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Understanding the self-declaration of good health and good character

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What are ‘good health’ and ‘good character’? How do they relate to fitness to practise? Student nurses and midwifes need to understand these requirements and their implications

Abstract

Each year student nurses and midwives are asked to self-declare their ‘good health’ and ‘good character’. Does this mean that you need to be in perfect health to become a nurse or midwife? How can you prove your ‘good character’? This article explains what ‘good health’ and ‘good character’ mean for health professionals, what issues can arise and what the consequences can be in terms of fitness to practise.

Citation: Landon-Campbell J, Kenward L (2017) Understanding the self-declaration of good health and good character. Nursing Times [online]; 113: 12, 38-41

Author: Jeanne Landon-Campbell is senior lecturer in nursing; Linda Kenward is principal lecturer in nursing; both at the University of Cumbria.

Introduction

Have you ever signed a document without really thinking about it? Do you always read the fine print? Most of us can probably answer ‘yes’ to the first question and ‘no’ to the second. While in many situations this will not create any problems, in a work context, nurses and midwives are accountable for all their actions, including signing their self-declaration of good health and good character.

Each year, student nurses and midwives are asked by their universities to self-declare that they are in ‘good health’ and have ‘good character’; they are also asked to sign such a self-declaration before joining the Nursing and Midwifery Council (NMC) register. Do they really understand what is meant by ‘good health’ and ‘good character’? Are they fully aware of the implications of making a false declaration, or omitting to let their university know of anything that may prevent them from making the declaration? Are nurse educators diligent in informing students about these matters?

This article provides an overview of ‘good health’, ‘good character’ and how they relate to fitness to practise, referring to official guidance and using two case studies to highlight potential issues.

Self-regulating professions

Good health and good character are fundamental to the values and professional practice of nurses and midwives. Nursing and midwifery are self-regulating professions where practitioners are expected to have significant personal and professional insight. A major aspect of self-regulation is the moral understanding of knowing what is right or important (Department of Health, 2006); this moral insight is an historical requirement dating back to Florence Nightingale and continues to be expected of nurses and midwives today (Clements et al, 2006).

All NMC registrants are required to abide by the NMC rules, standards and professional code of practice (NMC, 2015). When students apply to enter the NMC register at the end of their programme, the registrar at their university will assess whether they are satisfied that each applicant is capable of safe and effective practice; the applicant’s health and character are part of that assessment.

What is ‘good health’?

For nurses and midwives, ‘good health’ means being healthy enough to deliver consistent, safe and effective practice without supervision. While it does not necessarily mean the absence of disability or health condition, nurses and midwives must have the physical and mental ability to practise safely and consistently. This implies that they have the self-awareness to recognise when they can no longer practise safely and consistently, and can admit it to themselves,and disclose it to their employer – and, if necessary, their regulator.

Disclosing health conditions

The assessment of good health relies to a great extent on the disclosure of health conditions by students, who have a statutory duty to disclose health conditions to their university. Prospective students who have serious concerns that a medical condition may have negative implications for their future fitness to train and practise should contact their university at an early stage, even before making a formal application. If appropriate, the university will need to offer them professional advice.

Health conditions and disabilities are not automatically incompatible with registration and the NMC recommends that each person is assessed on an individual basis (NMC, 2016); it does not have a list of acceptable or unacceptable health conditions. When students haved a disability or health condition, their case will be considered on an individual basis to determine whether their fitness to practise is impaired.

Reasonable adjustments

Universities are obliged to make ‘reasonable adjustments’ for students with disabilities, if these adjustments are likely to enable students to achieve safe and effective practice without supervision by the end of the programme. The NMC (2011) states that students with disabilities are entitled to have reasonable adjustments considered in relation to their academic work and practice learning. Reasonable adjustments must be made to enable students to meet the same standards or competencies as other students, but the competencies or standards themselves cannot be adjusted (NMC, 2015). It is good practice to manage each case individually.

The NMC advises universities to “foster an inclusive environment which encourages students to disclose disabilities and health conditions safely”. To ensure that processes are safe and non-discriminatory, university staff should receive disability and equality training, and work with their institution’s disability service (NMC, 2010).

The Equality Act (2010) (Bit.ly/EqualityActProtected) protects people with a wide range of disabilities and health conditions from discrimination. It states that organisations – such as the NMC – have a duty to make “reasonable adjustments” to policies, practices, procedures and physical access to ensure that disabled people are treated fairly.

