Article Three: Complaints about nurses and midwives relating to competence and poor professional performance

The Role of NMBI

As the statutory regulatory body for nursing and midwifery in Ireland, NMBI’s objective is to protect the public in its dealings with nurses and midwives (registrants) and to ensure the integrity of the two professions. It does this through the promotion of high standards of professional education, training and practice and professional conduct among registrants. These standards help to assure the public and the professions that registrants are safe, competent healthcare practitioners.

What are competence and poor professional performance?

As defined by NMBI, competence is the ability of the registrant to practise safely and effectively, fulfilling their professional responsibility within their scope of practice. This ability is based on the attainment of knowledge, practice skills, integrity and professional and ethical values. The Nurses and Midwives Act 2011 defines poor professional performance in relation to registrants as “a failure to meet the standards of competence (whether in knowledge or skill or the application of knowledge or skill or both) that can reasonably be expected of a registered nurse or registered midwife, as the case may be, carrying out similar work.” Typical complaints about clinical practice or competence have been listed in Article 1 of this series.

How common are complaints about competence and poor professional performance?

Between 2016 and 2018 seven registrants were found guilty by the Fitness to Practise Committee of poor professional performance in relation to their clinical practice; in four of these cases the registrant was also found guilty of professional misconduct and/or non-compliance with a code of conduct. Proven allegations included:

• failing to assess the risks involved in moving a patient with a hoist;
• repeatedly recording that specific aspects of care had been given when the registrant knew that this was not the case;
• failing to indicate that nursing notes were made retrospectively;
• repeatedly preparing drugs for administration to more than one patient at a time in breach of drug administration protocols;
• repeatedly failing to administer prescribed drugs and then omitting to record why these were not administered;
• repeatedly administering an incorrect dosage of medication;
• failing to monitor and record a patient’s deteriorating condition;
• inappropriately delegating care to a student;
• failing to provide appropriate care after a patient had fallen; and
• failing to document care given.

Avoiding a complaint

Principle 3, Standards 5 and 6 of the Code of Professional Conduct and Ethics for Registered Nurses and Registered Midwives require registrants to be competent to practise safely and to keep their knowledge and skills up to date; they should also address any limitations to their competency. Registrants can continue to practise safely and effectively in the first instance by adhering to the Code, the Scope of Practice Framework and other guidance issued by NMBI. Registrants should also adhere to policies, procedures and other guidance relating to specific areas of clinical practice issued by national authorities, e.g. HIQA, or by their employers.

Inevitably, registrants make errors but not all errors result in a complaint being made to NMBI. Omissions such as failing to document care may be remedied by disclosure and writing a retrospective note. Isolated medication errors should also be disclosed and managed in accordance with local policy. Errors may be compounded if a registrant tries to conceal it or persuades a colleague to collude in a “cover-up”. Repeated deficits in care that do not respond to remedial efforts may also result in a complaint.

Principle 5 of the current Code of Conduct requires registrants to take appropriate action to protect people from harm. While practitioners may generally feel confident that their colleagues are competent, they should be alert to deficits and failings in delivery of care, documentation and medication management.

Concerns about competence may be addressed at a local level by providing structured development programmes, clinical supervision and support with regular feedback, all of which should be documented. Consideration should also be given to the possibility that the registrant’s performance is being affected by ill health, personal issues or interpersonal conflict in the workplace. In these circumstances referral to occupational health or employee assistance programmes or relocation may be appropriate.

Learning from fitness to practise inquiries

Where the Fitness to Practise Committee finds that allegations against a registrant have been proven and that they amount to one or more of the relevant grounds, the Board of NMBI must impose a sanction upon the registrant such as the attachment of conditions to their registration or possibly cancellation of registration. In some cases more than one sanction has been imposed, typically a censure and conditions. The purpose of most conditions imposed to date has been to address the registrant’s competence deficits by requiring them to complete an education programme approved by NMBI. The most common topics have been medication management; record-keeping; caring for vulnerable adults; consent; supervising and supporting students; and falls prevention. These sanctions have been imposed in order to protect the public, maintain confidence in the professions and uphold standards.