NMC
Regulator / Inspectorate
Noted
The Nursing and Midwifery Council outlines existing standards and processes related to DNACPR understanding and fitness to practise, without describing new actions taken or planned. (AI summary)
View full response
Dear Mr Craze
Prevention of Future Deaths Report following the Inquest into the death of the late Robert George Murray
Thank you for sharing your Prevention of Future Deaths Report (which I refer to as the ‘Report’), and for giving us an opportunity to respond to the important concerns that you have raised.
Before I address the concerns in your Report, I would like to extend my deepest sympathy to Mr Murray’s family and friends.
In your Report you identified the following as a matter of concern:
“From listening to the 999 call between the registered nurse at the care home and the call operator, and also from evidence heard at the inquest, it is apparent that no one involved understood that there are circumstances when the DNACPR should not be applied. I am concerned that this may potentially be an issue elsewhere in the country and further training and clarification is therefore necessary.”
You have asked us to respond to this concern and have specifically identified further training and clarification about the circumstances in which DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) notices should not be applied is necessary across the country.
I would like to provide you with some assurance about how our standards of proficiency for registered nurses, our Code1 and our revalidation process2 require registered nurses
1 A link to our Code: https://www.nmc.org.uk/standards/code/ 2 A link to our Revalidation information: https://www.nmc.org.uk/revalidation/
to understand the requirements of DNACPR notices. This letter therefore provides information about:
• Our role as a regulator and how we set and maintain the standards of education and training to ensure safe, effective and kind nursing care.
• Our standards of proficiency (which all nurses must meet to be able to join our register), which includes specific standards that relate to the knowledge, skills and experience that a registered nurse must have about end of life care and DNACPRs.
• The requirements of registered professionals throughout their practice including an explanation of how, once a registered nurse has joined our register, they are expected to maintain their knowledge and skills in line with their scope of practice, in accordance with our Code and through our revalidation process.
Our role
Our vision is safe, effective and kind nursing and midwifery that improves everyone’s health and wellbeing. As the professional regulator of almost 745,000 nursing and midwifery professionals, we have an important role to play in making this a reality.
Our core role is to regulate. First, we promote high education and professional standards for nurses and midwives across the UK, and nursing associates in England. Second, we maintain the register of professionals eligible to practise. Third, we investigate concerns about nurses, midwives and nursing associates. We believe in giving professionals the chance to address concerns, but we’ll always take action when needed.
Our role in undergraduate education for nursing professionals
Nurses who wish to practise in the UK must be registered with us. Those who apply to be registered with us must meet the standards of proficiency3 necessary for safe and effective practice and additional requirements for registration, for example our health and character requirements.
Nursing and midwifery professionals can demonstrate that they have met these standards of proficiency by completing approved qualifications as part of a pre- registration education programmes that have been approved by us in the UK. We set wider standards for nursing and midwifery education and programme standards4 which enable our approved education institutions to deliver programmes related to the relevant standards of proficiency. The approved education institutions will design their curriculums to be able to meet our standards. We approve programmes and monitor the education institutions and their programme delivery as part of our Quality Assurance
3 The standards of proficiency for registered nurses can be found here:
4 Our standards for education and training can be found here: https://www.nmc.org.uk/standards-for- education-and-training/ and our standards for pre-registration nursing programmes can be found here:
programmes/
activities. Our responsibilities and powers are set out in the Nursing and Midwifery Order 2001 and accompanying Privy Council Orders and Rules5. We explain below how our standards of proficiency for registered nurses and the standards within our Code address the concerns you have raised in your Report.
Future Nurse: Standards of Proficiency for registered nurses
In 2016 we embarked on a significant programme of change in relation to all of our education and training standards, which has included revising our standards of proficiency for registered nurses and midwives to strengthen public protection and continue to make sure that they are fit for purpose. We introduced new standards of proficiency for registered nurses in 2018 (described as the Future Nurse standards6).
The Future Nurse standards were approved by our Council following extensive consultation and engagement over a two year period. All pre-registration programmes in the UK have been approved against the new Future Nurse standards. We expect the first nurses will graduate under these new standards in 2022.
