The Challenges of Nursing

NS421
Aims

 To develop an understanding of the importance of maintaining

professional boundaries
 To develop an understanding of the importance of ensuring
confidentiality
 To understand how and when concerns should be raised
 To review real life NMC fitness to practise panel hearings
Professional Boundaries

 Difference between a professional, therapeutic relationship and a

non professional or personal relationship
 If professional boundaries are crossed, the nurse is behaving in an
unprofessional manner and misusing the power in that relationship.
Small Groups – Consider these
scenarios and answer the question
 You are on placement in the ED and a ‘celebrity’ attends for
treatment. You ‘whatsapp’ your friends to tell them who you are
looking after, but do not give any information regarding their illness
or treatment. Is this okay?
 One of your patients is very grateful for the care you have
delivered. They recognise the financial burden of being a student
nurse, so they slip you £50 to ‘get yourself some food’. Is this okay?
 One of your patients is being a bit flirtatious with you. They are pretty
fit, so you decide to be a bit flirty back. You receive and accept a
friend request from them on Facebook. Is this okay?
Confidentiality

 A duty of confidence is a legal obligation and professional

requirement for nursing, health and social care professionals
entrusted with any information about patients and service users of
health and social care services in the course of their duties
(NMC, 2015).

 Patients/clients/service users entrust professionals with sensitive

information and ‘have the legitimate expectation that staff will
respect their privacy and act appropriately.’ (DH, 2003 p11)
Disclosure of Personal Information

 The person must be in agreement

 There is a legal obligation to do so
 There is an overriding public interest or a duty to protect individuals
from harm
 (DH, 2007)

We can only breach confidentiality:

 If we suspect someone is in danger of harm
 If we suspect abuse is occurring
The Data Protection Act, 1998

 The Data Protection Act 1998 is to protect the right of the person with
respect to the processing of personal data.
 It is designed to prevent confidential and personal information from being
passed on without a person’s consent.
 The keeping of records, storing of data and passing information on is strictly
regulated by this Act.
 This covers both paper and electronic information.
 Most information collected and held in settings will be confidential.
 Anyone processing information must comply with the 8 enforceable
principles.
8 Data Protection Enforceable
Principles
 Used fairly and lawfully
 Used for limited, specifically stated purposes
 Accurate
 Used in a way that is adequate, relevant and not excessive
 Kept for no longer than is absolutely necessary
 Handled according to peoples data protection rights
 Kept safe and secure
 Not be transferred outside the EU area without adequate protection
Group Discussion

 How do we keep the information we have on

patients/clients/service users safe?
Raising Concerns
 The Nursing and Midwifery Council give clear guidance to
professionals;

‘You make sure that patient and public safety is protected. You
work within the limits of your competence, exercising your professional
‘duty of candour’ and raising concerns immediately whenever you
come across situations that put patients or public safety at risk’
(NMC 2015a).

‘As a nurse or midwife, you have a professional duty to report any

concerns from your workplace which put the safety of the people in
your care or the public at risk’
(NMC 2015b).
Raising Concerns

 The inquiries into the events that occurred at Winterbourne View

and Mid-Staffordshire recognised that if all staff complied with the
codes of conduct of their profession, those events would not have
occurred

 They also highlighted widespread failings within our healthcare

system to hold professionals to account for their actions

 So why do these things happen??

NMC Fitness to Practise (FTP) Panel
The FTP panel can impose 4 different sanctions:
 Conditions of practice: This will prevent a registrant from carrying out
certain types of work in a particular setting, it may require them to attend
occupational health or do retraining. The order can be applied for up to 3
years and must be review by a FTP panel before expiry.
 Caution: The nurse or midwife is cautioned for their behaviour, but is
allowed to practise without restriction.
 Suspensions: The nurse or midwife will be suspended from practise for a
period of initially not longer than one year, but this can be extended
following review by an FTP panel
 Striking off: A nurse or midwife is removed from the register and not allowed
to practice in the UK. The nurse or midwife must apply to be readmitted to
the register.
 Case 1 – The Charge

