Etica de los Cuidados ISSN:1988-7973 2015; 8(15): et10425e














Comentar este articulo

Documentos relacionados

Version en espa�ol



Enviar correo-e a autor



Relationship between technical competencies and ethical and legal aspects of the accountability in Emergency Nursing in England
Opinion article

Alfonso Rubio Navarro
Departamento de Urgencias, Leicester Royal Infirmary. Leicester, Reino Unido

Ética de los Cuidados 2015 ene-jun; 8(15)




Cómo citar este documento

Rubio Navarro, Alfonso. Relationship between technical competencies and ethical and legal aspects of the accountability in Emergency Nursing in England: Opinion article. Ética de los Cuidados. 2015 ene-jun; 8(15). Disponible en <https://www.index-f.com/eticuidado/n15/et10425e.php> Consultado el




Nursing in England: the competent nurse

    Since an English nurse begins the degree in college until he finishes his basic training as a nurse, that nurse acquires both theoretical and practical knowledge, applicable to everyday clinical practice in his filed. However, their ability to perform nursing techniques is not presupposed as part of the profession exercised, it must be demonstrated through competences.

In this context, competencies are legal documents that prove the ability of a professional to make a skill or technique and know the basic theory of it. They often develop through the hospitals themselves like daily courses and internships in the workplace, thus providing professional basic knowledge, skills and legal support for this technique. This means that many techniques in other countries are nursing techniques are multidisciplinary, or what is the same, that techniques such as cannulation can be done by a nurse, a healthcare assistant or a doctor. In addition, these competencies differ between different hospitals in England. However, the ability of the nurse to provide nursing care is assumed from being a nurse, and not evaluated per se after university education.

After training as nurses, they can not only choose to develop their nursing skills and technical competencies, but also can choose to become a specialty nurse or a nurse practitioner.

In England there are dozens of specialties in nursing. These specialties are better recognized social and economically, and have a physical workload generally lower. These issues affect many skilled nurses specialize, especially after the economic problems related to NHS nurses.

Another type of specialization, but in another range, is the nurse practitioner. They can diagnose and prescribe legally, working with the medical team. The increase of patients per nurse practitioner and the change of their role force nurse practitioners to do not practice nursing care, although their previous training facilitates their collaboration in the implementation of nursing care by nurses.

The increase in the elderly population, the lack of social and economic recognition of the profession, the emigration to the United States or Australia and the specialization are some factors that influence that England has a lack of nurses. This lack of nurses is attempted to alleviate with various policies, one of which is the recruitment of foreign nurses. These must under go the same process of acquiring skills that local nurses passed, regardless of their background and capabilities, as it is a legal requirement to perform certain techniques.

Another way to alleviate the nursing shortage is the use of "agency nurses." These nurses work as autonomous organized by various agencies, seeking shifts that still to be filled by the staff nurses for a salary between two and eight times higher than public nurse in the same post. These "agency nurses" demonstrate their competence through the agency that represents them, but do not know the department, the multidisciplinary team or any hospital protocols. They difficult the continuity of care, they are more difficult to monitor by the coordinators and undermine the economic resources of the hospital. However, being a "nurse agency" remains a fast to increase their salary at the expense of lower quality and lower and cost effectiveness nursing care.

Emergency Nursing Ethics in England

    To understand the values and morals ofEnglish nurses and the accountability that is expected of them when they apply their techniques, we must dig a little on English nursing ethics. To do this, we must take into account the influence of the philosophical branch of utilitarianism in the modern Anglo-Saxon society,1 cradle of liberal thought, and its nursing. This philosophical branch up holds the principle of morality of each act should be to find as much happiness (pleasure) for the greatest number of people, trusting the feelings of sympathy and altruism the regulation of the instrumental role of a calculator moral rationality. He has also been heavily influenced by European or international documents such as the Universal Declaration of Human Rights. If we talk purely bioethical influences, better known in English regarding nursing for ethical decision making it is Johnstone, although there are many other influences (Beauchamp / Childrens, Raths, Brody, etc.).2

Regarding the training of nurses in ethics, many studies emphasize the need for specific training in nursing ethics,3 even one study shows that 90% of respondents in training programs for nurses and midwives in the UK reported the need to include ethics in the nursing curriculum. Another more recent study says that ethics is included in the nursing curriculum4 in all curriculums in England. There is a consensus on the general goal of nursing ethics is to produce morally responsible professionals, with skills in decision making. However, the curriculum, and therefore the extent of training in nursing ethics depends on each university.

