- The practice of nursing, midwifery and health visiting
requires the application of knowledge and the
simultaneous exercise of judgement and skill. Practice
takes place in a context of continuing change and
development. Such change and development may result from
advances in treatment and care, from alterations to the
provision of health and social care services, as a result
of changes in local policies and as a result of new
approaches to professional practice. Practice must,
therefore, be sensitive, relevant and responsive to the
needs of individual patients and clients and have the
capacity to adjust, where and when appropriate, to
changing circumstances.
- Education and experience form the foundation on which
nurses, midwives and health visitors exercise judgement
and skill, these, naturally being developed and refined
over time. The range of responsibilities which fall to
individual nurses, midwives and health visitors should be
related to their personal experience, education and
skill. This range of responsibilities is described here
as the "scope of professional practice" and
this paper sets out the Council's principles on which any
adjustment to the scope of professional practice should
be based. The contents of this paper are set out below.
- Just as practice must remain dynamic, sensitive, relevant
and responsive to the changing needs of patients and
clients, so too must education for practice.
Pre-registration education prepares nurses, midwives and
health visitors for safe practice at the point of
registration. The pre-registration curriculum will
continue to change over time to absorb relevant changes
in care as advances are made. Pre-registration education
is therefore, a foundation for professional practice and
a means of equipping nurses, midwives and health visitors
with the necessary knowledge and skills to assume
responsibility as registered practitioners. This
foundation education alone, however, cannot effectively
meet the changing and complex demands of the range of
modern health care. Post-registration education equips
practitioners with additional and more specialist skills
necessary to meet the special needs of patients and
clients. There is a broad range of post-registration
provision and the Council regards adequate and effective
provision of quality education as a pre-requisite of
quality care.
- The act of registration by the Council confers on
individual nurses, midwives and health visitors the legal
right to practice and use the title
"registered". From the point of registration,
each practitioner is subject to the Council's Code of Professional conduct and
accountable for his or her own practice and conduct. The
code provides a statement of the values of the
professions and establishes the framework within which
practitioners practise and conduct themselves. The act of
registration and the expectations stated in the Code are
central to the Council's key role in regulating the
standards of the professions in the interest of patients
and clients and of society as a whole.
- Once registered, each nurse, midwife and health visitor
remains subject to the Code and ultimately accountable to
the Council for his or her actions and omissions. This
position applies regardless of the employment
circumstances and regardless of whether or not
individuals are actively engaged in practice. This
position will only change if the decision is made by the
Council (through clearly established legal processes
related to professional misconduct or unfitness to
practise due to illness to remove a name from the
Council's register. This reflects the central role which
the registration process plays in maintaining standards
in the public interest. On the specific question of
employment of nurses in the personal social services in
general and the residential care sector in particular,
the Council recognises that there are ambiguities. these
are addressed in paragraphs 20 and
21 of this paper.
The code includes a number of explicit
clauses which relate to changes to the scope of practice
in nursing, midwifery and health visiting. These clauses
are: "As a registered nurse, midwife or health
visitor you are personally accountable for your practice
and, in the exercise of your professional accountability
must:
- act always in such a manner as to promote and
safeguard the interests and well being of
patients and clients;
- ensure that no action or omission on your part,
or within your sphere of responsibility, is
detrimental to the interests, condition or safety
of patients and clients;
- maintain and improve your professional knowledge
and competence
- acknowledge any limitations in your knowledge and
competence and decline any duties or
responsibilities unless able to perform them in a
safe and skilled manner;
- The Code, therefore, provides a firm bedrock upon which
decisions about adjustments to the scope of professional
practice can be made. There are, however, important
distinctions relating to the scope of practice in
nursing, midwifery and health visiting. These are
described in the paragraphs that follow the Council's
principles for adjusting the scope of practice. These
principles apply to the practice of nursing, midwifery
and health visiting, addressed later in this paper and to
any application of complementary or alternative or other
therapies by nurses, midwives or health visitors.
- although the practices of nursing, midwifery and health
visiting differ widely, the same principles apply to the
scope of practice in each of these professions. The
following principles are based upon the Council's Code of Professional Conduct and,
in particular, on the emphasis which the Code places upon
knowledge, skill, responsibility and accountability. The
principles which should govern adjustments to the scope
of professional practice are those which follow.
