November 28th 2019
Since my last blog I find myself managing an internal conflict that just won’t disperse. My professional duty to my regulator is set through my Code of Conduct, for this I must respect the “rules” they lay down and adhere by the Code in my everyday work. However the more I speak with nurses and midwives going through Fitness to Practice the more I find myself having more and more difficulty respecting an organisation that seems to feed in to bullying workplace culture and fails to safeguard the vulnerable.
I was lucky enough to attend the annual Stand Up To Bullying conference held by The Ben Cohen foundation which was the first conference I have been to for a long time that held my attention throughout, no doubt assisted by the lack of “death by PowerPoint” and led more by respectful interactive discussions. The themes of the day were varied but also had common threads – no matter where we work we need to step back and look from the other’s perspective. We need to not make assumptions about why people act in the way they do but ask questions and learn.
Appreciation that others may view the world differently, hold different values or have challenging perception with issues relating to neurodiversity seems lacking in a healthcare society that is supposed to be expert at recognising these aspects of patient care but is impotent and unskilled in recognising them in their workforce. I came away from the conference inspired and followed on with supporting a registrant at her hearing for the next few days.
The hearing was a constant rollercoaster. Initial hope when the panel demanded that the NMC produce some evidence that had been denied to the registrant – elation when it was produced to deflation again when key parts of evidence agreed to not be put forward was “slipped in by mistake”. The registrant did an incredible job representing herself and pulling both the case presenter and panel up, politely, when time after time evidence that had agreed to be redacted was produced in full again “by mistake”. It struck me when observing that if a nurse or midwife had continued to make such documentation errors they could expect disciplinary action and yet here we were with our regulators being told that it often happens and the panel are professional enough to disregard it. Once the evidence is out there it would be difficult for anyone to strike it from their minds but also how can there be a guarantee that they are basing their decision-making on the evidence agreed upon and not on evidence that has been shown to be flawed? The rollercoaster continued with apparent care by the panel when the registrant disclosed her psychological distress at having to face her ex-employer and his behaviour towards her. They said all the words of appreciating it was stressful etc but as the day progressed it became apparent that these words were hollow and process trumps any distress it may be causing.
The mood lightened later in the week when it felt like members of the panel were supportive of the registrant’s case and congratulated her on her thorough evidence presented and the quality of it. Hope resumed that at last she was being listened to and they were seeing the cracks in the NMC case at last. Then decision day… were the charges going to be found proven or not? Would the panel believe the registrant’s evidence-based account of proceedings or that of the witness for the NMC? Would the panel recognise that there may be an element of biased in their statements and preparation to ensure an identical story? -The 3 main witnesses were husband, wife and son and the other 2 were dependent on the 3 for their jobs. One of which had had accusations made towards him by female employees but no action taken, the registrant tried to introduce this to show poor character and dependence on the other witnesses to secure his employment but she was not allowed and told: “it is not relevant to the case”. The shock that a panel could allow inaccurate evidence to be put forward by the NMC but would not allow contextual evidence to be submitted by the registrant in her defence seemed very unfair. Would the panel see the character traits that the main witness showed throughout his evidence and realise that this registrant was between a rock and a hard place, doing her best in a job that had little structure, processes or policies within a far from ideal workplace? Would they see the witnesses as unreliable, because the registrant showed clearly the dates and times they gave as being inaccurate? Their claim that they had concerns for “a long time” didn’t make sense when text messages and emails showed a different story from the registrant – would the panel see this?
Hope was alive again, the registrant felt, at last, she was being listened to and perhaps things would work out. She has always admitted her mistakes, taken responsibility for them and action to ensure they don’t reoccur. She is in employment with a proven track record and numerous testimonials to show she is a safe and highly skilled practitioner – again hope continued the rollercoaster plateauing.
Decision day came – on reading the hearing notes it felt like we were in a different hearing! All facts proved, witnesses credible and reliable and registrant not so. The Rollercoaster well and truly crashed and burned! Hearing adjourned til the New Year – registrant now disengaged and of the mentality “let them get on with it, I’m done!”
I felt incredibly sad to witness all I did with this case. Yes perhaps as it resumes in the New Year they may still decide despite facts proven that there is no benefit to sanction or such. But for this registrant, she has been turned from someone keen to engage to someone switched off and angry at her regulator. Her current employment does require her to have an active PIN and so she will no doubt not fight to remain on the register if the worst outcome occurs. At no point did anyone from the panel or support staff assess her support network, check how she was getting home or check in with her after the hearing was completed. They were made aware of her personal circumstances during the hearing and that she was struggling psychologically but made no attempt to was made to safeguard her, not even a check to ensure she knew about the recently implemented Careline.
Every day we read about how our healthcare services are in crisis. Poor staffing, vast numbers of unfilled vacancies, burnout, stress, car accidents on the way home and suicides. The papers then hit with articles about more poor care and horrendous systemic and individual failures which never highlight the full picture and rarely lead to a full investigation of contextual factors to avoid repetition. The recently leaked report into Shropshire Maternity Deaths was shocking to read and embarrassing to imagine colleagues and peers behaved in the way described. How did it go on for so long? Were there whistleblowers ignored? How many staff members raised concerns verbally and left rather than continue to witness poor practice?
I recently attended a national oncology conference and this issue was discussed a great deal with a particular focus on the need to retain staff rather than just put a sticking plaster on with less qualified, higher-in-numbers staffing. Incidents rising with lower qualified staff is not a surprise and having more nursing associates were shown not to reduce an RN’s stress or burnout – in some cases it was found to exacerbate it.
Deskilling the workforce increases the risk of death to patients – it’s not rocket science!!
Every organisation whether NHS Trusts, individual providers, private sector and our regulator has a part to play in ensuring the workforce is not put at further risk. ALL options need to be examined before removing someone with many years experience from the workforce. Our regulator needs to lead by example – stamp out the bullies, see through the vexatious referrals of whistleblowers, celebrate those who have been brave enough to raise concerns and support individuals when they make genuine mistakes. They can play an active role in helping registrants remediate and increase their skills to ensure patient safety – discarding them is not helping the situation.
“Nursing” is a skill set and lifestyle that is difficult to box, intuitive in many ways and complex always. Those determining our nurses, midwives, and nursing associates, fitness to practice need to demonstrate a high level of skill in understanding this and not just an ability to decipher case law and legislative rules. They need to understand the clinical environment that the individual before them works in and the impact of alleged omissions or errors in that workplace. The risk assessment needs formalising so it can be measured and audited and not left as it is currently, open to interpretation and varied in how it is understood.
The NMC promise that the culture is changing. Yet how many registrants raised concerns about practice prior to Morecambe Bay, Mid Staffs and Shropshire?
The NMC is aware the process is very stressful for the registrant and aims to not be punitive. Yet how much more data do they need on suicide risk and the mental health impact of the process?
All members of panel, legal teams and support staff go off for their weekend content with the fact they have done their job and are in no worse state than when they started their day.
The registrant goes home, demoralised, beaten and fearful.
There is a public interest to care for our carers.
There is a public duty to ensure the process does not pose a further risk.
Our regulator should mentor not punish.
The process must ensure it does not feed the bullies.