How is the Nursing Council’s Code of Conduct used when a concern is raised about a nurse?

The Nursing Council of New Zealand measures a nurse's conduct against its Code of Conduct, which sets out principles on respect for health consumers, cultural needs and partnership with Māori and whānau, partnership in care, safe and competent practice, privacy and confidentiality, work with colleagues, honesty and integrity, and public trust in the profession, with numbered standards beneath each. The Council's guidelines on professional boundaries and on social media are read with it. When a concern is raised, the Council's letter, a Professional Conduct Committee's proposed findings and a Tribunal decision each name the principle and the standard that apply and set the record against them. Your response and reflection are stronger when they are written the same way: the standard named, what the record shows, where it matches and where it does not, and what you have done since.

What the Code of Conduct is

The Health Practitioners Competence Assurance Act 2003 (the HPCA Act) gives the Council the function of setting standards of clinical competence, cultural competence and ethical conduct for nurses. The Code of Conduct is the Council's statement of the conduct it expects of every nurse on the register, in every scope of practice and every setting. It is written as principles, each followed by numbered standards that say what the principle requires in practice. The Council states that the Code is used when a concern is raised about a nurse's conduct and that a serious or repeated departure from it can lead to action against registration.

Beside the Code sit the competencies for each scope of practice, which are the measure in a competence review, and the Council's guidelines on professional boundaries and on social media and electronic communication, which set out what the Code requires on those subjects. The Council's guidance on cultural safety, Te Tiriti o Waitangi and Māori health is read with the principle on cultural needs and values.

What each principle requires

• Respect for the dignity and individuality of health consumers. Treating each person with respect, explaining care in a way they understand, and acting on their decisions. A concern about the way a nurse spoke to a patient or a resident, or treated a request, is measured here.
• Respect for cultural needs and values, and partnership with Māori and whānau. Practising in a way that is culturally safe, as the health consumer and whānau define it, and giving effect to Te Tiriti o Waitangi. A concern about communication with whānau, about a cultural need that was not asked about, or about a decision made without the family the patient wanted present, is measured here.
• Partnership with health consumers to promote and protect their well-being. Informed consent, information, advocacy and the right to refuse. The Code of Health and Disability Services Consumers' Rights sets the same expectation from the patient's side and the Health and Disability Commissioner applies it.
• Trust through safe and competent care. Practising within your scope and competence, following the plan of care, medication safety, delegation and direction, recognising deterioration, escalating, and documenting. A medication error, a missed observation, a delegation without direction, or an incomplete record is measured here.
• Privacy and confidentiality. Accessing a record only for a care reason, disclosing information only with authority, and keeping information safe. The Privacy Act 2020 and the Health Information Privacy Code 2020 set the legal duties. A record looked at without a care reason, a disclosure to a family member without authority, or a message sent to the wrong person is measured here.
• Respectful work with colleagues. Communication, handover, raising a concern about a colleague through the proper channel, and conduct toward colleagues. A concern about bullying, a handover that was not given, or a concern about a colleague raised in public rather than through the process, is measured here. A boundary with a colleague is measured here and under the guideline on boundaries, in the same way as a boundary with a patient.
• Honesty and integrity. Accurate records, truthful accounts to an employer and the Council, declaring a conviction or an interest, and not using the nursing relationship for personal gain. A late entry not marked as such, an incident report that does not match the record, or an untrue account to an investigator is measured here, and the Council and the Tribunal treat a departure here as the gravest category.
• Public trust and confidence in the profession. Conduct outside work, social media, a conviction, and fitness to practise. A post in a nurse's own time that identifies a patient or a colleague or that the public would read as unprofessional is measured here and under the social media guideline.

How an allegation is mapped to the Code

1. The conduct is identified. The Council or the Committee states what it understands you did or did not do, in the words of the notification and the record: a medication given without a second check, a record accessed without a care reason, a message to a patient after discharge, a handover not given.
2. The principle is matched. A medication concern to safe and competent care; a record access to privacy; a message to a patient or a colleague to the boundaries guideline and the principle on trust; a post to the social media guideline and public trust.
3. The standard is named. The letter or the proposed findings cite the numbered standard beneath the principle, and the competency where the matter is on the competence route.
4. The record is set against the standard. What the record shows is compared with what the standard requires. Where the record is silent, the Council treats the step as undocumented and asks you to account for it.
5. The gap is weighed. The Council or the Committee decides whether the gap calls for advice, a competence review, conditions or a charge, and it weighs what you have done since and whether you understand the standard now. The guide to what happens after a notification to the Nursing Council describes those routes.

Where the Code is used

In the Council's first assessment. The Council reads the notification and your response against the principle that covers the concern. A response that shows the record meets the standard can close the matter there.

In a competence review. A review under section 36 of the HPCA Act measures your practice against the competencies for your scope, which include professional responsibility and draw on the Code, so a reviewer describes a gap against both. The guide to the Nursing Council competence review and competence programme covers the review and what follows it.