Cassie’s case

Box 1 describes Cassie, a second-year student whose studies are interrupted by an exacerbation of ulcerative colitis (UC). While the UC should not preclude Cassie from finishing the programme or becoming a nurse, her university will have to make reasonable adjustments, in partnership with Cassie and occupational health if necessary. One possible scenario would be for Cassie to take six to 12 months off to allow her symptoms to abate. Cassie and the university would work together to find the best way to support her on her return; once Cassie had recovered she would be reviewed by occupational health. If deemed fit to resume the programme, she could return to university and would complete a new declaration of good health and character.

Box 1. Cassie’s case

Cassie (not her real name) was diagnosed with ulcerative colitis (UC) in 2003 at the age of 15. At the age of 26, she started a pre-registration adult nursing programme. She had been given the go-ahead by occupational health to undertake these studies, and was fit and well when she started the programme. In her second year, Cassie started to feel unwell. She ended up in hospital with an acute exacerbation of UC. Her hospital stay lasted three weeks, and after discharge she was unable to resume her studies. She has had to suspend her studies until her health improves and she is worried that the UC will stop her from completing the programme and becoming a nurse.

What is ‘good character’?

Good character is as important as good health, as nurses and midwives must be honest and trustworthy. The NMC broadly considers good character as “based on an individual’s conduct, behaviour and attitude”, including conduct in personal life (NMC, 2010). The theory underpinning the notion of good character, however, is hotly debated. A brief review of the literature on the good character of health professionals reveals two underlying perspectives: the dispositional and the situational.

Dispositional perspective

The dispositional perspective gives primacy to the underlying character of an individual in determining behaviour. Sellman views character as a semi-permanent set of traits through which behaviour is demonstrated, and believes it is possible to assess the underlying character by looking at their behaviour (Sellman, 2007). In more recent work, however, he acknowledges situational factors and the notion of good character as a changing disposition (Sellman, 2011).

‘Enactment’ refers to professionals adopting behaviour that is expected in their role, but may not necessarily be indicative of their own character, beliefs and values. Enactment in health professional roles cuts across the assumed causal relationship between values and behaviour, and challenges the use of behaviour to assess character.

Scott argues that healthcare educators should teach role enactment and make explicit any gaps between the character of individuals, as demonstrated by their underlying beliefs, and the professional behaviours they exhibit (Scott, 1995). Students would be expected to consider whether their beliefs and assumptions match the values and behaviours associated with their profession, challenging them and asking themselves how they fit their role.

Situational perspective

The situational perspective emerges from a long philosophical tradition recently embraced by social psychology. It emphasises the primacy of situational over dispositional factors in influencing behaviour. Psychological experiments undertaken by Milgram in the 1960s investigated how far people would go in obeying instructions, even if this involved harming other people; these are still discussed and continue to raise interesting issues. One classic Milgram experiment was replicated in 2010 in a French television game show, when contestants were asked to administer what they believed were increasingly powerful electric shocks to other contestants for failing to answer questions correctly (Chazan, 2010), reigniting the debate on the importance of situational factors in influencing behaviour.

Harman highlights the problematic causal relationship between character and action, but does not challenge the actual existence or nature of character themselves (Harman, 1999). He argues that attempting to explain behaviour in terms of character traits leads to major misunderstandings and incorrect judgments (Harman, 2000). He believes this to be particularly visible in Milgram’s studies, where observers make assumptions about the character of participants rather than the situational aspects of the experiment.

As an alternative to assessing character, Harman suggests giving primacy to the situational aspects of individual behaviour (Harman, 2000). This fits well with the notion of enactment, but challenges the link between good character and morality put forward by the NMC (2010).

After the Stamford prison experiments, in which participants were randomly allocated to be prisoners or guards and some guards inflicted psychological torture on prisoners, and the real-life abuses that took place at Abu Ghraib prison in Iraq, Zimbardo took this further by considering the organisational aspects influencing behaviour (Zimbardo, 2007); this has key implications for nurses trying to deliver care at a time of significantly reduced public spending.

Demonstrating good character

The conflict between dispositionalists such as Sellman (who believe that the nature of individuals’ character explains their behaviour) and situationalists such as Harman (who believe behaviours are shaped by situational factors more than by individual character traits) sets the theoretical context for the assessment of character.

Notwithstanding the theoretical debate, the practical starting point for assessing character is currently the enhanced Disclosure and Barring Service (DBS) check. This is the highest level of scrutiny required for positions that involve caring for, training, supervising or being in sole charge of children or vulnerable adults. All nursing and midwifery students are required to complete an enhanced DBS check before starting their programme.

Character assessment considers any convictions and cautions that are not seen as be compatible with registration and might bring the profession into disrepute. This means that all applicants for initial registration have a duty to declare any pending criminal charges, police cautions and convictions, as well as any findings of impaired fitness to practise by other regulators, professional bodies and educational establishments. Criminal offences, particularly those involving dishonesty, and the use of drugs or alcohol are likely to raise questions about fitness to practise.

