The fitness to practise process demystified: what every nurse and manager needs to know

FtP referral is distressing, but understanding what to expect can help you feel prepared

FtP referral is distressing, but understanding what to expect can help you feel prepared

  • Referral to the NMC is one of the most worrying things that can happen during a nurse, nursing associate or midwifes career
  • Its important to bear in mind the FtP process is calibrated, and very few cases go as far as a strike-off order
  • Expert advice on what to do if you have been referred or if you are the registrants manager
Picture: Charles Milligan

Every year, the Nursing and Midwifery Council (NMC) receives more than 5,000 complaints about nurses, midwives and nursing associates.

Each case needs to be considered via the regulators fitness to practise (FtP) process to


FtP referral is distressing, but understanding what to expect can help you feel prepared

  • Referral to the NMC is one of the most worrying things that can happen during a nurse, nursing associate or midwife’s career
  • It’s important to bear in mind the FtP process is calibrated, and very few cases go as far as a strike-off order
  • Expert advice on what to do if you have been referred – or if you are the registrant’s manager
Picture: Charles Milligan

Every year, the Nursing and Midwifery Council (NMC) receives more than 5,000 complaints about nurses, midwives and nursing associates.

Each case needs to be considered via the regulator’s fitness to practise (FtP) process to decide if the registrant should be allowed to continue to work in the same way as they have been.

But what effect does this have on the nurse who has been referred and their manager – and what kind of support should the manager provide to the registrant ?

What is fitness to practise?

All registrants must uphold the professional standards set out in the NMC code.

The NMC will investigate whether someone on its register is fit to practise if an allegation is made that they do not meet the standards required for skills, education and behaviour. Only 0.8% of the register – about eight in every 1,000 registrants – is ever investigated.

Who can refer a nurse to the NMC?

Anyone can raise a concern about a nurse if they feel an individual patient or public safety may be at risk: a patient, member of the public, a manager or employer, a colleague, the police, or a health or care regulator. It could even be the nurse themselves.

What kind of concerns should be raised with the NMC?

The regulator investigates serious concerns that could put patient safety at risk or undermine public confidence in the nursing and midwifery professions.

This could include abuse of professional position, such as conducting a sexual relationship with a patient or service user, discrimination, serious or repeated mistakes in patient care, conviction for serious criminal offences, violence, dishonesty or fraud, serious breaches of patient confidentiality, health concerns including addiction, and safety concerns in relation to English language skills.

Will I know if a member of my team is referred?

The NMC contacts the nurse who is the subject of the complaint, and asks if they want to comment on it.

The regulator generally engages with the registrant’s employer when a referral is received, but unless an interim order has been issued against their practice while the NMC investigates the complaint, nurses are not necessarily obliged to share their referral with their employer or manager.

‘Nurse managers need to understand the trauma of NMC referral’

Going through the fitness to practise (FtP) process is a challenging experience for the nurse referred.

The NMC says it is important that employers – who have a duty of care to their team members – encourage their staff to engage with the process to enable the regulator to understand and resolve the issue as quickly as possible.

Cathryn Watters of NMC Watch, which supports nurses and midwives who have been accused of misconduct, has been through FtP proceedings herself and says a supportive and understanding manager can make a huge difference.

Nurse Cathryn Watters of NMC Watch

‘Managers need to understand just how traumatic the process can be,’ she says.

‘Someone going through the process will probably not be fully functioning, they will tend to have good days and bad days. The nurse they see may not be the nurse they would be normally.

‘There might need to be some realistic conversations about what kind of impact it is having, and around the expectations of what they can achieve work-wise. The registrant will be loath to appear like they are not coping, but they are very vulnerable.’

Empathy will help the registrant cope

Empathy and good management skills will go a long way to helping a nurse going through the process, she says.

Managers need to be aware that the impact can go on for a long time, even after the case is closed.

‘The affect on confidence, the paranoia and the ongoing fear of making a mistake does not go away quickly,’ says Ms Watters. ‘There are long-term psychological effects from referral and the process. Even if there is no case to answer, registrants feel lost, let down and lacking in confidence, with some elements of post-traumatic stress disorder.’

Emotional support service

The NMC’s annual 2018-19 report revealed that four nurses were recorded as having died by suicide in 2018-19, while under FtP investigation. Registrants going through the process now have access to a free emotional support service established by the NMC in 2019.

The confidential 24-hour Careline service can provide counselling sessions, delivered face to face, via phone or Skype, or online using email or a secure chat room.

NMC deputy director of professional regulation Clare Strickland says: ‘We know being referred to our FtP process can have a significant impact on the health and well-being of those involved, which is why it’s important we continue to work with employers to support those involved.’

The RCN says it can point members to services that offer help, including immigration, employment legal advice and financial support.

Call the NMC’s FtP Careline on 0800 587 7396 or the Samaritans on 116 123.

I have been referred to the NMC – what is the first thing I should do?

Rebecca Siegle, RCN senior legal officer

The fitness to practise process is complex and daunting, and a registrant’s first phone call should be to access sound legal advice, the RCN says.

‘Being referred to the regulator is incredibly distressing for a nurse, whether or not they have done anything wrong,’ says Rebecca Siegle, senior legal officer at the RCN. ‘Time is of the essence. We have various opportunities to shape and direct investigations.’

