As an NT survey shows that most nurses have legal concerns about treating someone outside work, Helen Mooney investigates the duty and risks involved in using clinical skills in public
You are minding your own business, walking down the street when, suddenly, you see a cyclist hit by a car. Or you are on an aeroplane when you hear the call: ‘Is there a nurse or doctor on board?’
Naturally nurses want to help – but would you be wiser to walk away for fear of the legal repercussions? When an emergency happens outside work, do you have a moral duty to act as a Good Samaritan, or would you be risking professional and financial ruin?
NT has questioned nurses across the country about whether they would use their clinical skills in public. Of the 3,500 who responded, almost two-thirds had been in a situation where they used their professional knowledge in an emergency outside work. Yet there is widespread confusion about the legal concerns and ethical implications.
Three-quarters of nurses who took part in the survey admitted they would be worried about the risk of litigation if they treated someone on the street. More than two-thirds did not know whether they would be covered by their employer’s indemnity insurance.
Legally, nurses are free to walk on by.
In the eyes of the law, they have no more responsibility than any other member of the public to intervene in such a situation.
Professional responsibility, however, is another matter. The NMC code of conduct used to state that nurses had a duty to intervene in a crisis wherever it happened.
‘In an emergency in or outside the work setting, you have a professional duty to provide care. The care provided would be judged against what could reasonably be expected from someone with your knowledge, skills and abilities when placed in these particular circumstances,’ it said.
But in the new code, brought in earlier this year, that crucial paragraph has been removed. Instead, it states that nurses and midwives are expected to ‘provide a high standard of practice and care at all times’ and ‘make the care of people your first concern’.
And a cautious note is sounded. As a nurse, ‘you must be able to demonstrate that you have acted in someone’s best interests if you have provided care in an emergency’. This is far less clear. Instead of a duty to intervene, it suggests a warning about the risks.
A spokesperson for the NMC defends the wording in the new code, saying that it is meant to be taken ‘in its entirety’.
‘The new code was developed following extensive consultation. Nurses and midwives had a strong hand in rewriting the code and that particular change reflected concerns raised by the professional bodies,’ she says.
So confusion reigns about whether to intervene and the ramifications of doing so. For doctors, it is straightforward. According to the General Medical Council’s Good Medical Practice guide, ‘in an emergency [doctors] must offer anyone at risk the treatment [they] could reasonably be expected to provide’. Yet nurses, a much larger professional group, do not have a written point of reference for this difficult dilemma.
Despite this, the results of our survey show that the vast majority of nurses do feel an overwhelming moral obligation to help – whatever the legal risk. Nearly nine out of 10 would provide nursing care outside work, even if they thought they were not indemnified. The same proportion say they would feel uncomfortable if they did not offer clinical care to someone who needed it.
Just under two-thirds of respondents confirmed that they had already used their clinical skills to help a member of the public.
One nurse, who wished to remain anonymous, was on holiday in Spain when she stopped to help victims of a coach crash. She did not hesitate.
‘I had a choice, either to drive past the scene of the accident or to stop and help. During the whole of your nurse training you are taught to actively help people to health and to preserve life, so it would have gone against everything I had trained for – not least against what I thought was the right thing to do morally and ethically,’ she says.
Another respondent agrees. ‘I recently helped out after a car accident where a man had been badly concussed and was bleeding. I didn’t even think about it – I gave very basic first aid. It is a question of whether you become a Good Samaritan because you are nurse or whether you already are a Good Samaritan.
‘I think being a nurse gives you a level head in a crisis and the ability to analyse the situation and act quickly. It is not in my personality to stand by and not do anything. I knew I was covered by my indemnity insurance but I also felt I had a moral and social duty to help,’ the respondent says.
Gail Adams, Unison’s head of nursing, was involved in such a situation when a young man collapsed in front of her at a tube station, inches from the edge of the platform. ‘My immediate thought was that he had stumbled and hit his head or fainted. I had not realised at that stage that he was not breathing.’
