Fitness to practise for student nurses: principles, standards and procedures
All schools of nursing must have a fitness to practice committee. The different procedures that apply to trainees compared with registered nurses are discussed
Timothy J David,MB, ChB, MD, PhD, FRCP, FRCPCH, DCH is pan faculty lead for student fitness to practise in the Faculty of Medical and Human Sciences; Elizabeth Lee-Woolf, PgDip, BSc, RN, RM, DipN, Cert Ed, is programme director in the School of Nursing, Midwifery and Social Work; both at the University of Manchester.
David TJ, Lee-Woolf E (2010) Fitness to practise for student nurses: principles, standards and procedures. Nursing Times; 106: 39, early online publication.
Since 2009, all schools of nursing have been required to establish a fitness to practise (FTP) committee to consider any pre-registration student health or character issues (Nursing and Midwifery Council 2008), and in 2009 fitness to practise standards were published (Nursing and Midwifery Council 2009a).
This article outlines how fitness to practise procedures apply to nursing and midwifery students in the UK and explains the key differences between how they are applied to trainees and to registered nurses.
Keywords Student nurses, Fitness to practise, Professional standards, Supervision
- This article has been double-blind peer reviewed.
The gravity of a breach of fitness to practise (FTP) standards may in part depend on the stage of a student’s career.
- Students must be aware that their behaviour outside the clinical environment may have an impact on their FTP.
- Members of the FTP committee must be independent with no significant prior involvement with the student or any preconceived view of the student or the case.
- FTP procedures must be clear and students encouraged to be accompanied to any hearing.
- The least possible sanction should always be considered first.
- Remember students are, by definition, still learning, and are entitled to receive feedback and advice from their teachers.
- A student nurse is entitled to receive a clear and unambiguous warning if at all possible.
The Nursing and Midwifery Council sets standards for education and practice and gives guidance and advice to the two professions. The body also maintains a register and upholds its standards of conduct, performance and ethics by investigating any allegations made against registered nurses and midwives.
What may be less well known is that the NMC has published guidance on professional conduct for nursing and midwifery students (NMC, 2009a), and requires that, from 1 January 2009, all schools of nursing must have a fitness to practise (FTP) committee to consider any preregistration student health or character issues (NMC, 2008).
This article explains the kind of student problems that cause FTP concerns and the principles of how student FTP procedures operate. The article also clarifies the important differences between student and registered nurse FTP cases.
FTP issues fall into different categories and have different levels of seriousness.As a general principle, the gravity of an FTP issue may in part be reflected by the stage of the student’s career. For example, inappropriate referencing leading to a finding of plagiarism might be more serious in students near the end of the third year than in first year students working on an early written assignment.
Students must be made aware that their behaviour outside the clinical environment, including in their personal lives, may have an impact on their FTP, and their behaviour at all times must justify the trust the public places in healthcare professionals.
Referrals to the university fitness to practise committee, which usually come from a senior member of staff of the school on behalf of a committee dealing with discipline and health matters, tend to fall into one or more of the following categories (David et al, 2009a).
Cases of plagiarism tend to be dealt with initially under university misconduct regulations. In addition to a penalty for the offence – for example awarding a zero mark – the case may cause a student nurse to be referred to a FTP committee. An important issue is the extent to which the student has been dishonest as opposed to careless.
Cheating and other forms of dishonesty
These include: cheating in examinations; falsifying research data; misrepresentation of qualifications and experience in a CV or job application; forging a mentor’s name in assessments or records of placement and forging a mentor’s assessment. They also encompass persuading another student to enter one’s name on an attendance register and making false entries in portfolios or logbooks. Students and staff may not realise that this kind of dishonesty is potentially a criminal offence (David et al, 2009a).
Criminal conviction, caution, reprimand and penalty notice for disorder
Minor motoring offences, such as exceeding a 30mph speed limit or a parking ticket, would not raise concerns about a student’s FTP. However, other criminal offences, particularly those involving dishonesty, violence, sex offences and offences involving drugs, are bound to raise questions.
In addition, as a result of the enhanced Criminal Records Bureau (CRB) process, a student nurse’s criminal conviction, for example, fare dodging or shoplifting, will be disclosed every time a job application is made.
In practice, this leads to two problems: one is that NHS trusts may be unwilling to accept on placement a student who has received a criminal conviction, and we encounter healthcare students whose studies have been halted because of difficulties arranging placements following a conviction. The second difficulty is that trusts may be reluctant to offer employment to applicants with a criminal record.
