledge and skills necessary to undertake that task effectively and efficiently. There should also be appropriate supervision. Compliance with Codes of Conduct and Practice All Codes of Conduct should make it clear that members of the profession concerned are required to comply not only with the provisions of the Code of Conduct itself but also with legislation and the provision of codes of practice and standards relating to specific professional services they may provide. Nursing Ethics 2008 15 (6)



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Professional Indemnity Insurance Codes of Conduct should make it clear that members of the profession concerned have an obligation to carry professional indemnity insurance at a level sufficient to ensure that in the event of a justified claim from a client or patient arising as a result of the provision of a service, the individual will be adequately compensated. Conflict with Moral or Religious Beliefs Codes of Conduct should make it clear that in the event of conflicts with moral or religious beliefs arising from a request for the provision of a professional service, members of the profession have an obligation to provide information on where that service can most conveniently be obtained from a professional colleague.

CEPLIS invited liberal professionals across Europe (including health professionals) to draft European codes of conduct for their professions, based on these values. From this shared structure the common values of the Code of Ethics and Conduct for European Nursing were eventually identified. The final phase of this process was underpinned by the FEPI General Assembly held in May 2007, followed by a process of consultation with stakeholders from 30 June to 10 September, 2007, and ending with the final presentation to the FEPI conference at Dubrovnik in September 2007.

Articulation of the Code The Code starts with a definition of its purposes and an introduction, followed by 13 fundamental principles, including respect for human dignity, human rights and equitable access to care and treatment for everybody. Of equal importance are the principles regarding information, informed consent, learning during the whole of nurses’ professional life, professional conflict with ethical and religious convictions, and the delegation of assignments to support staff. The key principles are set out below.

Quality and excellence Patients can expect that nurse regulators will have systems in place to define and monitor the content, standards and quality of the education and practice required to become a nurse and to continue working as a nurse. These quality standards of education for nurses are the first and most important steps towards guaranteeing, at European level, excellent and safe care. Nurse regulators should have systems in place that enable them to verify the continued competence of nurses in the interests of safety and health of patients or clients.

Continuing professional development This point is closely linked to the previous one. Patients have a right to expect that nurses will maintain their competence throughout their working life. This statement implies professional accreditation of excellence through lifelong learning that will accompany nurses in a dynamic and changing society. The right to safe nursing services has to be guaranteed from a professional who applies the principles of evidence-based nursing practice. Nursing Ethics 2008 15 (6)


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Lifelong learning is an essential element for health professionals all over Europe. In this context, and in a constantly more closely linked Europe, lifelong learning strategies built on a knowledge-based society and economy are necessary to improve social cohesion, a good quality of life and equal opportunities for health for everybody.

Human rights Patients have the right to human dignity, which is the basis of human rights. Human rights have the highest level of importance in this Code and all relevant human rights legislation applies, irrespective of nationality or country-specific legislation. Patients have the right to be protected by their own nurse and never to be victims of actions of torture, cruelty or other inhuman or degrading treatments. The philosophy of health as a fundamental human right is additionally guaranteed by numerous documents at international and European level,12–18 and by article 25 of the United Nations Universal Declaration of Human Rights, which states: Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.4

Equitable access to quality health care Patients have the right to fair and equal access to quality health care and treatment from nurses, according to their needs. The responsibility for shifting to fairer and equal access in order to benefit from the right to health must involve all the social stakeholders of the health sector and their institutions. Common objectives and effective collaboration are essential to develop a health care system that adequately meets the social and health care demands of European populations. Some of these populations currently do not fully benefit from this right; such action would therefore allow them to lead healthier and more dignified lives. According to Mairis, dignity means: That an individual is capable of exerting control over his or her behaviour, surroundings and the way in which he or she is treated by others. He or she should be capable of understanding information and making decisions. He or she should feel comfortable with his or her physical and psychosocial status quo.19

This can be seen in two different perspectives: the dignity of others, a well-known concept in health literature, and the respect of one’s own dignity as a professional; this still requires major insight. In the Code of Ethics and Conduct for European Nursing, the basic dignity that Pullman20 mentions is something that a person already has as a human being. As Nordenfelt21 states, this concept – which unfortunately in relation to health is not fully accomplished yet at European level – has four main aspects: Provision of the necessary means of existence, Freedom from strong and continued pain,




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Minimal liberty, Minimal self-respect.