Future Nurse: Standards of Proficiencies relevant to end of life care and DNACPRs
In our Future Nurse Standards, we include proficiencies that relate to the person– centred care and decision-making for people at the end of life and the involvement, support and care of their families. The following standards are relevant:
“At the point of registration, a registered nurse must be able to:
3.14 identify and assess the needs of people and families for care at the end of life, including requirements for palliative care and decision making related to their treatment and care preferences
3.15 demonstrate the ability to work in partnership with people, families and carers to continuously monitor, evaluate and reassess the effectiveness of all agreed nursing care plans and care, sharing decision making and readjusting agreed goals, documenting progress and decisions made, and
3.16 demonstrate knowledge of when and how to refer people safely to other professionals or services for clinical intervention or support…
…4.9 demonstrate the knowledge and skills required to prioritise what is important to people and their families when providing evidence-based person- centred nursing care at end of life including the care of people who are dying, families, the deceased and the bereaved
4.10 demonstrate the knowledge and ability to respond proactively and promptly to signs of deterioration or distress in mental, physical, cognitive and behavioural health and use this knowledge to make sound clinical decisions.”
5 Details about the legislation that governs us can be found here: https://www.nmc.org.uk/about- us/governance/our-legal-framework/our-order-and-rules/ 6 ‘Future Nurse: standards of proficiency’, published May 2018
The Future Nurse Standards includes communication and relationship management skills and nursing procedures that at the point of registration, a registered nurse will be able to do. The relevant sections related to end of life care and use of DNACPRs is below:
“10. Use evidence-based, best practice approaches for meeting needs for care and support at the end of life, accurately assessing the person’s capacity for independence and self-care and initiating appropriate interventions
10.1 observe, and assess the need for intervention for people, families and carers, identify, assess and respond appropriately to uncontrolled symptoms and signs of distress including pain, nausea, thirst, constipation, restlessness, agitation, anxiety and depression
10.2 manage and monitor effectiveness of symptom relief medication, infusion pumps and other devices
10.3 assess and review preferences and care priorities of the dying person and their family and carers
10.4 understand and apply organ and tissue donation protocols, advanced planning decisions, living wills and health and lasting powers of attorney for health
10.5 understand and apply DNACPR (do not attempt cardiopulmonary resuscitation) decisions and verification of expected death 10.6 provide care for the deceased person and the bereaved respecting cultural requirements and protocols.”
(Excerpt from Annexe B: Nursing Procedures, Future Nurse: Standards of Proficiency)
Education institutions are expected to ensure the curriculum they design allow the students to achieve the above standards of proficiency. We therefore expect registered nurses at the point of registration to have the knowledge and skills of DNACPRs as part of their pre-registration education.
Our Code
I note that you have not specifically asked about our Code and have focussed on our education standards. However, I think it is helpful to understand our expectations regarding the standards and behaviours for nurses who have entered our register and what we would expect that a nurse who was involved in Mr Murray’s care should consider.
Once admitted to our register, professionals are required to meet the requirements of our Code7. The Code details professional practice and behaviours that all of our
7 https://www.nmc.org.uk/standards/code/read-the-code-online/
professionals must meet and reflect upon as part of their revalidation and renewal of their registration every three years8.
The Code requires nurses and midwifery professionals to prioritise people and the decisions they make in relation to their care, make timely referrals when there is a worsening condition and act within the relevant policies about protecting and caring for vulnerable people. I highlight the following sections of the Code:
“1.1 treat people with kindness, respect and compassion …
..2.5 respect, support and document a person’s right to accept or refuse care and treatment
6 Always practise in line with the best available evidence …6.2 maintain the knowledge and skills you need for safe and effective practice
…13.1 accurately identify, observe and assess signs of normal or worsening physical and mental health in the person receiving care
13.2 make a timely referral to another practitioner when any action, care or treatment is required
13.3 ask for help from a suitably qualified and experienced professional to carry out any action or procedure that is beyond the limits of your competence…
…15.1 only act in an emergency within the limits of your knowledge and competence
…15.2 arrange, wherever possible, for emergency care to be accessed and provided promptly
…17.3 have knowledge of and keep to the relevant laws and policies about protecting and caring for vulnerable people”
We recognise that nurses use their professional judgement with reference to the relevant provisions of the Code (outlined above) to make decisions based on evidence and often in difficult and complex situations. The Code supports their professional practice and on the rare occasions when things go wrong, they are expected to be open and honest (the duty of candour9) and reflect on what they do well and what they can do better and how they learn from their mistakes.