- This label is used to describe a variety of problem behaviours:
- Repeated failure to attend appointments with academic staff;
- Persistent disregard for regulations, requirements and official communications;
- Persistent disrespect to teachers, colleagues or others;
- Persistent rudeness to patients, colleagues or others;
- Persistent neglect of administrative tasks;
- Poor time management;
- Breach of patient confidentiality;
- Persistent failure to accept and follow educational advice;
- Inappropriate patient examinations or failure to keep within appropriate boundaries in behaviour;
- Sexual, racial or other forms of harassment such as malicious postings on the internet or on social networking sites such as Facebook.
Drug or alcohol misuse
The most common problems in this category are drink driving, alcohol consumption that affects clinical work or the work environment, and dealing, possessing or using illegal drugs, even if there are no legal proceedings. There may be a degree of overlap with mental illness, for example the use of cannabis can lead to severe psychotic illness.
Mental illness need not in itself render a student unfit to practise. However, if the condition cannot be controlled because there is an inherently poor response to treatment or the student fails to seek or comply with medical treatment, there might be a risk to the public and the student’s FTP may be called in to question.
The FTP committee is likely to need a report from a treating psychiatrist and from an independent psychiatrist. The FTP committee will need to be aware of the university’s responsibilities under the Disability Discrimination Acts of 1995 and 2005, particularly on the need to provide reasonable adjustments and support for students who require them to access learning.
Should FTP be found to be impaired by mental illness or other health problems, the panel’s determination is likely to be supportive of the student but should have patient safety as the primary consideration. So, for example, a student may be suspended for a period while treatment is sought.
Other health problems
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Other health issues that can impair FTP include treatment-resistant progressive neurological disorders, for example those involving loss of sight and/or sensation. The student’s FTP may be compromised not just by the condition itself, but also by failure to seek medical treatment, refusal to follow medical advice or care plans (including monitoring and reviews), and a failure to recognise limits and abilities, or a lack of insight into how their health problems affect FTP.
FTP hearings for the student nurse
The composition of the FTP committee is determined by local FTP regulations and by the requirements of the NMC (2008). There will be representation from both the school and trusts offering placements, and there should be representation from the same field of practice as the student, such as from adult, children’s, mental health or learning disability nursing.
It is essential that members of the committee are independent and they must not have a preconceived view of the case or rely on information obtained outside the FTP process. Therefore, staff who have had prior involvement with a student should not be on the panel considering the case.
It is self evident that a student must be invited to attend a FTP committee hearing, and the regulations should stipulate whether attendance is compulsory or not. The regulations should also specify what should happen if the student does not attend.
The student may need to attend the occupational health department before a hearing, particularly in a case involving drugs, alcohol or mental health problems.
Students should be encouraged to be accompanied or represented at a FTP committee hearing, and support should be provided to help them prepare for it.
Regulations should stipulate the kind of person permitted to accompany a student. The supporter can help the student to prepare a statement and can, if requested, advise the student during a hearing. However, the supporter cannot answer questions on behalf of a student as the committee will want to hear from the student in person.
The case papers
The student must be given, well in advance of the hearing, the full set of papers provided to the FTP committee. This should include a copy of the FTP regulations, all relevant university rules and regulations, and copies of relevant NMC guidance, such as the code (NMC, 2008a), guidance on good health and good character (NMC, 2008b), and guidance on professional conduct for nursing and midwifery students (NMC, 2009).
The student must be given an opportunity to submit a statement and any other supporting documents in advance of the hearing, and these items should be sent to the panel before the hearing.
If the regulations state that papers should be circulated to the student and to the panel in advance of the hearing, then papers received late should not be taken account of by the panel without the consent of the student.
If papers are submitted too late to be circulated to everyone involved and contain significant new information, the hearing may need to be adjourned so this new material can be considered.
The procedure at the hearing should be set out in the regulations, but the usual arrangement is for the school to present the case, followed by any witnesses, with the student then responding.
The school representative, the witnesses (if there are any) and the student are questioned by the committee members. In addition, the student can question the school representative and vice versa.
The committee needs to maintain a neutral stance. It should respect the difficulty of the student’s position when appearing at a hearing, and bear this in mind when asking questions. This difficulty may be apparent if a committee member does not like the answers to questions; the challenge is to try to avoid being confrontational or oppressive. The aim of questioning should not ever be to browbeat or to pressurise, but simply to get a better understanding.
Once the questioning is complete, the student and the school representative retire, to enable the committee to consider the case.
Outcome and sanctions
If the committee has either not found the facts proved or has determined the facts do not raise concerns as to FTP, it will dismiss the case.
The wording of other possible outcomes where the committee has found an issue concerning fitness to practise varies somewhat between institutions. Possible sanctions are listed in Box 1.