- the registered nurse, midwife or health visitor: 9.1 must
be satisfied that each aspect of practice is directed to
meeting the needs and serving the interests of the
patient or client;
9.2 must endeavour always to
achieve, maintain and develop knowledge, skill and
competence to respond to those needs and interests;
9.3 must honestly acknowledge any limits of personal
knowledge and skill and take steps to remedy any relevant
deficits in order effectively and appropriately to meet
the needs of patients and clients;
9.4 must ensure that any enlargement or adjustment of
the scope of personal professional practice must be
achieved without compromising or fragmenting existing
aspects of professional practice and care and that the
requirements of the Council's Code of Professional
Conduct are satisfied throughout the whole area of
practice;
9.5 must recognise and honour the personal
accountability borne for all aspects of professional
practice and
9.6 must, in serving the interests of patients and
clients and the wider interests of society, avoid any
inappropriate delegation to others which compromises
those interests.
- These principles for practice should enhance trust and
confidence within a health care team and promote further
the important collaborative work between medical and
nursing, midwifery and health visiting practitioners upon
which good practice and care depends.
- The Council recognises that care by registered nurses,
midwives and health visitors is provided in health care,
social care and domestic settings. Patients and clients
require skilled care from registered practitioners and
support staff require direction and supervision from
these same practitioners. These matters are directly
concerned with standards of care. This paper, therefore,
also addresses the matter of the "identified"
practitioner, practice in the personal social services
and residential care sector and support for professional
practice.
- The practice of nursing has traditionally been based on
the premise that pre-registration education equips the
nurse to perform at a certain level and to encompass a
particular range of activities. It is also based on the
premise that any widening of that range and enhancements
of the nurse's practice requires "official"
extension of that role by certification.
- The Council considers that the terms "extended"
or "extending" roles which have been associated
with this system are no longer suitable since they limit,
rather than extend, the parameters of practice. As a
result, many practitioners have been prevented from
fulfilling their potential for the benefit of patients.
The Council also believes that a concentration on
"activities" can detract from the importance of
holistic nursing care. The Council has therefore
determined the principles set out in paragraphs 8 to 10
inclusive to provide the basis for ensuring that practice
remains dynamic and is able readily and appropriately to
adjust to meet changing care needs.
- the reality is that the practice of nursing, and
education for that practice, will continue to be shaped
be developments in care and treatment, and by other
events which influence it. This equally applies to
midwifery and health visiting.
In order to bring
into proper focus the professional responsibility and
consequent accountability of individual practitioners, it
is the Council's principles for practice rather than
certificates for tasks which should form the basis for
adjustments to the scope of practice.
- The position in relation to midwifery practice is also
set out in the Council's Midwife's Code of Practice. This
indicates that it is the individuals midwife's
responsibility to maintain and develop the competence
which she has acquired during her training, recognising
the sphere of practice in which she is deemed to be
equipped to practise with safety and competence. It also
indicates that, while some developments in midwifery
become an essential and integral part of the role of
every midwife (and are subsequently incorporated into
pre-registration education), other developments may
require particular midwives to acquire new skills because
of the particular settings in which they are practising.
The importance of local policies which are in accord with
the Council's policies and standards and the guidelines
issued by the National Boards for Nursing, Midwifery and
Health Visiting is self-evident. The importance of the
midwife practising outside the area of her employing
authority or outside the National Health Service
discussing the full scope of her practice with her
supervisor of midwives is emphasised in the Midwife's
Code of Practice.
- It can be seen from this position that it is accepted by
the Council that some developments may become part of the
role of all midwives and other developments may
become part of the role of some midwives. The Council
believes that the Midwife’s Code of Practice, cited
above, and the Code of Professional
Conduct, together provide key principles to underpin
the scope of midwifery practice. These are now
supplemented by those stated in paragraphs 8 to 10
inclusive of this paper.
- the position of health visiting differs from that of
nursing and midwifery, as there are frequent occasions
when the full contribution of health visitors may not
find expression where it is most needed. There is, for
example, often a concentration on the role of the health
visitor in relation to those in the under five age group
at the expense of other groups in the community who need,
and would benefit from, the special preparation and skill
of health visitors. These circumstances have the effect
of constraining practice and limiting the degree to which
individuals are able to benefit from the knowledge and
skill of health visitors. There is merit in allowing
health visitors, where they judge it to be appropriate,
to use the full range of their skills in response to
needs identified in the pursuit of their health visiting
practice. To single out any aspect of practice would be
unwise but, where health and nursing need is identified,
the health visitor is well placed to determine what
intervention may be necessary and able to draw on both
her nursing and health visiting education.
