With responsibility comes vulnerability
The Medical Defence Union warns that as nurses take on more responsibilities, they are more vulnerable to complaints and clinical negligence cases. Advanced nurse practitioners are advised to work within their competence, communicate clearly and apologise when things go wrong.
Last year MDU’s nurse practitioner members reported 25 clinical negligence claims arising from their practice – up from two a decade earlier. The organisation has dealt with more than 400 issues involving nurse practitioners in the past five years.
There has been a steep rise in complaints against nurse practitioners, with wrong or delayed diagnosis as the most common reason
Wrong or delayed diagnosis was the most common reason, featuring in three out of ten complaints and 40% of claims. This was followed by delayed referrals and prescribing errors. One case involved a payout of more than £2 million for a patient who had a stroke after being prescribed a contraceptive. Other nurses have faced allegations of failing to diagnose serious conditions, such as meningitis or malignant melanoma.
MDU medico-legal adviser Beverley Ward says: ‘It is well known that complaints and claims against GPs are increasing year-on-year, but the rise is even steeper among nurse practitioners working in primary care.’
As more people are living longer and more patients with long-term conditions are being managed in primary care, nurse practitioners are shouldering greater responsibility to cope with rising demand. ‘However, in taking on roles such as assessing and diagnosing patients, prescribing medicines, and running minor injury clinics, nurse practitioners are also at an increased risk of patients holding them individually accountable if something goes wrong,’ says Dr Ward.
But in its guide to advanced nursing practice, the RCN suggests that ANPs are no more likely to be subject to claims of negligence than any other nurses. Revised in 2012, the guidance says: ‘The risk to the ANP, like all other nurses, is dictated by the extent to which any practitioner is able to acknowledge their own limitations regarding advanced competences and knowledge, and sets limits to their own practice. These principles apply to any registered nurse, regardless of their level of practice.’
RCN ANP forum chair Wendy Fairhurst believes that the large increase in the number of ANPs, particularly compared with ten years ago, is a key issue that helps to explain the MDU’s figures. ‘We’ve had a huge rise in our membership, reflecting the fact that more ANPs are now practising, with many more in GP surgeries,’ she says.
So what should ANPs do to avoid getting into difficulties? The MDU advises:
Keep your knowledge up to date and work within your level of competence.
If there is doubt about a diagnosis, get advice from a colleague or refer the patient for further investigations or treatment.
Clearly communicate with patients, explaining what you are doing and why. Check the patient has understood and ensure they know under what circumstances and time frame to seek further medical care.
Tell patients about the risks, benefits and alternative options open to them – including the option of doing nothing – so they can make an informed choice.
Keep a record of all discussions with patients, including those over the phone. Record positive as well as negative findings.
If things go wrong, apologise to the patient. Explain what has happened and what can be done to rectify it.
In addition, the RCN guidance says: ‘Meticulous practice, good record-keeping, a thorough educational preparation, ongoing self-assessment, and critical appraisal with colleagues, are all essential.’
‘I don’t think people understand exactly what we do. It’s confusing for the public,’ says RCN ANP forum chair Wendy Fairhurst. ‘There’s no standardised training, so an ANP in one part of the country may have had a completely different educational preparation from an ANP in another.’
To try to address the problem, the RCN is devising a voluntary credentials system, although it is still in the early stages of development. There is also broad agreement that preparation should include a master’s degree level academic programme, alongside time to develop advanced skills, with the support of a clinical mentor. ANPs work in primary and secondary care, for example emergency departments, paediatrics and cancer care. According to the RCN’s guidance, the level of practice at which ANPs work encompasses:
Making autonomous decisions for which they are accountable.
Treating patients with undifferentiated and undiagnosed problems, and making an assessment of their healthcare needs based on physical examination, diagnosis, prescribing and referring.
Screening patients for disease risk factors and early signs of illness.
Making differential diagnoses using skills in decision making and problem solving.
Ordering necessary investigations.
Admitting or discharging patients from their own caseload and referring them to other healthcare providers, as appropriate.
Providing a leadership and consultancy function as needed.
Every nurse must also self-declare that they hold an appropriate indemnity arrangement, when applying to join the Nursing and Midwifery Council register or renewing their registration. This can be either in your own right or through your employer, says the NMC.
Since July 2014, the RCN’s indemnity scheme has not applied to a member’s work carried out under a contract of employment, because it says this should be covered by the employer’s own arrangements.
‘Nurses should expect their employers to do this – it’s part of being a responsible employer,’ says Ms Fairhurst.