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The NMC Code: How professional tenets became weaponised and meaningless

Feb 29, 2024 | Opinion | 0 comments

This is a guest post from Deborah Hughes of The Midwives Haven.

Background to The Code

When I first registered in 1982 there was no Code.  There were some rules that spelled out requirements for the Central Midwives Board, registration, post registration qualifications and updating, a midwife’s duty in relation to analgesia and anaesthesia and record-keeping, and midwives’ uniform.  We were issued with a little black handbook with all this in.  It was simple, short and not open to misinterpretation or abuse.  

In 1983 the Central Midwives Board ceased to exist as much contested legislation brought midwifery together with nursing under one regulator, the United Kingdom Central Council for Nursing and Midwifery (UKCC), the predecessor of the NMC.

In 1986, the UKCC issued a little booklet called “A Midwife’s Code of Practice” and a copy was sent to every registered midwife.  It was 8 pages long and included The Activities of a Midwife (a fantastic list of the scope of a midwife’s practice) as agreed by the International Confederation of Midwives (ICM), the Internation Federation of Gynaecologists and Obstetricians (FIGO) and the World Health organisation (WHO).  It also listed midwifery responsibilities around maintaining competence, medicines, record-keeping, home birth, equipment, birth notification and other related legal responsibilities.  It remained simple, permissive and not open to misinterpretation.  

By 1994, The Midwife’s Code of Practice had grown threefold and was 26 pages long (15 pages in 1989, 19 pages in 1991) but was still factual (based on legal requirements), permissive and still very much a practical guide to fulfilling midwifery responsibilities.  Importantly it still started with the definition and activities of a midwife.

The NMC and its Code

Fast forward to 2002 when the UKCC was replaced by the Nursing and Midwifery Council (NMC).  The NMC issued a very different Code, replacing professional duties and guidance with a treatise of professional moral behaviours.  The oldest copy I have is dated 2008 and it contains 61 professional commandments (each beginning with “You must….”) under 16 headings:

  1. Treat people as individuals
  2. Respect people’s confidentiality
  3. Collaborate with those in your care
  4. Ensure you gain consent
  5. Maintain clear professional boundaries
  6. Share information with your colleagues
  7. Work effectively as part of a team
  8. Delegate effectively
  9. Manage risk
  10. Use the best available evidence
  11. Keep your skills and knowledge up to date
  12. Keep clear and accurate records
  13. Act with integrity
  14. Deal with problems
  15. Be impartial
  16. Uphold the reputation of your professional

It is immediately clear that this is very much open to interpretation, and dependent on adequate staffing levels and a positive workplace culture to be effective.  Whilst emphasising team work, the Code makes no mention of power differentials,  medical hegemony, or the fact that care is rarely given by one individual but by a team of people.  Its “You must….” statements are both mandatory and aspirational, taking no account of the daily reality of many registrants’ working lives.  They are heavily weighted towards clinical registrants’ duties and not the context in which these take place.  More on this later.

The current Code (2023) has expanded to 109 professional commandments under 25 headings:

  1. Treat people as individuals and uphold their dignity 
  2. Listen to people and respond to their preferences and concerns 
  3. Make sure that people’s physical, social and psychological needs are assessed and responded to 
  4. Act in the best interests of people at all times 
  5. Respect people’s right to privacy and confidentiality 
  6. Always practise in line with the best available evidence 
  7. Communicate clearly 
  8. Work co-operatively
  9. Share your skills, knowledge and experience for the benefit of people receiving care and your colleagues
  10. Keep clear and accurate records relevant to your practice 
  11. Be accountable for your decisions to delegate tasks and duties to other people 
  12. Have in place an indemnity arrangement which provides appropriate cover for any practice you take on as a nurse, midwife or nursing associate in the United Kingdom 
  13. Recognise and work within the limits of your competence 
  14. Be open and candid with all service users about all aspects of care and treatment, including when any mistakes or harm have taken place 
  15. Always offer help if an emergency arises in your practice setting or anywhere else 
  16. Act without delay if you believe that there is a risk to patient safety or public protection 
  17. Raise concerns immediately if you believe a person is vulnerable or at risk and needs extra support and protection 
  18. Advise on, prescribe, supply, dispense or administer medicines within the limits of your training and competence, the law, our guidance and other relevant policies, guidance and regulations 
  19. Be aware of, and reduce as far as possible, any potential for harm associated with your practice 
  20. Uphold the reputation of your profession at all times 
  21. Uphold your position as a registered nurse, midwife or nursing associate 
  22. Fulfil all registration requirements 
  23. Cooperate with all investigations and audits 
  24. Respond to any complaints made against you professionally 
  25. Provide leadership to make sure people’s wellbeing is protected and to improve their experiences of the health and care system 

This verbiage contrasts with the Nolan Principles for Conduct in Public Life, the NMC’s and other similar bodies’ Code, which comprises just 7 statements:

1.1 Selflessness -Holders of public office should act solely in terms of the public interest.

1.2 Integrity – Holders of public office must avoid placing themselves under any obligation to people or organisations that might try inappropriately to influence them in their work. They should not act or take decisions in order to gain financial or other material benefits for themselves, their family, or their friends. They must declare and resolve any interests and relationships.

