It’s Mental Health Awareness Week, but the importance of good mental health is a key issue for the Royal College of Nursing year round as we support our half a million members – nurses, midwives, nursing support workers, nursing students and retired members – working in the UK and abroad.
The COVID-19 pandemic has had a lasting impact on the mental and physical health of many nursing staff. Stress is one of the key reasons nursing staff give when they leave the Nursing and Midwifery Council (NMC) register. Supporting the mental health and wellbeing of nursing staff is key to an effective workforce, especially when dealing with referral to the NMC in relation to a work issue.
Health and wellbeing of nursing staff
Sadly, the Royal College of Nursing is increasingly concerned about the health and wellbeing of nurses, which impacts on the service safely and sustainably.
With a workforce that is dangerously understaffed, there is an increasing prevalence of burnout across the nursing profession. The debate on the timing and process for returning to ‘normal’ must have patient-need at its centre – but that cannot come at the expense of nurses’ wellbeing. Stress and fatigue can cause nurses to make unintended errors, impacting patient safety and leading to issues of professional misconduct.
The role of the regulator
As the biggest healthcare regulator, the NMC has a vital role to play. The NMC Code sets out the standards required to ensure that nurses and midwives in the UK and registered nursing associates in England have the skills, knowledge, education and standards of behaviour that allow for safe, effective and kind care.
It is these standards which allow the public to have complete trust in the profession. It is perhaps not surprising that nursing is often voted the most trusted profession by the UK public.
An important distinction is that the NMC’s role is not to punish people for things that might have happened in the past, but to make sure that nurses, midwives, and nursing associates learn from the past and meet certain standards to practise safely. Despite this, nurses can feel very much under scrutiny and that the process itself is punitive.
Being at the receiving end of a Fitness to Practise (FTP) referral can be devastating, and the long process that follows, overwhelming. Even some experienced nurses, who have enjoyed an unblemished career, and have the support of an employer, report heightened anxiety and fear when their fitness to practise is in question and often refer to a life and career ‘in limbo’.
Nurses also hold themselves, and their colleagues, to very high standards. Any nurse who makes an error, is likely to carry it with them for the remainder of their career. Referral to the NMC can impact on many other areas of your professional and personal life, including issues relating to finance, career development, relationship breakdowns and maintaining professional registration.
All nurses go to work to do a good job, but mistakes can happen. The trauma of any error can be enormous. One way we understand this trauma is through the idea of ‘moral distress’, which “occurs when you know the ethically correct action to take but you are constrained from taking it.”
In the context of Fitness for Practice, moral distress can occur when the error made infringes on the nurse’s ethical and moral values. Moral distress is not a mental illness, but prolonged moral distress can lead to moral injury and increased risk of developing mental health problems.
They may struggle to move on from mistakes, however big or small. Nurses must never be afraid or ashamed to access formal and informal services that support their mental health and wellbeing, including our members accessing the RCN counselling service.
Working while under investigation
Unless put under an interim restriction during this time, registrants are allowed and encouraged to continue to work while the investigation is ‘ongoing’. Of course, this is one of the best ways to demonstrate safe and effective and strengthened practice.
On a practical level, while waiting for the outcome of a case, nurses sometimes put off holidays, weddings, starting a family, seeking a promotion, and even working at all. Many start the FTP journey, which can take years, saying ‘I will wait and see what happens before applying for a new job’.
In gathering evidence of safe and effective and strengthened practice, nurses will be expected to provide testimonials, which also requires them to disclose the investigation to existing and prospective employers and colleagues. This, and providing evidence of reflection, can be a soul-searching exercise. Access to career coaching can be helpful in this situation.
Positive process changes
There have been various changes over the years to the FTP process seeking to ensure a consistent and transparent way of working and a more person-centred approach, which is welcome. There is also a commitment to looking at the context in which something may have gone wrong. Early and proactive engagement is therefore crucial and means that nurses that have representation or support in place are likely to achieve a better outcome.
The FTP process provides a number of opportunities for the NMC to close a case. In 2020-2021, the NMC made the decision not to investigate 2788 cases after an initial assessment.
