Disciplinary processes for nurses, from organizational supervision to outcomes: A document analysis of a regulatory authority's decisions.

AIM: This study aims to explore the disciplinary processes for nurses, from organizational supervision to final decisions by the Finnish regulatory authority. BACKGROUND: Regulatory authorities are responsible for protecting the public, by ensuring that they receive safe, competent and ethical nursing care, but little is known about the disciplinary processes for nurses. METHODS: This is a retrospective document analysis of 296 disciplinary decisions by the Finnish regulatory authority from 2007 to 2016. The data were analysed using a quantitative design with descriptive statistics. RESULTS: We studied 204 disciplined nurses (81.4% female) with a mean age of 43.5 years. The disciplinary process comprised organizational supervision, complaints, investigations and decisions. Nurses with substance abuse issues were more likely to face criminal investigations and receive temporary decisions. The process lasted from under 1 month to years and could have profound effects on nurses, colleagues and nurse managers and compromise patient safety. CONCLUSION: This study identified key factors that could inform the disciplinary processes for nurses. More knowledge is needed about how organisations ensure patient safety when unprofessional conduct is suspected. IMPLICATIONS FOR NURSING MANAGEMENT: Retaining nursing professionals is vital due to global shortages, and more attention should be paid to organizational supervision and support for nurses during disciplinary processes.

[Dutch medical disciplinary law cases concerning psychiatry, 2015-2019]. / Uitspraken van regionale tuchtcolleges in zaken betreffende de psychiatrie, 2015-2019.

BACKGROUND: The aim of medical disciplinary law (as part of the Dutch law 'Wet BIG') is to safeguard the quality of professional practice in the health services. Quantitative data about Dutch medical disciplinary law is sparse: little is known about the nature, quantity and the verdicts of disciplinary law complaints against psychiatrists and residents. AIM: Gaining insight in Dutch medical disciplinary law, in particular with regard to number and nature of disciplinary law complaints against psychiatrists(-psychotherapist) and psychiatry residents. METHOD: Descriptive retrospective study. We examined all medical disciplinary law cases against psychiatrists(-psychotherapist) and psychiatry residents in the period 2015-2019. RESULTS: In the study period the regional medical disciplinary courts handled 353 cases against psychiatrists(-psychotherapist) and residents psychiatry, on average 70.6 per year. 321 of these cases were against psychiatrists and 32 against residents. Complaint density was 1.74 for psychiatrists and 0.37 for residents. Subject of most cases was 'wrong diagnosis', followed by 'wrong therapeutic plan' and 'incorrect communication'. The number of cases resulting in a disciplinary measure was on average 31%: warning (49%), reprimand (30%), (conditional) suspension (15%). In 17 cases the professional was (partially) denied to practice. CONCLUSIONS Within Dutch psychiatry little attention is paid to disciplinary law, despite the fact that psychiatrists are relatively often confronted with disciplinary law complaints. The current explorative analysis underlines the need for further research, especially on the difference between male/female psychiatrists and an international comparison with respect to complaints about (sexual) misconduct.

Experiences and outcomes of nurses referred to a peer health assistance program: Recommendations for nursing management.

AIM: To provide recommendations for nursing management based on the experiences of current and former nurses who were served by a peer health assistance program (PHAP). BACKGROUND: Providing help for nurses with impaired practice is critical to their health and well-being, assuring patient safety and public trust, as well as returning competent nurses to the healthcare workforce. METHODS: Nurses (n = 268) who were current clients or former clients of a PHAP were surveyed about their experiences. RESULTS: Nearly half of nurses were referred by the board of nursing with 69% reporting the referral was due to substance use, alcohol being the most common. Most (62%) did not believe that their substance use affected their practice yet relayed that recognition of their emotional or physical condition could have led to earlier identification. Key barriers to seeking assistance were fear and embarrassment, along with concerns about losing their nursing license. CONCLUSIONS: Nurses in management are in key roles to identify and intervene with nurses who are at risk for impaired practice. IMPLICATIONS FOR NURSING MANAGEMENT: Nurses in management and nurse colleagues would benefit from workplace education on the warning signs of impaired nursing practice and how to address it.

Key differences between severity of disciplinary issues and medical student insights.

