Nurses and Reflective Writing in NMC Cases (Showing Insight)

Demonstrating Insight in NMC Cases

‘Insight’ is a key consideration in NMC fitness to practise cases. A nurse needs to demonstrate to the Nursing and Midwifery Council (NMC) that they have insight. The nurses will also have to shoe the steps that  they have taken to overcome any weaknesses in their practice or in their professional approach generally. A nurse might have no insight, little insight, emerging insight, or full insight. Depending where a nurse’s insight falls on that continuum will have an impact on how the case will be viewed by an NMC panel or case examiners, and the outcome of the case overall.

Demonstrating insight is not an easy task. Many nurses fail to grasp what is required. It is not enough to merely say sorry. Anyone can say sorry. Apologies in themselves fail to show how a nurse has reflected on their past failings and fail to demonstrate the remediation that has been embarked upon to overcome past sub-optimal practise.

The NMC likes to see how nurses have explored all issues connected with their past misconduct, poor performance, or ill-health.

A written reflection is seldom enough and it will usually need to be accompanied by other evidence that supports the nurse’s comments. A nurse therefore needs to step back and take an objective look at their past failings, so as to identify with some considerable precision how things went wrong and how the nurse might, as a consequence of reflection, reduce the risk of repetition in the future.

The types of evidence that will be required in support of a nurse will be dependent on the details contained within the NMC allegations and the bundle of evidence relied upon by the NMC. The more serious the allegation the more detailed the written reflection and supporting evidence will need to be.

The Nurses Defence Service will give detailed advice to nurses on the nature and scope of the supportive evidence to be obtained, in their case, in order to demonstrate insight and remediation. A good outcome at the NMC is dependent on the level of engagement a nurse has shown in seeking to remedy any deficiencies in their nursing practice or in their attitude to their responsibilities or their ill-health.

The following diagram may assist nurses to undertake the exercise analysing what went wrong, and how they can evidence learning and remediation.

A nurse should look at each NMC allegation separately, and work through the following flowchart of considerations, noting down in as much detail as possible why things went wrong and how the nurse views those past errors or judgement or failure to manage their past ill-health.

This flowchart below been created by one of the Nurses Defence Service’s senior lawyers, who has represented many practitioners over the past twenty years, and who advises nurses on the steps they might take to improve their overall prospects of success at the NMC.

Those nurses who are able to work through the themes set out in the flowchart below, and who take steps to improve their insight and practice more generally, will often fair better within NMC proceedings than those who do not.

The above diagram is also available in PDF format: Reflective Writing in NMC Case Diagram for printing in A4.

Working through the flowchart, the nurse must ask: why did the incident or misconduct occur? Was it because of carelessness, a good faith response (act or omission) but based on outdated nursing practice, was it criminal activity, shoddiness, not being competent, was it dishonesty, a failure to adhere to protocol, failure to keep oneself in check? There may be many reasons why a nurse falls into difficulties. On occasions it may be down to personality. Is it, by way of example, because the nurse has a deep-seated attitudinal problem? Alternatively, were they or are they still unwell? How can they manage their illness or risk of relapse in the future, so as to reassure others?

The reasons for the nurses’s poor practice or misconduct need to be identified early on. A nurse educator or mentor may be able to assist the nurse to identify where they went wrong, in some circumstances.

This approach, in turn, allows the nurse to analyse in greater detail how they might improve their skills and knowledge in the future, in order to prevent repetition. It also enables the nurse to identify (and take) the steps that will help them to overcome their shortcomings and weaknesses in their practice and their personal conduct. This is called remediation.

So, by way of example, a nurse who has not kept up to date with pressure area skin care, and who has caused harm to an unconscious patient by not implementing the minimum safeguards (or nursing interventions) that were necessary, should go on a number of courses on skin care and pressure sore prevention, and be assessed in their workplace in order demonstrate that they can practically apply their skills and knowledge to the workplace. Evidence that the nurse has improved their practice and performance might also be obtained from collagues and other clinicians.

The other concepts within the flowchart also need some consideration. If the misdemeanors or weak practices occurred over a long period of time, there is a greater risk of harm having been caused to others. The nurse must fully recognise the impact of their failings on their clients, colleagues and others, so as to remedy their shortcomings.

A nurse might write a reflective piece for stage 1, stage 2 or stage 3 of the NMC investigatory process. The reflective piece should take into account and comment on a nurse’s responsibilities pursuant to the Nursing and Midwifery Code of Conduct, the professionalism of a nurse generally or specifically (according to the nature of the NMC allegations or NMC Charges) , as well as evidencing the steps of remediation that the nurse has undertaken as a consequence of any historic failings.

‘Insight’ is not just about saying sorry. It is much more than that, and many nurses fail to properly understand the need to fully analyse what has gone wrong, in order to identify the necessary steps the nurse needs to take to remedy the problem area of practice or of poor attitude.

A nurse who is writing a reflective piece should also take into account the NMC’s Indicative Sanctions Guidance, in order to fully understand the public policy principles that underpin the NMC fitness to practise process and to identify the elements of learning that may need to be evidenced.

The nature of the allegations (or failings) may require a change of attitude or approach on the part of the nurse. The nurse may need to change their style of practise, or the way they engage with colleagues, or care for patients. The reflective piece might also need the citation of academic literature, with extracts discussed in the narrative, so as to evidence that the nurse has appropriately identified learning objectives and undertaken sufficient analysis or research of the history of events, so as to come up with a robust remediation plan. A remediation plan is like a learning plan, setting out the steps the nurse is to take to demonstrate full proficiency and insight in the area of concern.

A nurse must avoid plagiarism when writing a reflective piece. It must be their own work. Citations, with proper bibliographies, are of course wholly acceptable. The nurse should also consider the impact of their conduct on others, including the wider public, their patients, colleagues, and the profession more generally.

Nurses Defence Service lawyers can offer guidance and feedback but a nurse must undertake the work personally, as that is what the NMC demands. This is so that the nurse, if questioned by the NMC, can properly demonstrate that they have a clear understanding of the standards expected of them, and that the words in their essay belong to them, so demonstrating whether or not that have full insight, developing insight or no insight at all. A nurse who develops too little insight is likely to face more severe consequences at the NMC.

On occasions full insight might only be gained through intensive additional training or a long period of supervised practice. The nurse will need to arrange this in good time, so as to evidence engagement in the process of rehabilitation. Bespoke training can prove to be difficult to arrange in many instances. A privately instructed tutor can be of assistance on occasions, where this is the case. A reflective statement will often be bolstered where it is backed up by properly considered, independent evidence.

To be able to reply fully to the NMC’s allegations, a nurse will be likely to need clinical or other documents that are not in their possession. A prompt request should, in such circumstances, be made to the NMC case officer to obtain them, if the NMC is willing to do so. This will usually only be entertained in the event that the nurse cannot obtain the documents through their own best efforts.

This article is not an exhaustive treatment of how to reflect on past difficulties. There is an array of literature in the public domain, much online, that will assist a nurse to achieve success in their reflective efforts.

Nurses Defence Service offers guidance, support, legal advice and representation to NMC registered nurses. Nurses Defence Service also gives bespoke guidance to nurses who need to write a reflective pieces for the NMC and on remediation packages that may help a nurse return to unrestricted practice. For more information call Nurses Defence Service without obligation on: 0800 0122 506