Doctors found guilty of sexual offences, theft and fraud tend to get off more lightly than nurses and midwives, suggests the first in-depth report into professional misconduct cases across health and social care.
The study, by Coventry University researchers, analysed more than 6,700 cases of misconduct and found similarities in the types and frequency of misconduct among doctors, nurses and allied health professionals.
“We’re examining relationships that are often intimate in nature and based on trust”
However, it suggested that nurses often faced harsher sanctions for similar instances of wrongdoing perpetrated by medical colleagues, with “striking” differences in punishments handed down”.
The report also warned that workplace social environments, such as a culture of “banter” and flirting, could encourage nursing staff to over-step professional boundaries.
It addition, it noted the strain of working in pressured environments may make health professionals more likely to make poor decisions, such as getting entangled in inappropriate relationships.
The study looked at 6,714 fitness to practise cases handled by three professional regulators – the General Medical Council, Nursing and Midwifery Council and Health and Care Professions Council. These included 4,852 NMC cases against nurses and midwives – comprising 12,599 charges in all.
“Several cases identified climates of ‘banter’ or flirtatious ‘joking’ behaviour as facilitating the wrongdoing”
The study revealed that the most common form of misconduct across all professional groups was poor or inaccurate record-keeping. This was the most common charge levelled against nurses and midwives, followed by substandard care and then dishonesty, fraud or theft.
In addition, the study went on to look in depth at sexual misconduct cases and those involving dishonesty. For this, it analysed 289 charges of sexual misconduct listed on the Professional Standards Authority’s database – 44% perpetrated by nurses and midwives.
Overall, it found sexual misconduct was “significantly more prevalent amongst male doctors”, yet they appeared to receive less severe sanctions compared to other professions.
The report noted “striking” differences in sanctions for sexual misconduct, with nurses more likely to be struck off than doctors.
“Doctors were also more likely to receive lesser sanctions (suspensions, caution or other discipline) than nurses,” added the report – titled Bad apples? Bad barrels? Or bad cellars? Antecedents and processes of professional misconduct in UK Health and Social Care: Insights into sexual misconduct and dishonesty.
However, it said further research was needed to understand whether this was because nurses were committing worse offences or because doctors were generally treated more favourably.
“This type of sanction is much harsher for nurses and midwives than doctors”
One reason might be that cases against nurses can be more “clear cut”, with incidents involving groping of colleagues or sexual relations with patients often taking place outside work.
Cases involving doctors were often more complex, with inappropriate relationships developing over time and cases of patient abuse could be “clouded by patient doubt over the appropriateness of consultations”, making them harder to investigate.
The report also suggested the reason lighter penalties were handed down to doctors could be because they ostensibly expressed more remorse or regret about their actions.
“It is, however, not possible from the current analysis to consider whether doctors are more insightful about their wrongdoing than nurses, or whether they ‘know the right things to say’ in order to better reduce their punishments,” said the report.
The study looked in detail at 24 cases of sexual misconduct by nurses and midwives – involving 21 male and three female perpetrators.
Eleven of the cases involving male nurses occurred at the perpetrator’s workplace, while 10 involved an “outside work” element. Six took place in mental health settings.
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“Past research has indicated mental health as a more prevalent context for such misconduct, which may relate to the vulnerability of these patients and this is also a context in which nurses’ relations with patients may be different,” said the report.
In contrast to doctors, nurse sex offenders were more likely to target a colleague. In 12 out of the 21 cases involving male nurses, the primary target was a colleague and in nine of these cases the colleague was a subordinate.
Incidents that occurred at work “frequently involved discrete locations around the workplace such as in a staff room or discrete ward locations”, said the report.
A clear theme running through sexual misconduct cases involving colleagues was the influence of organisational culture.
“Several cases identified climates of ‘banter’ or flirtatious ‘joking’ behaviour as facilitating the wrongdoing, emphasising the power of group norms,” said the report.
