Nursing as part of health care is a moral endeavour. It is not something we do in isolation from others nor is it something we do to another. It happens through relating with another person so that both parties should feel the benefit from the encounter. Caring is a key value underpinning nursing practice and has a complexity of meaning (Watson & Lea 1997). For the purposes of this chapter the dimension of caring chosen is one that captures the moral ideal of valuing all people as unique persons with basic human rights and who have similar and different needs (Sadler 1997, Watson, 1997 and Watson, 1999). With this in mind it might be useful for you to reflect on stories reported in the media about nurses not caring for patients but neglecting their care. For example a television drama ‘Dad’, shown in the UK in 2005, was based on elderly persons’ experiences of abuse. Other television programmes such as ‘Panorama’ and ‘Dispatches’ also highlight instances of poor care or abuse of vulnerable patients occurring in hospitals.

Consider Case history 4.1:

The standard of conduct expected of professionals when caring for patients and carers is laid down in the ‘Nursing and Midwifery Council Code of professional conduct’. You might well think that in the case described in Case history 4.1 you don’t need a code of ethics to know that treating patients in this neglectful and cruel way is wrong. Those nurses were removed from the register of qualified nurses and midwives maintained by the NMC and, in order to protect the public, are no longer allowed to practise. Becoming a health care professional such as a nurse is about becoming a certain kind of person and nurturing the development of those characteristics associated with being a good nurse. It is about questioning what kind of person you are, what you are trying to achieve as a health care professional and how you are relating to patients/clients and colleagues. It is about trying to better understand the potential that you as a person bring with you either for doing a great deal of good or for doing a great deal of harm. In identifying the characteristics you consider essential for becoming a good nurse you might have included in your list qualities such as honesty, kindness, generosity, justice and fairness, tolerance, compassion and respect for basic human rights in one’s dealings with one another.

The concept of caring as a guide to ethical nursing practice occupied a prominent position in the nursing literature in the 1980s and 1990s with authors such as Benner & Wrubel (1989), Gilligan (1982), Leininger, 1981Leininger, 1984 and Leininger, 1998, Noddings (1984), Tschudin (1992) and Watson (1997). Inherent in nursing practice is the moral sense of caring. Caring is a central value that underpins a special way of being and doing within the nurse–patient relationship that can promote good and enhance patients’ and nurses’ lives. The moral sense of caring is a universal value that guides practice. Feminist moral philosophers such as Held, 1990 and Held, 1993 argue that theories of ethics that emphasize right action will never satisfactorily provide an account of what is actually done in practice. It is one thing to contemplate through reason the weighting of moral principles and to undertake rational calculation when deciding what is the right thing to do. Knowing the right thing to do does not necessarily mean that the nurse is motivated to take what is judged to be right action. The taking of action will depend on the particular qualities, virtues and vices of the nurse’s character. To understand nursing ethics we must try to understand what makes a good nurse, one who is motivated to act ethically. A survey of over 200 nurses, conducted in the USA by Plunkett (1999), found that the most disturbing ethical dilemma reported by these nurses was having to work with colleagues they described as being unethical and impaired. They described their colleagues as lacking in motivation to enhance the health and well-being of their patients and clients. They were seen to condone unethical practice through their inaction; that is, they stood back and did nothing to challenge their colleagues.

The writers from the caring movement highlight particular features of the caring relationship, including ways of relating, the existence of particular conditions within the relationship, specific aims for interacting and the presence of particular caring qualities or characteristics of the caregiver. Virtuous caring qualities and characteristics highlighted include: empathy and concern for others (Gilligan 1982); being non-judgemental and accepting of others, tolerance (Noddings 1984); compassion, competence, confidence, conscience, commitment, nurturance, presence, being supportive, trustworthiness, patience, honesty, humility, courage (Leininger 1981). Through self-actualization and the development of these qualities and characteristics, the nurse will strive for the good of self and the good of others (i.e. for the good in general) (Wagner 2002). Character is the source of ethical nursing practice. Actions spring from a firm and unchangeable virtuous character. For example, the kind nurse will habitually think and act in kind ways as a matter of principle, not just occasionally or when it is to her advantage. A virtue is a trait of character that is manifest in habitual actions that is good for a person to have. In contrast, we tend to avoid people with vices such as those who have no regard for the truth, lack compassion, are cruel, disloyal and intolerant of others who have different values and beliefs.

Sadly, patients and their carers find they cannot always avoid those they would prefer not to have giving them care. An elderly relative, recently hospitalized with a fractured femur, reported to the author that he was full of praise for the care he had received. The one exception was a night nurse who he said had terrified him. He recalled she was cruel with him and seemed to go out of her way to be mean and unhelpful, removing an extra blanket from his bed given to him by another nurse, despite being told he was cold. She had not returned as promised with his drink and medication on two separate occasions despite giving him reassurance that she would. He had spent the next three nights cold in bed, in pain and too frightened to speak out. The other nurses did not challenge the nurse about how she was behaving nor did they care to bring him a blanket, a drink or medication despite knowing his situation. They said they feared her retaliation! Was this cowardice on their part? Did they lack the courage to deal with the situation? What was the nature of their responsibility for the poor standard of care he had received? What was difficult for the elderly relative to understand was that he had witnessed this same nurse being very ‘kind’ to some of the other patients. Whilst he could accept that nurses are human and will not necessarily like all the patients they meet, he could not accept this as sufficient reason for a nurse being so cruel and uncaring and providing poor standards of care. More importantly, he could not understand why the other nurses did not tell the ‘modern matron’ or support him in telling her about this nurse’s behaviour. Surely they knew that what the nurse did was wrong so why were they not motivated to do something to prevent any further abuse? The two Nursing and Midwifery Council guidelines ‘Reporting unfitness to practise: a guide for employers and managers’ (NMC 2004a) and ‘Reporting lack of competence: a guide for employers and managers’ (NMC 2004b) are to support employers and managers in dealing with such incidents reported to them. Your university will also have procedures in place so that students are able to report incidences of unprofessional practice and obtain support in acting morally well in their responses.

