Disciplinary processes and the management of poor performance among UK nurses: bad apple or systemic failure? A scoping study

Disciplinary processes for nurses, from organizational supervision to outcomes: A document analysis of a regulatory authority's decisions

AIM

To explore the disciplinary processes for nurses, from organizational supervision to final decisions by the Finnish regulatory authority.

BACKGROUND

Regulatory authorities are responsible for protecting the public, by ensuring that they receive safe, competent and ethical nursing care, but little is known about the disciplinary processes for nurses.

METHODS

A retrospective document analysis of 296 disciplinary decisions by the Finnish regulatory authority from 2007-2016. The data were analysed using a quantitative design with descriptive statistics.

RESULTS

We studied 204 disciplined nurses (81.4% female) with a mean age of 43.5 years. The disciplinary process comprised organizational supervision, complaints, investigations and decisions. Nurses with substance abuse issues were more likely to face criminal investigations and receive temporary decisions. The process lasted from under one month to years and could have profound effects on nurses, colleagues and nurse managers and compromise patient safety.

CONCLUSION

This study identified key factors that could inform the disciplinary processes for nurses. More knowledge is needed about how organizations ensure patient safety when unprofessional conduct is suspected.

IMPLICATIONS FOR NURSING MANAGEMENT

Retaining nursing professionals is vital due to global shortages and more attention should be paid to organizational supervision and support for nurses during disciplinary processes.

Integrative review of studies about nurses who have been disciplined by their professional regulatory bodies

AIM

To synthesize knowledge in studies about nurses who had been disciplined by their professional regulatory bodies.

BACKGROUND

Unprofessional conduct that violates patient safety, nursing standards or legislation can result in disciplinary action that affects nurse's professional rights to practice. However, research on disciplinary procedures in nursing is fragmented.

METHODS

An integrative review was carried out with systematic searches between January 2006 and November 2018, using the CINAHL, PubMed, Scopus and Web of Science databases and manual searches. The quality of the 17 included studies was evaluated with the Mixed Method Appraisal Tool.

RESULTS

The evidence in the included studies focused on various databases. Disciplined nurses were described in relation to their characteristics and disciplined because of numerous patients, practice and behaviour related violations. Similar disciplinary actions against nurses were reported.

CONCLUSION

This review provides knowledge on contributory risk factors that can be used to develop professional standards and early interventions in nursing management. More systematic research is needed, together with clear definitions of disciplinary procedures.

IMPLICATION FOR NURSING MANAGEMENT

This knowledge could strengthen the abilities of nurse managers to recognize and prevent events that seldom occur but seriously threaten the safety of patients and nurses when they do.

The social utility of community treatment orders: Applying Girard's mimetic theory to community-based mandated mental health care

Serious mental illness (SMI) has long posed a dilemma to society. The use of community treatment orders (CTOs), a legal means by which to deliver mandated psychiatric treatment to individuals while they live in the community, is a contemporary technique for managing SMI. CTOs (or a similar legal mechanism) are used in every province in Canada and in many jurisdictions around the world in the care and management of clients with severe and persistent mental illness (most frequently schizophrenia) who have a history of treatment non-compliance and subsequent relapse. Although there is ongoing controversy around CTOs, their use continues to be on the rise. René Girard's mimetic theory, in which he posits the social utility of the scapegoat mechanism, may shed some light on how established cultural patterns contribute to contemporary responses to SMI: how culture depends on the reproduction of certain narratives, and how these act to shape the identity of those involved. The CTO specifically can be seen to act as a scapegoating mechanism, wherein, by singling out and controlling individuals who appear to threaten social order, social order is restored. This paper reviews Girard's theory, looks at how it has been applied to SMI, and then considers how it may illuminate the social role of the CTO. This examination may provide mental health nurses with insight into the constructed identities of their patients, as well as the role of mental health care within broader cultural narratives.

Compassion in nursing: Solution or stereotype?

Compassion in healthcare has received significant attention recently, on an international scale, with concern raised about its absence during clinical interactions. As a concept, compassionate care has been linked to nursing. We examined historical discourse on this topic, to understand and situate current debates on compassionate care as a hallmark of high-quality services. Documents we looked at illustrated how responsibility for delivering compassionate care cannot be consigned to individual nurses. Health professionals must have the right environmental circumstances to be able to provide and engage in compassionate interactions with patients and their relatives. Hence, although compassionate care has been presented as a straightforward solution when crisis faces health services, this discourse, especially in policy documents, has often failed to acknowledge the system-level issues associated with its provision. This has resulted in simplistic presentations of 'compassion' as inexpensive and the responsibility of individual nurses, a misleading proposal that risks devaluing the energy and resources required to deliver compassionate care. It also overlooks the need for organisations, not just individuals, to be charged with upholding its provision.

