Creating a Code of Conduct for Healthcare: Facility Guide

Whether a healthcare worker is delivering a meal tray or a life-changing diagnosis, they have a duty to maintain a professional presence that reflects the integrity of the organization. While this unspoken behavioral code may be taught in some healthcare professionals’ training, it’s ultimately up to employers to create policies that set expectations for staff.

In this article, we share what’s typically included in a code of conduct for healthcare workers. Learn how to create a guide that shows staff how to promote person-centered care and embody your company’s values in daily practice.

What Is a Code of Conduct for Healthcare Professionals?

A code of conduct for healthcare workers covers the expected behaviors for staff in the clinical and administrative settings. For clinicians, a code of conduct guides ethical decisions in complex situations, particularly in patient care. For healthcare administrators and other non-clinical staff, it serves as a reminder to prioritize patient-centered motivation over self-gain.

Having a code of conduct allows healthcare organizations to set high standards for their staff in order to uphold the public’s trust. This helps foster a culture of accountability and integrity in healthcare.

How Are Ethics Addressed in a Code of Conduct?

Having a code of conduct can serve as a support tool for healthcare workers who often face moral and ethical dilemmas in patient care. Healthcare leaders must also consider the conditions in a healthcare environment that may contribute to a provider’s ability to do what’s right for patients. Addressing factors that test individuals’ morality and ethics can help prevent burnout and promote patient safety.

Morals are personal beliefs that guide decision-making and often relate to gut instincts. When a healthcare provider repeatedly faces situations out of their control that challenge their ability to “do the right thing,” it can lead to moral distress, moral injury, or burnout.

Example: A hospital CEO denies the nursing staff’s request for facility-wide standardized nurse-to-patient ratios, and the new normal on med-surg becomes 1:8. Toward the end of the shift, a med-surg nurse notices neuro changes in one of their patients and calls a Code Stroke. The medical team discovers the patient had a brain bleed hours earlier, and several signs were missed due to the demands of the nurse’s assignment. The nurse is distressed that they missed the warning signs in this patient harm event.

Ethics are a set of standards from an external source that determine which behaviors are “right” or “wrong.” These are often set by an institution, such as in a code of conduct for healthcare staff.

Example: A Spanish-speaking patient is scheduled for surgery and needs to sign consent, but the interpreter is temporarily unavailable to translate. The surgeon arrives at the bedside and explains the procedure in English, asking the bedside nurse to witness the consent. The nurse faces an ethical dilemma about how to proceed.

Code of Conduct Examples for Healthcare

As a healthcare facility leader, you likely see the value in creating a code of conduct for your employees in the form of a manual or policy guide. This gives employees a centralized place to read about the organization’s values, behavioral standards, and stances on complex issues arising in the workplace. Many healthcare workers likely have a set of professional standards that inform their everyday practice in addition to facility-based guides. Here are a few healthcare code of conduct examples:

• Nursing Code of Ethics — This guide outlines how nurses should carry out their nursing responsibilities in a way that aligns with the ethical obligations of nursing.
• American Medical Association (AMA) Code of Medical Ethics — Considered the most comprehensive ethics guide for physicians, this aims to promote patient trust and public confidence in medicine.

• International Council of Nurses (ICN) Code of Ethics — Providing a framework for ethical nursing practice, this describes the professional accountabilities, ethical values, and responsibilities of nurses and nursing students.

• Hippocratic Oath — Most medical schools require students to take this oath before becoming a doctor. Traditionally associated with the saying, “first, do no harm,” the oath allows physicians to swear they will uphold a set of ethical standards in practice.

• American College of Healthcare Executives (ACHE)Code of Ethics — This code serves as a guideline for ethical behaviors among healthcare leaders. It reminds healthcare executives to put patients at the center of their decisions and to resist the temptation to make decisions for self-gain.

What Does a Code of Conduct for Healthcare Include?

A code of conduct at a healthcare organization should serve as a statement about the expected behaviors, ethical standards, and principles that guide the behavior of those affiliated with the institution. It should be inclusive of healthcare professionals, nonclinical staff, vendors, and volunteers.

Your facility may choose to require staff to sign an attestation stating they’ve read the code of conduct and are familiar with its contents. By doing so, they agree to abide by the code when representing the healthcare organization, both in the practice setting and in the community. Healthcare staff agree to follow the basic ethical standards and legal requirements necessary to perform their work. The code of conduct should elaborate on these foundational concepts by including elements such as:

• Purpose. Dedicate a section to explaining why a code of conduct exists at your healthcare organization. Explain your company’s commitment to delivering care in a way that embodies its mission, vision, and values while conducting work in an ethical manner.
• Professional Standards. These describe the professional expectations for competency in delivering care. They also relate to the behavioral standards expected when representing an organization in the professional setting and in patient care.
• Patient Rights: Privacy and Confidentiality. The code of conduct should have a section describing the organization’s commitment to handling protected health information (PHI). It can list policies about privacy and confidentiality, including consequences for mishandling PHI.
• Quality of Care. Healthcare workers agree to follow standards of care that promote patient safety by employing the latest evidence-based practice guidelines and policies. Elaborate on the behavioral standards that reflect organizational ethics for quality of care.
• Ethical Guidelines. When facing ethical decisions in the workplace, healthcare professionals exercise their best judgment to support patients. Discuss which resources are available to navigate challenges arising in clinical practice, such as a hospital ethics committee.
• Third-party Responsibilities. Remember to include a section describing expectations for third-party vendors and business associates who are also responsible for maintaining patient privacy and confidentiality.
• Financial Integrity. Healthcare institutions must promise to maintain integrity when handling financial matters and billing. Include your organization’s statement about following regulations about kickbacks or financial incentives for physician referrals.
• Disciplinary Guidelines. This describes the consequences of violating the code in the form of disciplinary action or termination, depending on the circumstances.
• Professional Environment. The organization states its commitment to providing an environment conducive to professional behavior and teamwork. This may cover a statement about lateral violence, workplace incivility, and bullying.

Find More Ways to Promote Best Practice Care

You’ve learned the basics of what’s included in a code of conduct for healthcare staff. Find more ways to create policies that promote patient-centered best practices in IntelyCare’s free newsletter.