Employers also play an important role in ensuring that the nurses they employ understand local policies and procedures, and support the development of the professionals they employ.
In some instances, a nurse’s conduct may result in a fitness to practise referral. Where a concern is raised about a nurse’s fitness to practise, we determine whether their skills,
8 Article 10 of the Nursing and Midwifery Order 2001 9 A link to our joint guidance with the General Medical Council on the duty of candour:
knowledge, education or behaviour fall below the standards needed to deliver safe, effective and kind care. Fitness to practise cases can include allegations about misconduct (where a professional’s conduct may fall seriously short of the expectations in the Code) or lack of competence (which would usually involve an unacceptably low standard of professional performance). We also take account of the context in which the nurse, midwife or nursing associate was practising when deciding whether there is a risk to patient safety that requires us to take regulatory action. We believe in giving professionals the chance to address concerns about their fitness to practise, but we will always take regulatory action where appropriate. This can include removing people from our register in the most serious cases10.
Furthermore as part of their revalidation, nurses on our register are required to meet standards of continuing professional development which include education, training and reflection against their scope of practice. Revalidation is something that nursing and midwifery professionals must do every three years, and is necessary to maintain their registration.
Further information
I note that you have not raised any specific concerns about specific nurses in your report. If you do have any concerns about an individual’s fitness to practise, please let us know.
I hope this letter provides you with information about our nursing standards and the steps and the work we do to minimise the risk of deaths occurring as a result of any potential gaps in the knowledge and skills for registered nurses, midwives and nursing associates.
Once more I would like to offer my deepest sympathy to Mr Murray’s family and friends.
Prevention of Future Deaths Report following the Inquest into the death of the late Robert George Murray
Thank you for sharing your Prevention of Future Deaths Report (which I refer to as the ‘Report’), and for giving us an opportunity to respond to the important concerns that you have raised.
Before I address the concerns in your Report, I would like to extend my deepest sympathy to Mr Murray’s family and friends.
In your Report you identified the following as a matter of concern:
“From listening to the 999 call between the registered nurse at the care home and the call operator, and also from evidence heard at the inquest, it is apparent that no one involved understood that there are circumstances when the DNACPR should not be applied. I am concerned that this may potentially be an issue elsewhere in the country and further training and clarification is therefore necessary.”
You have asked us to respond to this concern and have specifically identified further training and clarification about the circumstances in which DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) notices should not be applied is necessary across the country.
I would like to provide you with some assurance about how our standards of proficiency for registered nurses, our Code1 and our revalidation process2 require registered nurses
1 A link to our Code: https://www.nmc.org.uk/standards/code/ 2 A link to our Revalidation information: https://www.nmc.org.uk/revalidation/
to understand the requirements of DNACPR notices. This letter therefore provides information about:
• Our role as a regulator and how we set and maintain the standards of education and training to ensure safe, effective and kind nursing care.
• Our standards of proficiency (which all nurses must meet to be able to join our register), which includes specific standards that relate to the knowledge, skills and experience that a registered nurse must have about end of life care and DNACPRs.
• The requirements of registered professionals throughout their practice including an explanation of how, once a registered nurse has joined our register, they are expected to maintain their knowledge and skills in line with their scope of practice, in accordance with our Code and through our revalidation process.
Our role
Our vision is safe, effective and kind nursing and midwifery that improves everyone’s health and wellbeing. As the professional regulator of almost 745,000 nursing and midwifery professionals, we have an important role to play in making this a reality.
