The Nursing and Midwifery Council (NMC, 2023) regulates the nursing profession in many areas; one such way is by investigating concerns about nurses, midwives and nursing associates. Nursing professionals must ensure that their skills, knowledge, education and behaviour do not fall below the standards set out in the NMC Code, to ensure they are ‘fit to practise’ (NMC, 2018) and that they work in a professional culture that values equality, diversity and inclusion, and prioritises openness and learning (NMC, 2022). If a concern is raised about an individual's right to be on the register, then that nurse, midwife or nurse associate has to go through a ‘fitness to practise’ process.
There are more than 700 000 nurses, midwives and nurse associates on the NMC register and the percentage of those who are referred by employers, or who even progress to the investigation stage, is very small, approximately 0.08% (NMC, 2019; Dean, 2020). However, referrals by members of the public are on the rise and have been the biggest source of fitness to practise cases since 2019, with a recorded figure of 33% (Foster, 2024). The main concerns raised are in the following categories:
However, many of these cases are closed at the screening stage, often because they were initially raised out of dissatisfaction with an employer's response or because of individuals finding it difficult to navigate the options when raising concerns about the care they or their family received (Foster, 2024). The NMC investigates serious concerns that put patient safety at risk, such as abuse of professional position, improper relationships, discrimination or serious mistakes in care, violence or fraud or serious breaches of confidentiality (Dean, 2020). Inherently, the NMC have an overarching objective to protect the public and to do this they need to:
There are 12 principles that the NMC uphold for fitness to practise, the essence of which is to ensure consistency and transparency, rather than penalise people for past events. These principles encourage employers to act first to deal with concerns, and those that are referred on to the NMC are handled swiftly; the context of where the nurse has been practising will always be considered (NMC, 2022). At the screening stage, the regulators check to see if the complaint meets four thresholds (Dean, 2020):
While the majority of referrals end here, an interim order can be imposed to suspend a nurse. If their case is considered to be serious, a conditions of practice order can limit how they can work (Dean, 2020).
Analysis of a case study
A case study (Box 1) has been summarised to provide a concise outline of the details, its influencing factors and the outcome. The content, interactions and analysis were far more detailed than can be discussed here.
Case study
Nurse B had been qualified for nearly 30 years when her case was presented to the Nursing and Midwifery Council (NMC). She was working as a community nurse with a trust in the west of England, where she had been in employment for 2 years.
As per the NMC regulations, although the hearing was public, parts of the proceedings were conducted in private to protect the privacy of all parties. It was noted that nurse B had accessed patient A's clinical records on three separate occasions over a 2-month period without any clinical justification, and had disclosed confidential medical information to third parties on more than one occasion. These records contained up to 5 years of sensitive medical history, the content of which was shared with a mutual friend. This friend then informed patient A of the breach in confidentiality and he requested an audit trail of the access to his medical records.
Nurse B had also shared this information with a colleague. In addition to the patient complaint documents, further evidence presented also included emails that outlined chronologies of conversations between nurse B and her colleagues. In reaching its decisions, the panel considered all the oral and documentary evidence in this case. Patient A presented live evidence and two witness statements were provided, from the complaint's investigator and clinical systems manager from the trust.
Nurse B initially disputed these claims and suggested that she was accessing the records for clinical purposes, even though the frequency and duration of such activities did not concur with this claim, as confirmed by evidence from all parties. Having reached its determination on the facts of this case, the panel then moved on to consider whether it amounted to misconduct and, if so, whether nurse B's fitness to practise was currently impaired. The panel took the view that this behaviour was misconduct and nurse B accepted this decision. They proceeded to find that her fitness to practise was also impaired.
The rationale for this was that nurse B had sought to conceal her true motives and suppressed evidence, failing to respect patient A's right to privacy on a personal and sensitive matter and to address the level of harm and impact of her actions.
In the context of this situation, it was clear that on reflection nurse B had remorse over the incident and had positive references from other colleagues, suggesting she was usually trustworthy and respectful.
Outcome:
The panel considered this case very carefully and decided to make a suspension order with a review period of 12 months. The NMC register also showed that nurse B's registration had been suspended. At the end of the period of suspension, another panel will review the order.
Following a hearing, the NMC need to consider whether the practitioner's fitness to practise is impaired and whether they could present a risk to the public. Moreover, it is also vital to question if they are able to uphold professional standards and public confidence in the profession. In the case of nurse B, there were several elements of the NMC Code (2018) that were not upheld. Through her behaviour it was suggested that she did not treat the patient (patient A) with kindness, respect and compassion, thus failing to uphold their dignity (section 1.1). She also failed to get informed consent and document it properly before she shared their information, therefore not acting in the best interests of the patient at all times (section 4.2). Nurse B also failed to respect patient A's right to privacy and confidentiality (section 5.1), and she did not uphold the reputation of her profession, as she took advantage of patient A's vulnerability, failed to respect their personal boundaries and did not communicate responsibly.
Following a hearing, several sanctions can be imposed; not intended as a punishment, but to protect the public (NMC, 2023). These include:
For nurse B, the outcome was a suspension order with 12-month review. This would mean that she would not be able to return to her place of work and resume her usual duties, which may have been very distressing for her.
The impact for the registrant
A fitness to practice investigation is daunting, complex and often a lengthy experience, which can be very distressing for the nurse, even if they may not have done anything wrong (Dean, 2020). As Watters (2018) suggests, while the impact of this is starting to be recognised, there is more to be done to safeguard registrants and to support their mental health, as individuals often do not know where to turn to for support. The stress can impact sleep, confidence, trust and induce feelings of paranoia.
It is expected that the nurse will have legal representation through their union, which will be specialised and tailored to their profession. Unions often provide additional support, including counselling, career guidance and financial advice (Royal College of Nursing, 2025).
It is clear that the NMC have clear processes when dealing with concerns raised by the public; for community nurses, this case serves as a reminder of how easy it can be for boundaries to be overstepped and professionalism to be questioned when providing care outside of an inpatient setting.