CONTEXT: This study explores the reliability of tools designed to rate the type of remediable medical student offences, their severity, and the quality of student insight in response to the remediation, and tests the relationships between these three constructs. METHODS: Data were collected via retrospective appraisal of remediation files from the 2009-2016 incoming classes of McMaster University's medical programme. Across two studies, 12 faculty members categorised the offences by type (academic or professionalism), and rated severity and insight by way of single anchored Likert scales. In Study 1, Krippendorff's alpha and independent, two-way, consistency type, average measures (k = 6), random-effects inter-rater reliability analyses were conducted to assess the inter-rater reliability of ratings of the measures. In Study 2, independent samples t-tests were conducted for the severity and insight measures as a function of offence type. Pearson correlations were used to assess the relationship between severity and insight as a function of offence type. RESULTS: High inter-rater reliability was found with respect to the type of offence (α = 0.86), severity (0.92) and student insight (0.88). Mean (±standard deviation) ratings of severity are significantly higher for professionalism (4.37 ± 1.20) than academic offences (2.89 ± 1.25), t(73) = -5.3, p < 0.001, |d| = 1.21, whereas the opposite is true for ratings of insight, (professionalism, 3.19 ± 1.37; academic, 4.48 ± 1.01), t(73) = 4.6, p < 0.001, |d| = 1.07. Ratings of severity and insight are moderately negatively correlated for both academic (r = -0.64, p < 0.001, n = 38) and professionalism offences (r = -0.57, p < 0.001, n = 37). CONCLUSIONS: Professionalism offences are perceived as more severe and are associated with lower insight than academic offences, pointing to the difficulty that learners face in assessing the constitution of a professionalism offence. This illustrates a need for deeper consideration about remedial strategies for lapses in professionalism.

Serious Ethical Violations in Medicine: A Statistical and Ethical Analysis of 280 Cases in the United States From 2008-2016.

Serious ethical violations in medicine, such as sexual abuse, criminal prescribing of opioids, and unnecessary surgeries, directly harm patients and undermine trust in the profession of medicine. We review the literature on violations in medicine and present an analysis of 280 cases. Nearly all cases involved repeated instances (97%) of intentional wrongdoing (99%), by males (95%) in nonacademic medical settings (95%), with oversight problems (89%) and a selfish motive such as financial gain or sex (90%). More than half of cases involved a wrongdoer with a suspected personality disorder or substance use disorder (51%). Despite clear patterns, no factors provide readily observable red flags, making prevention difficult. Early identification and intervention in cases requires significant policy shifts that prioritize the safety of patients over physician interests in privacy, fair processes, and proportionate disciplinary actions. We explore a series of 10 questions regarding policy, oversight, discipline, and education options. Satisfactory answers to these questions will require input from diverse stakeholders to help society negotiate effective and ethically balanced solutions.

The Association Between Maintaining American Board of Emergency Medicine Certification and State Medical Board Disciplinary Actions.

BACKGROUND: In certain medical specialties, board certification is associated with a lower risk of state medical board disciplinary actions. OBJECTIVE: The association between maintaining American Board of Emergency Medicine (ABEM) certification and state medical disciplinary actions had not been studied. This study was undertaken to determine if maintaining ABEM certification was associated with a lower risk of disciplinary action. METHODS: This investigation was a historical cohort study using Cox regression. Physicians who did not have a lapse in ABEM certification were compared with physicians who had a lapse to determine the risk of disciplinary action. Lapsing was determined at the expiration of the initial certificate. This study included all physicians who obtained initial ABEM certification from 1980-2005. Additional covariates of interest included the number of attempts on the ABEM Qualifying Examination (1 vs. >1), the geographic region of the physician's residence, and the country of medical school. RESULTS: There were 23,002 physicians in the study cohort. Of these, 3370 (14.7%) let their certification lapse after initial certification. There were 701 (3.0%) physicians with disciplinary events. Lapsed physicians had higher rates of disciplinary actions than physicians who did not lapse (6.4% vs. 2.5%). ABEM-certified physicians who did not lapse were significantly less likely to be disciplined as physicians who let their certificate lapse (hazard ratio 0.50 [95% confidence interval 0.42-0.59]). CONCLUSIONS: The absolute incidence of physicians with a disciplinary action in this study cohort was low (3.0%). Maintaining ABEM certification was associated with a lower risk of state medical board disciplinary actions.

Understanding Client Vulnerability in the Disciplining of Legal Professionals in New South Wales.