The German expression Menschenwürde summarizes very well this sort of basic dignity that is inextricably linked to fundamental human rights and to the right to health. It is a dignity all human beings have from birth, not a dignity to aspire to, which is strongly reaffirmed by this Code. It is a dignity linked to the right to health, as recognized by the United Nations4,6,7 and other international documents, which every human being should be able to express without influences and obstacles. This dignity needs to be ensured for all citizens of the EU. It is still not the dynamic concept identified by Haddock,22 but it is a good basis for development of the ethics of dignity.20

Compliance with the Code of Ethics and Conduct for European Nursing European citizens have the right to expect assistance of high quality from nurses, according to the Code. Patients have the right to expect that nurses will provide high-quality care that is compliant with their national codes of ethics and conduct and all relevant legislation.

Honesty and integrity Patients have the right to demand that nurses are honest, sincere and trustworthy, and that they will assist them with integrity. Honesty and integrity imply coherent decisions relating to the values declared and practiced by professionals. A tendency to congruence of behaviors and choices should characterize professional quality. An honest professional is someone who patients can trust and be sure that such trust will not be betrayed.

Relationships with others Patients have the right to demand that nurses complete their duty, and that they adhere to ethical and professional values. Nurses have to build their relationship with patients, colleagues and other workers on trust, solidarity, collaboration, integration and mutual respect.

Information Patients have the right to demand that nurses communicate with them and provide information and make suggestions in an appropriate, clear, easy and comprehensible way. The level of communication has to be simple and easily understandable by patients so that nurses can demonstrate the support or advocacy23–25 that underpins nursing competence, which is manifested by:

• Responsibly defending the rights, affairs and dignity of patients, interacting in a therapeutic relationship, and helping patients and significant others to develop realistic expectations. Nursing Ethics 2008 15 (6)


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• Encouraging patients to be aware of their own resources and abilities in the process of health promotion.

• Identifying together with patients the objectives of nursing care and analyzing with them the best ways to reach their health objectives.

• Recognizing patients’ value system for reaching health objectives, avoiding imposing on patients the nurses’ own values or those more diffused in the community, as well as refraining from considering patients to be guilty of certain behaviors or views held.

Informed consent Patients have the right to self-determination and to freely communicate their own wishes as expression of their own personal autonomy. They have the right to decide whether or not to accept nursing care (informed consent) or to refuse to receive information, suggestions or assistance. Nurses must respect these decisions.

Confidentiality Patients have the right to expect that any information they disclose is confidential between themselves and their nurses. Safeguarding and not revealing to others the information acquired during professional activity is of prime importance and was noted in all the national codes of ethics and conduct consulted. This right concerns all patients, even very young persons and adults who are not able to make their own decisions. It also persists after the death of an individual.

Conflict with moral and ethical beliefs In case of conflict caused by deep moral or ethical convictions, in the course of their work nurses are invited to find solutions through dialogue with the respective parties: the patient, the employer, the regulatory board, and their professional organization. If nurses are not able to find a solution for stated reasons or intend to activate a conscientious objection, they must refer to and respect the legislation in place in the country where they work. In an emergency situation or if there is imminent risk to a patient’s life, nurses must provide the necessary assistance and put aside any conflict with their own moral convictions or ethics.

Delegation to and supervision of staff Patients have the right to demand that whoever provides health services is adequately trained and has the competence to give such assistance. Support staff often do not have an adequate level of competence for this role. To ensure patients’ safety, nurses have to manage support staff and make sure that they are adequately trained.




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Professional indemnity insurance Patients have the right to demand that the nurse who cares for them is adequately insured.

Overview These key principles, dealt with in detail by the Code, would allow European nurses to have a common vision of their work space and facilitate transnational mobility. In addition to the Code, a glossary of 56 terms was developed to facilitate their interpretation across the various EU languages and cultures, for example: accountability, patient safety, trustworthiness, confidentiality, responsibility and others. These terms can often be seen from different philosophical perspectives and can generate different meanings. In the layout of the Code, the unambiguous interpretation of terms has been one of the major difficulties to overcome.