While employed as a nurse at an NHS trust, it was alleged that Nurse A

breached professional boundaries with Patient A by:
 Visiting Patient A when he had no clinical need to do so, on one or more
occasion;
 Giving a mobile phone to Patient A;
 Holding hands with her.
 Case 1 - Background

 Nurse A was a registered nurse employed at a Healthcare NHS trust. He was referred
to the NMC by the assistant director of nursing at the trust. The referral raised
concerns about allegedly inappropriate behaviour towards Patient A by Nurse A,
who had attended to her whilst she was in hospital. Patient A was discharged from
hospital and returned to a care home.
 It was alleged that Nurse A sought to persue a relationship with Patient A and
attended her home when there was no clinical need for doing so. Patient A suffered
from Korsakoff’s syndrome and had been deemed as not having capacity regarding
major decisions or relationships. It was alleged that Ms 1, the deputy manager of the
home, saw Nurse A with Patient A on two separate occasions.
Case 1 – Background (cont’d…)

 On the first occasion Ms 1 found Nurse A in Patient A’s room holding her
hand, and on the second occasion, Ms 1 saw Nurse A visiting the home
and giving a mobile phone to patient A.
Case 1 – At the Hearing

 Nurse A admitted all charges and accepted that his behaviour was neither
appropriate nor acceptable
 Nurse A undertook training on ethics and maintaining professional
boundaries in the workplace
 Nurse A indicated that he was fully aware that his visits to patient A had
been closely monitored by staff and at no point did he conceal his identity
or the fact that he is a nurse
 The FTP panel felt that Nurse A’s actions and behaviour fell seriously short of
the standards reasonably expected of a nurse and amounted to
misconduct
What do you think is the right action for
the NMC to take?
 Conditions of practice: This will prevent a registrant from carrying out
certain types of work in a particular setting, it may require them to attend
occupational health or do retraining. The order can be applied for up to 3
years and must be review by a FTP panel before expiry.
 Caution: The nurse or midwife is cautioned for their behaviour, but is
allowed to practise without restriction.
 Suspensions: The nurse or midwife will be suspended from practise for a
period of initially not longer than one year, but this can be extended
following review by an FTP panel
 Striking off: A nurse or midwife is removed from the register and not allowed
to practice in the UK. The nurse or midwife must apply to be readmitted to
the register.
Case 1 – The Result

 The FTP panel determined that a finding of impairment was necessary on

public interest grounds.
 The panel considered the case carefully and decided to impose a caution
order for a period of two years.
 This period would mark the importance of maintaining public confidence in
the profession and a clear message about the standards required of a
registered nurse.
Case 2 – The charge

 Nurse B was charged with striking Child B on the head. Following the
incident, she did not undertake a physical assessment of Child B; undertake
or record neurological observations; complete a body map; seek medical
attention; report the incident; record the incident; inform he on-call
manager; contact the out-of-hours social worker; or hand over details
about the incident to the night staff that Child B has sustained a strike to
the head.
Case 2 - Background

 Nurse B was a registered nurse employed at a trust that cares for people
with complex care needs.
 As Nurse B was preparing Child B for bed, the child threw a doll into the
path of their wheelchair. As Nurse B retrieved the doll, Child B struck her on
the back of the head. Nurse B then struck Child B in the head area. She
reported the incident to Ms C, the nurse manager, and Ms D, head of
nursing care for the trust.
Case 2 – At the hearing

