Rules and regulations can only be truly effective in contributing towards patient safety if individual healthcare practitioners take on accountability for their own actions and omissions.
The regulation in ensuring safety of the patient will play a very important role. The Nursing and Midwifery Council (NMC) was set up by the UK Parliament for the expressed purpose of safe-guarding the health and well-being of patients and the public. The Council does this by establishing and maintaining standards of education, training, conduct and performance for nurses and midwives. Similar regulators exist to help ensure the other healthcare professionals, such as doctors, dentists and pharmacists practise to safe standards.
However, professional healthcare regulators like the NMC cannot work in isolation. Patient safety is a shared responsibility between regulators, employers, service users and most importantly, practitioners. The NMC believes that the starting point for public protection rests with individual nurses and midwives, and the professionals on their register are personally accountable for their actions and omissions in their practice.
This principle is enshrined in the NMC Code through a set of standards nurses and midwives can use to demonstrate the safety of their working practice and behaviour to patients, members of the public, employers and colleagues. The NMC Code, which was updated and re-launched earlier in April 2008, emphasises that nurses and midwives must make the “care of people their first concern, treating them as individuals and respecting their dignity.” It also states that they must, at all times, protect and promote the health and well-being of those in their care. The Code also emphasises that failure to comply with it could bring the fitness to practise of a nurse or midwife into question and endanger his or her registration. The Code is not just a tool for the professionals. It is also a document aimed at patients and the public to help them understand what they can expect from the nurse or midwife providing care.
However, NMC Code cannot provide a blue print to nurses and midwives as to how to behave in every circumstance—professionals will always have to make judgements in a wide variety of changing circumstances. Fundamentally, the accountability of these professionals rests on their responsibility to weigh up the interests of patients using their professional knowledge, judgement and skills to make a decision. As mentioned above, it requires a partnership for the Code to be effective, involving the NMC, employers, nurses and midwives themselves.
A key element of the NMC’s role in this partnership is support for professionals. The NMC believes that regulation can only be effective when it ensures that nurses and midwives are encouraged in their efforts to achieve the highest standards, and to provide the best possible care at all times. This principle of supporting best practice of offering advice and guidance is becoming increasingly important as nurses and midwives take on new responsibilities, and are faced with fresh challenges and situations. These challenges include, for instance, working in multi-disciplinary teams. This can mean that nurses work under managers who are not qualified nurses, or that they are required to delegate tasks to a healthcare assistant who may not be registered with the NMC. Similarly, in the UK we are seeing a greater emphasis on delivering healthcare close to patient’s homes and moving away form the hospital model of care. This concept has come with many challenges that are directly impacting on nurses within both community and acute care. The NMC is aware of these challenges, and is doing what it can to support nurses and midwives, wherever they work, in giving the best care.
One way in which we do this at the NMC is through the Professional Advisory Service (PAS). This service facilitates professionals to get speedy advice from experts using a direct phone line and an e-mail address. Our professional advisors are often asked about how to maintain registration, the role of healthcare assistants and the rules around conscientious objections to particular procedures or types of care. To give an idea of the use of the service, we receive on average, around 29,000 enquiries a year. Another service the NMC provides is the Advice by Topic section of the NMC website. This facility allows nurses and midwives quick access to information on topics ranging from delegation to rules on receiving gifts from those in a nurse’s or midwife’s care.
Another strength of the NMC’s mandate is its capacity to undertake risk assessment in relation to public protection and the direction of practice, and act upon identified risks. NMC reflects that responsibility by providing guidance regarding those issues that affect practice in the 21st century. One of the key challenges is to develop a revalidation mechanism, which demonstrates to patients and the wider public that nurses and midwives remain up-to-date in their education, training and skills and are fit to practise. It is currently working with Government and other healthcare regulators to develop a system of revalidation, which is proportionate to the risks inherent in the work with which nurses and midwives are involved. The NMC is also working at improving networks and partnerships with other nursing and midwifery regulators, both within the European Union and beyond. A major focus of such partnerships is developing systems for the exchange of information about practitioners seeking to practise across borders. Dialogue with other regulators, within the UK and more widely, also provides the NMC with opportunities to learn about innovations in regulatory systems, including advanced ways of applying IT to the goal of public protection.
But no matter how effective a system of regulation and revalidation is, nurses and midwives can face conflicts when exercising professional accountability. This is especially the case where resources are limited or badly managed. Employers—and ultimately Government—must ensure that systems are designed and resources are provided to support nurses and midwives in their practice. Patient safety can be compromised in circumstances in which there are inadequate staffing levels. For example, the potential risk to patient safety is increased if a midwife is left unsupported in charge of a busy maternity ward over a weekend shift. The risk increases further, if the midwife is exhausted by the lack a much-needed rest break due to lack of any cover. Individual nurses and midwives placed in such situation are faced with difficult decisions. It is their duty to raise concerns, if they feel their ability to provide safe care is being compromised. Indeed the Code states specifically that, “You must inform someone in authority if you experience problems that prevent you working within this Code or other nationally agreed standards”. In practice, it can be difficult for nurses and midwives working in such high-pressured environments to make their voices heard.
The final element of responsibility for patient and public safety lies with service users themselves. Without a well-informed public willing to get involved in the process of setting standards for healthcare professionals, regulation can never truly reflect the needs of society. The NMC works hard to involve the public in its work—not just through lay membership of Council, but through wide consultations. These consultations take a variety of forms. For instance, in drafting the Code, the NMC consulted not just nurses and midwives, but patient groups, employers, trade unions, nurse and midwife educators, and the four government departments in England, Scotland, Wales and Northern Ireland. The focus groups provided invaluable insight into how NMC as an organisation is viewed from the ‘outside’—and it certainly gave it food for thought.
The NMC, alongside the other healthcare regulators in the UK, is currently moving towards a governance structure that will see the lay voice being strengthened. Currently, the Council consists of 33 Members, of which 24 are elected nurses and midwives (although only 12 of those sit at Council meetings at any one time). Following proposals in the Government’s recent White Paper entitled “Trust, Assurance and Safety – The Regulation of Health Professionals in the 21st Century”, the NMC will be moving to a smaller, fully appointed Council. This new 14-member board-like Council, which will see parity between lay and professional members, will take up office on January 2009. Lay involvement is not just about making use; the voice of patients is heard and their input flows directly into the business of regulation, although that is of course, a key element. Lay participation also means the NMC benefits from the knowledge and skills of experts in different fields, such as law, accountancy and management. The structure of the new Council sets a clear message that modern regulation is aimed squarely at representing the interests of patients and the public, rather than representing interests of nurses and midwives, which is the role of trade unions and professional bodies.
In conclusion, healthcare regulators can and do set out standards, rules and guidance to enable healthcare practitioners to practise safely and effectively. But such activity can only be truly effective in contributing towards patient safety if individual healthcare practitioners take on accountability for their own actions and omissions. Where does the responsibility ultimately rest for patient safety? Although, as previously explained, there is a shared responsibility for patient safety, ultimately such responsibility must start with the individual healthcare practitioner. Rather than talking about ‘the buck stops here’, perhaps we should be talking about the buck starting somewhere—with individual healthcare practitioners.
Jill Crawford was elected President of the Nursing and Midwifery Council in August 2008, having been a lay member of the Council for six years. Jill has a background in campaigning for improvements in maternity services in the UK. She is a member of the National Childbirth Trust and has chaired Maternity Service Liaison Committees.