Professional conduct and ethics

The Code (NMC 2018) contains a series of statements that taken together ‘signify what good practice by nurses, midwives and nursing associates looks like. It puts the interests of patients and service users first, is safe and effective and promotes trust through professionalism’.

Professional regulations, such as the Code (NMC 2018), can provide a template for guiding nurses’ professional conduct. The Code provides a set of standards that nurses should adhere to and which can be monitored and benchmarked; in addition, nurses can be held to account if these standards are not met (Davidson et al 2018, NMC 2018). Morals shift over time and so must the regulatory Code to ensure that it aligns with changes in society. If the regulatory Code that governs nurses’ professional behaviour was not updated, it would simply reflect the moral standards of the past.

Beauchamp and Childress’ (2019) four principles are linked to the Code (NMC 2018) in that they provide a guide for how individual nurses can value their fellow human beings and respect their relationships with others, but above all, protect patients’ rights. Box 1 provides a summary of how the four principles of biomedical ethics are reflected in the Code (NMC 2018).

Autonomy

Autonomy is linked to person-centred care and the principle that patients should be involved in decisions about their treatment. A nurse must respect the patient’s morals and right to autonomy by providing adequate information to enable them to make their own decisions based on their own beliefs and values, even where these differ from those of the nurse. The Code (NMC 2018) reinforces patients’ autonomy by requiring nurses to obtain their consent for any treatment or procedures, with standard 4.2 requiring nurses to ‘make sure that you get properly informed consent and document it before carrying out any action’.

The principle of autonomy is not without limits, as it relies on the patient having capacity in accordance with the Mental Capacity Act 2005, with informed consent being the foundation of treatment decisions (Wagner and Dahnke 2015, Craig et al 2018, Bryant 2020). If the patient lacks capacity, the nurse may have to make decisions in their best interests, with the overall intent of causing the least harm possible (Podgorica et al 2021). However, section 1 of the Mental Capacity Act 2005 promotes autonomy through an initial presumption that an individual has the capacity to make decisions unless it can be demonstrated otherwise. Therefore, nurses should empower patients to participate actively in their own care and make decisions based on their individual circumstances and choices, while seeking to uphold their dignity. To make a fully informed decision, the patient needs to understand the risks, benefits and likelihood of success of any treatment (Lajiness 2021).

Nurses should remember that not all patients wish to make autonomous decisions. Similarly, nurses may find it challenging when patients make decisions that may harm their health, such as refusing to attend hospital appointments. Mortensen et al (2019) stressed that the patient should not be forced to make treatment decisions when they do not want to, or when they do not have the necessary capacity. In such situations, the nurse’s legal duty of care is to ensure the patient has all the information required so they can make a fully informed decision. Moreover, informed consent is designed to protect patients from abuse and exploitation and therefore requires that healthcare professionals disclose any information about treatment accurately and in a way the patient can understand (Schrems 2014). By ensuring that they provide patients with all the necessary information to make treatment decisions, and by not constraining their right to make informed choices, nurses can ensure that patients are treated with respect and that their autonomy is maintained (Bryant 2020).

With regards to children’s healthcare, patient autonomy relies on assessment of ‘Gillick competence’ (in England and Wales), which is used to determine whether a child under the legal age of consent (16 years) is sufficiently mature to make their own decisions and consent to medical treatments (Bryant 2020). Gillick competency involves consideration of a range of factors including, for example, the child’s age, maturity and mental capacity, and their understanding of the issue, including the benefits, disadvantages and potential long-term effects of any treatment and their understanding of alternative options. In Scotland, the Age of Legal Capacity (Scotland) Act 1991 gives medical practitioners authority to make a judgement about the level of understanding of a child regarding consent to a health procedure or treatment (Scottish Government 2023).

Although autonomy is a significant factor in ethical care, if the patient requests a treatment or intervention that contradicts the principle of non-maleficence (do no harm), the nurse should not feel obliged to operate outside the standards of the Code (NMC 2018). Furthermore, the COVID-19 pandemic demonstrated the removal of patient autonomy ‘for the greater good’, where the needs of the individual were sometimes superseded by the interests of the population at large (Vearrier and Henderson 2021).

Advocacy

The theme of advocacy is linked to autonomy and involves the nurse recognising their role as patient advocate (Barlow et al 2018). In this role, the nurse supports the patient’s wishes with regards to their treatment and/or decisions regarding health outcomes, which in turn promotes autonomy. Where a patient is considered to lack capacity to make autonomous decisions – for example, in a person with advanced dementia – they may be reliant on the nurse advocate to assist them in representing their views and beliefs in treatment decision-making processes (Cole et al 2014).