Ms Adams and a fellow passenger alerted station staff, who called 999 and halted trains coming into the station. ‘Once I realised he wasn’t breathing I started cardiac compressions and airway breathing. When the paramedics arrived I used suction to try and clear his airway, continued cardiac compressions and then gave the paramedics the history of what had happened before they took him to hospital.’
Ms Adams says that she did not hesitate in acting to help the person and attempt to save his life. Sadly, the young man died
and Ms Adams was called to give evidence at the inquest. It transpired that he had a complex history of drug misuse who had sniffed glue prior to running up stairs at the station and had aspirated.
‘Nurses must be prepared to be questioned at inquests,’ she warns. ‘They should also be offered counselling by their employers even if the event did not take place at work, because intervening in such situations can be quite traumatic.’
Ms Adams emphasises that, before nurses intervene in such a situation, they must assess any risk to themselves first. ‘Nurses need to ask themselves whether the environment or situation is safe to intervene and then they have a moral duty to preserve life and provide care to a reasonable level given their professional training.’
It is important to remember the basics, she adds. ‘You have to remember that you are there to preserve life so you need to concentrate on basic first aid – check ABC (airway, breathing and circulation), check heart rate and so on,’ she advises.
What NT’s survey revealed about using skills in public
While nurses may feel a moral duty to intervene, it seems this public-spirited attitude is not backed by their employers.
More than two-thirds of respondents to our survey did not know whether they were indemnified if they used their clinical skills outside work.
NHS Indemnity, a guide drawn up by the NHS Litigation Authority, states that: ‘Good Samaritan acts are not part of the healthcare professional’s work for the employing body.’ Any insurance that covers an employee at work does not apply when they are off duty.
A spokesperson for the authority explains: ‘Good Samaritan acts will not be covered by an employer’s insurance unless the employing trust has previously agreed to extend it to provide indemnity in emergencies and this is already stated in a contract of work.’
Chris Cox, acting director of legal services at the RCN, explains that once a nurse has chosen to intervene in such a situation they create a legal duty of care and therefore could potentially be found negligent over the healthcare they provide.
‘If you were found to be negligent you could be sued. However, in practice I don’t know of any case law where a nurse has been sued for intervening because they gave help in such a situation,’ he explains.
‘If they were a member of the RCN they would in any case be covered by our indemnity insurance. We would protect them. It would be no different from any other negligence claim made against a nurse and we would step in and pick up the bill.’
Howard Catton, the RCN’s head of policy development and implementation, says that the overwhelming majority of nurses will intervene in an emergency situation outside work because ‘every sinew of their being makes them help, they would cross the road to help and I don’t think that is a bad thing’.
However, while it is important for nurses to be aware of their legal position and the NMC’s code of conduct, Mr Catton is worried that society in general is changing and people are less likely to help strangers.
‘It is a broader societal change, people are more willing to sue and nurses need to make sure they have indemnity insurance to cover themselves,’ he says.
Alasdair Maclean, a senior lecturer in healthcare law and ethics at the University of Dundee, goes further and suggests that there is a ‘good argument’ to say that all members of the public should be under a legal duty to act as a Good Samaritan – as is the case in France – even if that just means that they phone for the emergency services.
‘Unfortunately, the fear of being sued is the major motivator for people not stopping to help, although people who do help tend not to get sued,’ he says.
There is clearly an urgent need for clarity about the legal risks of responding to an emergency outside work. Mr Cox suggests that nurses would benefit from mandatory legal training around the issues either before or after registration.
‘There does seem to be a gap in the knowledge of many nurses on where they stand legally and ethically in this situation and whether they are covered. Although we do endeavour to make sure nurses have the information, I think it should be in the education of all health practitioners. If they are delivering healthcare, they should have some legal training,’ he says.
It is not ‘rocket science’, he adds: ‘There is no legal duty to intervene but, ethically, nurses could be expected to provide basic first aid and care that was reasonable and within their competencies.’
When nurses have to help
You only have a legal obligation to intervene in a public emergency if: