Abstract
Introduction
In October 2022, a group of scholars and practitioners came together to discuss some of the most challenging questions relating to ethical care practices. The theme of the symposium was Cultivating Character for Care. The context for the event was a post-pandemic ecology of care which increasingly symbolised care as in ‘crisis’. Challenges in care, regularly reported in the media and in everyday conversations, related to the escalating need for care due to demographic changes; to problems with staff recruitment, retention and professionalism; to under-resourced and overwhelmed health and social care services; and to the impact of climate change. Symposium participants came from a range of disciplinary and professional backgrounds and had lived experiences of engaging with health and social care provision.
This special issue of Nursing Ethics brings together articles from the symposium, along with additional submissions to the journal, which focus on some key questions relating to ethics and care: what do we mean by ‘good character’ in a care context? What is the relationship between ‘character’ and ‘conduct’ in professional life? How do we go about ‘cultivating character’ to increase the likelihood of care recipients, families and communities having a positive care experience? Which virtues/character traits are required by leaders to support the sustainability of ethical care? And what is the role of a regulator in governing the ‘good character’ of a registrant?
In this special issue, we can commit only to starting a conversation which, we hope, will stimulate further scholarship and research which impacts ethical care. We aim to provide a direction of travel to support reflection on the cultivation of character in health and social care into the future. The work of the Jubilee Centre at the University of Birmingham is currently leading the way in supporting, producing and disseminating research, relating to character, which impacts a wide range of practices. 1 It is recommended that the work of the Jubilee team is engaged with and reflected on in relation to nurses’ areas of practice, in particular.
In the paragraphs that follow, we provide an overview – and critique – of ‘good character’ requirements by the Nursing and Midwifery Council (NMC) 2 for registered nurses in the United Kingdom.
Good character and nursing
All health and care professionals are expected to enact high standards both in clinical practice and in their conduct outside of the workplace, for example, if an issue arose in a nurse’s private life that raised questions about their trustworthiness. Nurses who consume alcohol or drugs on duty, who make careless mistakes in practice resulting in harm and/or who are cruel or neglectful towards patients are subject to investigations by the regulator and, in some cases, to criminal or civil proceedings. At the point of registration with the NMC, and periodically thereafter, nurses make declarations to say they are of good character. This is understood as not being subject to criminal proceeding or having breached the terms of the NMC Code. While the NMC does provide guidance on how character is assessed, the emphasis does appear to be on unlawful conduct.
However, making a judgement about a person’s character is nuanced and relies upon moral judgements and not simply avoidance of criminal proceedings. There is also the problem of extrapolating from what are considered to be morally wrong actions to making more general statements about a person’s character. Acknowledging that a person’s conduct has fallen below the standard expected by the regulator or indeed the law does not necessarily allow us to make moral judgements about the person’s character.
Role of the regulator
On entry to the professional register, and at subsequent points of re-registration and revalidation, nurses are required to make a self-declaration of good health and good character. The Higher Education Institution (HEI) is also required to make a declaration of good health and character for each student once they have completed the programme requirements and are eligible for graduation and registration with the NMC.
While separate declarations are made for health and good character, both may be relevant in making judgements about conduct. Nurses called to account by the NMC, because of a failure to meet the requisite standard of practice, may be due to poor conduct, incompetence, a health issue or a combination of all three.
The role of any professional regulator is to protect the public by establishing and maintaining requisite standards of practice. For example, the NMC’s principle responsibilities include the following: • Protecting, promoting and maintaining the health, safety and wellbeing of the public; • Promoting and maintaining public confidence in the professions; • Promoting and maintaining proper professional standards and conduct for members of those professions.
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The NMC Code
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sets the standards of health and character expected of registered nurses, midwives and nursing associates on the register. This includes the expectation that practitioners will, for example: • Keep to and uphold the standards and values set out in the code (20.1); • Act with honesty and integrity at all times, treating people fairly and without discrimination, bullying or harassment (20.2); • Be aware at all time of how your behaviour can affect and influence the behaviour of other people (20.03); • Keep to the laws of the country in which you are practising (20.04).