Healthcare managers' perceptions of managing poor performance

Purpose The purpose of this paper is to understand the perceptions and experiences of healthcare managers working within a community and ambulatory health service who manage poorly performing staff and, to identify the supports, and gaps in supports, that are available to these managers. Design/methodology/approach Data were collected via two focus groups using a semi-structured schedule. The data were transcribed, themed and conclusions summarised. Findings On analysis of the discussion of the line managers' experiences and perceptions of competence, six themes were identified, five themes common to both groups. When discussing the availability and gaps in supports available when managing poor performance, managers were aware of the majority of the supports available to them in the workplace but there was a disconnect between managers and the HR department. Research limitations/implications Though the results of this study are not generalisable, as the participants came from programs within a single hospital, they may be transferrable to other healthcare environments. Future research should attempt to replicate these findings using other research techniques. Practical implications The findings in this paper indicate that methods should be identified to build better relationships between managers and HR departments, develop clear management learning pathways, and to support managers to manage their emotional responses. These strategies will support organisations to achieve improved outcomes from the performance management processes. Originality/value This study contributes to the current literature by identifying key themes that may have an impact on the outcome of performance management processes. These themes would benefit from further exploration.

“Resisting the Ban”

Purpose

The purpose of this paper is to present an evocative story “Resisting the Ban” which illustrates the ethical and pragmatic issues that nurses face when contending with smoking ban policies in inpatient psychiatric settings.

Design/methodology/approach

The creative story “Resisting the Ban” was developed based on an organisational auto-ethnographic approach. The story was crafted through employing creative writing techniques and through framing and critiquing memories via several theoretical frames.

Findings

The story illustrates how smoking ban policies have created pragmatic and ethical issues on wards. The work practices of nurses have changed as have their relationships with patients. The liberties of involuntary patients have also been infringed.

Research limitations/implications

This approach can illuminate links between acts of resistance and issues associated with public policies.

Practical implications

The effects of smoking bans need to be considered more carefully particularly in relation to their effects on workers and patients. The social meaning of the smoking bans needs closer investigation. Policy needs to be recrafted so that it better addresses the liberties of involuntary patients. Also ward nurses need to be able to carry out their roles in a manner which is consistent with their values.

Social implications

Public policies, such as smoking bans, can produce negative consequences maligning relationships, practices and cultures. Critical auto-ethnography provides a means of understanding issues that have resulted from problematic policies.

Originality/value

Scholarly work conducted on the relationship between everyday resistance in workplaces and public policies is rare. This study offers new “insider” insights into the negative effects of a smoking ban policy in psychiatric inpatient settings.

Confidentiality, anonymity and amnesty for midwives in distress seeking online support - Ethical?

BACKGROUND

Midwife health is intrinsically linked to the quality of safe patient care. To ensure safe patient care, there is a need to deliver emotional support to midwives. One option that midwives may turn to may be a confidential online intervention, instead of localised, face-to-face support.

RESEARCH DESIGN

Following the Realist And MEta-narrative Evidence Syntheses: Evolving Standards publication standards, this realist synthesis approach explores the ethical considerations in permitting confidentiality, anonymity and amnesty in online interventions to support midwives in work-related psychological distress. An iterative search methodology was used to select nine papers for review. To assimilate information, papers were examined for ideas relating to ethical dimensions of online interventions to support midwives in work-related psychological distress. This review takes a narrative approach.

FINDINGS

Online interventions can support the development of insight, help seeking and open discussion. Additionally, Internet support groups can become morally persuasive in nature. Anonymity and confidentiality are both effective and therapeutic features of online interventions when used in collaboration with effective online moderation. Yet, ethical dilemmas remain where users cannot be identified.

DISCUSSION

Confidentiality and anonymity remain key components of successful online interventions. However, sanctioning the corollary component of amnesty may provoke moral discomfort for those seeking immediate accountability. For others, amnesty is seen as essential for open disclosure and help seeking. Ultimately, the needs of midwives must be balanced with the requirement to protect the public and the professional reputation of midwifery.

CONCLUSION

In supporting midwives online, the principles of anonymity, confidentiality and amnesty may evoke some resistance on ethical grounds. However, without offering identity protection, it may not be possible to create effective online support services for midwives. The authors of this article argue that the principles of confidentiality, anonymity and amnesty should be upheld in the pursuit of the greatest benefit for the greatest number of people.

