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The New Code of Conduct for Italian Nurses

The New Code of Conduct for Italian Nurses 

History is made of events, happenings and recurrences, just like the progress of Italian nurses who, together with the Provincial Colleges and the National Federation of the IPASVI Colleges, have built across the years a great history, full of happenings and events to remember and celebrate. 
In February 1999, an important event happened for Italian nursing: the law n. 42 was enacted, which by abrogating the job description, it indicated and still outlines within the code of conduct one of the elements that, along with the profile and the teaching programmes, defines the nurse’s own scope of practice. 
In October 1999, during the 12th Congress of the National Federation of the IPASVI Colleges, the current Code of Conduct for Italian Nurses was presented and celebrated. 
Ten years later, in February 2009, the 15th Congress of the National Federation of the IPASVI Colleges will present and celebrate the new Code of Conduct for Italian Nurses, the fruit of a widespread and choral commitment of the entire professional community. 
Ten years have passed, full of happenings, facts, goals and the achievement of a mature professional identity, which is now finally clear-cut and well-defined.
Nurses are no longer “health workers” holding a qualifying diploma, but health professionals in charge of nursing care”. They are professionals who, as such and in their own autonomy, take care of individuals and communities by means of the nursing “act”, considered as a complex set of knowledge, skills, activities, competences and responsibilities that nurses have in all the professional areas and in the various healthcare settings. 
This is a significant turning-point for nursing that clearly identifies itself through the “nurse – person/patient” relationship, implying the interaction of two autonomous subjects, reciprocally accountable for the healthcare pact. A part which in itself is valid and operating without the mediation of other professionals and that acquires its own specificity within the therapeutic and clinical-healthcare processes. 

Nurses and their relationship with the person/patient 
The New Code of Conduct sets out the rules of professional conduct and determines the guiding principles that structure the ethical system according to which the nurse–person/patient relationship takes place. It is a relationship made of specific, autonomous and complementary interventions, bearing an intellectual, technical-scientific, managerial, relational and educational nature. 
The terms adopted to define the healthcare interventions contain the interpretative keys of the nature of the nursing act that seeks and pursues, across the different stages of the healthcare process, the appropriateness and pertinence to the primary interest of the person/patient.
Specific” means “own”, that is within the profession, as a patrimony of distinctive nursing competences and experiences.
Autonomous” means “own decision-making” compared with other professionals. 
Intellectual, technical-scientific, managerial, relational and educational nature” means the knowledge of various disciplines underlying the various nursing duties and the inalienability of relationship, education and information. 
Also accountability, linked to autonomy, is seen as a guiding principle of professional practice. Being accountable means that nurses are constantly committed: when they nurse, when they cure and take care of a person, in the respect for the individual’s life, health, freedom and dignity. 
When nurses take decisions falling within their scope of practice, they refer to the principles of equity and justice, in the respect of the ethical, religious and cultural values, as well as the gender and the social status of the person/patient.
Nurses are active subjects, who act directly with the autonomy to decide and with responsibility within a set of values where the respect for the human fundamental rights and the ethical principles of the profession, is an essential condition to favour and pursue health as a fundamental patrimony of the individual and a specific interest of the community. A patrimony to protect across all the professional areas, through prevention, treatment, rehabilitation and palliation.
Nurses develop their knowledge and their professional experience in relation to the person they care for. “Person” and “Patient”: two complementary meanings of a specific conceptualization. 
A person is “a citizen”, someone who has rights and is the protagonist of activities that promote and protect his/her ever-changing state of health.
A patient is “a person” with whom nurses set up a specific, distinctive and professional relationship made of respect, comparison and dialogue, experienced as guiding principles of professional conduct.
The nurses’ primary mission is to take care of their patients in a holistic manner, taking into account their social relations and the surrounding environment. Caring means putting into practice an empathetic and trustworthy relationship, especially when patients go through difficult situations, becoming “even more fragile” and therefore even more needful of help and support. 
In the caring process, nurses direct their actions to achieve the good for their patients, by using the resources available and supporting them in order to achieve the highest possible degree of autonomy in case of disability, disadvantage or fragility.
The relationship embedded in the nurse–patient relationship is full of encounters, exchanges, confidentialities, confrontations and requests. It is possible that during such an intense relationship, misunderstandings, tensions and conflicts may arise due to diverging ethical views, such as, for instance, the conception of life, the meaning of suffering, the idea and perception of one’s own dignity, the freedom to choose various diagnostic, therapeutic and nursing procedures. As well as many other things. 
In the most difficult moments, the principle tools that allow to settle tensions, misunderstandings and conflicts are to listen, respectful confrontation and above all, dialogue. Dialogue has to be maintained even when our patient continues to repeat behaviours and requests that continue to generate ethical contrasts and induce nurses to avail themselves of the “clause of conscience”.(1) 
When nurses resort to the clause of conscience, they manifest their opposition to requests that go against the principles of the profession and their values, for those situations where conscientious objection is not provided for or regulated by the law. 
The intimate and consistent compliance with the principle of the profession and therefore of caring, curing and taking care of a person” in the respect of the individual’s life, health, freedom and dignity, would in any case induce nurses to do their best so that their patient receives - through the intervention of other colleagues or by involving their medical centre - the necessary professional services to ensure the patient’s safety and protect his/her life. 
Acting in this way, nurses protect their patients by never abandoning them and at the same time guarantee their right to express their will. However, nurses can ensure patient safety also through their daily work, so that patients never end up suffering harm or injury due to professional practice. 
Nurses therefore must act with “prudence” to avoid causing “harm” and must resort to the principle of equity when deciding what to allocate for an optimal use of the resources available.