The Code clearly sets the moral tone in the language it uses and is the key reference document when a practitioner’s conduct is alleged to have not met the expected standard. The NMC also points out that the standards described in the Code are not those of the regulator alone but are based upon what members of the public have expressed as the conduct they expect from health professionals. 4 Nurses are also expected to commit to ‘Uphold the reputation of your profession at all times’ (NMC, 2019, p. 5), implying these standards of conduct are required outside of, as well as during, practice. This is also clear in the title page which describes the Code as standards of practice and behaviour. Hence, the link between practice and behaviour is established and extends beyond clinical competence.
The good character declaration
The NMC produces a guidance document on health and character with the aim of explaining how health and character are assessed. Section 4 of the guidance document begins with a statement about the necessity to inform the NMC about ‘police charges, police cautions, convictions or conditional discharges’.
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The NMC does make a link between good character and safe practice in its definition of good character: your character is such that you are capable of safe and effective practice as a nurse, midwife or nursing associate. This includes consideration of any: • Criminal proceedings • Findings by another regulatory body (including health and social care) • Conduct which may amount to a breach of the requirements of the Code’. (2 p. 14)
While the NMC does appear to see a direct link between good character and safe practice, the key issues explored in this section largely relate to legal issues, such as police charges, cautions, convictions or criminal charges. Approximately eight pages relate to this and approximately one page is given to outlining the factors, which are taken into account, when considering character issues. The NMC do state that ‘the test of whether someone is of good character to be admitted to the register is a high one’ (2 p. 21), but it is difficult to get a sense of what this test actually is.
For the NMC, there seems to be an emphasis on legal assessments and/or definitions of good character. For example, Arkell 5 notes that nurses and midwives are asked to provide evidence of moral character through checking criminal records, and the NMC 2 in its guidance on Health and Character lists criminal proceedings first in the list for making character assessments. This focus on legal judgements seems curious as a ‘not guilty’ decision made in law does not necessarily mean that that there isn’t a moral case to answer particularly where the conduct and/or character is seen as morally reprehensible.
Conclusion
Decisions are made, both in the NMC’s Fitness to Practice processes and on entry to the professional register, regarding a registrants’ conduct and character. However, it is rarely the case that deeper questions are reflected on regarding the meaning and implications of ‘good character’ in everyday practice including, as above, what we mean by ‘good character’ in a care context? One regulatory approach appears to conflate this with ‘not known to be of bad character’ based on the absence of cautions and convictions. The relationship between ‘character’ and ‘conduct’ in professional life is, it seems, too rarely interrogated. That is, the assumption that a nurse whose conduct results in suffering or harm to a patient was previously of ‘good character’ may be unquestioned. Questions regarding the cultivation – and sustainability – of good character in care contexts bring us to a wide-ranging body of research and scholarship relating to ethics education and organisational culture. Solutions are proposed; however, there is no simple solution or panacea, and the specific education and care cultures need to be examined carefully. So, too, discussions relating to specific virtues and character traits and the role of regulators in ‘governing’ good character in the health and social care professions.
The ever evolving and expanding multi-disciplinary and international literature relating to these questions provides much food for thought and can – and should – be engaged with and built on. The contributions of leading philosophers and nurse ethicists in this special issue make a modest contribution to current debates.
Regardless of the evolving state of research and scholarship, which engages with the complexity of cultivating character for care, it is the case that decisions have to be made regarding admission to the professional register and fitness to practice. Whilst the current legal approach holds sway, this needs to be challenged and reflected on by teachers and students in nurse education programme. It needs to be reflected on also in practice settings lest nurses consider that ‘good character’ relates only to legal requirements and patient safety. An ethical approach to care which prioritises ‘good character’ from a virtue ethics approach requires space and time to, for example, ask fundamental questions regarding the meaning and demonstration of specific virtues in care practices.
Most specifically, we recommend that space and time is devoted in the Academy and in care practice contexts, to enable further reflection and enactment of care-related virtues. These may include humility, integrity, courage, compassion and justice. However, unexamined assumptions should not be made regarding virtues that determine conduct and which are aligned to our purpose of enabling and sustaining excellence in health and social care. Further reflection, scholarship and research are required to respond prudently to the interesting and important questions which initiated our symposium conversation.