Although ethical problems arise in any branch of nursing, the ones in A&E Nursing have a particularity: the presumption of emergency. In an emergency situation, decisions must be taken quickly and sometimes can be too late. Such situations occur mainly in emergency departments or outpatient care, which is why professionals in an emergency department must be prepared to take quick and appropriate decision if an ethical problem arises in an emergency. However, given the pressure and stress in such situations, a decision made at that time may not be the most appropriate ethically speaking, but if it respectsan ethical minimum it is accepted by consensus of the multidisciplinary team for lack of a better options in that moment.

Legislation in Emergency in England: the fear of losing the NMC PIN number

    In England, the organization that regulates the quality of nursing and dictates theEnglish nursing ethics code is the Nursing and Midwifery Council (NMC). Created by the British Parliament to protect the public by ensuring that nurses and midwives provide a high level of care to their patients and clients, NMC regulates the deontological, legal and ethical bases for nursing practice in England. Also, the NMC registers all the professional nurses or midwifes in a register through a code (NMC PIN number) that gives them authorization to practice in England, for which the professional has to contribute an annual fee. Without this NMC PIN number you cannot practice as a nurse or midwife in England, as it is assumed that every professional in the register must follow the code English NMC code of ethics. This implies that unregistered foreign professionals in the NMC or professionals who have removed them NMC PIN number for any infraction he may not exercise whatever legal training or experience they have.

Even if the NMC checks the standard of care that a nurse must provide, the nurse must answer five entities for their practices, techniques and care:5

-To the patient, through the law of civil liability (tort law).
-To society through public law.
-To the employer, through the employment contract.
-To the nursing profession, through the written or statute law and the Nursing and Midwifery Order, 2001.
-To the Ministry of Health, through the independent regulator Care Quality Commission.

English law also takes into account the presumption of emergency, whereby a nurse is not considered negligent simply because a reasonable and competent nurse would have made a different choice, giving her more time and information. In cases like Wilson v Swanson (1956) or Wilsher v Essex HA (1988), the presumption of emergency was being used to declare not negligent unnecessary treatment or consider acceptable a professional ability level which in a standard situation would not be acceptable.

Since the NMC protect citizens of poor nursing practice, but not to nurse, unions were created to represent the interests of this group of professionals. There are several, but the most representative is the Royal College of Nursing (RCN). These institutions represent nursing professionals, debate health policies with the NMC and the British government and promote excellence in practice through courses, magazines and conferences.

Emergency Nursing in England and the responsibility for your competencies relative to the patient, practice, profession and colleagues

    "The primary professional responsibility of the nurse is to be with people who need nursing care," said the first point of the code of ethics of the International Council of Nurses. This is a fact that this defines the nursing profession and determines the need for a trained and independent professional to provide care of the highest possible quality, always trying to achieve excellence.

One way to evaluate the results in an emergency department are surveys of patient satisfaction. These surveys are a requirement of the NHS, so the department must obtain a minimum of surveys or is fined. The results compared with other departments are not good, as shown by a study that affirms that the least satisfaction score is given in emergency departments. These patients are in a noisy, busy and gore environment, where resources should be allocated to patients by their acuteness and necessity. However, another study showed how various changes in an emergency department, where staff ethics training is included, increased patient satisfaction in that department.6 This prompts implementing training in ethics for health professionals as a way to improve health care, patient satisfaction and quality of health professions themselves.

An independent quality practice in England can be given by experienced professionals who have all the technical competencies they need to deliver such care. However, in a situation where the nurse does not have all the competencies needed to care for patients in their care, continuity of care is fragmented by having to rely on other professionals who have the competencies that the first nurse did not have to complement patient care. However, this care is her responsibility and must ensure that the patient receives the necessary techniques to supplement their care, although these techniques cannot do done by her. The other side of the coin is the professional who has the technical competencies, but have to bear the burden of extra work that goes into making nursing techniques for professionals who have not any competencies in these techniques. Also, any professional who do a technique is responsible for it. In emergency services; given its technification, its unpredictable workloads and the emergency of care, this problem is accentuated.