Beneficence

Beneficence involves undertaking ‘good acts’ that benefit others, in this case the patient (Cheraghi et al 2023). Unlike non-maleficence, which involves simply doing no harm, beneficence obliges nurses to actively help others. However, the two principles are often seen as ‘two sides of the same coin’ with beneficence involving acts that benefit others and non-maleficence involving acts that avoid harming others (Cheraghi et al 2023).

Beauchamp and Childress (2019) defined beneficence as having three principles: preventing harm or pain; removing harm or pain; and acting to promote the patient’s best interests, such as providing pain relief. Practising beneficence means that the nurse has a duty to actively promote the patient’s best interests, defend their rights and remove any circumstances or conditions that will cause them harm (Bryant 2020). Nurses therefore have a moral obligation to contribute to the well-being of patients and act in their best interests at all times, as well as considering what is acceptable to them.

The ‘prioritise people’ standard in the Code (NMC 2018) concerns beneficence and nurses’ moral obligation to act for the benefit of their patients (Beauchamp and Childress 2019). Beneficence ensures that nurses consider the patient’s individual needs, while also accepting that what is in one patient’s best interests may not necessarily be in the interests of another. In the author’s opinion, beneficence can be summed up by asking oneself: ‘Does this action or decision benefit the patient?’

Non-maleficence

The ethical principle of non-maleficence dictates that the nurse does not cause harm to another person or patient (Beauchamp and Childress 2019) or at least minimises potential harm (You and Ulrich 2023). As well as avoiding actions that harm oneself or others (Cheraghi et al 2023), non-maleficence also involves a duty to avoid causing pain, suffering and disablement (Bryant 2020) or depriving others of the ‘goods of life’ (Beauchamp and Childress 2019).

Non-maleficence directs nurses to consider all the benefits of treatments and weigh them against the potential risks. Adhering to the principle of non-maleficence involves trying to ensure that the potential benefits of an intervention outweigh the potential harms (Craig et al 2018). Non-maleficence can appear simple to achieve initially; however, it is complicated by the fact that common nursing actions can cause pain and discomfort. For example, inserting a cannula can involve significant discomfort even though it usually has a justifiable clinical purpose. This demonstrates the presumption of ‘compensatory good’, which outweighs the pain and short-term harm caused and is warranted if the patient is to receive a longer-term benefit (Wagner and Dahnke 2015). As such, even routine decisions in nursing, such as whether to change a patient’s dressing, have an ethical basis. While changing a dressing may initially involve pain, it may reduce the risk of infection and sepsis and improve the patient’s outcomes, therefore the nurse must consider all of these eventualities. In this sense, all nursing decisions are ethical in nature (Milliken and Grace 2017).

For nurses, adhering to the Code (NMC 2018) reflects non-maleficence in the ‘practice effectively’ and ‘preserve safety’ standards; the Code makes clear that nurses must preserve the safety of those receiving care and reduce any potential harm as far as possible.

Bryant (2020) emphasised the difference between non-maleficence and beneficence, with non-maleficence dictating that the nurse refrains from harmful action, where beneficence requires positive action. The balance between these two principles is important in all nursing actions, but the basic principle of non-maleficence and ‘do no harm’ should take precedence in the nurse’s decision-making.

Justice

Although justice is often regarded as the fourth ethical principle, it is as important as autonomy, beneficence and non-maleficence. Justice reflects the need for a fair and equal distribution and allocation of healthcare resources in society (Bryant 2020), in which each person is regarded as deserving (Beauchamp and Childress 2019). In the author’s opinion, the main principles within the concept of justice are whether the proposed action is legal, whether it adversely affects the person’s human rights and whether it is fair and balanced.

Injustice can be seen in healthcare when certain treatments are available to some patients and not others, for example through a ‘postcode lottery’ of care provision (Edwards-Maddox et al 2022). Strøm and Engedal (2021) explained that the challenge for healthcare staff is how to offer everyone the same level of care based on the principle of justice while simultaneously taking individuals’ needs into consideration. This challenge is demonstrated by the need to sometimes refuse treatment when other patients are deemed to be of a higher priority and to do this in an ethical manner (Strøm and Engedal 2021). For example, the Institute of Cancer Research (2022) expressed disappointment at a National Institute for Health and Care Excellence decision that it was not cost-effective to recommend the cancer medicine olaparib for men with previously treated, hormone-relapsed metastatic prostate cancer, despite it being available to people with other forms of cancer.

For the nurse, demonstrating justice in their everyday practice can involve remaining impartial and non-judgemental in their relationships with patients, providing resources equitably and treating all patients fairly whatever their ethnicity, socioeconomic status, sexual orientation or physical and/or mental health status (Edwards-Maddox et al 2022). Demonstrating justice is enshrined in the Code (NMC 2018) in the ‘prioritise people’ standard, which states that nurses should ‘act as an advocate for the vulnerable, challenging poor practice and discriminatory attitudes and behaviour relating to their care’ and that they should always ‘respect and uphold people’s human rights’.