Debate: Staff substitution

Registered nurses are obliged by the Nursing and Midwifery Council (NMC) to ensure that they are competent to remain on the Register. Having undertaken a period of pre-registration education, a nurse registers with the NMC and may then call themselves a ‘Registered Nurse’. For the rest of their career they will need to maintain their competence to be on the Register.

Once a nurse starts their career they will generally move towards working in clinical areas where they have a particular interest. They will ‘manage’ their career with a view to progressing in their chosen clinical speciality. This means that many nurses will see themselves as competent in a particular field of nursing and less competent in others.

While all nurses will retain an acute understanding of their professional commitments to patients and the need to maintain public trust in the profession, this does not mean they would be clinically competent in areas outside their sphere of professional practice. For example, a nurse who has developed a career in General Surgical Nursing may not feel sufficiently confident to suddenly undertake a role in an acute medical unit or on a care of the elderly unit.

At a time when there is a clear shortfall in the number of nurses in the service, employers may wish to ‘flex’ their staff. For example, this might mean moving them between clinical areas in times of shortage rather than make the more difficult decision (in their eyes) to close beds or close units. Such an approach is often taken in the belief that ‘a nurse is a nurse is a nurse’. If there is full consultation with the nurse involved and appropriate training and development is provided, then the risks will be minimalised. If, on the other hand, no such support or engagement is provided, it exposes the individual nurse and the patients they care for to some risk.

Anecdotally it has been said that nurses who express a professional concern about such requests and refuse to move have been threatened with disciplinary action. It has also been suggested that by refusing to move they have put patients at risk.

Registered nurses are required by the NMC to put the interests of patients first. The Code requires them to make known to their managers any concerns they have in respect of patient care. They are also reminded that they should acknowledge the limits of their own professional competence and not work beyond them. Another difficulty in these situations is that, in most cases, it is a fellow registered nurse – who is also bound by NMC requirements – who is making the request. It can be difficult for nurses to challenge a senior nurse’s authority.

If a nurse accepts a move to a clinical area where they do not feel competent, their personal and professional safety might be at risk because they are working in an unfamiliar environment, with unfamiliar equipment, in unfamiliar clinical conditions and with unfamiliar processes and procedures. If a problem develops and a complaint is made to their employer or the NMC, they will have to defend their practice not on their past clinical competence but on their competence in that particular environment and with patients with that particular condition.

The RCN in Northern Ireland has been raising concerns with the Department of Health and employers over many years about the casual redeployment of nursing staff within the context of a broader range of workforce issues. In 2013, the RCN in Northern Ireland published a position statement on the use of nurse banks, which stated that the RCN does not support, and has called for a review of, the deployment of registered nurses and health care support staff via the nurse bank to clinical areas for which they may not have the required skills to practise. The RCN also highlighted the responsibility of employers to provide adequate induction, supervision and continuing professional development for nursing staff who are deployed in this way.

In Wales, the Nurse Staffing Levels (Wales) Act 2016 (Parliament, 2016) clearly evidences the need for staffing establishments to be based on a triangulated approach including professional judgement, to enable the provision of sensitive care. Registrants must be supported to work within the field of practice in which they are registered, to maximise the opportunity to provide safe and sensitive care. The statutory guidance relating to the duty for health boards and NHS Trusts to calculate and maintain nurse staffing levels in adult acute medical and surgical inpatient wards comes into effect from April 2018. 

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