Tikanga Whanonga
Code of Conduct

New Code of Conduct for nurses

The Nursing Council has published a new Code of Conduct setting out the standards of behaviour that nurses are expected to uphold in their professional practice.

The Code both advises nurses and tells the public what they can expect of a nurse in terms of the professional role. It also provides a yardstick for evaluating the conduct of nurses.

Most nurses will have already internalised many of its fundamental values and core principles, and treat their patients with respect and build relationships of trust. The Code supports this by reflecting and articulating the values and principles at the heart of competent nursing.

The Council has produced the new Code, to replace the previous (now outdated) Code, in line with its statutory role to protect the health and safety of the public by setting standards of clinical competence, ethical conduct and cultural competence for nurses. Please see the documents in the right-hand downloads box on this page.

The Code is framed around four core values – respect, trust, partnership and integrity – and eight primary principles. It is a practical document that clearly describes the conduct expected of nurses. Without the public's trust and confidence in the profession, nurses cannot fulfil their role effectively. This means that what is personal and what is professional will inevitably overlap. 

Professional development on the Code of Conduct and the Guidelines: Professional Boundaries needs to be completed by end of July 2015.

Please note: The Council requirement to complete professional development on the Code of Conduct and Professional Boundaries is a one off requirement.

Guidelines: Professional Boundaries

The booklet Guidelines: Professional Boundaries discusses the sometimes challenging but critical issue of professional boundaries in more detail. It is designed to be read alongside the Code.

The key message of both documents is that nurses must make the care of patients their first concern. To do this effectively, they must maintain professional boundaries.

Nurses are expected to familiarise themselves with the Code and the Guidelines and incorporate these standards in their practise. Over the next three years, as part of the continuing competence requirements, all nurses will be required to complete professional development on the Code of Conduct and professional boundaries.

A series of interactive presentations is currently being planned around the country to support nurses in meeting this requirement and to foster examination and discussion of the new principles and guidance. Online learning is also being explored as a way of making education available to all nurses, whatever their place or time of work.

Guidelines: social media and electronic communication

Guidelines: Social Media & Electronic Communication is a new guidance document to help nurses think about their use of social media and electronic communications in relation to standards of professional conduct. The new guidelines explore the benefits and pitfalls of social media providing detailed guidance to expand on the principles and standards of behaviour outlined in the new Code of Conduct for nurses, published in the middle of 2012. Of the eight principles in the Code, four directly intersect with the use of social media and electronic communications.

Clear direction is given to nurses. For example in relation to protecting patient privacy, nurses are reminded to be aware that patient emails, answer phone messages and texts may be accessed by others. In relation to maintaining professional boundaries, nurses are advised that boundaries could be breached when health consumers are made ‘friends’ on personal social media websites. The new guidance document is the second in a series of guidelines expanding on the Code and follows the release of guidelines on professional boundaries.

What has become clear is that even when social media is used with good intentions, patient confidentiality and privacy can be inadvertently breached. Patients don’t have to be named to be identifiable and even with the strictest privacy settings, information can forwarded and shared in potentially ever-expanding networks. Similarly deleted content may remain accessible.

The strengths and limitations of using text-messaging to deliver health services

by Michael Thorn, Senior Policy Adviser, Medical Council of New Zealand

The way we communicate is changing all the time. New technologies provide us with new ways of sharing information, and of providing health care.

Text-messaging is not particularly new, but for a significant proportion of the public, particularly for young people in more deprived communities, it has become the primary means of communicating.

Using text-messaging can build bridges to patients who have traditionally been difficult to connect with, improve your relationship with these patients and make it easier, cheaper and more convenient for patients to seek information and advice. It can also lead to new ways of delivering care. Automated systems can be used to send supportive health messages to patients in times of particular need – for example when trying to quit smoking or make other healthy lifestyle changes like being more active or managing weight. Automatic reminders can be sent to patients whose wellbeing is dependent on regular medication and to support people with long-term conditions to self-manage between clinic visits. It can also allow you to swiftly communicate test results and to ask and answer simple questions.

