Volume 1, Number 1, December 2003 WH Ecitoral 1 Aminath Faiz Bl Message from the Minister of Health 2 Abmed Abdulla I Accountability and Responsibility: important Attributes toNursing 3 Hatoeza lbrahim BJ Observations and Comments on Standards of Nursing Practice in the Maldives 8 Aminath Faiz Bll Providing an Environment Conducive for the Recovery of the Hospitalized Children: A Literature Review 13 Asiya Ibrahim Hi AIDS Stigma: Key note Addross Presented at the Nurse Conference on the Intemational Nurses Day, 12 May 2003 17 thusana Ahmed I Fational Drug Therapy in Pregnancy & Lactation 19 Dr Sajid Patel Sickle Cell Thalassaemia in a Family: A Cinical Case Finding 26 Ibrahim Mustafa =ae=z Faculty of Health Sciences stinmtsw — Maldives College of Higher EducationEditorial Board Aminath Faiz, Editor Aminath Riyaz, Associate Editor Asiya Ibrahim, Associate Editor Dr. Ahmed Razee, Medicine Aishath Shaheen, Public Health Aishath Shabana, Information Technology Hafeeza brahim, Nursing 8.8, Mageswaran, Pharmacology Mariyam Sihara, Medical Laboratory Technology Mariya Warujeena, Student Association ‘Special Editorial Assistance Margaret MeMilan Vicki Parker Dr. Hassan Hameed Mohamed Ismail Fults Husnia Razee Maldives Journal of Health Scionces, volt, issue 1, 2003Important Attrbutes to Nursing (pp.3-7) Holistic nursing involves direct inerventions wth human beings and renders it necessary to incorporate ethical considerations in patient care. Thus the need for two important attributes, responsibilty ‘and accountability to be practiced in nursing in order that patients receive quality care. The main responsibiltias of nurses are to recognize the unique nature of the ‘care-giving role and identify that hisher role is caring and not only curing, With the establishment of the Maldives Nursing Coun in 1999, itis hoped that nurses in the Maldives wil find that their responsibilties and expected standards of practice are mare distinct. Some of the functions ot ‘Nursing Councils are to monitor and take action for breach of responsibilities. In addition such bodies also safe guard practice, give guidance, security and support for exercising nurses’ rights, Observations and Comments on ‘Standards of Nursing Practice in the Maldives (pp8-12) Standards of practice is one of the professional issues in nursing in the Maldives. itis imperative that Nursing practice is monitored and Quided by a regulatory body, Until recently there has been no regulatory body to guide nursing Practice. In Soptember 1989 a Maldivian Nurses Council (MNC) has been established. One of its objectives is to establish/maintain, ‘and improve standards of nursing/midwilery education and practice. With the establishment of the MNC a regulatory body now exists to ensure that nursing practice is within a code of professional conduct. Ths anticle addresses the issues regarding standard of practice and the impact of a regulatory body on nursing. A. literature review will discuss regulations, code of professional conduct, accountability, continuing education and nursing competence, Providing an Environment Conducive For the Recovery of the Hospitalized Children: A Literature Review (pp.13-16) Providing an environment ‘conducive for the recovery of the hospitalized children needs to be ‘addressed as itis also considered as one of the principles of fundamental paediatric nursing Practice. Hence a literature review was conducted wit the aim to review and analyse aspects in providing a conducive environment {or the recovery of the sick children. ‘The issues which mainly emerged tom the literature included psychological issues related to hospitalization, effects and influences of physical environment ‘on children and their parents, importance of incorporating play, preparation for hospitalization for the psychological well-being and the concept of family-centered! care inproviding holistic care. Rational Drug Therapy in Pregnancy & Lactation (pp.19-25) Drugs can have harmful effects on the mother and fetus al ary time during the pregnancy. Use of ‘medications during pregnancy requires a careful assessment of tisks and benefits for hem. During the first timester teratogenic effects are frequent. There is higher risk {rom third to eleventh week of gestation, During the second and third ttimester drugs may affect the {growth and functional development of the fetus or have toxic effects on the fetal tissues, Drugs administered shortly before term or during labour may have adverse effects on mother or on noonate, ‘The FDA has established five categories (A,B,C, D, X) which indicate the potency of a systemically absorbed drug causing bith detects. These categories are indicative of the level of effects to the fetus. The category X includes the drugs for which