“In many such cases those targeted explained they had tolerated inappropriate behaviour, as it was common within their organisation or in the department in which they worked with senior management often unaware.”
The sample included 11 cases of nurse sexual misconduct towards patients – three involving multiple patients. “Cases which targeted patients involved some of the most severe sexual misconducts analysed, with abuses of power or exploitation as central components,” said the report.
This was reflected in the severity of the punishment, with most nurses found to have abused a patient being struck off.
Nine of these 11 incidents happened outside work and several involved mobile phone communication as part of an “inappropriate relationship”. These cases tended to involve vulnerable patients such as those with mental health issues and drug or alcohol problems.
Source: Dana Heinemann
While patients did report these incidents, it was more often nursing colleagues who raised the alarm.
“It therefore appears that nurses are more vigilant to misconduct regarding those impacting on patient safety, proactively reporting instances, rather than being aware of their own or their colleagues’ safety,” said the report.
Patients were the targets in the handful of cases involving female perpetrators, with cases reported by nursing colleagues or others in the organisation.
These were often more complex than cases involving male nurses, with triggers including “home and work pressures, lack of organisational support and other mitigating circumstances”.
When it came to dishonesty and theft, the analysis again revealed the sanctions handed down to doctors tended to be less severe than for nurses.
“Doctors appeared more likely than nurses and midwives or allied professionals to receive short-term, suspension or interim suspensions and not permanent sanctions from their regulator. This type of sanction is much harsher for nurses and midwives than doctors,” said the report, which found some doctors got away with no sanctions for dishonesty.
Doctors were also less likely to be struck off than nurses in cases of fraud where healthcare professionals lied about their qualifications.
“Given the obvious increased financial rewards for fraud for this profession [doctors], it was somewhat surprising that greater sanctions were not applied to those who could arguably do greater harm to service users and to institutions,” said the report.
It found staffing and funding pressures to be “a key facilitator of theft” in nursing and midwifery settings, including the use of bank and agency staff in “already busy and understaffed settings”.
Other factors that could facilitate or encourage dishonesty and fraud included an overall lack of monitoring of staff, the fact there were more opportunities to take on higher paid roles and the fact that in some workplaces errors might only be discovered when the person had “long since left”.
“As per best practice, bank organisations should have completed pre-checks on individuals verifying their qualifications and identifying and not placing those with gross misconducts,” noted the report.
“Yet often such checks do not appear to have been adequately undertaken, with failures to verify why nurses and midwives had left their previous employment,” it warned.
It found the lack of checking by employers, especially when it came to qualifications “created tangible risks for patients”. It cited the case of one nurse who was found to have dispensed more than 1,400 prescriptions when they were not qualified to do so.
The study also suggested stress at work may have an impact on misconduct, because it increased someone’s “moral disengagement” and made them more likely to do things they know are wrong.
It found evidence of “stressed health professionals making poor judgements, which at times is exacerbated by the intimate and emotional nature of health consultation and treatment, or from relentlessly witnessing ongoing traumas”.
This was apparent in cases involving female sexual abusers but also in dishonesty cases,“with previously well-performing individuals unable to cope”.
Meanwhile, the analysis suggested NHS staff survey results could be used to detect “compromised workplaces” where professional misconduct was more likely to occur.
This could include looking at questions directly related to sexual harassment but also where staff reported increases in hours worked and reduced training levels.
Doctors ‘get off more lightly’ than nurses in misconduct cases
“All of these are indicative of an organisation in which additional pressure and strain is occurring for individuals and groups of professionals,” stated the report.
Lead study author Professor Rosalind Searle said the findings were important when it came to understanding and tackling misconduct.
“In shining the spotlight on professional practice in the health sector, we’re examining relationships that are often intimate in nature and based on trust and confidence between health workers and service users,” she said.
“It’s crucial, therefore, for us to analyse where and how these taken-for-granted notions are being undermined through misconduct, and to take steps towards reducing instances of such behaviour,” she added.
Doctors ‘get off more lightly’ than nurses in misconduct cases