Cathryn Watters, nurse and founder of NMCWatch, which supports registrants going through FtP, says: ‘Don’t do it alone – contact us as we have all been through it and understand the impact.’

Should a manager engage with the process?

The NMC says if an allegation arises from a nurse’s practice with an employer, it is important managers engage with the process and are prepared to provide information requested quickly, so cases can progress as efficiently as possible.

If an allegation arises about a nurse’s practice outside their employer, the NMC will still usually be in touch to ask the employer to provide details about their current practice.

The regulator may ask if the nurse has told their employer about the allegation, and whether the employer has any concerns about the nurse’s ability to practise safely in light of the allegation.

Picture: iStock

It is helpful if the employer can share with the NMC any information it may have that the registrant has reflected on the issue relating to their referral, has insight into it, and has taken action to remedy it, the regulator says.

NMC deputy director of professional regulation Clare Strickland says: ‘We encourage managers to play their part in helping us resolve issues safely and efficiently by supporting any member of their team going through FtP. Managers can encourage them to engage with our processes, reflect on their practice, and take steps to remediate concerns raised.’

What happens at the screening stage?

Screening is the first step the NMC takes after it receives a complaint, although officers may already have spoken to employers seeking advice on whether a complaint needs to be made.

NMC Watch’s Ms Watters urges managers to consider whether a complaint needs to be made at all, or whether the registrant could be supported in other ways. ‘Often a series of things have happened that lead to the issue that leads to a complaint. In one case, a newly qualified staff nurse made some drug errors, but she had had no induction, was put on a busy ward where she was the most senior member of staff, and she was asking for help. Instead of referral, she needed support, mentorship and maybe some extra training.’

Picture: Charles Milligan

When a complaint is made, the regulator checks whether it meets the threshold criteria to take it further: whether the concerns are serious enough; if it meets formal requirements. Next, the regulator establishes whether it can obtain credible evidence, and finally, it considers whether the issue can be considered already settled if the registrant can demonstrate they have already remedied it. In most cases, referrals end here.

How can a nurse show they have remedied any issues?

Even if the case meets the criteria to move to the next stage, managers should know nurses may prevent this by showing they have acted to ensure the issue in question does not recur. If registrants submit evidence of having reflected on the issue, or undertaken extra training, the NMC may consider risk to the public has subsided and close the case.

What is an interim order?

If a case is considered serious enough, an FtP panel can impose an interim order on the registrant while the investigation continues. This could be an order to suspend practice, or a conditions of practice order that limits how a nurse can work, for example only allowing practice under supervision or requiring certain aspects of practice to be avoided.

The nurse is responsible for notifying their employer immediately if an interim order is imposed. Where conditions are imposed, there will almost always be a condition requiring the nurse to inform their employer of those conditions.

The employer should review the conditions with the registrant, contacting the NMC if they have any questions.

How are concerns investigated?

The NMC usually begins by seeking documentary evidence of the facts. Investigators speak to the parties involved. The nurse is always asked to provide information at the beginning and end of the investigation.

Picture: iStock

Officials also speak to referrers, employers and witnesses to gain a full picture of what is alleged to have happened and how serious it was. Any official witness statements will be passed to the registrant.

If the issue involves the nurse’s health, the NMC will contact the GP, and may ask the nurse to undergo a medical examination.

If English language skills are the concern, the registrant is likely to be asked to take a written language test.

The case examiner

Once an investigation is complete, a case examiner will decide what will happen to the case. They do not decide whether the case is proved or if the nurse is fit to practise.

But they do decide whether or not there is a case to answer, and if there is a realistic possibility the FtP committee would decide the alleged incidents did happen, or that the concerns – the registrants health, for example, are still valid and that the nurse’s, midwife’s or nursing associate’s fitness to practise is currently impaired.

If they decide there is no case to answer, they can still offer the registrant advice or issue a warning to them. If they deem there is a case to answer, they can resolve it by recommending undertakings with the nurse, including restrictions on practice and rehabilitative steps. Or they can refer the case to the FtP committee.

What happens with the committee?

The case still does not have to end with a full hearing.

If there is no disagreement between the nurse and the NMC about the critical issues, the case will generally be sent to a private meeting of the committee.

The committee is a three-person panel, one of whom is a nurse or midwife. It has the same powers whether it is a meeting or a hearing.

A case is most likely to move to a full hearing to resolve central aspects of a case that the regulator and nurse don’t agree on.

What are the possible outcomes if the panel decides FtP is impaired?

The panel can decide to take no further action or impose a caution order – which imposes no practice restrictions, or a conditions of practice order – which impose practice restrictions for a period of time. Other orders are a suspension order, prohibiting the registrant from practising for a period of time, and, most seriously, a striking-off order.

The nurse can apply for voluntary removal from the register at any time during the Fitness to Practise process, including during a final hearing.

How long does the process take?

This depends on what level of the process the complaint reaches. The NMC seeks to deal with the complaint at the earliest possible point. If the referral runs through to a full hearing it can take 15 months, but the vast majority do not get this far.

Can the registrant appeal against the decision?

A nurse can appeal in court within 28 days. In the case of a final substantive order, nurses in England and Wales appeal to the High Court, in Scotland, the Court of Session and to the High Court Justice if they are in Northern Ireland.

Further information

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