there is enough data to implicate thei teratogenicity and the risk versus benefit ratio. does not support the use of the rug and hence these are contraindicated in pregnancy, A few drugs present variable risk to the fetus depending on the time and duration of their use, The use of ‘drugs in pregnancy is complicated by their potential harmful effects on the growing fetus, altered maternal physiology and difficulties of research in this field. Because experience with many drugs in pregnancy is severely limited it should be assumed that all drugs fare harmiul unti sufficient data exist to indicate otherwise, Social drugs (alcohol and cigarette smoking) are definitely harrnful & their use should bbe discouraged ‘The stage of gestation influences the effects of drugs on the fetus. It 's convenient to divi pregnancy in three stages: pre implantation (2 weeks from fertiization), the orgenogenesis\embryonic stage (hd to 8th week) and the fetogenic stage (9th week tl term), Animal studies suggest that interferences wilh the fetus before 2 weeks of gestation cause no harm if pregnancy continues (James, Steer, & Weigner 2000), ‘Sicle Cell Thalassaemia in a Family: clinical case finding (pp.26-30) A larnly case report of sickle thalassaemia syndrome shows, diagnostic difficulties, such as to differentiate sickle coll thalassaemia from sickle cell disease due to wide range of similar clinical picture. The diagnosis of this syndrome could bbe missed o1 confused with siokle cell disease, and this is important to ‘a country like Maldives, where prevalence of haemogiobinopathies is very high. Around 18% of Maldivian population carries the ‘gene for beta thalassaemia tal The methodology used includes, Hb electrophoresis by cellulose acetate al alkaline pH and quantity ‘of Hb was done by HPLC, Hematological parameters were oblained by ERMA PC 170 Parlcle counter. The findings are suggestive of a thalassaemia trait {and itis also consistent with sickle cell anaemia. In this report Thalassaeria is not contitmed but recommended to do ONA analysis {0 We out alpha thalassaemia, because the homatological findings of family gives picture of alpha thalassaemia, ii Maldives Journal of Health Sciences, vol.t, issue 1, 2003Editorial Aminath Faiz ‘The Maldives Journal of Health Sciences aims to publish up-to- date health information annually to enrich the awareness of health professionals. The journal intends to publish articles of scholarly and research origin from all areas of health sciences. This is an important step in narrowing the inforrnation gap by the dissemination and sharing of research findings, The journal shal also provide information about important events and programs occurring within the health care system, We have long wanted to develop a journal where we Could publish the results of our research and scholarly work Most research work are not available to the general reader. Maldives Journal of Health Sciences encourages research and jooks forward to publishing articles, essays, short write-ups, case reports and book reviews. Maldives Journel of Health Sciences, vol, ‘The journal has an Advisory Board whose expertise embraces disciplines in the areas of medical science and health care. All material will undergo a double biind review by experts from the relevant areas before publication. Inthis fist issue, "Rational Drug Therapy in Pregnancy and Lactation” presents information fon some important drugs and their effects on pregnancy. It has implications not only for those prescribing but also to those taking care of the pregnant woman, “Providing an Environment Conducive for the Recovery of Hospitalized Children” is about ‘oteating the right environment {or hospitalized children, “Accountability and Responsibility” is an article on {wo important attributes of nursing, Thalassaemia major is a significant problem in the Maldives. "Sickle Cell Thalassaemia in a Farry’ addresses the complexity of differentiating sickle cell thalassaemia from sickle cell disease To develop and maintain good standards of practice we must identify errors and search for solutions, “Observations and ‘Comments on Standards of Nursing Practice in The Maldives” is about the implication of regulations on nursing practice, dealing with cultural differences, ‘communication and other issues intelation to nursing in the Maldives | appreciate the ‘encouragement from the MOH and the Rector of the Maldives College of Higher Education for ‘our work, | thank Professor Margaret McMillan and Vicki Parker of the University of Newcastle, Australia tor their encouragement and advice in the development ofthis journal = issue 1, 2003 1Message from the Minister of Health — Ahmed Abdulla | would like to congratulate the Faculty of Health Sciences for Publishing