Nurses and midwives will not be automatically struck off for attempting to cover up when things go wrong, under revised plans for a new approach fitness to practise.
The move is among measures designed to make the FtP process fairer with more emphasis on the context surrounding even the most serious types of misconduct and patient safety incidents.
“Encouraging registrants to learn from mistakes is more likely to promote a learning culture”
Proposals for a new direction for FtP were first unveiled by the Nursing and Midwifery Council in March this year in response to concerns the current system could actually hamper efforts to improve patient safety.
A major consultation concluded in June and the NMC has now published the results alongside a near final version of the FtP strategy due to be considered by its governing body this week.
A report on the consultation shows nearly 900 individuals and organisations took part with more than 570 identifying themselves as a UK registered nurse or midwife.
The consultation also included independent research conducted with more than 200 registrants, employers and members of the public.
A total of 113 nurses and midwives from a mix of settings and areas of practice, different backgrounds and at different stages in their careers were involved in this phase of the consultation, said the report.
Overall, it shows there was broad support for the NMC’s attempt to move away from a “culture of blame and denial” to a system that put more emphasis on learning from mistakes.
“Automatic removal from the register in cases, such as deliberately covering up when things go wrong, is too restrictive”
Respondents also welcomed new measures to reform the “cumbersome, lengthy and adversarial” FtP process, which has been shown to put immense strain on all concerned.
The revised version of the strategy to be put before the NMC Council at its meeting on July 25 shows the regulator intends to forge ahead with plans to hold most misconduct hearings in private despite some concern this would reduce transparency and remove a deterrent against poor conduct.
Under the strategy, full hearings will only take places in “exceptional circumstances”.
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The strategy also places more emphasis on the context surrounding mistakes and makes it clear nurses who have done something seriously wrong may not necessarily be sanctioned if it is clear they owned up and have learned from the error.
The consultation report shows an overwhelming majority of respondents – 94% – felt the context in which a patient safety incident occurred was incredibly important.
“When incidents of poor practice actually happen because of underlying system failures, taking regulatory action against a registrant may not stop similar incidents happening again the future,” said the strategy.
“Regulatory action against an individual registrant may give false assurance, direct focus away from a wider problem and cause a future public protection gap,” it said.
“We’ve amended our policy principles to reflect this feedback and our position”
Meanwhile, the strategy states that the NMC may not need to take action for a clinical mistake even when is caused “serious harm” as long as a registrant “has been open about what went wrong and can demonstrate that they have learned from it”.
“Encouraging registrants to learn from mistakes, including mistakes with serious consequences, is more likely to promote a learning culture that keeps patients and members of the public safe than taking regulatory action to ‘mark’ the seriousness of the consequences,” said the document.
The regulator also wants to see employers making more effort to resolve issues locally before resorting to an NMC referral.
Key changes made in the light of consultation include a pledge to ensure a more “person-centred” approach to FtP, especially when it comes to engaging effectively with patients and the public who raise concerns.
This follows severe criticism of the way the regulator dealt with families from Morecambe Bay and those affected by the care scandal at Gosport War Memorial Hospital.
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Key questions raised by the consultation include the regulator’s role when it comes to maintaining public confidence in the nursing profession as a whole and upholding professional standards.
To date nurses and midwives have faced harsh sanctions because their actions could be seen to damage the reputation of the nursing profession – even if they had made a relatively minor mistake and clearly did not pose a risk to patients.
Despite concerns raised by its own regulator – the Professional Standards Authority (PSA) – the NMC said it would push ahead with plans to change the threshold for action in such cases.
In its response to the consultation, the PSA expressed concern that changing these thresholds risked “side-lining the importance of the regulator’s role in upholding professional standards”.
However, the NMC said it recognised punishing people who were not a risk “can have profound implications both for the individual registrant and the wider environment” and may increase “the potential for registrants to focus on avoiding blame rather than acknowledging errors or weaknesses in their practice”.
“It has considerably less justification in cases where the nurse or midwife has already addressed the concern, or where it’s of a less serious nature,” said the document.
“Indeed, in pursuing a case in such situations on the basis that it is necessary to maintain public confidence or uphold standards has the potential to conflict with our patient safety responsibilities, if by doing so we undermine a culture of openness and learning,” it added.
The strategy now makes it clear that in cases about clinical practice, taking action “solely to maintain public confidence or uphold standards” is only likely where a concern cannot be remedied.
In cases unrelated to clinical practice, taking action on this basis “is only likely to be needed if the concerns raise fundamental questions about the trustworthiness of a registrant as a professional”.
Another key change to come out of the consultation is a decision not to automatically strike people off for certain types of misconduct.
Initial proposals suggested a nurse or midwife should automatically be removed from the register if it could be shown they had attempted to cover up something that had gone wrong – such was the seriousness of this kind of behaviour,
“How will registrants be able to put across the merits of their if they are not heard face to face”
The regulator also suggested there were other regulatory concerns, particularly those that raised fundamental questions about a registrant’s professionalism, that simply could not be remedied and warranted an automatic striking off order.
However, the NMC decided to row back on these policies due to fears they were too restrictive and did not allow individual circumstances to be taken into account.
“We agree that automatic removal from the register in cases, such as deliberately covering up when things go wrong, is too restrictive and that removal will not always be appropriate in all circumstances,” said the consultation report.
“We agree that there may be other factors and context to consider. We’ve amended our policy principles to reflect this feedback and our position.”
Instead registrants will be warned that “restrictive regulatory action” is either required or highly likely.
The strategy sets out a series of steps the NMC will take in 2018-19 and 2019-20 to put it into practice. These include making more effort to engage with nurses and midwives whose conduct has been called into question in order to sort out issues early on.
It will also update its criteria for holding full hearings, produce new guidance for employers on making referrals and bring in new guidance on context and how this should be taken into account in decision-making.
Cathryn Watters, founder of the NMCWatch group, which campaigns for improvements to FtP for registrants, welcomed the spirit of the proposals but said she had concerns about various aspects including how success would be measured.
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Her group is calling for all registrants undergoing FtP to be surveyed to capture their experiences and has said the NMC generally needs to do more to reach out to nurses and midwives who have gone through FtP to inform their plans.
She said it was vital registrants, who can still opt for a full hearing, were given clear information about how hearings in private and on paper only would be conducted in order to make an informed choice.
“Many registrants will agree to holding their case in private in order to ‘get it over with’ but may not understand the implications of this,” she said. “How will registrants be able to put across the merits of their if they are not heard face to face?”
She said it was important registrants were also given clear guidance on the kind of evidence they needed to present to show they had learned from mistakes and had take steps to improve their practice.
Meanwhile, she hoped the regulator’s new “tone of voice” would also apply to communication with nurses and midwives and said the NMC needed to start from a position of neutrality with registrants seen as “innocent” until proved otherwise.
“How will the NMC ensure registrants can trust ‘open and honest’ conversations with them?” she asked. “At the moment they are frightened of being open for fear the information given will be turned against them in their case.”