Every year we see a number of our nursing colleagues disciplined for inappropriate responses to clients, professional boundary violations, or breaches of client confidentiality.
I have often wondered what circumstances led to nurses contravening nursing’s values and beliefs about how our profession ought to conduct themselves with clients, families and colleagues. These values and beliefs, about what constitutes professionalism and professional conduct, are integral to the socialisation of students in preregistration programmes and the Nursing Council of New Zealand professional development requirements for registered nurses. A belief that we need to understand more about what lies behind these disciplinary cases inspired me to research case reports published on the Health Practitioners’ Disciplinary Tribunal website between 2012 and 2014.
Each of the 14 disciplinary cases I reviewed represents a professional life lost to nursing or, at the very least, a nursing career that has been profoundly disrupted. In these cases, some nurses were deregistered for breaches of conduct that clearly compromise public safety and the reputation of nursing in New Zealand. Their professional lives were lost to nursing for good reasons. However, other nurses found guilty of professional misconduct were not deregistered, and after appropriate sanctions and a period of supervision, were permitted to return to practice.
The effects of being disciplined are profound. The case reports suggest nurses were either dismissed from employment or resigned. Finding further employment in such circumstances is challenging and it is likely that some of these nurses do not return to the workforce. The question in my mind is whether nurses could do more to help colleagues moderate or modify their behaviour in noticing conduct that leads to disciplinary action.
Factors leading to misconduct
In the cases I reviewed, there was a ‘perfect storm’ of elements that coalesced in situations where nurses made inappropriate decisions about how to respond to a client, family or colleague. These elements included professional, personal and organisational factors, that were present in the circumstances surrounding an inappropriate response or series of actions that constituted professional misconduct. I am not suggesting that these factors in any way mitigate the actions of these nurses. However, a deeper understanding of the context in which misconduct events occur may help nurses to understand more about how to recognise and call a colleague’s attention to professionally unsafe practice.
Some professional factors apparent in the descriptions of nurses’ behaviour included a borderline level of competence or lack of knowledge about some aspects of practice, or a lack of ability to capably respond to an unusual or demanding situation. Failure to check out what a colleague might do in a similar situation is an important aspect of teamwork and communication that was missing in these cases.
Personal factors were apparent in descriptions of stress and anxiety experienced in relation to major life events such as relationship loss or breakdown, the death or critical illness of a child, partner or other family member, financial stress and other life challenges. Being stressed, impulsive, defensive, or ‘set in their ways’ seemed to isolate nurses from their colleagues, particularly when they decided on a course of action knowing it was wrong or thinking they knew best. An inability to reflect on or modify their behaviour, and a lack of personal control was evident in descriptions of the nurses’ actions in the case reports.
Organisational, or workplace factors also impacted on nurses’ ability to make appropriate decisions. High patient acuity and particularly complex and challenging clients created demanding situations where the nurse either loss control or responded inappropriately. Unresolved or ongoing dissention within collegial relationships and team conflict provided further stress within the work environment. There was also reference in some cases to a ward unit or culture that tolerated unprofessional behaviour in the spirit of ‘everyone is doing it’.
While each of the nurses in these cases acted on their own account, and ought to have known their actions breached established norms of the profession, nurse colleagues might have had some influence in helping them to notice the ‘perfect storm’ gathering.
What can colleagues do to help?
Be mindful of other nurses’ needs for compassionate and respectful support. Notice those moments when you see other nurses enduring personal challenges such as a relationship breakdown or other personal loss. While people manage such things in their own unique way, sometimes we are not aware of the impact personal events might have on our professional work. I remember the support I received from colleagues when my husband was dying 18 years ago. This was a time when much of my energy and thinking was focused on managing all of the emotional and practical issues around a profoundly life-changing event. While my mistakes involved such things as booking cars or classrooms for the wrong day, it could also have impacted on client care in my clinical teaching. Eventually someone was brave enough to tell me about these mistakes and I understood it was time to take some leave to focus on my own life events. This experience taught me that supporting others helps them to become stronger and more resilient practitioners having resolved personal challenges.
Encourage members of your team to talk about professional issues in your daily practice and be self-responsible in reflecting on feedback from colleagues. Professional issues are often concerned with doing the right thing at the right time in the right context. Colleagues help us to ‘benchmark’ what another thoughtful, careful nurse might do in similar circumstances. I regularly seek peer supervision on challenging aspects of my current practice, because it enables me to be challenged and reflect more deeply on whether I am doing the right thing.
Compassionate care of colleagues also involves noticing the impact of organisational factors such as high workloads and rapidly changing care contexts, including new technologies. Developing our own individual and team support systems is essential to manage the demands of work load and ongoing change that are the hallmark of contemporary workplaces. Being professional requires us to be responsible in both setting limits and engaging with our colleagues and the organisational systems we work within.
Author: Dr Patricia McClunie-Trust PhD RN is the principal academic staff member at Wintec’s Centre for Health and Social Practice.