the Maldives Journal of Health Sciences. My sincere thanks and good wishes go to the Faculty’s able Dean Mrs. ‘Aminath Faiz and her dedicated team, Itis a very important initiative taken by the Faculty in this age of information and ‘communication. We Maldivians are very fortunate that our Goverment is investing heavily on human development. Our economic and social progress has been tremendous due to our Govemment's decisive Policies. We are extremely grateful to President Maumoon Abdul Gayoom for spearheading our country's development and progress, resulting in far reaching strides inall spheres of lf. The Government has attached great importance to science and technology in development. Science and technological progress has great significance in the modernization and achievement of development goals, Therefore, itis very heartening that our institutes of training are giving greater importance to the leaming and imparting of scientific. knowledge in many areas. itis particularly relevant that the county's leading health personnel training institute - Faculty of Health Sciences ‘embrace this vital development In order to achieve optimal results in the fields of scientific learning and application of this knowledge for the health services of the country, Maldives Journal of Health Sciences is a big step forward, We ate very proud of the Faculty's pivotal contribution in training a large number of personnel for the health sector ‘The quality of the Faculty’s training has improved remarkably. The Faculty has made many achievements by training quality health personnel and hence we are very pleased for the Faculty's reputation as an institute of quail and excellence. Its very important for the Faculty to have the necessary means and facilities to provide information and knowledge to teachers and students. Information and communication technology has made it possible to access knowiedge to people in all comers of the world and all walks of ile, Access to scientific knowledge and research is available in a large amount What is very crucial is to choose ‘900d and reliable information and credible research, Therefore, there should be a reliable way to determine and select the best information and knowledge for you, Otherwise, there can be many problems and confusions that will be harmitul for the process of leaming, | feel that the Maldives Journal of Health Sciences ‘would be a valuable source to bring reliable information for student's scientific leaning Itis also essential that students and even teachers always try to reach the bountiful horizons of knowledge. The knowledge acquired in every ‘course of study must be refreshed and updated to keep abreast with the fast development and flow of knowledge and sciences | hope that the stuxdents at the Faculty and all those serving in the health sector would greatly benefit from the Journal also hope that our dedicated and knowledgeable health professionals would contribute to enrich the Journal. # 2 Maldives Journal of Health Sciences, vol.1, issue 1, 2003,Scholarly Articles Accountability and Responsibility: Important Attributes to Nursing Hafeeza Ibrahim, my, an, aw Lecturer, Faculty of Health Sciences, Male’, Republic of Maldives Abstract Holistic nursing involves direct interventions with human beings and renders it necessaty to incorporate ethical considerations in patient care Thus the need for two important attributes, responsibilty and accountability to be practiced in nursing in ofder that patients receive qualily care. The main responsibilities of nurses are to recognize the unique nature of the care-giving role and identify that his/her role is caring and not only curing. With the establishment of the Maidives Nursing Council in 1999, itis hoped that nurses in the Maldives will tind that their responsibilities and expected standards of practice are more distinct, Some of the functions of Nursing Councils are to ‘monitor and take action for breach of responsibilities, In addition such bodies also safe guard practice, give guidance, security and support for exercising nurses’ rights. Keywords responsibilily, accountability, code of ethios Introduction In this article, the author illuminates the importance of accountability and responsibility in nursing practice and highlights the significance it has for health care in the Maldives. The iterature review that follows explores the different views of various nursing authors on this aspect of ethical practice. The article concludes with a discussion of the relevance of these views to our own context inthe Makdives. Responsibility and accountability are not the same but they go hand in hand. While responsibilty is making independent decisions, accountabilty is being answerable to the decisions that