Conclusions The fundamental principles contained in the document will allow nursing regulatory boards to rewrite their own codes of ethics and conduct for nursing with the purpose of informing patients, groups, families and communities about what should be expected of nurses working in Europe. In this way, FEPI could promote the safety of European citizens. The content of the European Code is of interest to various groups: patient populations, the European nursing community and European nursing regulatory boards. By promoting this document, FEPI invites all regulatory boards and all who are interested, inside and outside of Europe, in both public and private sectors, to use its content. The present Code is a strategic, high-level document and will be updated every three years to keep pace with developments in the nursing profession and in European nursing services.

Limitations The strategy of dissemination and implementation26 of this Code should be a dynamic process, involving all the regulatory boards and the ministries of health of European countries. It therefore requires to be translated into all EU languages. Alongside the Code, it may be useful in the future to develop a practical guide to ethical decision making illustrating how to cope with problematic ethical dilemmas in practice.

Acknowledgements We wish to thank all the members of the FEPI Working Group on Codes of Ethics who contributed to the completion of the Code with effort and commitment. In particular



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we would like to thank: Sandra Arthur (UK), rapporteur of the Group; Sonja Kalauz (Croatia); Katerina Kolyva (Head of FEPI Office); Christiana Kouta (Cyprus); Theodoros Koutroubas (CEPLIS, Belgium); M Teresa Monzón (Spain); Lucilia Nunes (Portugal); Javier Sánchez Caro (Spain); Rafael Lletget (Spain); Rafael Pellicer (Spain); Judith Foley (Republic of Ireland); Liliana Iordache (Romania); Christina Mackenzie (UK); Mireille Malafa (France). Loredana Sasso, President of the European Federation of Nursing Regulators (FEPI). Alessandro Stievano, Italian Nursing Board (Ipasvi), Rome, Italy. Máximo González Jurado, President of the Consejo General de Enfermeria de Espana, Madrid, Spain, and Vice President of FEPI. Gennaro Rocco, Secretary of FEPI, Vice President of the Italian Nursing Board (Ipasvi).

References 1

CEPLIS. Common values for liberal professions in Europe. 2007. Retrieved 2 November, 2007, from: http://www.ceplis.org/indexengl.htm 2 Directive 2005/36/EC of the European Parliament and of the Council of Europe. On the recognition of professional qualifications. Official Journal of the European Union. L 255/22. 7 September 2005. 3 Directive 2006/123/EC of the European Parliament and of the Council of Europe. On services in the internal market. Official Journal of the European Union. L 376/36. 12 December 2006. 4 United Nations. Universal declaration of human rights. General Assembly of the United Nations, 10 December 1948. Retrieved 2 November, 2007, from: http://www.unhchr.ch/udhr/lang/eng.htm 5 ICN. Position Statement. Nurses and human rights. 2006. Retrieved 11 November, 2007, from: http://www.icn.ch/pshumrights.htm 6 United Nations. International covenant on civil and political rights. 1976. Retrieved 2 November, 2007, from: http://www1.umn.edu/humanrts/instree/b3ccpr.htm 7 United Nations. International covenant on economic, social and cultural rights. 1976. Retrieved 11 November, 2007, from: http://www1.umn.edu/humanrts/instree/b2esc.htm 8 World Health Organization. A declaration on the promotion of patients’ rights in Europe. Amsterdam: WHO, 1994. 9 Council of Europe. Oviedo Declaration: convention for the protection of human rights and dignity of the human being with regard to the application of biology and medicine: Convention on Human Rights and Biomedicine. 1997. Retrieved 9 July, 2008, from: http://conventions.coe.int/treaty/en/ treaties/html/164.htm 10 European Council. Charter of fundamental rights of the European union. December 2000. Retrieved 9 July, 2008, from: http://www.europarl.europa.eu/charter/pdf/text_en.pdf 11 International Council of Nurses. Code of ethics for nurses. Geneva: ICN, 2005. 12 World Health Organization. Constitution of the World Health Organization. 4th edition, Supplement, October 2006: 1–20. Retrieved 11 December, 2007, from: http://www.who.int/ governance/eb/who_constitution_en.pdf 13 World Health Organization. Declaration of Alma-Ata. 1978. Retrieved 11 December, 2007, from: http://www.who.int/hpr/NPH/docs/declaration_almaata.pdf 14 World Health Organization. Ottawa charter for health promotion. 1986. Retrieved 11 December, 2007, from: http://www.who.int/hpr/NPH/docs/ottawa_charter_hp.pdf 15 World Health Organization. Second international conference on health promotion. 1998. Retrieved 11 December, 2007, from: http://www.who.int/hpr/NPH/docs/adelaide_recommendations.pdf Nursing Ethics 2008 15 (6)