In a Professional Conduct Committee. A Committee appointed under Part 4 of the Act sets out in its proposed findings the conduct and the standards it departed from, and you respond to those findings before it decides. The guide to how a Professional Conduct Committee process runs explains that stage.

In the Tribunal. The Health Practitioners Disciplinary Tribunal decides whether conduct amounts to professional misconduct under the Act and reads the Code and the guidelines as the evidence of what the profession expects. At penalty it weighs whether the nurse has since shown an understanding of them.

Writing your response and reflection against the Code

Write your response under the standards the Council has named. For each one: the standard quoted, what the record shows with the page reference, where the record meets the standard, and where it does not. Where it does not, one plain sentence, then what you have done since and what you have understood. Where you believe the standard was met in a way the notifier did not see, show it from the record. The guide to how to write a response to a Council notification gives the order of the whole document.

Write your reflection the same way, one standard to a paragraph. A reflection that says "I am sorry for the distress this caused the family" describes a feeling. A reflection that says "the Code expects a nurse to work in partnership with whānau; on that shift the patient's partner asked to be present for the conversation and I went ahead without him; I now ask every patient at admission who they want present for care decisions and record it on the care plan, and my charge nurse has reviewed my last twenty admissions with the result attached" describes a change in practice measured against the standard. The guide to showing insight and building a remediation plan covers the difference between regret and insight.

Where remediation fits

A remediation plan reads as evidence when each item answers a standard in the Code. Professionalism for Nurses is written against the Nursing Council's Code of Conduct and covers the principles the Council measures conduct against: respect, partnership, trust, work with colleagues, honesty, public trust, records and the use of social media. Ethics for Nurses covers consent, confidentiality, cultural safety, dual relationships with patients and colleagues, and the reasoning behind the standards. Reflection for Fitness to Practise covers how to write a reflection against a standard so that it reads as insight.

Each course is NZ$200, takes 2 CPD hours, is self-paced with immediate access, and ends with a dated certificate issued by Healthcare Ethics Courses that you can submit to the Council or put in your remediation plan. The remediation courses for nurses facing a Nursing Council investigation are listed on one page, and the Council and Board investigation process explained shows where each course sits in the stages. The guide to what happens after a notification to your Council or Board covers the HPCA Act process the Code is applied within.

Sources and further reading

• Nursing Council of New Zealand: the Code of Conduct, the competencies for each scope of practice, the guidelines on professional boundaries and on social media and electronic communication, and the guidance on cultural safety, Te Tiriti o Waitangi and Māori health.
• Health Practitioners Competence Assurance Act 2003: the Council's standard-setting function, section 36 on competence reviews, and Part 4 on Professional Conduct Committees and the Tribunal.
• Health Practitioners Disciplinary Tribunal: published decisions involving nurses, which show how the Tribunal reads the Code and what it weighs at penalty.
• Health and Disability Commissioner: the Code of Health and Disability Services Consumers' Rights, which the Commissioner applies to the same conduct.

Frequently asked questions

What are the principles of the Nursing Council's Code of Conduct?

The Code is built on principles that require a nurse to respect the dignity and individuality of health consumers, to respect their cultural needs and values and work in partnership with Māori and whānau, to work in partnership with health consumers to promote and protect their well-being, to maintain trust by providing safe and competent care, to respect privacy and confidentiality, to work respectfully with colleagues, to act with honesty and integrity, and to maintain public trust and confidence in the profession. Numbered standards sit beneath each principle.

Is the Code of Conduct used in a competence review as well as a conduct matter?

Yes. A competence review under section 36 of the HPCA Act measures practice against the competencies for your scope, and the competencies include professional responsibility, which draws on the Code. A reviewer who finds a gap in documentation, delegation, communication with whānau or privacy describes it against both the competency and the Code's standard. A conduct matter before a Professional Conduct Committee or the Tribunal is measured against the Code directly, with the guidelines on boundaries and social media read beside it.

What do the Nursing Council's guidelines on professional boundaries say?

That the nurse, not the health consumer, carries the duty to keep the professional relationship within its limits, and that a boundary can be crossed by a personal or sexual relationship, a dual relationship with a patient or a colleague, gifts, personal disclosure, contact outside care and contact on social media. The guideline expects a nurse who sees a boundary at risk to seek advice and step back. A boundary concern is measured against the guideline and the Code's principle on trust.

How do I write a reflection against the Code?

Take the standard the Council has named. Write what it requires in your own words, what the record shows you did, where the two differ, why that happened, what you have changed in your practice to meet the standard, and the evidence that the change has happened: a supervisor's note, an audit result, a dated certificate. One standard, one paragraph. A reflection in that form reads as insight; a reflection that describes how you felt reads as regret, and the Council and the Tribunal distinguish the two.

Can I be found to have breached the Code outside work?

Yes. The Code's principle on maintaining public trust and confidence in the profession covers conduct outside work, and the Council's guideline on social media covers what a nurse posts in their own time. A conviction, a post that identifies a patient or a colleague, or conduct that would lead the public to question a nurse's honesty can be measured against the Code even when no patient was involved. The HPCA Act also requires a practitioner to tell the Council about certain convictions.