Suicide risk for nurses during fitness to practise process
In the past year, the RCN’s counselling service has supported more than 100 nurses facing fitness to practise investigations by the Nursing and Midwifery Council. According to the college, ‘many’ of these nurses are suicidal
In the past year, the RCN’s counselling service has supported more than 100 nurses facing fitness to practise investigations by the Nursing and Midwifery Council (NMC). According to the college, ‘many’ of these nurses are suicidal.
RCN members who turn to the counselling service have typically experienced stress, depression, anxiety or suicidal ideation, and much of the work the counselling service undertakes with them involves NMC proceedings.
RCN counselling service lead Sarah Murphy says: ‘We have counselled many suicidal members going through NMC proceedings.’
It is difficult to determine whether any such nurses harmed or killed themselves while under investigation.
In response to a Freedom of Information request, the NMC said: ‘[We] do not record incidents where a nurse or midwife who is subject to fitness to practise (FtP) proceedings has died before their case has been concluded.’
This means the nurses’ governing body has no record of suicide among nurses during FtP investigations, which can take years to complete. In the medical profession, however, there is a growing awareness of the distress FtP investigations can cause in people whose careers are at stake.
In 2014, the General Medical Council (GMC) pledged to review how it treats doctors after it found that up to 28 doctors had killed themselves while facing FtP investigations.
An independent review commissioned by the GMC (2014) states that, between 2005 and 2013, 114 doctors died while under investigation. Of these deaths, 24 were classified by coroners as suicide and four were suspected to be suicides.
The review recommends that doctors under investigation should know they are regarded as innocent until proven guilty.
Although there is no similar data for nurses who may have died while under investigation, two British research studies show nursing carries a higher suicide risk than many other occupations (Hawton et al 2002, Meltzer et al 2008), which underlines the potential vulnerability of nurses who are under investigation.
Ms Murphy says she is glad the GMC takes the issue so seriously and wants the NMC to do the same. ‘I am surprised to hear that the NMC does not record deaths of nurses undergoing FtP proceedings,’ she says. ‘The NMC should look at what doctors do and recreate it.’
The GMC has appointed England’s former national clinical director for mental health Louis Appleby to review its FtP processes and better support vulnerable doctors. With advice from Professor Appleby, the doctors’ regulator has published a set of draft aims and proposals (GMC 2015), including:
- Making mental health safety ‘a strand that runs throughout the way the GMC performs its role’ – in culture, leadership, standards and training.
- Promoting and funding increased use of doctors’ support services – with greater focus on unsupported doctors at tribunal hearings.
- Reducing stress in all investigations through changes to process, communication and duration.
- Reducing the overall number of full investigations.
- Improving learning when doctors die by suicide.
The aims and proposals will go before the GMC council later this year.
Average case length
Figures supplied to Mental Health Practice by the NMC show that the average FtP case takes nearly two years (23 months) from beginning to end. A few years ago, the average case took nearly three years (32 months). Of all the cases completed in the past five years, the longest took almost seven years (82 months).
Ms Murphy says these delays can place a heavy burden on nurses’ mental health and push many to breaking point. ‘The length of time taken by the cases takes a tremendous toll on members’ health. [The sense of] being in limbo [before resolution] is difficult and creates huge anxiety.
‘A lot of members are the main breadwinners in their homes, which means maintaining finances [while the FtP process goes on] is almost impossible,’ she says.
‘Having a case hanging over your head for two years or more is intolerable. I have members going through two-year cases [only to find] the allegations were unfounded.’
A case study involving a nurse dismissed from her job before a six-year-long investigation overturned the decision is set out in the panel.
An NMC spokesperson said the regulator understands the stress nurses go through while under investigation. ‘If we identify a nurse as requiring mental health support we strongly encourage them to seek this through their union, representative body or other organisations,’ she said.
The NMC is undertaking work on the mental health of nurses under investigation, and it collaborates and shares information with other regulators, including the GMC, she said.
There will always be complaints against health professionals and, while some are clearly warranted, many are unfounded.
In 2014-15, 5,183 complaints about nurses or midwives were made to the NMC. Of the 2,207 of these complaints that were considered to warrant FtP investigations by the NMC Investigating Committee, more than half (53%) were closed on the grounds that there was no case to answer (NMC 2015).
Almost one quarter (23%) of adjudicated cases concluded that FtP had not been not impaired. Only 3% of referrals to the NMC were based on concerns about the nurse or midwife’s health, while 80% were related to misconduct.
The number of registered nurses and midwives on whom sanctions were imposed due to impaired FtP represents about 0.2% of the total number of nurses on the NMC register.
One experienced senior nurse who has been practising for more than 20 years says her NMC referral ‘effectively ended’ her previously untarnished career.
Not knowing how long the NMC proceedings will last ‘is soul-destroying’ she says. ‘There has to be a regulator, but the time frames for investigations are ludicrous and part of what affects your mental health.
‘It has taken away my confidence. Everyone I know has told me I am not me anymore. A couple of times I have thought about taking antidepressants.’
The financial impact of FtP investigations can also be devastating. ‘My partner said we are going to have to put the house on the market,’ the senior nurse continues, explaining she has used her children’s savings to pay the mortgage. With four children to feed and clothe, she has run up thousands of pounds in credit card debt, and has had to work as a cleaner to pay bills.
Another nurse undergoing NMC proceedings, who also did not wish to be identified, says the regulator should refer nurses under investigation to counselling services. She points out there is information and financial support for witnesses to attend NMC hearings, but that the subjects of referrals do not qualify for the same treatment.
Ability to defend
‘If hearings are far away, the ability of people [without money to travel] to defend themselves is affected,’ she says.
The nurse says has been given diazepam because she cannot sleep and thinks that she cannot move on with her life until the case is resolved.
‘It’s not so much the hurt, guilt and shame, but that it has stopped my clinical progression because I cannot work in the area I want to,’ she says. ‘There are no conditions on my practice, but every time I apply for a job, I have to tell them I have been referred to the NMC.’
Band 5 adult nurse Dani Gray was dismissed from her job in 2010 on the grounds of gross misconduct after she had been qualified for two years.
The ensuing fitness to practise (FtP) case continued for six years until its conclusion in January, when all Ms Gray’s conditions to practise were removed and she was given a ‘clean’ PIN.
For Ms Gray, however, a successful closure did not make up for her ordeal, and she thinks that the Nursing and Midwifery Council should do more to direct nurses to sources of support.
She says she effectively stopped working and the financial burden became hard to bear.
She also says it was difficult coming to terms with still being in a band 5 job when she had expected to be much further along her career pathway.
During the six-year process, Ms Gray was diagnosed with a neurological disorder, which her GP directly linked to the stress of the NMC proceedings.
Ms Gray is part of a private online support group set up by and for nurses going through NMC FtP proceedings.
‘Everyone in the group says they feel the same,’ she says.
‘A lot of them have been diagnosed with depression and one with post-traumatic stress disorder.
‘The NMC does not know how FtP proceedings affect you and your family. You are constantly thinking: “Do people know about me?” It feels awful and shameful, and it makes you want to hide away.’
Ms Gray says the regulator should improve how it communicates with nurses who are under investigation.
‘This is a big issue,’ she says, explaining that she waited a year after her referral to get a hearing date.
‘Waiting for a hearing can take months and there is no correspondence from the NMC on the proceedings.
‘I get the feeling the NMC does not care about you [as an individual]; they even refer to you as a “respondent” and entirely dehumanise you.’