The progress and outcomes of black and minority ethnic (BME) nurses through the Nursing and Midwifery Council's "Fitness to Practise" process: Final report
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BACKGROUND\ud This is the first investigation of the relationship between ethnicity and regulation of the nursing profession conducted internationally. The study was commissioned by the Nursing and Midwifery Council which is the regulator of the professions in the UK. \ud \ud AIMS OF THE STUDY\ud “To establish whether the progress and outcomes of Black and minority ethnic (BME) nurses in relation to fitness to practice, from the point of referral to the point of case closure, is different from that of White nurses and midwives (N&M); and whether we can from the data account for any differences identified” (Call for research, NMC 2015). The study was designed to investigate whether BME N&M nurses are more likely to be referred and whether they were more likely to progress through the stages of the Fitness to Practise (FtP) process (screening, investigation or adjudication) and whether they were more likely to receive a severe penalty at the end of the process.\ud \ud DATA\ud The NMC made available a copy of the register which had socio-demographic information on 681,258 nurses and midwives between April 2012 and December 2014 as well as data on referrals from April 2012 to December 2014 which totalled 5,851. Over that period the total number of cases that went to adjudication was 946.\ud \ud VARIABLES\ud The main independent variable is ethnicity which we divided into Black, Asian, White, Other and Unknown. The latter category accounted for 40% of all referrals. The outcomes studied were rates of referral, the imposition of interim orders (where the referred individual is not allowed to work, progression through screening, investigation, adjudication and final outcome, which was dichotomised into “can work” or “cannot work”. The regression models also controlled for: age, gender, source of referral (9 categories), region of qualification (Africa, Asia, Europe, Other, UK), country of referral (4 counties of the UK) and whether or not the individual referred had a representative, such as a Union.\ud \ud METHODS OF ANALYSIS\ud Descriptive statistics, cross-tabulation analysis, logistic regression and ordinal logistic regression\ud \ud FINDINGS\ud Descriptive statistics showed that BME nurses are more likely to be referred than white nurses and to progress through the FtP process. Having trained in Africa is also a risk factor for referral. Older N&M and males are more likely to be referred. Most referrals come from employers but members of the public are also an important source of referral. Inferential statistics show that relative to Whites, being Asian, Black or of Unknown ethnicity is associated with progressing through FtP process. However, when “source of referral” is entered into the regression model only the “Unknown ethnicity” category remains significantly more likely to progress than White N&M. Males are more likely to progress through the FtP process but age, though positive, is not significant. There were few significant differences among the countries of the UK. The imposition of interim orders did not vary by ethnicity. The presence of a representative seems to reflect the stage of the FtP process rather than being a factor that contributes to the outcome. Finally, at adjudication, being Asian or Black is associated with a less severe penalty than White. Only those of Unknown ethnicity are more likely than Whites to get a severe penalty. These results are not altered by controlling for the source of referral.\ud \ud STRENGTHS AND WEAKNESSES OF THE STUDY \ud The strengths include: the fact that this is the first study of its kind, the datasets analysed are large and the statistics are appropriate. Weakness include the fact that in 40% cases the ethnicity of the referred individual is not known. Some of the registered N&M may not be working which means that their risk of being referred to the NMC is low which could be a threat to the comparison of different ethnic groups. The administrative data which we analysed did not provide information about the specialty (e.g. mental health, maternity), job setting (care home, acute hospital) or level of seniority (staff nurse or Director of Nursing of the individuals referred were not amenable to analysis.\ud \ud RECOMMENDATIONS\ud The analysis reported here could be enhanced in the future if the information on ethnicity, the setting in which the referred individual is working and their grade is made available. Some jobs may simply carry a higher risk of referral to the NMC and BME nurses may disproportionately occupy those positions. The main finding, which is that the relationship between ethnicity and FtP is mediated by referral by the employer, directs our attention to the need for further research to understand how the working environment leads to an over-representation of BME nurses in the FtP process. Within the NMC, further research needs to be conducted to understand why White nurses are more likely to be given a severe penalty at adjudication even though they are underrepresented in referrals and less likely to progress through the process. With the introduction of the NMC code and revalidation, the collection of data by the NMC and the FtP process will undoubtedly change. At the same time, the NHS has introduced policies to directly affect the working environment of BME nurses and midwives. This means that this study should be repeated to take account of these changes in the wider environment.
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