 Nurse B admitted all charges

 The FTP panel accepted that the nurse’s actions were reflexive rather than
intentional and came about from the shock of being struck
 Nurse B reported the incident to her managers and the lack of handover to
the night staff was due to them
 Nurse B demonstrated remorse and insight into how she would manage this
situation differently if it occurred again- She also provided evidence of
suitable training undertaken
 The FTP panel determined that she would be unlikely to repeat this
misconduct again
What do you think is the right action for
the NMC to take?
 Conditions of practice: This will prevent a registrant from carrying out
certain types of work in a particular setting, it may require them to attend
occupational health or do retraining. The order can be applied for up to 3
years and must be review by a FTP panel before expiry.
 Caution: The nurse or midwife is cautioned for their behaviour, but is
allowed to practise without restriction.
 Suspensions: The nurse or midwife will be suspended from practise for a
period of initially not longer than one year, but this can be extended
following review by an FTP panel
 Striking off: A nurse or midwife is removed from the register and not allowed
to practice in the UK. The nurse or midwife must apply to be readmitted to
the register.
Case 2 – The Result

 The FTP panel decided that Nurse B’s fitness to practise was not impaired
 The FTP panel felt that Nurse B showed remorse and insight into how she
would manage the situation differently in the unlikely event of recurrence –
This was supported by the training independently taken place
 Nurse B also supported her case with written reflections, feedback form
service users and colleagues and her oral evidence given to the panel.
 The FTP panel felt that the public view would be the same following review
of the evidence given.
Case 3 – The charge

Nurse C was charged as follows:

 ‘That you, while employed at the nursing home, sat on the patient’s knees,
cut her fingernails against her wishes, caused her to become agitated and
caused injury to her finger. It was therefore alleged that your fitness to
practise was impaired by reason of your misconduct.’
Case 3 - Background

 Nurse C was a staff nurse employed by a trust and via a agency at a nursing home.
While on duty at the home, it was alleged that the incident took place. The resident
had the capacity to refuse care and treatment.
 The trust and agency suspended Nurse C from undertaking any more nursing duties
and a safeguarding alert was sent out. She still works for the agency but in an
administrative capacity.
 The matter was referred to the police and the decision not to prosecute was made.
Before this incident, Nurse C had an unblemished nursing career spanning 40 years.
Case 3 -At the hearing
 Nurse C demonstrated limited knowledge of the policies on nail care and
of the content of residents’ care plans.
 She provided evidence of training she had undertaken since the incident
(safeguarding – Child & Adult)
 Lack of remorse or empathy for residents distressed state
 Did not show any insight into the reputational damage this would have on
public confidence in the profession
 FTP panel recognised training undertaken but did not have any evidence
regarding how this has been applied to practice – Panel therefore
concluded that Nurse C had not enough evidence to show she has fully
remedied her misconduct
 Panel noted that this was the only ‘incident’ in an otherwise unblemished
nursing career
 However, the FTP panel felt that there remained a real risk of the
misconduct being repeated.
What do you think is the right action for
the NMC to take?
 Conditions of practice: This will prevent a registrant from carrying out
certain types of work in a particular setting, it may require them to attend
occupational health or do retraining. The order can be applied for up to 3
years and must be review by a FTP panel before expiry.
 Caution: The nurse or midwife is cautioned for their behaviour, but is
allowed to practise without restriction.
 Suspensions: The nurse or midwife will be suspended from practise for a
period of initially not longer than one year, but this can be extended
following review by an FTP panel
 Striking off: A nurse or midwife is removed from the register and not allowed
to practice in the UK. The nurse or midwife must apply to be readmitted to
the register.
Case 3 – The Result
 The FTP panel felt that Nurse C’s conduct had fallen significantly short of the
standards expected of a registered nurse.
 It is the panels duty to protect the public from the risk of harm and to
declare and uphold proper standards of conduct, as to maintain public
confidence
 Nurse C was given a suspension order for 12 months
 It was felt that this would allow he time to reflect on the incident and give
the opportunity to demonstrate fuller evidence of remediation to a
subsequent panel who would review the suspension order before its expiry.
Questions?
References

 Department of Health (DH), (2007), Making Decisions: A Guide for People

who Work in Health and Social Care
 Nursing and Midwifery Council, (NMC) (2015), The Code: Professional
standards of practice and behaviour for nurses and midwives
 The Data Protection Act 1998. Available at: https://www.gov.uk/data-
protection/the-data-protection-act. Accessed 21 September 2016