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World Health Organization. Jakarta declaration on leading health promotion into the 21st century. 1997. Retrieved 11 December, 2007, from: http://www.who.int/hpr/NPH/ docs/jakarta_declaration_en.pdf World Health Organization, Pan American Health Organization, Ministry of Health of Mexico. The fifth global conference on health promotion: bridging the equity gap. 2000. Retrieved 11 December, 2007, from: http://www.who.int/healthpromotion/conferences/previous/mexico/en/hpr_mexico_report_en.pdf World Health Organization. Bangkok charter for health promotion. 2005. Retrieved 11 December, 2007, from: http://www.who.int/healthpromotion/conferences/6gchp/en/index.html Mairis ED. Concept clarification in professional practice: dignity. J Adv Nurs 1994; 19: 947–53. Pullman D. The ethics of autonomy and dignity in long-term care. Can J Aging 1999; 18: 26–46. Nordenfelt L. Dignity of the elderly: an introduction. Med Health Care Philos 2003; 6: 99–101. Haddock J. Towards further clarification of the concept ‘dignity’. J Adv Nurs 1996; 24: 924–31. Kohnke MF. The nurse as advocate. Am J Nurs 1990; 80: 2038–40. Mitty EL. The nurse as advocate: issues in LTC. Nurs Health Care 1988; 12: 520–23. Curtin LL. The nurse as advocate: a philosophical foundation for nursing. ANS Adv Nurs Sci 1979; 1(3): 1–10. Verpeet E, Dierckx de Casterlé B, Lemiengre J, Gastmans C. Belgian nurses’ views on codes of ethics: development, dissemination, implementation. Nurs Ethics 2006; 13: 531–45.

Appendix 1 A selection of articles from the Code of Ethics and Conduct for European Nursing (September, 2007) 1. The Code of Ethics and Conduct for European Nursing aims to:

• Ensure the safety and protection of those receiving nursing care in Europe by •

advising nursing regulatory bodies on the key principles to take account of when developing their own code of ethics and conduct. Inform patients and nurses of the common standards of ethics and conduct expected of all nurses practising in Europe.

2. Introduction FEPI [Federazione Europea delle Professioni Infermieristiche; European Federation of Nursing Regulators] is leading best practice by establishing the first Europe-wide code of conduct for health professionals. The contents of this Code will be relevant to a number of groups including patients, FEPI, the European nursing community, nurse regulators and other health professionals. FEPI is pleased to present this reference document and encourages all regulators and others within or without Europe to make use of its content. At the heart of this Code is protection of the public and ensuring patient safety. As such, the Code is written in a way that highlights that the rights of the patient must always come first. The Code has been developed via a consultation process



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with European nurse regulators, European patient organisations and other health professionals. This Code is published by FEPI as a high level strategic document. FEPI recommends that this Code is used by all nursing regulatory bodies, irrespective of whether they regulate general or specialist nurses in private, public or self employed settings. The development of this Code has been informed and inspired by relevant European Directives, human rights legislation and by the work of the European Council of the Liberal Professions (CEPLIS), which liberal professions in Europe were invited to use in developing their codes of ethics and conduct. It has drawn on the existing codes of FEPI members. The Code will evolve over time and be updated to keep pace with advances in the nursing profession and service delivery across Europe. The key principles within this document will enable nurse regulators to develop their own codes of conduct and to inform patients, individuals, groups, families and communities whether healthy or ill about what they can expect from a nurse working anywhere in Europe. It will also inform nurses about the standard of ethics and conduct that they are required to meet and be committed to within Europe and the country in which they are practising. Nursing regulatory bodies in Europe are advised to include the following principles in their code of ethics and conduct:

3. Key Principles 3.1 Quality and excellence Patients can expect that nurse regulators will have systems in place to define and monitor the content, standards and quality of the education and practice required to become a nurse and to continue working as a nurse.