Despite the increasing use of "vulnerability" in policy and legal documents, and the emerging scholarly literature about vulnerability and the law, there is little research focused on vulnerability from clients' perspectives. To address this gap, we analysed the New South Wales Civil and Administrative Tribunal (NCAT) and appellate court cases involving vulnerable clients and disciplined lawyers in NSW from 1 January 2011 to 30 January 2019. Our analysis of the cases draws from the "vulnerability theory" literature. We identified the following characteristics of clients for analysis: older age, gender, health impairment, and immigrant status. Twenty-eight tribunal cases and two appellate court cases involved vulnerable clients. Overall, the cases revealed that the relationship between public protection and vulnerability is not expressly discussed by NCAT. To optimise the legislative intent to safeguard the public, the NSW legislation should explicitly include vulnerability as a relevant feature of the disciplinary regime.

The relevance of nurses and midwives code of conduct in Australia.

AIM: This study explores Australian clinical nurses' and midwives' familiarity with a new code of conduct and understanding in what ways the code is important for nurses as they carry out clinical practice. BACKGROUND: Codes specify the expectations of nurses' responsibilities, legal requirements, behaviour and conduct. Being familiar with the code is central to being a professional nurse or midwife. As nursing continues to advance, updating the code is crucial to maintain professional and safe practice. DESIGN: This project utilized a cross-sectional descriptive design. METHODS: A survey was developed incorporating Likert-type scale assessments of the 7 value statements from the 2018 Australian Nurses' Code of Conduct for familiarity and importance. The survey included open-ended questions to elicit clinical nurses' experiences of conduct breaches, opinions regarding usefulness and relevance of the code for current practice. Data were collected at an acute care hospital in Sydney during January 2018. RESULTS: Significant differences relating to cultural and patient-centred approaches were revealed in the study. The new value involving the role of research was least understood and ranked least important by nurses and midwives. Professional 'integrity' resonated with participants when considering the behaviour of nurses, and short, unambiguous values were the most popular. Additionally, a substantial number of participants had no knowledge of the code or were not aware of the recently revised version. CONCLUSION AND IMPLICATIONS FOR NURSING: A code of conduct provides structure and guidance for workplace values and principles. A respected code is important to the nursing profession to help prevent inappropriate and incompetent behaviour and as a guide for nursing performance. Nurses in this study claimed the code was highly relevant to their work as a nurse and was incorporated into their daily practice.

A duty of care to the nurse as well.

Sam Foster, Chief Nurse, Oxford University Hospitals, reflects on the responsibility employers have to ensure that disciplinary procedures and processes are fit for purpose.

The Legal Underpinnings of Medical Discipline in Common Law Jurisdictions.

Medical regulators have a responsibility to protect, promote, and maintain the health and safety of patients. Here, we compare and contrast the processes for addressing concerns about doctors in four countries with legal systems based on English common law: the UK, Australia, the United States, and Canada. The legal provisions underpinning each jurisdiction's disciplinary processes depict distinctive outlooks from the different authorities as each works toward the same goal. The initial stages of the investigation process are broadly similar in all of the jurisdictions examined. Each process, however, has subtle differences with regard to its comparators. Factors include how matters of discipline are framed, the constitution of disciplinary panels, and how the perceived independence of these panels all philosophically affect the public safety remit of each regulator. This work constitutes the first comparison of international regulatory frameworks for the profession of medicine.

The American Board of Internal Medicine Maintenance of Certification Examination and State Medical Board Disciplinary Actions: a Population Cohort Study.

BACKGROUND: Some have questioned whether successful performance in the American Board of Internal Medicine (ABIM) Maintenance of Certification (MOC) program is meaningful. The association of the ABIM Internal Medicine (IM) MOC examination with state medical board disciplinary actions is unknown. OBJECTIVE: To assess risk of disciplinary actions among general internists who did and did not pass the MOC examination within 10 years of initial certification. DESIGN: Historical population cohort study. PARTICIPANTS: The population of internists certified in internal medicine, but not a subspecialty, from 1990 through 2003 (n = 47,971). INTERVENTION: ABIM IM MOC examination. SETTING: General internal medicine in the USA. MAIN MEASURES: The primary outcome measure was time to disciplinary action assessed in association with whether the physician passed the ABIM IM MOC examination within 10 years of initial certification, adjusted for training, certification, demographic, and regulatory variables including state medical board Continuing Medical Education (CME) requirements. KEY RESULTS: The risk for discipline among physicians who did not pass the IM MOC examination within the 10 year requirement window was more than double than that of those who did pass the examination (adjusted HR 2.09; 95% CI, 1.83 to 2.39). Disciplinary actions did not vary by state CME requirements (adjusted HR 1.02; 95% CI, 0.94 to 1.16), but declined with increasing MOC examination scores (Kendall's tau-b coefficient = - 0.98 for trend, p < 0.001). Among disciplined physicians, actions were less severe among those passing the IM MOC examination within the 10-year requirement window than among those who did not pass the examination. CONCLUSIONS: Passing a periodic assessment of medical knowledge is associated with decreased state medical board disciplinary actions, an important quality outcome of relevance to patients and the profession.

