Moral values have an important influence on the approach that nurses adopt, the way in which they think and act, and consequently the care they deliver¹. Jormsri et al. (2005, p. 586) suggest ‘Morals are an individual’s application of values’. However, Horton et al. (2007) defines morals as the distinction between good and bad or right and wrong and highlights that the terms morals and values are frequently used in conjunction with each other. If moral behaviour then (i.e. acting on the distinction between good and bad, right and wrong, for example) are reflective of our values, then consideration of our values is crucially important.

If our personal values and beliefs influence our thinking, attitudes to people, and situations, and thus also influence our behaviours, this is a significant issue when we consider our professional roles as nurses. Of course it is essential to recognise that we are human beings first and foremost, and secondly we are professionals. However one of our aims as professional nurses is to enhance the nurse-patient caring relationship, as the important means through which we deliver good quality care, while respecting patient’s ethical values and beliefs².

Values can influence our ethical decision-making, and for nurses values influence our perspectives on the delivery of patient care. However, conflict may occur between professional and personal values and present the nurse with complex challenges. For example we may personally feel it is acceptable to tell a lie in certain circumstances and yet in our professional roles honesty is viewed as paramount and the cornerstone of trust in the nurse-patient relationship.³ Understanding professional values is crucial to equipping nurses with the skills and knowledge in dealing with these conflicting values.

Professional values can be viewed as the tools which enable you to become a morally sensitive practitioner. The values of the profession are captured not only in codes of practice such as within the Nursing and Midwifery Council (NMC) code of conduct (2015a) but are also articulated within the English health care context, through the Department of Health publication ‘Compassion in Practice: Nursing, Midwifery and Care Staff: Our Vision and Strategy (DoH 2012)’. This work outlines what is believed to be the six core values that underpin health and social care. These values are branded as the 6cs of caring;

These values are not dissimilar to those personal virtues articulated by Beauchamp and Childress (2013, p. 33–44).

Three of the core values identified within the DoH (2012) guidance are relevant when we consider the case of Joanne. The values that raise some concerns are competence, courage and communication. If communication is central to a trusting and caring relationship with our patients, and an effective and successful relationship with our colleagues, then the cornerstone to all communication needs to that of honesty and integrity. Joanne is presented with the challenge of communicating her situation to staff in both the university and the clinical setting or falsifying the records. Honesty and integrity in this situation would require Joanne to openly acknowledge her failure to complete essential documentation which may result in a delay in completing the assessment. This acknowledgement of her failure also indicates a requirement for Joanne to show courage, as being late with her assignment will have potentially serious implication for her ability to progress through her programme successfully and within the required time frame. Joanne makes the decision to falsify the document – indicating a lack of courage, honesty, and integrity. Having integrity is an essential aspect of good character and is considered to be a desirable quality in the nursing profession. Laabs (2011) describes integrity in terms of being a certain kind of person who is honest and trustworthy, consistently does the right thing, and is able to stand up for what is right despite the consequences.

Following the Francis Inquiry (Francis 2013) there has been an increased emphasis on values within the NHS. The NHS Constitution (DoH 2015) clearly outlines the rights and responsibilities for patients and staff. It identifies its core values as: respect and dignity, quality of care, compassion, improving lives, and working together.

The Francis Inquiry (2013, p. 1399) suggested that the NHS Constitution was a source of values and principles and stated ‘All staff should be required to commit to abiding by its values and principles’. This suggests that NHS staff should have an understanding of the values and principles required for caring for patients. The NMC (2015a) also stipulates the standards (values) required of registered and student practitioners.

When we consider an individual case such as Joanne it is important to remember that the broad ideas of the NHS Constitution (DoH 2015) are reflective of the 6C’s (DoH 2012). Care, Compassion, Competence, Communication, Courage, and Commitment are relevant to every individual case and nurse. Joanne is required to deliver a high quality of nursing care and to demonstrate this through her assessed competence, compassion and commitment. The latter, i.e. commitment, may, on occasion, also demand the personal characteristic of courage – for example in advocating for a patient⁴ or reporting inappropriate or inadequate care. Demonstration of competence to practice underlies the notion of being fit to practice. That is, being deemed worthy of a licence to practice as a nurse that is enshrined in the nurse’s registration, with the national body responsible for nurse registration – in the UK this is the NMC.

Professionalism is the term most frequently used in relation to aspects of behaviour that relate to fitness to practice. Professionalism is defined in a variety of ways, and could include aspects of character and ethical behaviour, as well as skill and competence (Boak et al. 2012). The NMC (2015a) advises that standards of professional behaviour are based on the code of conduct. This informs the practitioner and the student that good character forms the foundation of professionalism. The structures in place to measure the professional standards of nurses are that of ‘fitness to practice’. We therefore may find ourselves asking the question ‘Is professionalism and fitness to practice the same thing’?

Arguably professionalism is concerned with high standards and the best aspired to behaviour. In contrast fitness to practice is concerned with maintaining the minimum standards required for safe practice. Understanding the concept of fitness to practice as well as the relevant processes, however, may inform our understanding of how the regulatory body, in England this is the NMC, view and consider professional conduct and professionalism.

Health and Social Care professionals are often subject to scrutiny regarding their practice and their professional conduct. The lens of that scrutiny is not only fellow professionals but also public concern. This is reflected in investigations of high profile incidents of patient harm, which involve health and social care professionals, such as the Clothier (Beverley Allit) Report (1994) and more recently the Francis Inquiry (2013). The resultant inquiries have recommended the need for effective professional regulation of health and social care professionals and reform across health care professions. Such inquiries have also formed the basis for changes in the regulation and the concept of fitness to practice (FtP).

In the United Kingdom the nursing profession is regulated by the Nursing and Midwifery Council (NMC). This body has both regulatory and statutory powers and came into force in 2002. One of its key functions is regulation. Professional regulation is achieved through a process of fitness to practice (FtP) which is defined by the Nursing and Midwifery Council (NMC) as

Being fit to practice requires a nurse or midwife to have the skills, knowledge, good health and good character to do their job safely and effectively (NMC 2015b, p. 7)

The Nursing and Midwifery Council (NMC) came into force following the introduction of Project 2000 and the significant educational changes within the nursing profession which led to the replacement of its predecessor the United Kingdom Central Council for Nursing, Midwifery and Health (UKCC). The UKCC was set up in 1983 and had the function of maintaining a register of nurses, midwives and health visitors in the UK in addition to management of professional misconduct. The NMC continues with this structure for regulation and provides clear guidance regarding best practice for nurses and midwives. The most recent advice is via the NMC (2015a) Code of Conduct. This guidance includes defining professional standards and what constitutes “fit for practice”. A referral to the NMC is a concern or complaint that is reported to the NMC. The concerns can be raised against the registered practitioner, by an employer, a colleague, or a member of the public. During 2014–2015 the Nursing and Midwifery Council received a total of 5,183 new referrals in comparison to 4,687 new referrals during 2013–2014. Of the 5,183 of the new referrals 1,835 did not progress to panel (NMC 2015b). This means that although concerns were raised these did not warrant escalation to a panel. This decision is made through the process of an investigation that gathers evidence surrounding the concerns raised. However, the figures suggest that 3,338 new referrals were escalated to a panel. The main types of allegations that proceed to panels are categorized into six areas of concerns. These are illustrated in the Table 13.2 which also provides comparisons with 2013–2014 figures.