Our core role is to regulate. First, we promote high education and professional standards for nurses and midwives across the UK, and nursing associates in England. Second, we maintain the register of professionals eligible to practise. Third, we investigate concerns about nurses, midwives and nursing associates. We believe in giving professionals the chance to address concerns, but we’ll always take action when needed.
Our role in undergraduate education for nursing professionals
Nurses who wish to practise in the UK must be registered with us. Those who apply to be registered with us must meet the standards of proficiency3 necessary for safe and effective practice and additional requirements for registration, for example our health and character requirements.
Nursing and midwifery professionals can demonstrate that they have met these standards of proficiency by completing approved qualifications as part of a pre- registration education programmes that have been approved by us in the UK. We set wider standards for nursing and midwifery education and programme standards4 which enable our approved education institutions to deliver programmes related to the relevant standards of proficiency. The approved education institutions will design their curriculums to be able to meet our standards. We approve programmes and monitor the education institutions and their programme delivery as part of our Quality Assurance
3 The standards of proficiency for registered nurses can be found here:
4 Our standards for education and training can be found here: https://www.nmc.org.uk/standards-for- education-and-training/ and our standards for pre-registration nursing programmes can be found here:
programmes/
activities. Our responsibilities and powers are set out in the Nursing and Midwifery Order 2001 and accompanying Privy Council Orders and Rules5. We explain below how our standards of proficiency for registered nurses and the standards within our Code address the concerns you have raised in your Report.
Future Nurse: Standards of Proficiency for registered nurses
In 2016 we embarked on a significant programme of change in relation to all of our education and training standards, which has included revising our standards of proficiency for registered nurses and midwives to strengthen public protection and continue to make sure that they are fit for purpose. We introduced new standards of proficiency for registered nurses in 2018 (described as the Future Nurse standards6).
The Future Nurse standards were approved by our Council following extensive consultation and engagement over a two year period. All pre-registration programmes in the UK have been approved against the new Future Nurse standards. We expect the first nurses will graduate under these new standards in 2022.
Future Nurse: Standards of Proficiencies relevant to end of life care and DNACPRs
In our Future Nurse Standards, we include proficiencies that relate to the person– centred care and decision-making for people at the end of life and the involvement, support and care of their families. The following standards are relevant:
“At the point of registration, a registered nurse must be able to:
3.14 identify and assess the needs of people and families for care at the end of life, including requirements for palliative care and decision making related to their treatment and care preferences
3.15 demonstrate the ability to work in partnership with people, families and carers to continuously monitor, evaluate and reassess the effectiveness of all agreed nursing care plans and care, sharing decision making and readjusting agreed goals, documenting progress and decisions made, and
3.16 demonstrate knowledge of when and how to refer people safely to other professionals or services for clinical intervention or support…
…4.9 demonstrate the knowledge and skills required to prioritise what is important to people and their families when providing evidence-based person- centred nursing care at end of life including the care of people who are dying, families, the deceased and the bereaved
4.10 demonstrate the knowledge and ability to respond proactively and promptly to signs of deterioration or distress in mental, physical, cognitive and behavioural health and use this knowledge to make sound clinical decisions.”
5 Details about the legislation that governs us can be found here: https://www.nmc.org.uk/about- us/governance/our-legal-framework/our-order-and-rules/ 6 ‘Future Nurse: standards of proficiency’, published May 2018
The Future Nurse Standards includes communication and relationship management skills and nursing procedures that at the point of registration, a registered nurse will be able to do. The relevant sections related to end of life care and use of DNACPRs is below:
“10. Use evidence-based, best practice approaches for meeting needs for care and support at the end of life, accurately assessing the person’s capacity for independence and self-care and initiating appropriate interventions
10.1 observe, and assess the need for intervention for people, families and carers, identify, assess and respond appropriately to uncontrolled symptoms and signs of distress including pain, nausea, thirst, constipation, restlessness, agitation, anxiety and depression
10.2 manage and monitor effectiveness of symptom relief medication, infusion pumps and other devices
10.3 assess and review preferences and care priorities of the dying person and their family and carers
10.4 understand and apply organ and tissue donation protocols, advanced planning decisions, living wills and health and lasting powers of attorney for health
10.5 understand and apply DNACPR (do not attempt cardiopulmonary resuscitation) decisions and verification of expected death 10.6 provide care for the deceased person and the bereaved respecting cultural requirements and protocols.”