Association between Performance in a Maintenance of Certification Program and Disciplinary Actions against the Medical Licenses of Anesthesiologists.

WHAT WE ALREADY KNOW ABOUT THIS TOPIC: WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: In 2000, the American Board of Anesthesiology (Raleigh, North Carolina) began issuing time-limited certificates requiring renewal every 10 yr through a maintenance of certification program. This study investigated the association between performance in this program and disciplinary actions against medical licenses. METHODS: The incidence of postcertification prejudicial license actions was compared (1) between anesthesiologists certified between 1994 and 1999 (non-time-limited certificates not requiring maintenance of certification) and those certified between 2000 and 2005 (time-limited certificates requiring maintenance of certification); (2) within the non-time-limited cohort, between those who did and did not voluntarily participate in maintenance of certification; and (3) within the time-limited cohort, between those who did and did not complete maintenance of certification requirements within 10 yr. RESULTS: The cumulative incidence of license actions was 3.8% (587 of 15,486). The incidence did not significantly differ after time-limited certificates were introduced (hazard ratio = 1.15; 95% CI, 0.95 to 1.39; for non-time-limited cohort compared with time-limited cohort). In the non-time-limited cohort, 10% (n = 953) voluntarily participated in maintenance of certification. Maintenance of certification participation was associated with a lower incidence of license actions (hazard ratio = 0.60; 95% CI, 0.38 to 0.94). In the time-limited cohort, 90% (n = 5,329) completed maintenance of certification requirements within 10 yr of certificate issuance. Not completing maintenance of certification requirements (n = 588) was associated with a higher incidence of license actions (hazard ratio = 4.61; 95% CI, 3.27 to 6.51). CONCLUSIONS: These findings suggest that meeting maintenance of certification requirements is associated with a lower likelihood of being disciplined by a state licensing agency. The introduction of time-limited certificates in 2000 was not associated with a significant change in the rate of license actions.

What 'Just Culture' doesn't understand about just punishment.

Recent years have seen the rise of 'Just Culture' as an ideal in the patient safety movement, with numerous hospitals and professional organisations adopting a Just Culture response to incidents ranging from non-culpable human error to intentional misconduct. This paper argues that there is a deep problem with the Just Culture model, resulting from its impoverished understanding of the value of punitive, fundamentally backward-looking, practices of holding people accountable. I show that the kind of 'accountability' and 'punishment' contemporary Just Culture advocates endorse disrespects both patients and providers. I claim, first, that punishment is good because it respects participants in the healthcare system by restoring an equilibrium of social and moral status that wrongdoing disturbs, and, second, that it only does so when it communicates a backward-looking message of resentful blame.

Self-regulating profession? Administrative discipline of "pill mill" physicians in Florida.

BACKGROUND: A relatively large number of "pill mills," in which physicians prescribed and sometimes dispensed controlled substances without medical justification, operated in Florida beginning in the mid-2000s. Investigations into these operations have resulted in the arrest and conviction of dozens of physicians for activities related to illegal trafficking in controlled substances. METHODS: Using information from the federal Drug Enforcement Administration, the Florida Department of Health, and court records, we constructed a database of Florida-licensed medical doctors who had been indicted or convicted of crimes related to illegal prescribing of controlled substances in Florida during 2010-2015. We then determined whether and when physicians in this data set were temporarily or permanently barred from practicing medicine in the state. RESULTS: We identified 43 physicians who faced criminal action for prescribing-related crimes during the study period. Twenty-eight of these physicians had been convicted or pled guilty as of September 30, 2016, of which 25 (89%) had been permanently barred from practicing medicine in the state. Only 1 of the 25 physicians permanently lost their license before they had been convicted or pled guilty. On average, physicians did not lose their license to practice for more than 9 months (291 days) after being convicted and 587 days after being indicted of a crime directly related to illegal prescribing of controlled substances. Seventeen physicians (68%) maintained their licenses for at least 1 year after being indicted. CONCLUSIONS: This review suggests that the adoption of a more proactive and streamlined process may reduce the time from when physicians are indicted or convicted of illegally prescribing or dispensing controlled substances to board investigation and potential sanction, potentially reducing opioid-related adverse events in the state.