are made (The Concise Oxford English Dictionary of Current English, 1990), The nursing/caring role involves direct interventions with human beings and this requires acting ethically and responsibly and being answerable all actions. Responsibily is an important element in caring because it affects rapport and development of trust needed in the nurse patient ‘lationship, Consequently it affects the quality of pationt care ‘The nurse is a professional practitioner, accountable to her patients and also to her employer for her actions, and bearing a moral as ‘well as an organizational responsibilty for her Practice (Wilmot, 1992), Our main conoem as nurses is the caring relationship between the nurse and patient. According to de Casterle, Gastmans and Roelens (1998), this personal bond Calls for nurses to be responsible for those in their care, Fry (1989, cited in Warelow, 1996} suggests that a caring relationship is not possible iit fails to include certain prescriptive qualities such as empathy and consideration of the welfare of others as its foundation. Significance of accountability and responsibilty to nursing Nursing is about caring and holistic nursing involves being responsible for the well being of our patients, Our numerous responsibilities include iving safe and holistic care and advocating for the patient: This includes facilitating autonomy, the patients’ right to independent decision-making to informed consent and above all not doing any harm, the ethical rule of beneficence (Mitchell & Lovat, 1993). These roles need to reflect the moral ‘and ethical values that our profession and our ‘culture are based upon. In the Maldives, the culture and religion of the people influence the issue of for example, informed consent. tis often ‘seen that patients do not receive adequate information about their conditions or of Maldives Journal of Health Sciences, vol.1, issue 1, 2003 aprocedures done on them. Itis accepted practice for a guardian to give consent on behalf of the patient Direct interventions on human beings for ‘example, invasive procedures may have major impacts on peoples’ ives and they sometimes determine fife and death. Therefore, these actions require ethical considerations, making all health care workers accountable for their actions. Consequently, nurses are faced with ethical lemmas in their daily lives and need the support of governing bodies such as the Maldivian Nursing Council (MNC), A number of peak nursing bodies ‘such as the International Council for Nurses (ICN), the United Kingdom Central Nursing Council (UKCO) have developed Codes of Ethics that has been used as a guide to nurses’ actions, Nurses, ‘also depend on this guide to make judgments ‘when faced with challenging situations involving patients’ rights and nurses’ rights and responsibiities. Similarly these governing bodies are Important sources of support while carrying ‘out the numerous respons\blties that are required inher role as a nurse (kistenwizon, 1390). For instance the distinction between the nurses! role and the doctors role in gaining informed consent, While itis the nurses’ duty to ensure that patients are adequately informed, itis the doctors’ responsibilty to explain the potential benetit or harm that may result from the procedure. From the writers view, nursing is claimed to be a profession, which requires responsible, independent decision-making. As nurses move away from the medical model, to continue to develop their own professional concepts and further define their role, further responsibilities are recognized. Providing holistic nursing care requires better understanding of the pationt, degper knowledge and insight to see the patient {rom a holistic perspective. A patient should not be Viewed as a case of appendicitis or asthma, but a human being with feelings and values. He /she may be now suffering from an illness but may have been well before, They may have left behind, possibly a family and given up hisfier job temporarily only to be claimed as ‘hospital property, Hence, the nurses! role involves more than carrying out doctors’ orders. lis the nurse's responsibilty to recognize the unique nature in the ccare-giving role and identity that his/her role is. caring and not only curing. Gone are the days when nurses followed doctors with a basin and towel! Nurses of the 21st century will not, hopefully let this continue. Nurses need motivation and enthusiasm to promote and further develop the profession and maintain its image of the caring role. This is necessary for recognition, to develop standards and improve training. in some developed countries, nurse practitioners are filing the role previously performed by general practitioners, in order to do this, nurses need to further thelr knowledge