Box 1. Sanctions against students
Where concerns have been found about a student’s fitness to practise, sanctions include:
- Permitting the student to continue, with advice and guidance;
- Permitting the student to continue, with close supervision;
- Requiring the student to resit a specified part or parts of the programme;
- Suspending the student’s studies for a specified time;
- Recommending other action considered appropriate by the panel to enable the student to successfully complete the programme;
- Recommending the termination of the student’s studies.
Some institutions’ FTP regulations include the option to recommend other action considered appropriate, and this is a potentially powerful tool to deploy to assist the student and help to overcome certain obstacles.
In the case of a student who is having difficulty with referencing and has fallen foul of plagiarism regulations, it may be important for the student to be able to submit a full draft of a piece of work specifically so that advice can be given about referencing.
Where students are allowed to continue with their studies, they may need to meet the FTP committee on further occasions so their progress can be monitored.
It is an accepted general principle that, when considering sanctions, one should first consider the least possible sanction, and only escalate to the next level if the lesser sanction will not meet the needs of the public, the profession and the student. It is common for a verbal decision to be delivered at the hearing, and a written determination then follows.
Support for the student is as important after the hearing as it is before the hearing.
The formal output of a FTP committee hearing is a written determination. This must list those who attended and the procedure that was followed and state the facts that were established by the committee.
The determination should indicate all matters that the committee took into account, including mitigating factors that were considered, and reasons must be given for decisions and the imposition of any sanctions.
In deciding upon sanctions, the committee needs to bear in mind the principle of proportionality, whereby the need to protect the public is balanced against the needs of the student.
Students can appeal to the university against the outcome of a FTP committee hearing. If the appeal is unsuccessful, the student may be able to bring a complaint to the Office of the Independent Adjudicator – a national body that deals with student complaints from all UK universities. Students can also take the matter to the high court.
Student vs registered nurse FTP cases
The underlying principles, the need to protect the public and to maintain confidence in the nursing and midwifery professions are similar for both students and registered nurses and midwives. But there are some important differences in the way that student FTP cases are handled.
Students cannot be held to the same standard as registered professionals who are in professional practice. They are by definition still learning, and are entitled to receive feedback and advice from their teachers.
The entitlement to feedback, guidance and educational advice is one important difference between student and other FTP cases. This feedback may extend to setting up some form of learning contract to facilitate the student developing the missing knowledge, skill, or attitude.
Other than in cases in which there is immediate danger to the public, evidence of gross dishonesty or serious criminal behaviour, a student nurse is entitled to receive a clear and unambiguous warning before a sanction is imposed for unsatisfactory professional behaviour.
This warning, preferably in writing, should set out what is unacceptable and why it is unacceptable, and it should advise the student of possible consequences if there is insufficient change in behaviour. It would be hard to justify excluding a student nurse from studies because of some long-standing behavioural problem if there has not been at least one clear prior warning.
Another difference between student and other FTP cases is the degree of legal involvement.
In a FTP hearing concerning a registered nurse, there are likely to be two legal teams, one acting for the nurse and one acting for the NMC, and the committee itself is likely to have a legal adviser who is present throughout the hearing and the panel’s deliberations.
In a nursing student case, it is unlikely that the student will be able to afford legal representation, and it would be unusual for the university to be legally represented. While the NMC can issue a witness summons and oblige witnesses to attend, universities do not have this power.
FTP hearings held by the NMC are held in public, and the outcome is usually published its website. However, as with other university committee hearings considering matters relating to the education or discipline of undergraduate students, most nursing student FTP committee hearings are held in private. A few universities do allow the student to request the meeting to be held in public, possibly as a means of allowing a student to be accompanied by a relative in addition to the representation described above.
Another difference is in the appeal procedures. For a student, these will initially be at university level, possibly followed by a complaint to the Office of the Independent Adjudicator, whereas for a registered nurse an appeal would be to the high court.
Less serious cases
Cases referred to the FTP committee represent one end of the spectrum of problem behaviours by students. The guiding principles for the management of less serious problems, which constitute the majority, are:
- Good documentation of concerns about a student;
- Sharing these concerns openly with students, both verbally and in writing;
- Giving students a chance to explain their side of the story;
- Aiming to support and educate rather than punish;
- Clearly documented warnings that spell out both what is wrong and the consequences of failing to heed advice;
- Additional meetings with staff, for example, tutor, mentor or academic adviser;
- Referral to occupational health if there appear to be health issues;
- The opportunity to repeat items of work;
- Stepping off the course to allow student to address issues or recover from medical or social crises.
Prevention of problems is most likely to be achieved by education, as healthcare profession students may be unaware of the requirements for professional behaviour.