Directing Discipline: State Medical Board Responsiveness to State Legislatures.

State medical boards are increasingly responsible for regulating medical and osteopathic licensure and professional conduct in the United States. Yet, there is great variation in the extent to which such boards take disciplinary action against physicians, indicating that some boards are more zealous regulators than others. We look to the political roots of such variation and seek to answer a simple, yet important, question: are nominally apolitical state medical boards responsive to political preferences? To address this question, we use panel data on disciplinary actions across sixty-four state medical boards from 1993 through 2006 and control for over-time changes in board characteristics (e.g., composition, independence, budgetary status), regulatory structure, and resources. We show that as state legislatures become more liberal [conservative], state boards increasingly [decreasingly] discipline physicians, especially during unified government and in the presence of highly professional legislatures. Our conclusions join others in emphasizing the importance of state medical boards and the contingent nature of political control of state regulation. In addition, we emphasize the roles that oversight capacity and strategy play in offsetting concerns regarding self-regulation of a powerful organized interest.

Practitioner Health Issues Featuring Before New Zealand's Health Practitioners Disciplinary Tribunal: An Analysis of Cases 2003-2014.

Increasingly, the health and wellbeing of professionals is causing concern, particularly when it compromises the interests of those they serve. Often their health issues are reported when their conduct results in professional disciplinary action. In New Zealand, health practitioners who appeared before the Health Practitioners Disciplinary Tribunal for misconduct reported a range of physical and mental health conditions. This study of 288 decisions revealed the professions that reported diverse health issues, including categories of health issues, in published decisions between 2004 and 2014. The study also identified how frequently practitioners self-reported impairment or submitted health evidence from others of their physical and/or mental health status and/or their substance dependence. The study's findings may be applied preventatively for the benefit of practitioners and the people they serve, thereby promoting the Health Practitioners Competence Assurance Act 2003 (NZ)'s emphasis on public safety.

Doctors with Conditions - Rehabilitation or Risk.

This article reports and updates a study that analysed protective orders in medical disciplinary tribunals over a three-year period. It argues that the concept of the protection of the public has been undermined by protective orders that focus on the rehabilitation of problem and impaired doctors in the management of risk. The article posits a medical or psychiatric model of misconduct in which misconduct is seen in terms of illness, rather than attracting negative moral judgment and severe disciplinary sanctions. The findings in the study and cases since indicate that the most common form of risk management in medical tribunals is the imposition of conditions upon a doctor's registration, such as supervision or psychiatric treatment. The article concludes that, given the paucity of research on the rationale and utility of such protective orders, the faith of tribunals in their effectiveness is misplaced.

Barossa Night: cohesion in the British Army officer corps.

Contrasting the classical explanation of military group cohesion as sustained by interpersonal bonds, recent scholars have highlighted the importance of ritualized communication, training and drills in explaining effective military performance in professional armies. While this has offered a welcome addition to the cohesion literature and a novel micro-sociological method of examining cohesion, its primary evidential base has been combat groups. Indeed, despite their prominent role in directing operations over the past decade, the British Army's officer corps has received relatively little attention from sociologists during this period. No attempt has been made to explain cohesion in the officer corps. Using a similar method to recent cohesion scholars, this paper seeks to address this imbalance by undertaking a micro-sociology of one ritual in particular: 'Barossa Night' in the Royal Irish Regiment. Firstly, it draws on the work of Durkheim to examine how cohesion amongst the officer corps is created and sustained through a dense array of practises during formal social rituals. It provides evidence that the use of rituals highlights that social solidarity is central to understanding officer cohesion. Secondly, following Hockey's work on how private soldiers negotiate order, the paper shows how this solidarity in the officer corps is based on a degree of negotiated order and the need to release organizational tensions inherent in a strictly hierarchical rank structure. It highlights how the awarding of gallantry medals can threaten this negotiated order and fuel deviancy. In examining this behaviour, the paper shows that even amongst an officer class traditionally viewed as the elite upholders of organizational discipline, the negotiation of rank and hierarchy can be fluid. How deviant behaviour is later accepted and normalized by senior officers indicates that negotiated order is as important to understanding cohesion in the British Army's officer corps as it is amongst private soldiers.

Evidence of discrimination against BME nurses revealed.

University of Greenwich researchers responded to an advert from the Nursing and Midwifery Council (NMC) offering funding for an investigation into its fitness-to-practise (FtP) processes amid concerns about the treatment of NHS staff from black and minority ethnic (BME) backgrounds.