and keep up-to-date with the recent advances in patient care and patients! rights Literature review According to The Concise Oxford English Dictionary (1990) - accountable means responsible, required to account for en's own conduct. Responsibility is defined as the state or fact of being responsible er authority, the ability to ‘ot independently and make decisions, According to Pennets (14¥/, p.162) "accountability is the requirement that each nurse is answerable and responsible for the outcome of his or her professional actions.” Responsibility and accountability are seen as a wey of life for expert nurses. However, junior or student nurses may need advice to guide their practice. Even expert nurses ned backing and guidance in certain situations of moral and ethical dilemmas and this is where the Code of Ethics, ICN or the Code of Ethics, UKCC come in, The ICN Code for nurses is accepted and followed throughout the world Ahtip:fonw.ion.chvabouticn him). Nurses’ numerous responsibilities include advocacy for her patients, and The UKCC views advocacy as protection and promoting the safety of patients. This includes patients’ rights, ‘autonomy and informed decision making (Willard, 1996). In this country, it is important to note that the educational background of patients must be considered while gaining consent as the patient ‘may misinterpret unfamiliar issues or terminology, Similarly nurses’ understanding of concepts such as advocacy need to be considered as misunderstandings may result in unsafe or Unethical practice. Hence, it could be argued that Not all nurses are competent to carry oul their 4 Maldives Journal of Health Sciences, volt, ssue 1, 2003functions in a responsible manner. When a nurse is competent in taking responsibly for the care that the nurse gives to his/her patients, his/ner actions can be termed as ethical endeavours (de Casterie et al. 1998). Nurses’ responsiblity does not end with patient care. Hissher responsibility is also towards the profession and includes promoting and maintaining professional standards (Thompson et al, 1994). Therefore nurses need knowledge and competency along with awareness of the professional codes of practice to safeguard their actions in what is now a multifaceted role, Nursing Iterature suggests that the Code of Ethics is stil the ‘corner stone’ of clinical nursing practice (Esterhuizen, 1996), However, the code should not be viewed as a solution to all problems, but considered to be a guide to safe and effective patient care. Inthe developed world, nurses have taken on an added responsibilty, which is prescribing even though froma limited pharmacopoeia of ‘medicines, This calls for a greater degree of responsibilty in decision making and accountabiily for those decisions (Luker et al, 1998). Although this new role may be helpful to patients and nurses in the developed wortd, it ‘could create problems for nurses in the developing countries. Nurses’ new role in prescribing may be viewed by doctors as threatening to the latter's profession and may even, wrongly believe that prescribing is beyond the soope of nursing ‘nthe nursing literature, responsibility and accountabilly has been discussed with autonomous nursing practice, dilemma, morality, ethics and codes of professional practice. In addition, maryy authors agree that competence, advocacy, patient's rights and patient safety cannot be discussed without the former concepts, (Esterhuizen, 1996, Pennels 1997, Willard, 1996 & Romig, 1998). This suggests the necessity for nurses to demonstrate these attributes in thelr practice. Responsibility is linked with freedom, as described by Holden (1991), because real responsibilty is connected to self-discipline and selt-estraint. According to the above author, possessing these two conditions are prerequisites for treedom to choose to do otherwise, The responsibilities of a nutse seem endless and this ccan be daunting to junior nurses. Holden (1991) states that nurses need effective emotional and self management to prevent 'bum out' by having clear understandings of limits and extents to one's responsibilities. When discussing the nurses" responsibilities further away from us, it is pertinent to examine that in our own setting. Significance to Maldivian Nurses Nursing in the Maldives is no longer just an honoured vocation but a profession in its own right, Until now much of the professional accountability rested with the moral integrity of individuals. However, with the establishment of the Maldives Nursing Council in1999, nurses in the Maldives, like our international counterparts will be supported to attain a high degree of professional accountability, among the other attributes, to claim that nursing is @ profession For nurses to be accountable in