A perennial challenge

As with health, a person’s character must be good enough for them to be capable of safe and effective practice without supervision. Good character is determined by proving the absence of incidents that might illustrate ‘poor character’. Herein lies the perennial challenge for educators: the absence of certain behaviours does not necessarily indicate the presence of good character, merely the absence of poor character. However, with the introduction of values-based recruitment in universities, which aims to attract and recruit students whose values and behaviours align with the NHS Constititution, the hope is that good character will be demonstrated and so be capable of being assessed.

Another difficulty lies in demonstrating the importance of this to students. They need to understand that their conduct, both during the training programme and in their personal lives, including on social media, matters for their professional lives. For example, inappropriate social media posts may have a negative impact on their perceived fitness to practise, their ability to complete the programme should they fail to demonstrate good health and character, and the willingness of the university to sign their declaration of good health and good character at the end of the programme.

James’s case

Box 2 describes the case of James, who has just started a nursing programme and is cautioned by the police for drunk and disorderly behaviour.

James would have to disclose the caution to his university as soon as possible. The NMC mandates that students must inform their university immediately if they have been cautioned, charged or found guilty of a criminal offence at any time before or during their studies. James would also have to mention the caution in all future declarations of good health and good character and, once registered, inform any prospective employers. Not disclosing the caution, equating an intention to deceive, may be deemed to not demonstrate good character.

Box 2. James’s case

James (not his real name), aged 21, recently started a nursing programme. During a fresher’s week party at a local nightclub, he had too much to drink and was verbally offensive to bar staff. Staff refuse to serve him but James continued to use offensive language and display aggressive behaviour, so they called the police. James was cautioned by the police for being drunk and disorderly. He is now worried that the caution will be recorded on his enhanced DBS and that he may have to leave the programme.

Fitness to practise

Failure to disclose a change in health condition or a breach of good character constitutes a fitness-to-practise issue and must be investigated by the university. Since January 2009, all universities running nursing or midwifery programmes are required to have a fitness-to-practise panel to consider any health or character issues and ensure the public’s protection at all times. The NMC identifies eight areas that may impair a student’s fitness to practise (NMC, 2012) (Box 3).

Box 3. What can impair students’ fitness to practise?

  • Aggressive, violent or threatening behaviour
  • Cheating or plagiarising
  • Criminal conviction or caution
  • Dishonesty
  • Drug or alcohol misuse
  • Health concerns
  • Persistent inappropriate attitude or behaviour
  • Unprofessional behaviour

Source: Adapted from Nursing and Midwifery Council (2012)

Haycock-Stewart et al (2014) summarise the principles of fitness to practise as:

  • The purpose of fitness-to-practise processes is the protection of the public;
  • The NMC code describes what is required for a nurse to be fit to practise;
  • Fitness to practise is a complex area with an important subjective and value-based quality;
  • Fitness-to-practise processes should be gradual, moving from informal and supportive interventions to a formal hearing that may impose sanctions up to and including the discontinuation of studies;
  • The student is in the process of becoming a professional nurse, and this should be taken into account;
  • Fitness to practise should not be used punitively. While the university’s primary responsibility is to ensure the safety of the public, it also has a responsibility to attend to students’ wellbeing;
  • Fitness-to-practise processes should be regarded as part of the learning process.

Devereux et al (2012) make five points about fitness to practise:

  • Good health and good character are key elements of fitness to practise;
  • Students’ disclosure of health issues or disabilities can be problematic for universities (for example, they can have financial implications if students have to leave the programme);
  • Students lack awareness of the scope and implications of fitness to practise;
  • Students need more information on fitness to practise and should be encouraged to identify and disclose any disability or health issues;
  • An online information zone on the university website can improve students’ knowledge of fitness-to-practise issues.

Conclusion

Students are not always fully conversant with what is meant by good health and good character, nor are they always fully aware of the implications when these requirements are breached. The onus is partly on universities to provide better information to students on good health, good character and fitness to practise. In doing so, they will encourage students to take ownership of the declarations that they sign.

Sources of information

Key points

  • By the end of their studies, student nurses and midwives must be capable of consistent, safe and effective practice without supervision
  • ‘Good health’ does not necessarily mean the absence of disability or health condition
  • ‘Good character’ is currently determined by the absence of incidents indicative of ‘poor character’
  • Failure to disclose a change in health condition or a breach of good character constitutes a fitness-to-practise issue
  • Universities need to encourage students to take ownership of their declarations of good health and good character
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