1.3 Objectivity – Holders of public office must act and take decisions impartially, fairly and on merit, using the best evidence and without discrimination or bias.

1.4 Accountability – Holders of public office are accountable to the public for their decisions and actions and must submit themselves to the scrutiny necessary to ensure this.

1.5 Openness – Holders of public office should act and take decisions in an open and transparent manner. Information should not be withheld from the public unless there are clear and lawful reasons for so doing.

1.6 Honesty – Holders of public office should be truthful.

1.7 Leadership – Holders of public office should exhibit these principles in their own behaviour and treat others with respect. They should actively promote and robustly support the principles and challenge poor behaviour wherever it occurs.

The NMC have been caught out breaching this Code on numerous occasions, a favourite being 1.5:  they commonly with-hold evidence prejudicial to their cases from Fitness to Practise panels and thereby fail to act with open-ness, honesty or integrity.  Holding them to account for this is notoriously difficult.  The NMC’s constant failure to respond to complaints about such breaches is itself a breach of 1.4 and 1.7.

The Weaponisation of The Code 

The NMC Code is no longer permissive or guiding,  but has become a tool by which registrants are controlled.  If you read the Code, you realise that, for most midwives and nurses working in the NHS or a busy, short-staffed care home etc., it is impossible to get through a shift without falling short of one or more of these requirements.  For example, 1.4:

“make sure that any treatment, assistance or care for which you are responsible is delivered without undue delay”.

It is common for midwives before the NMC to be accused of such delay and of failing to advocate adequately for a mother when the system has taught the midwife that she has to manage rather than prevent delay.

And how about 16.1?:

“raise and, if necessary, escalate any concerns you may have about patient or public safety, or the level of care people are receiving in your workplace or any other health and care setting and use the channels available to you in line with our guidance and your local working practices”. 

Concerns about patient safety are rife but escalating concerns is one thing, getting effective action entirely another.  It also spells danger for those doing so in a bullying culture.  What about induction rates?  One-to-one care in labour?  Postnatal care and support?  The number and length of antenatal appointments?  The closure of birth centres?  Who hasn’t raised these issues until they are blue in the face?  Or bullied into silence?  Or disciplined for being a perceived trouble maker?  Or given up and left?

Headings 22 to 24 have, I believe, been introduced primarily to enforce the NMC’s authority. Unfortunately and effectively, whether intended or not, they strengthen the hand of toxic employers by preventing registrants from walking away from spurious, blame-shifting or malicious investigations, instigated to head off whistle-blowing, or practices which highlight the shortcomings of those employers.  So the patient-focus of these moral tenets is a code aimed to keep registrants cowed and blameworthy, now supplemented by an injunction to comply with the regulator, a body so damaging to the professions that many midwives feel the moral choice is to come off the register that the NMC maintains.  

The NMC, of course,  justifies anything and everything it does on the basis of protecting the public and promoting public safety, a myth successive governments allow to continue in the face of the now overwhelming evidence that the NMC itself does not act in the best interests of the public or the professions it regulates.  Its hounding (there is no other word for it) of independent midwives alone justifies this view.  Code 12 is nothing more than the NMC taking control of independent practice in all forms and making adherence to conforming with the UK health mono-culture a requirement for registration.

The NMC (and some employers) have weaponised The Code (interesting the capital T, as in The Bible or The Koran).  It is quoted at registrants who make an error, annoy/challenge a colleague, question or refuse to implement dodgy guidelines, try to make changes, try to defend best practice, advocate for a mother’s personal choices and interests,  practise outside the mainstream…….  

For example, a midwife does not have to advocate for a woman who is being given good information and whose choices are respected.  Advocacy comes into play when information, choice and respect are sub-optimal (Code 1 to 4).  They are sub-optimal because someone else isn’t giving good or full information or respecting a choice made.  Advocacy from a midwife (or doula) tends to annoy that person, as it does imply at least some criticism.  It challenges their position to some extent, even when done well.  The Code allows that person to then complain about the advocate’s adherence to Code 8, to “work co-operatively”.  We have seen registrants criticised at the NMC for in effect advocating too much and therefore not being a team player, and advocating too little and therefore falling foul of Code 3 and 4.  

We can all accuse each other of breaching the Code because we can use it to defend our own position and criticise others.  The problem is that it is in reality a tool or weapon for the most powerful – managers, the regulator, bullies.  We have seen managers at the NMC lie under oath – a clear breach of Code 20 and 21 as well as committing perjury.  Registrants have repeatedly attempted to refer these people to the NMC but without success.  The interpretation of The Code lies with the powerful, not the clinical midwife on Bands 5 and 6.

Conclusion

The Code is so aspirational, so generalised and all-encompassing, so lofty that is has become professional and moral clap-trap and a threat to every registrant.  Which is exactly how it is increasingly being used.  We need a proper inclusive professional discussion on this before the NMC brings out the next longer, wordier, more controlling version.  We need to return to something clear and simple like the Nolan Principles and take control of our own professional moral tenets.

Deborah Hughes

Retired but still NMC Registered Midwife, Co-ordinator The Midwives Haven, Breastfeeding Peer Supporter.

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