The NMC Annual Fitness to Practise report indicates that 48% of queries to the Employer Link Service (ELS) resulted in advice that a referral to the NMC was not necessary and the matter should initially be managed locally. This might be through employment procedures or further training. There will of course always be cases where a case needs to be dealt with at a public hearing (private if health related) where a panel will hear the evidence and make a decision as to the facts, misconduct, impairment and sanction. Although it is ultimately for the NMC to prove any misconduct, the burden of proof is only on the balance of probabilities.
One of the types of concerns that the NMC investigate includes ‘serious ill health’. Ironically, pre-existing conditions can be exacerbated by the stress and intrusion of these proceedings. Albeit there are privacy safeguards in these cases, nurses report feeling unable to move forward with their health often because of the stress and anxiety the process causes.
Cases directly involving a registrant’s health are usually dealt with by the regulator with sensitivity and focus on ensuring that registrants are able to safely manage any health condition in the workplace. However, these cases often take a long time which can impede recovery.
Of course, there are also those cases where health is a mitigating factor and/or the stress and anxiety of the proceedings themselves have been a factor in a decline in mental health and wellbeing.
Changes to healthcare regulation
Healthcare regulation reform is around the corner, and it is hoped that more cases can be dealt with expeditiously, thus allowing nurses to move forward with their lives and careers, swiftly learning from any mistakes and allowing the regulatory process to be a positive experience of strengthening practice.
Our concern is that nurses on the register who have protected characteristics may be more likely to be referred, unrepresented, and more likely to have a case go to a final hearing.
In 2015, at a local level, a Freedom of Information request alerted the RCN West Midlands team to over-representation of BAME staff in the employee relation process. The RCN Cultural Ambassador Programme was developed from then, which enables trained RCN Cultural Ambassadors to identify and explore issues of culture, behaviour, potential discrimination and unconscious or conscious bias in the employment relations process. It is likely that further work can be done in respect of the FTP process following receipt of more detailed data from the NMC.
We are pleased to see the commitment from the NMC it wishes to continue to review the data and work with stakeholders to maximise fairness and consistency .
It is worth remembering that many of the nurses referred to the NMC have their cases closed with no finding against them. Unfortunately, this outcome can take a long time which takes its toll on a nurse’s mental health and wellbeing, career progression, reputation and have financial implications. It is our experience that the pandemic has certainly played a part in a backlog of cases at the NMC and inevitable delays in resolving cases and listing hearings.
It is reassuring that only 56 nurses were struck off the register in 2020-2021. In the same year 3821 registrants were referred to the NMC.
Role of the employer
We have found that the support of employers differs enormously. Those working in the independent sector, or agency nurses often report having little to no support during any ongoing investigation. This might be in terms of ongoing training, supervision, PDP support, occupational health reviews, or even continuing employment.
The support of an employer who is fully aware of these proceedings is vital in ensuring both a good outcome, and continued support for registrant’s mental health and wellbeing. Not only is maintaining the welfare of employees a recommendation, but a legal expectation under health and safety legislation.
The right support
Our members often reflect on how isolated they felt during the investigation. Nurses may be prohibited from speaking to colleagues or just lose touch. Some members turn to family and friends for support, but they may not always understand what they are going through.
We always encourage nurses to join a union so that they have the help they need through the fitness to practise process. The RCN also offers wider support packages to help nurses manage their mental wellbeing. Our RCN counselling team support thousands of nurses every year. In 2021, there were 5848 counselling sessions undertaken to support nurses through challenging times, many of whom are going through NMC proceedings. The NMC also acknowledge that registrant’s will find the process distressing and launched Careline in 2019.
The nursing workforce is dangerously understaffed and there is an increasing prevalence of burnout across the nursing profession. The NMC’s role is not to punish people for things that might have happened in the past, but to make sure that nurses, midwives, and nursing associates meet certain standards to practise safely. Whilst public protection is paramount, we must remember that there is an individual nurse at the centre of any referral. Moral distress can occur when the error made infringes on the nurse’s ethical and moral values. Moral distress is not a mental illness, but prolonged moral distress can lead to moral injury and increased risk of developing mental health problems. We encourage nurses to join a union so that they have the help they need through the fitness to practise process. Nurses must never be afraid or ashamed to access formal and informal services that support their mental health and wellbeing.