Framework for Nursing in General Practice
8 Accountability for Professional Practice
As employers of nurses it is vital that general practices understand the professional responsibilities and accountability of both nurses and general practitioners. This is particularly important under the new GMS contract, where the practice based nature of the contract creates new opportunities to change skill mix within the practice and enable nurses to develop new roles which might previously have been undertaken by doctors. This chapter sets out to clarify the statutory position regarding the accountability of nurses and doctors and is based on standard 6.1.
Professional regulation for nurses
Nurses are individually accountable for their own professional practice. The profession is regulated by the Nursing and Midwifery Council (NMC). The NMC is an organisation set up by Parliament to protect the public by ensuring that nurses, midwives and health visitors provide high standards of care to their patients and clients. It replaces the UKCC, which was the former regulatory body.
To achieve its aims, the NMC:
maintains a register of qualified nurses, midwives and health visitors
sets standards for education, practice and conduct
provides advice for nurses, midwives and health visitors
considers allegations of misconduct or unfitness to practise due to ill health
Further details of the full range of NMC responsibilities is available at www.nmc-uk.org
Code of professional conduct
The NMC has established a Code of Professional Conduct, which sets out the standards of conduct required of all registered nurses and midwives. Nurses must follow these standards at all times. The code states:
"As a registered nurse, midwife or health visitor, you are personally accountable for your practice.
In caring for patients and clients, you must:
respect the patient or client as an individual
obtain consent before you give any treatment or care
protect confidential information
co-operate with others in the team
maintain your professional knowledge and competence
act to identify and minimise risk to patients and clients.
These are the shared values of all the United Kingdom health care regulatory bodies".
The purpose of the code of professional conduct is to:
inform the professions of the standard of professional conduct required of them in the exercise of their professional accountability and practice
inform the public, other professions and employers of the standard of professional conduct that they can expect of a registered practitioner.
The code states:
"As a registered nurse, midwife or health visitor, you must:
protect and support the health of individual patients and clients
protect and support the health of the wider community
act in such a way that justifies the trust and confidence the public have in you
uphold and enhance the good reputation of the professions.
You are personally accountable for your practice. This means that you are answerable for your actions and omissions, regardless of advice or directions from another professional.
You have a duty of care to your patients and clients, who are entitled to receive safe and competent care.
You must adhere to the laws of the country in which you are practising".
During local discussions and workshops in developing the framework, there was considerable discussion about accountability. A commonly held myth is that GPs delegating new tasks to nurses retain accountability and would therefore cover the nurse if something went wrong. The NMC is unequivocal on this. There is no such thing as vicarious professional accountability. Nurses are "answerable for their actions and omissions, regardless of advice or directions from another professional". A nurse cannot therefore be required by an employer to take on a new role or task if they do not consider themselves to be competent to do so without breaching the Code of Professional conduct and being open to a charge of professional misconduct.
Six principles are identified within the Professional Code of Conduct that must underpin a nurse's approach to expanding their role and increasing responsibilities beyond the traditional boundaries of practice. These principles should underpin any discussions within practices relating to developing roles of nurses and the nurse should be involved in these discussions. The nurse must:
1. Be satisfied that the patient and client needs are uppermost
2. Keep up to date and develop their knowledge, skills and competence
3. Recognise their limits to personal knowledge and skill and competence
4. Ensure that nursing care is not compromised by new developments and responsibilities
5. Acknowledge personal accountability
6. Avoid inappropriate delegation
General Practitioners also have a duty under the General Medical Council's standards which states: "Delegation involves asking a nurse, doctor, medical student or other health care worker to provide treatment or care on your behalf. When you delegate care or treatment you must be sure that the person to whom you delegate is competent to carry out the procedure or provide the therapy involved. You must always pass on enough information about the patient and the treatment needed and provide safe systems of working". ( http://www.gmc-uk.org/standards/default.htm ). For these reasons a doctor who improperly delegates to a person who is not a registered medical practitioner functions requiring the knowledge and skill of a medical practitioner is liable to disciplinary proceedings.
Chapter 5 sets out a framework for role development which is being developed as part of the Facing the Future work on nurse recruitment and retention and which may be of use to practices in supporting the safe development of nursing roles.
A small number of practices may employ practicing midwives. It is important that practices recognise that there are different rules set out by the NMC to ensure the safe practice of midwifery. Simply having a midwifery qualification does not in itself signify the ability to practice. A practicing midwife must fulfil the criteria laid down in the rules and standards for midwives, submit a notification of intention to practice annually to the Local Supervisory Authority for Midwives and have a named midwifery supervisor.
Accountability and health care assistants
Health care assistants are unqualified and as yet unregulated members of the team, who have been trained to fulfill specific duties delegated to them by a health professional. The rules of delegation outlined above apply equally to health care assistants. The UK Health Departments are currently consulting on whether they should be regulated and if so, how this should take place. Regulation of health care assistants would in effect mean that they had to register with a central body which could specify levels of training and a code of conduct. This has obvious benefits in terms of public safety, however it does not alter the position in relation to accountability. Health care assistants will not be independent health care professionals and the person delegating duties to them will continue to be accountable for the safe and effective delivery of those duties.