a cout of law we need good documentation of our nursing actions, Careful recording and prompt reporting should be routinely used, despite the distractions while carrying out a task and lack of time avaliable together with the many administrative chores of nurses every day life on the wards, According to Ehrenburg et al. (1996) the patient record is an important too! to ensure sataty, continuity and quality of care. Moreover, with the advancement of technology more and more hospitals have computerized their records. This adds to the responsibilty of nurses to upgrade their skills in this regard and promote the development of nursing practice and research, ‘With the employment of international staff and considering the different taining institutes from which our graduates received their training, itis imperative that standards of care are established in ordar to ensure a higher level of care provision. Accountability requires knowledge and ‘competency (Pennels, 1997). Thus it holds implications for us as nurse tutors to give students ‘adequate training and for clinical staff and supervisors to understand the liability that they have for actions of students, According to the same author, student nurses cannot be held responsible for their actions until they have successtully completed their training, However, i needs to be pointed out that students do have a certain degree of responsibilty and that they are Maldives Journal of Health Sciences, vol.1, Issue 1, 2003 5answerable to their supervisors and repeated misconduct or negligent actions will be cause for ‘action at the level of the training institute Nurses should be learning continuously and upgrading their knowledge and skills, Senior nurses have a role in teaching junior nurses the ‘appropriate attitudes apart from the correct skills and imparting accurate knowledge. Furthermore, nurses need to educate themselves to understand present technology, nursing research and modern changes to practice, Nurses should be faciitated in finding information and given access to continuing education. It may be in the form of procedure review meetings or case presentations. {tis usoful to have access to the Interet and library and thase facilities should be used more for productive and educational purposes. itis not the duty of every nurse to initiate research projects, But each nurse can contribute to research by recording accurate and clear findings on patient's records and being generally aware of differences in practice. For exampie, considering how one method of treatment is different from another or listen to patients’ concems that may contain valuable data for recording and later researching. While these theories are meaningful and lagicatit is necessary to see how relevant they are to our practioe Application to clinical practice With the advancement of technology, more and more invasive procedures are being cartiad oul. ‘This requires greater accountability on the part of health professionals. The responsibilities of nurse educators in clinical settings and classrooms have increased due to the growing need for improverent in the quality of teaching and leaming The nature of the caring role involves nurses being in close ‘encounters’ with patients, thereby increasing the risk of breaching patients’ rights. ‘During such times the Code of Ethics is the ‘guiding light. Therefore, even though the actions that can be taken by bodies like the Maldives Nursing Council may be seen as threatening, the ‘monitoring, support and guidance offered by them are invaluable in protecting the rights of nurses With the increase in the number of post ‘graduate nurses in the country, there is reason to booliove that these nurses wil initiate nursing research in the future. Research will open up further avenues for demonstration of responsibility ‘and accountability. In addition it will change the image of nursing in the Maldives. Conclusion Inthe past, ethical considerations has remained the integrity of individuals. However, with the establishment of the Maldives Nursing Council (1999) itis envisaged that the Council wil begin exercising its rights, thereby alerting nurses and other health care workers in relation to ethical issues. The nursing profession and the community at large will appreciate the benefits that the Council has for nursing and the general publi. It is our responsibilty as nurses to be accountable for our actions, if we claim our profession to be ‘autonomous and inclependent to decision- making. * References de Casterle,8.D., Roelens, A. & Gastmans, C. (1998) An ajsted version of Kohlberg moral theory: discussion ofits val for research in nursing ethics. Jounal of Advanced Nursing. 