In this situation, the teamwork and the distribution of tasks is essential to provide adequate care to all patients. To create a team that mixes the competencies needed, English nursing follow a hierarchy. This hierarchy can be simplified in nursing in 6 ranges, from low to high (commonly divided by bands, according to salary):

-Staff Nurse (Band 5): The standard nurse, responsible for the care of patients in their care and to be part of the multidisciplinary team.
-Deputy sister / Deputy charge nurse (band 6): Experienced nurse who has all the competencies needed for care in your work area, plus leadership andadministrative tasks.
-Sister / Charge nurse (band 7): Nurse who have clinical roles, but his work is primarily administrative. Usually they manage leadership and task distribution of the lower ranks.
-Matron (band 8): Dedicated to manage relationships between other departments, personnel management, resource allocation, etc.
-Deputy Head of Nursing: Nurse who coordinates the matrons of connected departments.
-Head of Nursing: Responsible to represent, promote and maintain appropriate standards of care through all ranges of nurses.

These ranges are not usually seen in hospital wards, being a band 6 and sometimes a band 7 which play the role of nurse in charge at the time. However, in an emergency department this distribution can change. The distribution in teams, the need for professionals with expertise in many techniques and the need for expert care in emergency situations make the band 6 and 7 join the team of staff nurses providing expert care and support for professionals less experienced. Moreover, they are who distribute the teams, soshould be a balanced distribution of competencies. All this means that a professional nurse who does not have a competence for a technique that her patient needs and informs his superior to provide him with a professional who can do it, the nurse is not solely responsible for the performance of this technique, it is also the superior which should provide a competencies balance in the department and move professionals where needed.

Another responsibility that professionals in emergency departments must meet concerning the hospital is which they are workingis "the four-hour target." This rule states that every patient who comes into an emergency department must be addressed and sent to another place in less than four hours or department will be punished financially. There is other sanction if the patient is eight hours in the department after being seen by a doctor, and the other after twelve hours. These sanctions are decided upon by the British Parliament to accelerate patient flow and reduce waiting time in the emergency department, which improved after implement it. In 2013-2014 data, we can observe a decrease of the amount of patients close to 240 minutes, due to this four hour target. However, compliance with this rule sometimes leads to prioritize it against patient care, increase pressure load and low staff morale. Also, a review of clinical studies relating to the four-hour target states that there is not enough evidence to say that this aim increase the quality of care in English emergency departments.7

Nurses are supported by healthcare assistants, which support the nurse with the care and techniques for which they have competencies. However, the actions of healthcare assistant should be supervised by the nurse, as she is responsible for the care of that patient. This is because, for now, there is no specific training for healthcare assistants. This leads to the only solid basis of knowledge for healthcare assistant is their experience, and therefore accountability for their actions lies in him and the nurse responsible for the patient who the health care assistant attended.This situation will improve through the Care Certificate, which will be a base of knowledge, skills and behaviour for them.

Ethical and legal problems when performing techniques in Emergency Nursing in England: continuous triage and decision making

    In an emergency department, triage is an essential part of the nursing role, especially in patients who do not have a diagnosis yet or patients who can deteriorate rapidly. However, triage is not limited to the health statusfor such patients, we must consider every patient holistically and the environment in which they are.

Assuming that the first responsibility is to the people who need nursing care, the priority should always be the patient. However, it is not always that easy. For example, if a patient needs a urinary catheter, the nurse should put it if she has the competence to do so. However, if there is not space in the department and patients are waiting to be seen, the time used putting the catheter is time added to another patient to be seen. There are other aspects to consider such as the time the patient is in the department, the severity of his situation, the urgent or not urgent need for a catheter and the possibility of being placed in the ward. This situation does not generate a legal issue, but generates an ethical one in the distribution of resources;8 in which they must decide between a known patient and another possible new patient, with the influence of your colleagues and department protocols.

Another aspect is consent to perform the techniques. In England, touching someone without their consent is a crime. This situation stems from the specific need to invade the physical privacy of the patient to certain nursing care, which may be undervalued due to the routine, stress or malpractice. In addition, the patient is entitled to decide on their autonomy and receive information about the care and techniques that he will receive. However, informed consent in nursing care and techniques is always verbal because written informed consent is reserved for very aggressive treatments such as surgery. This situation with good patient communication and good record should not be a problem, but the clinical reality is rather different. Assuming that the unconscious or incapable for decision making patients cannot consent techniques, other patients should be informed of the technique, its performance, its contradictions and side effects. After this, the patient should repeat the information about the technique he consents in order to demonstrate that the information was understood, without ever being coerced in their decision making. This consent is necessary, but consume between one and five minutes for technique and patient. In a saturated emergency department we have to decide between adequately inform the patient or do the technique with a presumed consent and save time for distribution to other patients. There are other aspects to consider such as how long the patient is in the department, how many patients are in charge of the nurse and the needs of them all, the acuteness of the situation of the patient, the severity of the side effects of this technique, time spent recording this technique and the possibility of delegating the technique to a healthcare assistant or a doctor. Make a technique without informed consent is a sign of malpractice and a crime. That is why the time used in the informed consent should be considered in the time assigned to triage and patient care or it facilitates malpractice when the nurse has heavy workload.