New students often do not appreciate that misbehaviour in their spare time, by undermining public confidence in them and their profession, may endanger their career. Students need advice about the perils of social networking, for example if this involves discussing a patient and thereby breaking confidence or making unprofessional remarks about fellow students or staff.
Developing professional behaviour occurs through a combination of information, education, role modelling and reflective practice. Managing that development requires an acknowledgement that students are colleagues who are novices and that adults learn best in the context in which they will use the knowledge (for nurses, the clinical context) and when the purpose of learning is clear.
Elements of sociology, psychology and ethics help students gain insight into the way in which societies work, and in understanding the concept of what a profession is and what it means to be a professional.
Students can explore different types of professions and the expectations they would have of that group, which can then be extended to establish what they feel are the attributes of a nurse. From here, students can see the skills that must be developed to be seen as a professional in this role.
Perhaps the hardest task is to appreciate at which point each individual student is on that journey. Encouraging students to reflect on professional issues in terms of both good practice and analysis of critical incidents as individuals or in groups foster professional development.
There should be clear guidance of what is expected in terms of behaviour at each stage of the programme of study. Equally, there must be guidance and consistency of approach should this expectation not be met.
It is vital that the level of expectation reflects the student’s progress on the course and also the level at which the student is called to account. For example, it may be understandable that a first year student may not appreciate the professional aspects of signing in for an absent student. Such an event would lead to a reminder to the whole group that we are aware of these actions, and that they are considered unprofessional.
Should the activity continue and a problem individual be identified, a meeting with the year tutor or equivalent should be arranged. Here, the student can be:
- Asked to explain why they acted in this way and why they thought it was all right to do so;
- Reminded of why these actions are considered unprofessional so that the deficit between current behaviour and what is expected can be seen;
- Asked to reflect on what has happened and comment on how their behaviour will change;
- Warned that, should this behaviour be repeated, it may affect their progress on the course.
As students move into their second and third year, such actions become less understandable and less acceptable. There is still a need to warn the student about poor behaviour, and to ensure there is a change, for a first “offence”. A repeat of such behaviour will cause greater concern and, where a student still appears unable to understand the nature of the unprofessional behaviour, their fitness to practise may be called into question. The principles for promoting professional behaviour are outlined in Box 2.
Box 2. Guiding principles of promoting professional behaviour
- When dealing with an episode of unprofessional behaviour, the context of the situation must be taken into account. An open and honest transaction should be encouraged and accurate records be kept to monitor progress, and to ensure that, should support be required from other sources, it is accessed and followed through.
- Learning outcomes must be clear and exist within a framework that allows the student to develop skills and professional behaviour in a timely and appropriate way in both theory and practice.
- An annual declaration of good health and good character (NMC, 2008) is required by the Nursing and Midwifery Council as stated in their Standards of Proficiency for Pre-registration Nursing Education (NMC, 2004). Students who present new information in their declaration or who fail to provide one should be followed up .
- Developing an open environment will help students declare adverse events (for example, a police acution) at the time of occurrence rather than waiting for the annual process of declaration.
- Remember not only the duty of care to the student, but also the requirement that students wishing to enter the professional register must be of good character.
The number of nursing and midwifery students whose behaviour is incompatible with a professional career is thought to be low (David and Bray, 2009b). These extreme cases are the “tip of the iceberg” of students whose health or behaviour cause concern.
Therefore, institutions delivering healthcare education need systems in place to educate students about professionalism, and to deal with problem individuals.
Depending upon local university regulations, there are two models for operating student FTP committees: subject specific committees (such as those only dealing with student nurses); and committees that deal with students from diverse healthcare programmes. The latter approach has the advantage that the greater caseload allows for the development of experience and expertise in handling cases, some of which can prove complex.
The essential point is that each educational institution needs to have fair written procedures which are followed and implemented.
Acknowledgement We thank Sally Bray for her comments on the manuscript.
David TJ et al (2009a) Fitness to practise procedures for undergraduate healthcare students. Education LawJournal; 10: 102-112.
David TJ, Bray SA (2009b) Healthcare student fitness to practise cases: reasons for referral and outcomes. Education Law Journal; 10: 3, 196-203.
Nursing and Midwifery Council (2004) Standards of proficiency for pre-registration nursing education. London: NMC.
Nursing and Midwifery Council (2008a) The code: Standards of conduct, performance and ethics for nurses and midwives. London: NMC.
Nursing and Midwifery Council (2008b) Good health and good character: guidance for educational institutions.London: NMC.
Nursing and Midwifery Council (2009a) Guidance on professional conduct for nursing and midwifery students. London: NMC.
Nursing and Midwifery Council (2009b) Standards for pre-registration midwifery education. London: NMC.