• Nurse regulators should have systems in place that enable the Regulator to ver• • • • • • •

ify the continued competence of nurses in the interests of safety and good health for patients or clients. Nurses have professional competencies linked to the good practice of the profession and should perform their duties with due dedication, caution, diligence, dexterity and reasonable care. Nurses should behave in such a way as to guarantee mutual trust between themselves and the patient. Nurses should abstain from substances that can change their mental or physical ability. Nurses should ensure they comply with their code of conduct. Nurses are responsible for evaluating and improving the quality of the care they provide. Nurses should share their knowledge and skills so that, either individually or within a team of professionals, they can try to identify the main causes for health problems and offer prevention, treatment and rehabilitation. Nurses should co-operate to develop health care and their profession by promoting health, participating in the education of the community and prevention of health problems.




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• Nurses should actively assess risk for their patients and take action to prevent risks stemming from their professional practice or work environment. 3.2 Continuous professional development Patients have a right to expect that nurses will maintain their competence throughout their working life.

• Regulatory bodies should develop a framework of assessment and certification to ensure registered nurses are safe to practise.

• Nurses should ensure that they maintain their competence throughout their career, and comply with the requirements for continuous professional development within the country in which they are practising. 3.3 Human rights Patients have the right to human dignity, which is the principle at the basis of human rights. Human rights have the highest level of importance in this Code and all relevant human rights legislation applies, irrespective of nationality or country-specific legislation. Patients have the right to be protected by their nurse and never be the victim of acts of torture, cruelty, abuse or other forms of inhumane or degrading treatment by a nurse.

• Nurses should respect the needs and requirements expressed by patients, pro-

• •

vided that they are consistent with meeting the principles and provisions of the applicable law, other professional self-regulation instruments and the code of the country in which they are practising. Nurses should provide the necessary care to relieve pain and alleviate suffering, whether it is physical, psychological or environmental. Nurses will be mindful of those who are vulnerable and who may be unable to voice their opinion, are fragile, or who may need additional support from the nurse or others because of their circumstances or situation.

3.4 Equitable access to quality healthcare Patients have the right to fair and equal access to quality healthcare and treatment from nurses, according to their needs.

• Nurses have an overarching responsibility to care for all patients equally and • •

without prejudice to age, gender, and economic, social, political, ethnic, religious or other status and irrespective of personal circumstances. Nurses are committed to recognising health as a fundamental right of the individual and will protect this right through prevention of illness, caring for patients and rehabilitation. Nurses have a responsibility to put the patient first and to minimize risk to the patient by providing appropriate and safe clinical care.

3.5 Compliance with Code of Ethics and Conduct Patients have the right to expect that nurses will provide high quality care, which is compliant with their code of ethics and conduct and all relevant legislation. Nursing Ethics 2008 15 (6)


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• Nurses have a duty to abide by the code of the regulatory body of the country in which they are practising.

• Nurses should demonstrate by their approach and behaviour that they are honest and trustworthy.

• Nurses should commit themselves to meeting their patient or client’s need within • • •

their scope of professional practice i.e. nurses will only do what they have been trained and educated to do. Nurses shall co-operate to promote and develop the nursing profession in the best interests of the patient and the community. Nurses should undertake their responsibilities in a competent, professional and self-regulating manner. Nurses should be impartial and objective when assessing circumstances and should exercise nursing judgement within their scope of practice, based on credible evidence.

3.6 Honesty and integrity Patients have the right to expect that their nurse is honest and trustworthy, and will care for them with integrity.

• The first priority of nurses should be the best interest of their patients. • Nurses should ensure that their actions when dealing with patients, clients and • • • • •

others, including colleagues, are underpinned by honesty, integrity and trustworthiness. Nurses should ensure their behaviour does not bring the nursing profession into disrepute or undermine public confidence in the profession. Nurses should use their qualification and registration status as a nurse only to undertake their nursing responsibilities and the role of a nurse. Nurses should not use their qualification or registration to promote any commercial product or service. Nurses should not compromise their professional judgment or be influenced by any other benefit or commercial consideration. Nurses are entitled to receive an appropriate remuneration or fee for the provision of their nursing services but should refuse any personal incentive, gift, benefit, favour, payment or otherwise which might be interpreted as having influence on their professional judgment, integrity, impartiality or trustworthiness.