You might rightly be wondering what the professional regulatory body has to do with you, a nursing student and not yet registered with the NMC as a nurse. The NMC is highly relevant. It is responsible for setting the standards for your educational programme that leads to initial registration, including the level of entry to the programme. This includes ensuring you can provide evidence that you are of good health and character; this will be continuously monitored by your university throughout your educational programme (NMC 2004c).

Each year the NMC publishes a report on its work in each of its areas of responsibility over the previous year. The ‘Fitness to practise annual report 2003–2004’ (NMC 2004d) described an increase in allegations of misconduct from 1301 in 2002–2003 to 1460 in 2003–2004. The ‘Fitness to practise annual report 2004–2005’ (NMC 2005a) records a slight fall in the figures to 1389 for the period of this report. Under the 1993 NMC ‘Fitness to practise rules’, anyone can make a complaint, but the largest number of complaints are made by employers, usually following disciplinary proceedings at the workplace. The police are also obliged to inform the professional regulatory body of any criminal conviction received by a practitioner on the NMC register. This means that, should you be found guilty of an offence, such as driving while under the influence of drugs or alcohol, in possession of drugs, etc., they will automatically notify the professional statutory body (the NMC); they will also investigate the matter, to decide whether further action needs to be taken.

The NMC also receives notice of complaints directly from patients, members of the public, colleagues, National Care Standards Commission and others. Complaints received before 1 August 2004 (the period of the 2003–2004 and 2004–2005 reports) have been dealt with under the 1993 ‘Fitness to practise’ rules. The procedure would be as follows. A panel of the Preliminary Proceedings Committee would conduct a preliminary inquiry to decide whether or not there was a case to answer, or whether the complaint was sufficiently serious to warrant further investigation. Where there is an allegation that a registered nurse or a midwife or a specialist community public health nurse is unfit to practise for reasons of ill-health, the Preliminary Proceedings Committee then refers it to the Health Committee. During the period of the 2003–2004 report they found that the main reasons for people being referred were associated with alcohol or drug dependence, mental health problems and a smaller number of physical health problems. The Professional Conduct Committee receives referrals that are considered serious and likely to lead to removal from the professional register based on the strength of the evidence available to support the charges. In such cases, the criminal standard of proof is applied. The NMC holds its Professional Conduct Committee hearings in public and in different locations across the country.

The current NMC, established under the Nursing and Midwifery Order 2001 (SI 2002/253), came into being in April 2002. The Order required the NMC to make new rules regarding various aspects of its functions, including the ‘Fitness to practise rules’ in April 2004 (NMC 2004e). All complaints received since 1 August 2004 are now dealt with under the NMC ‘Fitness to practise 2004’ rules.

The importance of competence features more centrally in the NMC ‘Fitness to practise rules’. The NMC sees the purpose of modern regulation as being to enable practitioners rather than to police them. This includes enabling employers to engage in NMC policy development, setting standards, and to make appropriate referrals for fitness to practise investigations. It also includes enabling and supporting registrants to meet their continuing professional development (CPD) standards. Under the new ‘Fitness to practise rules 2004’, the NMC Investigating Committee will refer complaints to the Conduct and Competence Committee or the Health Committee. As a result, cases against practitioners who face lack of competence allegations are now separated from misconduct investigations, and there is a clear set of criteria to be met prior to referral to the Conduct and Competence Committee. New sanctions for lack of competence have been introduced. Any cases brought since August 2004 are dealt with under the 2004 rules. Charges considered by the Conduct and Competencies Committee include neglect of basic care, patient abuse (physical sexual verbal), drug maladministration, poor record-keeping, abuse of colleagues, unsafe clinical practice, drug misappropriation, failure to take action in an emergency. Allegations received after 1 August 2004 and dealt with under the new rules are reported in the NMC ‘Fitness to practise annual report 2004–2005. It is important that you read this report, which is available on the NMC website and which contains some case studies.

Fair and anti-discriminatory nursing practice, recognizing and respecting alternative cultures and beliefs, is constructed around the valuing of the individual as a person with rights, a key value in the ‘NMC Code of professional conduct’. The moral principle of justice as fairness, together with the moral principle of autonomy, are pivotal to current health care practice and central to many of the arguments within medical and nursing ethics. Both these moral principles will provide the ‘anchors’ for you to understand the source of the rules or duties laid down in the ‘NMC Code of professional conduct’. When you are faced with situations in practice and feel confused or lost, then it is a good idea to return to these two principles and to consider how you are applying them in the situation you are facing. It may help you to get back on track if you ask yourself how you respect and recognize an individual’s autonomy. In addition, it is important to reflect and question whether you can demonstrate that you are being just and fair in the way you relate to your patient. If you find yourself treating a patient differently (or unfavourably) compared with your conduct towards other patients, you need to ask yourself what the reason is. Is it a good reason or is it due to some prejudice about age, race, gender, culture? Valuing an individual as a person with rights includes a positive acceptance of difference, arising, for example, from ethnic origin, cultural beliefs, personal attributes, social status, property, birth, health problems, political and personal opinions. An important piece of research conducted by Stockwell in 1972 and republished in 1984 demonstrated that these nurses discriminated negatively against patients who are less able to comply or who require additional care, such as people who have a sight or hearing deficit.