(1)The concept of “clause of conscience” in the healthcare area was defined by the National Committee of Bioethics (CMB) in 2004, within the scope of a declaration regarding the legitimacy of a health worker to resort to conscientious objection in the event of a request to prescribe and administer the so-called “morning-after pill”. In that circumstance, the National Committee of Bioethics identified in the concept of “clause of conscience” a guiding principle informing the ethical conduct of health workers in those cases for which conscientious objection in the true sense of the word is not provided for by the law. In the legal system of the Country, conscientious objection is provided for only in case of voluntary interruption of pregnancy, law 194/78, experiments on animals, law 413/98, and medically assisted procreation, law 40/04.

Nurses and the patient’s will and dignity during healthcare processes and treatment 
For nurses, pursuing the centrality of the patients in the healthcare processes and treatment, means recognizing their dignity at each stage of the disease. It means nurses must do their very best to prevent and counter pain and suffering; be sure that patients receive the treatment they need and provide them empathetic support whatever their clinical conditions may be, until the end of their lives, even by means of palliation and by providing physical, psychological, relational, spiritual and environmental comfort. 
The end of life is something that nurses look upon with respect and sensitivity, putting themselves on the side of the patient, understanding his/her needs and wishes with regard to the services to provide.
Nurses therefore must safeguard the patient’s will to limit interventions that are not proportional to his/her clinical conditions and consistent with his/her expressed conception of the quality of life and counters any kind of nursing or therapeutic obstinacy.
It may also occur that patients are not in the condition to express their will; in such cases nurses take into account what patients have clearly expressed or reported previously, but always firmly reasserting that they shall not perform, or take part in interventions aiming at inducing death, even when this is the will expressed by the patient.
By interiorising the value of “pietas”, nurses must support the patient’s family members or next of kin, especially during the terminal stage of the disease, upon death and cope with bereavement. Nurses also commit themselves to provide information and education about the donation of blood, tissues and organs – understood as a gesture of solidarity – and to support people involved in donating and receiving. 

Nurses, professional relations and their interaction with the healthcare system 
The sphere of professional and inter-professional relations includes all the dynamics inherent in every-day practise among colleagues and other health professionals. 
In this context, the nurse’s approach is based on collaboration, valuing teamwork and the protection of one’s own dignity and that of our colleagues. A nurse’s behaviour must therefore be inspired to respect and solidarity, but also take the responsibility to report to their IPASVI College any abuse or negligence committed by other nurses, or any other action infringing the rules of good profession conduct. 
Nurses must safeguard their personal decorum and their name, as well as the prestige of the profession – practicing with honesty and loyalty – towards colleagues and other health workers. In addition, they should pay attention to the advertisements on nursing, and comply with the instructions given by the IPASVI Colleges. 
Engaging in high quality nursing processes, also means to side with efficient healthcare focusing on the needs of the public. This involves the profession as a whole and becomes particularly important in the light of the nursing development, in terms of scholarship, professional profile and healthcare progress and innovation. 
Knowledge, experience and nursing competences are at the basis of an active role for the entire professional community, as well as for monitoring new nursing centres and the services provided, the proposals for their improvement and adapting the healthcare system to the evolution of the new health demands. 
According to this logic and at various levels of responsibility, nurses contribute to guiding the policies and the developments of the healthcare system, in order to ensure that the patient’s rights are respected, that resources are used in a sensible and appropriate manner and that the professional role is valued.
Therefore, nurses must report any failures or inefficiency to the professionals in charge of the centre they work for or to their patient’s institution when practicing independently. 
The complexity of the healthcare organizations, the great number of operational processes and the numerous correlations between human resources, workloads, contractual rights and duties and the diversification of healthcare demand and of the way to respond, can lead to organisational problems and organizational-healthcare inefficiency. 
Should this happen, consistently with their own mission – in the best interest of the patient – nurses should compensate any failures and inefficiencies that may exceptionally occur in the centre they work for. 
Always consistently with their own mission, nurses should refuse to compensate failures and inefficiencies when these are not the exception, but the rule; when the same problems and failures constantly recur and remain unresolved or when a nurse’s professional mandate is systematically compromised, i.e. due to job downgrading, inappropriate use of professional competence, inability to ensure appropriate healthcare standards due to chronic staffing shortage. 
Always according to this logic, nurses undertake to protect the public with regard to good health and safety, by reporting any abuse of the profession and situations where circumstances or environmental and structural conditions may limit the quality of treatment and care or the dignity of professional practise. 

To conclude…
The New Code of Conduct is an excellent tool that allows to pursue high-quality nursing and to express the way nurses want to commit themselves, through professional practise, in the best interest of single patients and of the public as a whole.
The rules of the Code of Conduct fully set forth the profile of Italian nurses, as it has emerged, on a juridical level and from the point of view of its status and competences, across an extraordinary season of innovation and professional development.
Today’s Italian nurses are in every respect health professionals, to whom any citizen may refer to through a direct relationship, without mediations and with the possibility to seize the great opportunity to receive professional, relevant and personalized nursing care. 
The nurse/patient relationship, relevant and fundamental to fulfil the healthcare requirements in constant and rapid evolution, manifests itself as a significant reality of the healthcare system. A reality capable of giving innovative and competent answers to the increasing demand of differentiated healthcare processes and of combining, systematically and durably, the ability to take charge, structured responses to the needs of the individual and the community, and healthcare continuum.
Moreover, through the rules of their New Code of Conduct, Italian nurses manifest their commitment to their ethical values through what “they are” and their professional values through what “they do” and put them into practice in the best way and in any place. 

Annalisa Silvestro 
President of the National Federation of the IPASVI Colleges 


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11^ Conferenza Nazionale
delle Politiche
della Professione Infermieristica
Firenze 31 maggio 2019

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