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'Consider the pillars of practice when making clinical decisions'

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As new students pick up their stethoscopes for the first time around the country some may be wondering what will be expected of them. Keith Bradley-Adams offers some advice for not just these fledgling nurses but for all nurses across the UK.

Nursing is a very broad church. Nurses work in many environments from the community to a range of institutions including, but not exclusively, hospitals, schools and prisons.

Nurses care for persons of all ages, from diverse backgrounds and with all sorts of physical, emotional and psychological needs. However, wherever we work as nurses we each share some fundamental beliefs, values behaviours and principles which underpin our practice. These canons of nursing are transferrable from setting to setting, from patient to patient across your career.

“Nursing care must always be in the patients’ best interests”

Nursing care must always be in the patients’ best interests. Whenever choosing to undertake an intervention, or choosing not to intervene, nurses must ask themselves one simple question: who am I doing this for? 

If the answer is for yourself it is probably wrong; if the answer is for your patient it is probably right. To help you make such decisions there are five basic criteria you must address – these are the pillars of practice, which support all nursing decision-making.


Nursing care must comply with the legislative framework of the country in which you practice. Legislation in healthcare is in place to protect the public by setting minimum standards of care; introducing a framework of criminalisation of inappropriate acts; and providing amends for patients who are wronged.

Compliance with the law of the land is not negotiable and is an over-riding principle as the other pillars of practice cannot ‘trump’ the law 


The care you deliver must uphold the ethical principles of the nursing profession. Ethical decisions are part of the daily practice of nurses worldwide, who have to make difficult choices, not only in regard to care of their patients, but also in terms of the relationships they have with other professionals.

Ethical dilemmas are not new to nursing, Florence Nightingale described the ethical challenges of sharing sensitive information whilst maintaining confidentiality.

Professional standards

Nursing in the UK is regulated by the Nursing and Midwifery Council (NMC). The NMC assert that the Code upholds the minimum standards for the profession and are underpinned by the expectations of nursing placed on the profession by patients and the public.

All nursing care must comply with the code of conduct and where nurses fall short of these professional standards their ability to practice may face sanctions including the ultimate sanction of being removed from the register.


Employers will set terms which they expect nurses to adhere to in order to continue their employment. These will involve basic principles such as attendance, uniform policy, etc. as well as rules and regulations concerned with nursing care.

These policies cannot over-ride the duty of care we owe to our patients, for example your employer cannot introduce a set of guidelines which are unlawful e.g. suggesting that patients should be locked in their rooms or denied access to visitors.

Under the law such measures would be deemed ‘ultra vires’ and as such unlawful. Adhering to policies also provides a level of protection to an employee however.

Where an employee commits a lawful and reasonable act or omission under the direction of their employer which inadvertently causes harm then any claim for reparation may be made against the employer and not the employee under a law known as ‘vicarious liability’. However if the employee is acting outside the instructions or policies and causes harm then he or she as an individual may be deemed responsible.


By providing care which is underpinned by the best available evidence clinical decisions may be made, which are most likely to produce the best outcomes

Evidence-based practice improves the quality of nursing care and reduces variation in delivery and outcomes. By persistently updating their skills and knowledge nurses are able, through this continuing professional development, to keep abreast of evidence and developments and thus provide care of the highest standard. 

In reality each of these principles overlap. For example; imagine you are asked to transfer a patient from their bed to a chair employing a manual handling procedure which you have not been trained to undertake and where you have never seen the device you have been asked to use before.

Could you be at risk of prosecution under the law if it went wrong? Which ethical principles may affect your decision? What does the NMC say about does the law say about preserving safety and practising effectively? How might this affect your duty of care to your patient? Are you covered under vicarious liability if things go wrong? What is the evidence base underpinning this act and what is the evidence base underpinning your decision?

No single act or omission exists in isolation, whenever making clinical decisions nurses must take cognisance of the pillars of practice.

Keith Bradley-Adams is a senior lecturer in mental health nursing at Swansea University

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