Living my narrative: storying dishonesty and deception in mental health nursing

This article proceeds from MacIntyre's moral philosophical perspective of individual human lives constituting unified narratives, in the context of co-evolving framing and guiding master narratives. This perspective accords specific episodes in people's lives the status of significant component parts of their developing, storied and enacted individual histories. From this philosophical base, autoethnographic principles will be employed in providing accounts from my own professional life narrative strand as a mental health nurse educator that speak to the issue of institutionalized dishonesty and deception in mental health nursing education and practice. On the basis of my pre-existing experience of publishing in nursing journals and scholarly identity, my argument will proceed from contesting the idea of an imagined stable foundational professional ethos underpinning mental health nursing practice, against which to judge professional dishonesty and deception. Using illustrative, relatively recent short stories, drawn from my lived-experience base as a mental health nurse educator, I will argue throughout at implicit and explicit levels that dishonesty and deception are always an inevitable part of the lives of mental health nurses and their educators. This is because of a constant gap between the nursing rhetoric and ideology that both groups espouse and how they actually behave on a day-to-day, mundane level, in and out of work and classroom practice. This gap shows up the public front of what mental health nursing is supposed to be about as dishonest and deceitful window dressing. I will assert that the many first-person, lived-experience accounts in mental health nursing teaching and publication are important educational resources in reducing this gap at professional practice, academic, and informal levels. Such storied accounts may also be useful in moving nurses and their educators towards more morally and ethically sensitive and reflexively attuned positions around what they talk and write into existence.

Measuring prevalence, reliability and variation in high-risk prescribing in general practice using multilevel modelling of observational data in a population database

Background

High-risk primary care prescribing is common and is known to vary considerably between practices, but the extent to which high-risk prescribing varies among individual general practitioners (GPs) is not known.

Objectives

To create prescribing safety indicators usable in existing electronic clinical data and to examine (1) variation in high-risk prescribing between patients, GPs and practices including reliability of measurement and (2) changes over time in high-risk prescribing prevalence and variation between practices.

Design

Descriptive analysis and multilevel logistic regression modelling of routine data.

Setting

UK general practice using routine electronic medical record data.

Participants

(1) For analysis of variation and reliability, 398 GPs and 26,539 patients in 38 Scottish practices. (2) For analysis of change in high-risk prescribing, ≈ 300,000 patients particularly vulnerable to adverse drug effects registered with 190 Scottish practices.

Main outcome measures

For the analysis of variation between practices and between GPs, five indicators of high-risk non-steroidal anti-inflammatory drug (NSAID) prescribing. For the analysis of change in high-risk prescribing, 19 previously validated indicators.

Results

Measurement of high-risk prescribing at GP level was feasible only for newly initiated drugs and for drugs similar to NSAIDs which are usually initiated by GPs. There was moderate variation between practices in total high-risk NSAID prescribing [intraclass correlation coefficient (ICC) 0.034], but this indicator was highly reliable (> 0.8 for all practices) at distinguishing between practices because of the large number of patients being measured. There was moderate variation in initiation of high-risk NSAID prescribing between practices (ICC 0.055) and larger variation between GPs (ICC 0.166), but measurement did not reliably distinguish between practices and had reliability > 0.7 for only half of the GPs in the study. Between quarter (Q)2 2004 and Q1 2009, the percentage of patients exposed to high-risk prescribing measured by 17 indicators that could be examined over the whole period fell from 8.5% to 5.2%, which was largely driven by reductions in high-risk NSAID and antiplatelet use. Variation between practices increased for five indicators and decreased for five, with no relationship between change in the rate of high-risk prescribing and change in variation between practices.

Conclusions

High-risk prescribing is common and varies moderately between practices. High-risk prescribing at GP level cannot be easily measured routinely because of the difficulties in accurately identifying which GP actually prescribed the drug and because drug initiation is often a shared responsibility with specialists. For NSAID initiation, there was approximately three times greater variation between GPs than between practices. Most GPs with above average high-risk prescribing worked in practices which were not themselves above average. The observed reductions in high-risk prescribing between 2004 and 2009 were largely driven by falls in NSAID and antiplatelet prescribing, and there was no relationship between change in rate and change in variation between practices. These results are consistent with improvement interventions in all practices being more appropriate than interventions targeted on practices or GPs with higher than average high-risk prescribing. There is a need for research to understand why high-risk prescribing varies and to design and evaluate interventions to reduce it.

Funding

Funding for this study was provided by the Health Services and Delivery Research programme of the National Institute for Health Research.

Forging a strong nursing future: insights from the Canadian context

Canadian nurses, with their colleagues around the globe, are experiencing waves of change in their practice and work lives, and in expectations of how they will continue to make a difference for health and health care. We describe how Canadian nurses have been called to action to lead system wide changes in nursing practice, and to influence the wider public policy arenas for health. We aim to add to the growing international awareness of the status of nursing prompted by the Francis inquiry by offering our analysis of nursing practice and nursing leadership in Canada, in the context of the dominance of a managerial culture in health care systems. A review of prior commission reports, task forces and research reports sheds light on strategies needed to support nurses to address today’s challenges in nursing practice, including staff and skill mix determinations. We share our reflection on the current situation in Canadian nursing as a basis for learning about how our issues compare and contrast with others profiled in the journal. Our goal is to join with colleagues from Canada and other countries to forge a strong future – a future in which nursing’s voices are clearly heard in practice and policy decision-making, and where our knowledge and actions actualise societal health.