3.7 Relationships with others Patients have the right to expect that nurses will fulfill their duties, including relationships with them and others, to a consistent standard and ethos.

• Nurses should base their relationships with patients, colleagues and co-workers on mutual trust and respect.

• Nurses should promote a working environment where respect and transparency

•

prevail, which is free from hostilities and harmful professional competition, and which is characterized by fruitful cooperation and team working among professionals and co-workers. Where it is necessary, nurses should advise and guide their colleagues by offering constructive criticism to ensure protection of the public and patient safety. Nurses should consider the most suitable means of raising criticisms and ensure they are addressed.




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• If a nurse thinks that one of their colleagues has acted with serious incompetence • •

or contrary to their code of conduct, they shall inform the regulatory body, the relevant organisation, and/or manager. Nurses should not make harmful or disparaging remarks about their colleagues to patients, clients, third parties or others in the interest of self-promotion or professional competition. Nurses should respect the ideas of other professionals and should consult them if wishing to use their work for research.

3.8 Information Patients have a right to expect that nurses will communicate with them and provide information and advice in an appropriate, clear and user-friendly manner.

• Nurses should communicate with patients in a way that can be easily under•

stood by patients. Information and advice must be impartial and based on credible evidence. Nurses will be truthful when giving information to patients.

3.9 Informed consent Patients have the right to self-determination and free will and this includes the promotion and protection of their personal autonomy. Patients have the right to decide whether or not to accept nursing care (informed consent) or to refuse to receive information, advice or care and that the nurse will respect this decision.

• Nurses should seek valid consent from their patient and must be sure that the patient is legally competent, is informed and that any consent is given voluntarily.

• It is the responsibility of the nurse to provide the relevant information to their patients, which will enable them to make an informed decision.

• Nurses should ensure that they apply the principle of informed consent or refusal •

to the wishes of the patient at the present time, but also take into account the interest of the patient where instructions have been given or expressed in the past. Where a patient is unable to give valid consent due to not being legally competent the following should be considered: Previous instructions where applicable The patient’s wishes, where known The patient’s best interests

3.10 Confidentiality Patients have the right to expect that any information they disclose is confidential between themselves and their nurses.

• Confidentiality is the cornerstone for building trust between nurses and their •

patients. Nurses have a responsibility to respect the confidentiality of information from their patients or about their patients’ matters and conditions. Nurses should not disclose confidential information unless in line with the law of the country in which they are practising. Where this is the case, nurses must meet the legal requirements for doing so. Nursing Ethics 2008 15 (6)


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L Sasso et al.

3.11 Conflict with moral and ethical beliefs In the event of conflict caused by deep moral, ethical or other beliefs arising from a request for nursing services, a nurse is encouraged to find a solution through dialogue with relevant parties such as the patient, employer, regulatory body or professional organisation.

• Where a nurse is unable to find a solution to the above or should they wish to •

give conscientious objection, they should refer to and be guided by the legal framework in force for the country in which they are practising. In an emergency situation or where there is an imminent risk to the patient’s life, nurses should provide care to the patient regardless of any conflict with their own moral or ethical belief.

3.12 Delegation to and supervision of staff Patients have the right to expect that anyone providing nursing care to them is appropriately trained and competent to provide that care.

• It is the responsibility of the nursing regulatory body to define the scope of delegation.

• Nurses cannot delegate their nursing function to others but may find it necessary to delegate tasks to others such as another nurse, a health worker or support staff.

• When a nurse delegates care the nurse is accountable for ensuring the appropri•

ateness of the delegation and that the person to whom the task is being delegated is competent to undertake the task and has adequate supervision or support. Nurses retain the ultimate accountability should they delegate tasks to another.

3.13 Professional indemnity insurance Patients have the right to expect that any nurse caring for them will be suitably insured in the event of any problems.

• All nurses should subscribe to professional insurance proportionate to the serv-

•

ices provided within the country in which they are practising. This should take account of the impact of damage that could be caused to patients or clients in their care and the risk of the likelihood of this occurring. Where indemnity insurance is not available in the country of practice, the nurse should be able to demonstrate that they have fully informed their patients that they will be practising without insurance and the consequences should any claim for professional negligence be made.