A situation that happens a lot with nurses trained in other countries working in England is the confrontation between the techniques they know how to do and the one for which they have competence. In an ideal situation, the nurse without competition should ask for help from a colleague to perform the technique for which she has no competence, even when she know how to do it and she done it for years. However, in an emergency situation the urgent need for a technique and the legal obstacles to do it confronts. However, the decision also depends on the severity of the situation, the type of technique, the time it takes to get help, previous experience with this technique and the knowledge or ignorance of this technique English protocol. In this situation two illegal actions (failure to provide assistance and conducting techniques without a competence) in a presumption of emergency are confronted, by what is the nurse ethical decision to do the technique, because the nurse is legally covered if she does not perform the technique because she do not have a competence for it, she should just ask for help and do whatever I have competencies to do.

These are three of the many ethical and legal problems that can occur in an emergency department related to the techniques that nurses perform. There is no global answer, because each context has its different characteristics which change decision making. The most effective way to solve day-to-day action is training in ethics, both during under graduate training and in hospital training, and the implementation of methods of ethical decision making in clinical practice. In this way nurses are encouraged to be able to make decisions, be flexible to adapt to every situation and be able to respect the autonomy and dignity of the patient. In addition, these professionals increase patient satisfaction and have a responsible use of resources.

Final thoughts

    In this opinion article I tried to capture the context of the reality of clinical care and the ethical and legal problems generated regarding techniques that professional nurses perform. Although I have made a preliminary literature search, this opinion article is partly subjective from my experience as a nurse in an English emergency department. From this, this opinion is useful for new nurses in emergency departments in England or in any department, as these situations are part of the reality of care. In addition, the ethical and legal consequences of their actions are vaguely explained in the hospital training, which fosters fear of losing the NMC PIN number for malpractice.

It should be borne in mind that when we talk about ethics in a healthcare profession, such as nursing, it is understood that the principles and knowledge of bioethics that apply to nursing ethics. This occurs because the bioethics is related to clinical ethics and the interactions between technology and people's health, unifying ethical concerns of the healthcare professionals and creating a multidisciplinary basis on which to rest through discourse ethics.

England hospitals need nurses, as the NHS has problems with retention of nurses. There are many reasons for this, but the hypothesis that the frustration of not having the right to exercise its role independently and the fear of being admonished in a legal system that is not always clearly explained may be reasons for it gain strength working in a crowded emergency department.


1. Gracia D. Fundamentos de bioética. 3º ed. Madrid: Triacastela; 2008.
2. Torralba MJ, Meseguer C, García DJ, Navarro MA. Formación bioética en Enfermería. 1ª ed. Murcia: Diego Marín Librero-Editor; 2012.
3. Fry ST, Duffy ME. The development and psychometric evaluation of the Ethical Issues Scale (IES). Journal of Nursing Scholarship. 2001; 33(3): 273-277.
4. Nolan PW, Markert D. Ethical reasoning observed: A longitudinal study of nursing students. Nurs Ethics. 2002; 9(3): 243-258.
5. Griffith R, Tengnah C. Law and professional issues in Nursing. 3ª ed. Londres: SAGE Publications; 2014.
6. Supreme Court of Canada. Wilson v. Swanson, [1956] SCR 804. Supreme Court Judgments, (2 de octubre de 1956).
7. House of Lords. Wilsher v. Essex Area Health Authority, [1988] 1 AC 1074.
8. Consejo internacional de enfermeras. Código deontológico del CIE para la profesión de Enfermería. Ginebra; 2012.
9. Yen-Ko Lin, Wei-Che Lee, Liang-Chi Kuo, Yuan-Chia Cheng, Chia-Ju Lin, Hsing-Lin Lin et al. Building an ethical environment improves patient privacy and satisfaction in the crowded emergency department: a quasi-experimental study. BMC Med Ethics. 2013; 14:8.
10. Jones P, Schimanski K. The four hour target to reduce emergency department 'waiting time': a systematic review of clinical outcomes. Emergency Medicine Australasia. 2010; 22(5): 391-398.
11. Fry ST, Johnstone, MJ. Ética en la práctica de enfermería. Traducido de la 3ª ed. California: Editorial El Manual Moderno; 2010.

Principio de p�gina 

error on connection