Inter-regulatory collaboration on NMBI’s agenda

CEO of the Nursing and Midwifery Board of Ireland, Ms Carolyn Donohoe,
speaks to Catherine Reilly about its new statement of strategy  

Ensuring a fair and “compassionate” fitness to practise (FTP) process is among the strategic aims of the Nursing and Midwifery Board of Ireland (NMBI). The NMBI Statement of Strategy 2026–2029 has three overarching objectives. These relate to public protection through ‘right touch’ regulation; the support and empowerment of nursing and midwifery; and organisational agility.

The strategy covers a four-year period – compared to the usual three-year timeframe. NMBI CEO Ms Carolyn Donohoe told the Medical Independent this provides an enhanced opportunity to implement and embed the objectives over the coming years.

As a regulator, the NMBI’s core activities are to maintain the register of nurses and midwives; to set standards for education and approve and monitor programmes leading to registration; to provide guidance on professional conduct and ethics; and to investigate and consider complaints against nurses and midwives.

Interdisciplinary working

Under the strategy, the NMBI plans to scope out “common issues of concern” related to public protection and interdisciplinary team working in the Irish health system. It will also produce a report on the subject.

Ms Donohoe said that no healthcare professional works alone and patients are cared for by healthcare teams. She noted that the issue of ‘lone working’ was raised during stakeholder engagement for the strategy.

With the advancement of more community-based and integrated care, a nurse may be the sole member of their profession working in an interdisciplinary team in a community hub – as opposed to a hospital-based nurse with a line manager and director of nursing on site. This heightens the importance of effective interdisciplinary communication, and understanding the boundaries of one’s professional practice. From the regulatory perspective, Ms Donohoe said the NMBI is keen to provide more support for registrants in these environments.

Every professional needs to be aware of their competence and conduct, said Ms Donohoe. She also emphasised the importance of clear communication between team members and with patients, enabling the patient voice, and recognising the social determinants of health when providing care.

The NMBI’s ‘north star’ is public protection, according to Ms Donohoe. She said the NMBI has also recognised the need to engage with the public in a more meaningful way. A patient and public interest forum will be established to obtain patient views on topics of interest. This will be a joint initiative of the healthcare regulators. An inter-regulatory symposium has already been established to share learning in Irish healthcare regulation.

FTP

Investigating and considering complaints against nurses and midwives is a core NMBI function. ‘Upstream’ or preventative regulation is also an increasing focus. This involves engaging in work that seeks to prevent poor professional performance or professional misconduct. The sharing of data insights is an important facet of this work. In respect of FTP, the NMBI’s strategy commits to sharing data with registrants, employers, and others to allow early identification of systemic risks or trends in professional conduct and guide the development of preventative strategies.

A small proportion of registrants are the subject of complaints (0.12 per cent of over 93,000 registrants in 2024). In 2024, the NMBI received 109 complaints, compared with 75 in 2023. Of the 100 cases examined by its preliminary proceedings committee (PPC) in 2024, 43 were deemed ‘non-prima facie’ and 45 were referred to the FTP committee for inquiry. In addition, the PPC accepted undertakings and/or consents in relation to 12 complaints.

From a regulatory perspective, a standalone mistake is generally of lesser concern than a pattern of poor practice. Human factors are considered when examining cases, in line with ‘right touch’ regulation. “Healthcare is hard, it is complex, and people make mistakes,” noted Ms Donohoe.

Where appropriate, the PPC can request the registrant to give an undertaking (eg, to complete further education and training).   If the registrant agrees to the undertaking, the matter will not be referred to the FTP committee. This power was introduced in the Regulated Professions (Health and Social Care) (Amendment) Act 2020. It is important the practitioner has shown insight and is demonstrating they are taking steps to prevent any recurrence.

“I think now we have better, stronger, quicker structures to deal with [such cases] through PPC,” stated Ms Donohoe.

This also provides the NMBI greater scope to focus on cases that require the FTP process. In recent years, healthcare regulators have noted a rise in the seriousness and complexity of cases. “Competence has become a bigger issue than it would have been,” stated Ms Donohoe, who added these complaints can entail longer investigations.

In cases that give rise to immediate patient safety concerns, the NMBI can apply to the High Court for an interim suspension order. It may also consider accepting an undertaking by the registrant not to practice. “Our Board will have these fast-tracked meetings within one to two weeks of us getting a really concerning complaint and they will consider that. And quite often, they will say to the nurse or midwife who is subject to that complaint, ‘are you willing to not practise’ [pending the determination of the FTP process].”

If the registrant refuses to give this undertaking, the NMBI may proceed to apply to the High Court for the interim suspension order (a ‘section 58’ application).

“That is a really important part of regulation that people don’t see very often, but for me, it is the most important thing we do – that is the far end of it.”

In 2024, the Board considered 19 cases under section 58 of the Nurses and Midwives Act 2011 (compared with 10 cases in 2023). In five cases, applications were made to the High Court, and in five matters the Board accepted undertakings. In nine cases the threshold was not met.

Witness and registrant care

The NMBI’s strategy commits to implementing a witness care project and commencing a registrant care project. The NMBI is aiming to ensure the FTP process is a more compassionate one for everyone involved, according to Ms Donohoe. In recent years, it has appointed a liaison officer and funded an independent emotional support service.

The NMBI engaged with the UK General Medical Council on the development of its witness care project. It also consulted with Prof Louise Wallace, Professor of Psychology and Health, Open University, who has carried out significant research in this field.

A key learning point is ensuring regular communication with all involved. Healthcare regulators can lose witnesses due to the length of the process, or because they found it stressful, noted Ms Donohoe.

The new registrant care project will consider each part of the FTP process and how it impacts on registrants. It will also involve a review of correspondence and guidance to ensure consistency of engagement with all registrants.

One of the difficulties is the length of the process. Currently, it takes approximately three to five years from receipt of complaint to the communication of the outcome. The NMBI is examining the process to identify areas where there are delays. Ultimately, the strategy aims to ensure inquiries start within 18 months of referral by the PPC. It also sets out a maximum target of 30 months from the receipt of complaint to final outcome.

Ms Donohoe said that reducing the length of the process – while maintaining its integrity – is a key priority. She noted the toll it can have on all concerned. For a registrant it can mean their livelihood is at risk, and they may also have undertaken not to practise during the process. Registrants in the process often report a negative impact on their mental health.

PCS

Nurses and midwives are professionally obliged to stay up to date in their practice. However, from 2027, registrants will be legally required to demonstrate maintenance of professional competence.

The NMBI professional competence scheme (PCS) will operate in a three-year cycle. Registrants will be required to undertake and document a minimum of 60 hours of continuing professional development (CPD) activities; and 450 practice hours.

“That is a big change,” said Ms Donohoe. “We have been working really hard with the different stakeholders to make it reasonable.”

She said the NMBI examined the evidence on CPD internationally, and conducted a PCS pilot last year. The scheme has been “received very well from the system” particularly due to its flexibility, said Ms Donohoe.

Activities such as engaging in ‘lunch and learn’ sessions or providing in-service education are all relevant under the PCS. “That is all going to help the culture within the organisations and in healthcare.”