Failure to embrace text-messaging when dealing with some patients may make it harder for you to reach them. On the other hand, this mode of communication also has its limitations, and embracing it in an uncritical manner can result in patient harm or risk privacy breaches.

The Code of Health and Disability Services Consumers’ Rights (the Code) requires providers to ensure that communication between providers and consumers of health care is effective, and that consumers receive the information that is appropriate to their needs, rather than specifying the form of the communication.

Text-messaging can be an unreliable method of communication, with delayed transmission and no ability to determine if a message has been received. Furthermore, text messages can be open to misinterpretation. For this reason you need to be clear to patients that text-messaging should not routinely be used in an emergency, and you should be careful about using it when information provided by the patient indicates that a face-to-face intervention or clinical assessment is needed.

Several cases considered by the Health and Disability Commissioner demonstrate the risks of trying to provide care by means of text message when a greater level of assessment and communication is required. For example, the Commissioner was critical of a counsellor for providing advice via text message to a patient with depression, when the counsellor did not have full information about the patient’s situation, and her attempt to provide fairly complex clinical advice in a single text left that message open to misinterpretation (see Opinion 09HDC01409)*.

In case 11HDC00596 the Commissioner was critical of a midwife communicating with her patient via text message, where the midwife had only recently assumed care for the woman, and had never met or cared for her previously. The woman sent a text to the midwife expressing concern about a lack of foetal movement. The midwife replied by text, but did not attempt to clarify the clinical situation by seeking more information from the patient, and did not follow up to ask whether the woman had felt foetal movement. Although the woman received the text message, it confused her and she did not follow the advice. In this particular context, a greater level of assessment and intervention was warranted. The use of text-messaging did not allow the midwife to properly assess the woman’s level of concern or allow her to be sure that the woman had received the advice and interpreted it as intended. In addition, the text message might have provided the patient with a false assurance that her situation was expected or normal. The Commissioner stated, “Phoning the woman allows the midwife to better assess any concern that has been expressed and determine whether a physical consultation is necessary. At the very least, text message advice should be followed up by a phone call”.

This case demonstrates how important it is that both the practitioner and the patient have the same expectations about when and how to use text messages. The midwife seems to have assumed that the patient would contact her if her symptoms continued or worsened, and it seems likely that the patient assumed that the midwife would have let her know if her reported symptoms were serious.

It is important to have a conversation with a patient before you start sending them information by means of text, primarily to make sure that they are comfortable communicating with you in this way. As part of that conversation you should make clear that if they are worried about their condition, or need urgent care, then they should telephone or attend in person. Likewise, you should make clear that in some circumstances it may not be appropriate for you to communicate urgent or critical information to them by text, and that you may instead phone or arrange an appointment to see them.

Case 11HDC00771 is another case involving midwifery care and provides similar lessons to the cases already discussed, but in this case the Commissioner was also critical of the midwife’s failure to appropriately document her contact with the patient. There are obviously some practical issues with incorporating texts into a patient record. There are some systems that will capture messages automatically, but in their absence transcribing texts into a file can be a time-consuming chore. You needn’t include everything sent or received by text, just what is relevant to the patient’s ongoing care. In particular, you should ensure that you note in the patient record any exchange which contains: relevant clinical information; decisions made about care or treatment; clinical advice provided to patients; a proposed management plan; or a treatment prescribed. Make these notes as soon as possible after the exchange. In other words, record what you would if you were providing information to the patient in a verbal exchange.

The lessons that we have learnt from the use of text-messaging apply just as well to other forms of modern communication such as email and applications such as WhatsApp, and of the next wave of innovation set to change our lives. Embrace technological change, but before taking the leap make sure that you: seek the patient’s consent and set clear boundaries for use with the patient; check assumptions; follow up appropriately if something raises concerns, including to ensure that the patient has received and interpreted the information correctly; use other options, if possible, in an emergency; and make sure that anything that is relevant to the patient’s ongoing care is captured in the patient record. Always aim to communicate effectively with your patient, regardless of the mode of communication utilised.