27 (8), 829- 835 Ehvenburg, A, Ehnfors, M, & Thorel-Exstrend, | (1996) Nursing documentation in patent records experience of the use of the VIPS mode! Advanced vou of Nursing, 24(4), 858-887, Esterhuizen,P. (1996) Is the professional code stil he Cornerstone of cirical nursing practice? Journ of ‘Advanced Nursing. 23 (1), 25-31 Holden RJ, (1991) Responsibility and autonomous ‘nursing practice. Jouma of Advanced Nursing. 16, 398-403, btiwwerine ohlaboutton htm (27. 05 2003) Lukes, Hogg.C., Austin, Fergusen.® & Smith K, (1988) Decision: making: the context of nursing prescribing, Journal of Advanced Nursing. 27 (3) 657-665, Maldives Nursing Council (1999) (Leal) (Avalable trom Ministy of Health Male’, Maldives). Mitchell, K.8, & Lovat, T. (1993). Bioethics for Medical ‘and Health Professionals. N.S.W: Social Science Press, Pennels,C.JE, (1997) Clinical responsibly Professional Nurse.13 (3), 162-164. Romig.C.. (1998) Consumer protection a hot topic in ‘Washington D.C, AORN Journal. 67. (2), 485-467. The Concise Oxtord Engylsh Dictionary of Curent English (1990) Alen,RE, (Ed), New Delhi. india: Thomeon Press. ‘Thompson, LE.. Malia M. & Boyed, KM. (1984) ‘Nursing Ethics. Chapter 3. {3rd ed.). New York: CChurchil Livingstone 6 Maldives Joural of Heath Sciences, vol, issue 1, 2003,Warelow, PJ. (1996) Is caring the ethicl ideal? Joursal Wilmot S. (1992) Ethics, agency and empowerment in of Advanced Nursing. 24 (4), 655-661 ‘nurse education, Nurse Eotication Today. 13 (3), Willard, C. (1996) The nurses' role as patient advocate: Heise) ‘obligation or imposition? Journal of Advanced Nursing. 24 (1), 60-66. Maidives Journal of Health Sciences, vol.1, issue 1, 2008Observations and Comments on Standards of Nursing Practice in the Maldives Aminath Faiz, wv, an, aw Dean, Faculty of Health Sciences, Mele’, Republic of Maldives ‘Abstract Standards of practice is one of the professional issues in nursing in the Maldives. It is imperative that nursing practice is monitored and guided by @ regulatory body. Until recently there has been no requiatory body to guide nursing practice. In September 1999 a Maldivian Nurses Council (VNC) has been established. One of its objectives is to establist/maintain, and improve standards of nursing/midwitery education and practice, With the establishment of the MNC a regulatory body now exists to ensure that nursing practice is within a code of professional conduct. This article addresses the issues regarding standard o practice and the impact of @ regulatory body on nursing. A literature review will discuss regulations, code of professional ‘conduct, accountability, continuing education and nursing competence. Keywords standard, nursing prectice, code of conduct, regulation body, ‘competengy, accountability Introduction Nurses comprise the largest group of health professionals in the Maldives. They have direct. influence on health care, health promotion and disease prevention, Maintaining acceptable standards of nursing practice is the responsibility of the nurses. There is growing ooncem amongst these professionals to improve the practice and care rendered to patients. A standard of practice is related to the performance of a professional nurse. This paper will discuss a review of literature and the existing standards regarding nursing practice in the Maldives. It will also address the issues pertaining to nursing practice and the implications of the registration body on nursing practice. As the literature concerning nursing practice in the Maldives is limited, personal views, experiences and that of colleagues contribute a large part of this article. Some readers may not agree with the views expressed in this article. Significance of the Topic Standards of practice describe the responsibilities for which nurses are accountable. It improves and regulates the health care rendered to the community. According to Salvage & Heijnen (1997) a large proportion of the work of health care professionals is detrimental and ineffective. ‘Therefore the need of a mechanism to scrutinize What is appropriate and effective for patients is essential Literature Review Some authors agree that the lack of a distinet and generally accepted definition of the word. ‘slandard' leads to difficulties in obtaining a clear picture of the concept (Idavall, Rooke & Hamsen, 1997). According to Thomas, Hardinge & Cutting (1997), a standard is an agreed, measurable level of atiainment. This could mean the minimum, accepted level of performance required for professional members, The Canadian Nurses Association provides a more comprehensive definition in which ‘standard! is viewed as pertaining to the performance of the individual nurse. It involves maintaining standards in enhancing knowledge, competence and discipline of nurses (Canadian Nurses Association 1991 cited in Leipert, 