- The community setting of health visiting practice, the
relationship between numerous agencies and services and
the health visitor's professional relationship with
clients and their families are factors which must be
taken into consideration. The health visitor, in all
aspects of her practice, is subject to the Council's Code of Professional Conduct and
should also satisfy the requirements of paragraphs 8 to
10 inclusive of this paper.
- The Council recognises that, in a growing number of
settings, patients and clients will be in the care of an
"identified" practitioner. The practitioner may
be identified as the primary, associate or sole
practitioner providing nursing, midwifery or health
visiting care. In such roles, individuals assume
responsibility for co-ordinating and supervising the
delivery of care, drawing on the general and special
resources of colleagues where appropriate. Professional
practice naturally involves recognising and accepting
accountability for these matters. The Council expects
that practitioners will recognise the need to provide all
necessary support for colleagues and ensure that practice
is underpinned by the required knowledge and skill. The
Council equally expects that practitioner identified in
one of these ways will be fully prepared for, and
supported, in this key role.
- the Council recognised that the community nursing
services have a duty to provide a nursing service to
those in need of nursing care in the personal social
services and residential care sector. Registered nurses
who are employed in this sector, whether in homes or in
the provision of other services, remain accountable to
the Council and subject to the Council's Code of
Professional Conduct, even if their posts do not require
nursing qualifications. In this regard, as explained in
paragraph 5 of this paper, the position of such nurses is
the same as that of nurses engaged in direct professional
nursing practice.
- The Council requires that registered nurses employed in
such circumstances will use their judgement and
discretion to identify the nursing needs of residents and
others for whom they may have responsibility, and will
comply with any requirements of the Council. The Council
expects that employers will recognise the advantages to
the personal social services and residential care sector
which result from the employment of registered nurses.
- Nurses, midwives and health visitors require support in
their work. In institutional and community settings, a
range of support staff form part of the team. The
development of the health care assistant role is linked
with a form of vocational training. The Council does not
have a direct role in this training, but recognises that
this development has an impact upon aspects of care and
on the practice and standard of nursing, midwifery and
health visiting, for which the Council is responsible.
- The Council's position in relation to support roles is as
follows: 23.1 health care assistants to registered
nurses, midwives and health visitors must work under the
direction and supervision of those registered
practitioners.
23.2 registered nurses, midwives and
health visitors must remain accountable for assessment,
planning and standards of care and for determining the
activity of their support staff;
23.3 health care assistants must not be allowed to
work beyond their level of competence;
23.4 continuity of care and appropriate skill/staff
mix is important, so health care assistants should be
integral members of the caring team;
23.5 standards of care must be safeguarded and the
need for patients and clients, across the spectrum of
health care, to receive skilled professional nursing,
midwifery and health visiting assessment and care must be
recognised as of primary importance;
23.6 health care assistants with the desire and
ability to progress to professional education should be
encouraged to obtain vocational qualifications, some of
which may be approved by the Council as acceptable entry
criteria into programmes of professional education and
23.7 registered nurses, midwives and health visitors
should be involved in these developments so that the
support role can be designed to ensure that professional
skills are used most appropriately for the benefit of
patients and clients.
- The principles set out in paragraphs 8 to 10 inclusive of
this paper should form the basis for any decisions
relating to adjustments to the scope of practice. These
principles should replace the system of certification for
specific tasks. They provide a realistic, effective and
rational approach to adjustments to professional
practice.
- This change has consequences for managers of clinical
practice and professional leaders of nursing, midwifery
and health visiting, who must ensure that local policies
and procedures are based upon the principles set out in
this paper and in the Council's Code of Professional
Conduct. Any local arrangements must ensure that
registered nurses, midwives and health visitors are
assisted to undertake, and are enabled to fulfil, any
suitable adjustments to their scope of practice.
- This statement sets out the Council's position relating
to the Scope of professional practice of the professions
it regulates, to the "identified" practitioner,
to practice in the residential care sector and to support
staff. The Council hopes that this statement, and the
principles which it sets out, will provide a clear
framework for the logical and desirable development of
practice and for the management of practice and care
teams. The framework provides for greater flexibility in
practice and for enhancing the contribution to care of
nurses, midwives and health visitors. Above all, the
framework and principles reflect the personal
responsibility and accountability of individual
practitioners, entrusted by the Council to protect and
improve standards of care.
- Enquiries in respect of this Council paper should be
directed to
Registrar and Chief Executive
United Kingdom Central Council for Nursing, Midwifery and
Health Visiting
23 Portland Place
London
W1N 3AFOriginal text document June 1992
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