(Excerpt from Annexe B: Nursing Procedures, Future Nurse: Standards of Proficiency)
Education institutions are expected to ensure the curriculum they design allow the students to achieve the above standards of proficiency. We therefore expect registered nurses at the point of registration to have the knowledge and skills of DNACPRs as part of their pre-registration education.
Our Code
I note that you have not specifically asked about our Code and have focussed on our education standards. However, I think it is helpful to understand our expectations regarding the standards and behaviours for nurses who have entered our register and what we would expect that a nurse who was involved in Mr Murray’s care should consider.
Once admitted to our register, professionals are required to meet the requirements of our Code7. The Code details professional practice and behaviours that all of our
7 https://www.nmc.org.uk/standards/code/read-the-code-online/
professionals must meet and reflect upon as part of their revalidation and renewal of their registration every three years8.
The Code requires nurses and midwifery professionals to prioritise people and the decisions they make in relation to their care, make timely referrals when there is a worsening condition and act within the relevant policies about protecting and caring for vulnerable people. I highlight the following sections of the Code:
“1.1 treat people with kindness, respect and compassion …
..2.5 respect, support and document a person’s right to accept or refuse care and treatment
6 Always practise in line with the best available evidence …6.2 maintain the knowledge and skills you need for safe and effective practice
…13.1 accurately identify, observe and assess signs of normal or worsening physical and mental health in the person receiving care
13.2 make a timely referral to another practitioner when any action, care or treatment is required
13.3 ask for help from a suitably qualified and experienced professional to carry out any action or procedure that is beyond the limits of your competence…
…15.1 only act in an emergency within the limits of your knowledge and competence
…15.2 arrange, wherever possible, for emergency care to be accessed and provided promptly
…17.3 have knowledge of and keep to the relevant laws and policies about protecting and caring for vulnerable people”
We recognise that nurses use their professional judgement with reference to the relevant provisions of the Code (outlined above) to make decisions based on evidence and often in difficult and complex situations. The Code supports their professional practice and on the rare occasions when things go wrong, they are expected to be open and honest (the duty of candour9) and reflect on what they do well and what they can do better and how they learn from their mistakes.
Employers also play an important role in ensuring that the nurses they employ understand local policies and procedures, and support the development of the professionals they employ.
In some instances, a nurse’s conduct may result in a fitness to practise referral. Where a concern is raised about a nurse’s fitness to practise, we determine whether their skills,
8 Article 10 of the Nursing and Midwifery Order 2001 9 A link to our joint guidance with the General Medical Council on the duty of candour:
knowledge, education or behaviour fall below the standards needed to deliver safe, effective and kind care. Fitness to practise cases can include allegations about misconduct (where a professional’s conduct may fall seriously short of the expectations in the Code) or lack of competence (which would usually involve an unacceptably low standard of professional performance). We also take account of the context in which the nurse, midwife or nursing associate was practising when deciding whether there is a risk to patient safety that requires us to take regulatory action. We believe in giving professionals the chance to address concerns about their fitness to practise, but we will always take regulatory action where appropriate. This can include removing people from our register in the most serious cases10.
Furthermore as part of their revalidation, nurses on our register are required to meet standards of continuing professional development which include education, training and reflection against their scope of practice. Revalidation is something that nursing and midwifery professionals must do every three years, and is necessary to maintain their registration.
Further information
I note that you have not raised any specific concerns about specific nurses in your report. If you do have any concerns about an individual’s fitness to practise, please let us know.
I hope this letter provides you with information about our nursing standards and the steps and the work we do to minimise the risk of deaths occurring as a result of any potential gaps in the knowledge and skills for registered nurses, midwives and nursing associates.
Once more I would like to offer my deepest sympathy to Mr Murray’s family and friends.