1998). Concepts of accountability and responsibility, ethics and law, competency, safe practice, knowledge and respect are all associated with standards of practice, A code of professional conduct should encompass the 8 ‘Maldives Journal of Health Sciences, voli, issue 1, 2008above. A nurse must meet a particular standard in order to practice nursing Most countries if not all have regulation councils that define criteria of admission, ‘educational standards, license to practice and cother areas of jurisdiotion. A nurse's registration council is not new to the profession but it is new to the Maldives. Until the establishment of the Nursing Council, Maldivian nurses practiced under alicense from the Ministry of Health (MOH). There was no code of professional conduct and nurses practiced according to the rules and regulations formed by the employing organization, Now all nurses are registered at the Maldives Nursing Council ‘The establishment of the Maldives Nursing Council is seen as an enormous advancement in the development of the nursing profession in the ‘country. As a regulatory body the councll willbe responsible to maintaining order, consistenoy and standards of nursing practice. A code of professional conduct and an ethical code of practice for Maldivian nurses have been developed. The council is formulated under the parliament Act G 1/68 Official Chapter 1 within the rights given to the Ministry of Health, and ‘approved by the office of the President (Ministry of Health, 1999). The WHO together with the MOH assisted in ts development through internationally recognized nursing professionals, This initiative has provided recognition and contributed greatly towards the advancement of the profession in this ‘country. The literature indicates that each regulation council is based upon a code of professional conduct, which outlines the status of the registered nurse, and her or his responsibilities to protect the interests of patients and clients According to Pyne (1998), the United Kingdom Central Council (UCC) s0es the Code of Professional Conduct as a portrait. According to the portralt, the professional nurse is described as person who will safeguard patients’ interest and wellbeing. The nurse is accountable and responsible for hisfher actions, and maintains professional knowledge and competence, protects confidentia information of patients and Upholds the standards of the profession. itis also referred as a model against which the actions of ‘misconduct are judged (ibid). A code of professional conduct seeks to satisty the requirements of the law and provide guidalines to registered nurses on standards of professional ‘conduct. It is thought of as a weapon that fights {or improved standards in order to prevent harm to patients (Pine, 1987;cited in Kenworthy, Snowly & Giling, 1996). The regulatory systems in many counties including the Maldives are based on the codes of the Intemational Council of Nurses (ICN). Accountability and autonomy are two notions considered as pillars of the code of conduct (Bradshaw, 1997). Each registered practitioner is responsible and personally accountable for his or her actions. It is no defence for practitioners to say that they were acting on someone else's orders. (UKCC, 1996). Nurses are faced with difficult situations where they make decisions with the use of professional knowledge, judgement and skils. ‘The ability to act in such a manner depends on the ‘competence of the nurse, which largely depends ‘on his/her education, ‘The UKCC expects that all those seeking registration should demonstrate their Competencies in order to practice as independent practitioners who are accountable for thelr actions (UKCC 1986, cited in Bradshaw, 1997), Competence is expected to increase with ‘experience (Benner, 1984). Competency standards to be achieved by registered nurses ‘have been identitied in many instances but there is ambiguily about haw this competency is judged. Sound professional education is a prerequisite to safe and competent nursing practice. Studies have shown that continuing professionel education can bring a positive contribution to nursing practice, to the individual and professional development of nurses (Perry, 19985). In the Maldives, continuing education is an opportunity available for very few nurses. The need to keep, nurses’ knowledge and skills up-to-date is evident (Ministry of Health, 1998; MNO, 1999). Some nurses are undertaking higher studies using government funds white others are studying on their own expenses. Many nurses practice by reflection ftom past experiences. With the strengthening of nursing services, more opportunities could be available for further continuing education, Maldives Journal of Health Sciences, vol.1, issue 1, 2003, 9