As a registered nurse, you are expected to maintain and uphold the standards and behaviours set out in the Code at all times. That means continuing to uphold those standards during these unprecedented times, where the pressure on our health system is so high it has been compared to working in a war zone.

Arguably, it has never been so important to ensure that those caring for patients work within the limits of their competence. With higher levels of staff absences and increasing numbers of patients, there are increased opportunities for things to go wrong.

The NMC has acknowledged that the health service is currently facing highly challenging circumstances and, as a result, nurses may be required to depart from established procedures to care for patients during this time. It is unclear what exactly is meant by departing from established practices. However, the NMC will expect nurses to use their professional judgment, work closely with colleagues and always work within the limits of their competence.

Recognising and working within the limits of your competence, is one of the key parts of the Code and is integral to maintaining patient and public safety, but what exactly does it mean?

Firstly, you must recognise your level of competence. That level of competence will differ for every nurse, based on your role, experience and knowledge. Naturally, your own level of competence will change over time, as you develop greater experience and knowledge. As a result, you are expected to re-evaluate your own competence on a regular basis. It is important to consider your level of competence whenever you face a new situation. This is particularly important, as you are accountable for your own actions. Reflective practice is strongly encouraged by the NMC as it enables nurses to assess their professional experiences and identify where any improvements may be needed.

Secondly, you always have to work within that level of competence. If you are asked to complete a task, which you do not feel comfortable or confident about completing, you must speak up. For example, in the current situation, it is anticipated that many healthcare professionals will be acting outside of their usual role. If you are asked to undertake a task, which you have not completed previously or a task that is not one you would normally be required to complete, and you feel that this may put patients at risk, you must inform your senior colleagues and explain that you do not have the appropriate experience or qualification for such a task.

If you identify a situation where there are gaps in your knowledge, you have a duty to take action to ensure that you have the necessary knowledge and skills. This may involve arranging to complete a certain course or arrange for supervision whilst completing a particular task for the first time.

Ensuring you are in good health, both physically and mentally, is also important. This cannot be underestimated during the current pandemic. If you are unwell, this directly affects your ability to practice competently. During these challenging times, you have a duty to ensure you care for yourself, ensure you are aware of, and follow current guidance appropriately.

Unfortunately, there are occasions where nurses place patients at risk of harm as a result of acting beyond the scope of their competence. Most of the time this is not intentional but is as a result of over-stretched resources and over-worked staff. This highlights the need to be able to identify your own level of competence and continually review that on a regular basis.

Below are some recent, real-life examples where nurses acted outside of their level of competence and received a sanction following a fitness to practise hearing:

• In January 2020, a nurse received a 12 month order of conditions. It was found proved that she had administered medication when she was not qualified as a nurse prescriber. The conditions included a requirement for direct supervision from a senior nurse. This is a clear example of ensuring that you have the necessary qualification to undertake certain tasks. If you are unsure, you should ask a colleague, before doing something you should not.
• In December 2019, a practice nurse was struck off the register after a number of allegations were proved. These allegations included a failure to seek advice from a GP on several occasions and carrying out examinations, which were outside of their scope of practice. Whilst the situation may have been different if an appropriately qualified Advanced Nurse Practitioner had undertaken such examinations, this case demonstrates the importance of ensuring you seek advice from senior colleagues, when necessary.
• In February 2020, a nurse was handed a 6 month suspension for misleading a doctor about their ability to carry out catheterisation. The nurse had provided incorrect information about their training, which showed they were not trained to carry out catheterisation, when, in fact, they were trained to carry out the procedure. An interesting lesson about the consequences of avoiding tasks, which you simply do not want to do, as opposed to tasks, which you are not trained or qualified to do. This case also highlights the importance of clearly and accurately documenting situations where you have voiced concerns that you do not have the necessary training or experience.

The important message to take away is that although all healthcare professionals are working under significant pressures, now more than ever, it remains vital to know and work within your limits of competence. You can and must refuse to undertake a task, which is out of the scope of your competence, as this may place patients and yourself at risk. In the event that you face any difficult situations, a clear and accurate record of the incident must be recorded in the appropriate place, usually the relevant patient’s medical record.  Remember, that as a nurse, you are accountable for your actions and if required, you must be able to demonstrate your decision making in any given situation.

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