* The full Opinions of all cases referenced can be found at www.hdc.org.nz. The easiest way to find them is to go to the “Decisions and Case Notes” page and then search using the last four digits of the reference number (eg, search for case 09HDC01409 by entering “1409” into the search box) or alternatively to google the full case reference (eg, google “09HDC01409”).

Developing the Code and Guidelines

The new Code of Conduct and Guidelines were developed through a rigorous process of research, analysis and consultation.  

The Code has not had a substantial review since its initial development in 1994–1995. Since then there have been major changes in society, technology, nursing practice, and the healthcare and legislative environments. These changes needed to be reflected in a new Code.

The project began by reviewing these changes and analysing the former Code of Conduct and competencies for registered nurses against the more recent Codes of Conduct that have been developed by other nursing (UK and Australia), medical (New Zealand and Australia) and midwifery (New Zealand) regulatory bodies. Information from disciplinary investigations and findings was also examined.

The resulting draft (which was sent out for consultation) was significantly different from the former Code. The four original principles were changed and extended to seven, to emphasise the needs and rights of the health consumer and to make more explicit the values of respect and trust as the foundations of ethical relationships and behaviour. More information was included on privacy and confidentiality, health consumer rights and documentation of care. New areas were included – for example, working with others in the health care team, and professional boundaries. 

Developing the guidelines began as a joint project by the Council and the Australian Nursing and Midwifery Council. In the end, however, the Council was not satisfied that this effectively reflected our specific New Zealand context, and decided to develop a separate New Zealand guidance document.

The consultation process

Between November 2011 and February 2012, the Council consulted with nurses, the wider health sector, Māori and consumer organisations.

Three focus groups were held with nurses and health consumers. The Council received 74 submissions on the Code, 40 from organisations and 34 from individuals. Of the 22 submissions received on the Guidelines, 21 were from groups and organisations. The Council’s Māori Advisors also provided feedback.

The majority of submissions were positive about the changes to the Code, seeing it as a relevant and more useful document. Most submissions on the Guidelines were also positive. Two submissions thought the guidance on professional boundaries could have been included in the Code.

There was widespread support for the move to making standards of professional behaviour more explicit. Many suggestions were made about rewording and many of these were incorporated in the final draft, which went to the Council in April 2012. Particular attention was paid to the wording of the principles, to keep them in alignment with the values. 

The most significant change was the addition of a new principle about respecting the cultural needs and values of health consumers. In line with this, a guidance box on working with Māori to improve health outcomes was removed. The content was made more relevant to individual nurses and integrated with the standards under the new principle. Definitions of “culture”, “cultural safety” and “kawa whakaruruhau” now appear in the guidance box on cultural safety. "Culture" is given a broad definition.

Another change to the Code was the removal of a guidance box on social media. This issue is now addressed under the principles of confidentiality and privacy, and professional boundaries. Advice on social media was added to the guidance box on professional boundaries and included in the Guidelines: Professional Boundaries.

Other smaller changes were made to ensure that the standards align with the Code of Health Consumer Rights (1996). The Code of Rights is now included in the Introduction to the Code.

Analysis of Submissions on draft code of conduct

Consultation with young people on the Code of Conduct

A new report & providing valuable insight into the views of young people about what matters to them when receiving nursing care has been released by the Nursing Council and the Office of the Children’s Commissioner. In developing the new Code of Conduct and the Guidelines: Professional Boundaries, the Council sought to consult widely and enlisted the assistance of the Office of the Children’s Commissioner to reach young people. Focus groups were held with a diverse range of young people aged 14–18, some of whom had considerable experience of nursing services.

One of the key findings of the consultation was the importance of the role nurses play in young people’s positive experience of health care.

The young people spoke about the importance of respect, being informed about their health situation, and the need for their information to be kept confidential when receiving health care from nurses.

They would like nurses to build relationships with young people to get the best health outcomes for them. They want to be consulted and included in all decisions to do with their health needs.

Young people stressed the importance of receiving information that is clear, easy to understand, non-judgemental, and given with a good dose of patience and warmth.

A Consultation with Young People on the Nursing Council of New Zealand’s Code of Conduct