Implications for practice and research

• Managerial experience or higher levels of education increase the likelihood of nurses reporting professional misconduct in home-care.

• Positive team environments, opportunities to discuss incidents and enhanced communication may contribute to preventing professional misconduct.

• Further research is needed to understand reasons why nurses do not report professional misconduct.

Context

Professional misconduct by nurses (encompassing either impairment or incompetence) working in home-care is thought to occur frequently. Nurses are governed by regulatory frameworks, including professional codes relating to ethics and professional conduct that make it incumbent on them to report suspected or actual misconduct. Despite this, nurses experience difficulty in reporting.1 Reasons for under-reporting by healthcare professionals can include fear of retribution or consequences, feelings of insecurity, a belief that someone else will act or that nothing will change and protecting professional reputation.2 ,3 Recognising the extent of the problem and understanding factors that contribute to difficulties in reporting misconduct in home-care is essential to protect vulnerable people in care.

Findings

Professional misconduct was either suspected or noticed by 42% of participants in the past 12 months; in 85% of cases, the misconduct related to a nursing colleague. Participants found it more difficult to report misconduct related to impairment (mean 3.18 on a Likert scale with a maximum score of 5) than incompetence (mean 2.95). Nurses with managerial task experience found it less difficult to report suspicions of misconduct than those without; nurses with a bachelor's degree were more likely to report suspicions of incompetence than colleagues with lower levels of education. Participants identified several factors as important in preventing professional misconduct among nursing staff: a positive team climate (75%), discussing incidents (67%) and communication between healthcare workers (57%).

Commentary

The focus of this study was to explore Dutch home-care nurses' experiences of professional misconduct. The findings are likely to underestimate the extent of professional misconduct occurring in home-care as care is commonly provided individually in the homes of clients, reducing the likelihood of witnessed misconduct and subsequent reporting by healthcare workers. This study highlights the importance of identifying and removing barriers to reporting by nurses and other healthcare professionals. The findings are important as they provide insight into an issue which is largely underexplored in the literature and under-reported in practice.

Higher levels of education have previously been reported as an important factor in attitude and willingness to report on inadequate care.4 This study found nurses with higher levels of education and those with managerial task experience more likely to report suspicions of incompetence, yet no difference was found in education level in reporting suspicions of impairment. Difficulty in reporting impairment is perhaps not surprising as impairment tends to be less obvious than incompetence, making it hard to identify and more reliant on subjective judgement than clear evidence. Nurses with managerial experience are more likely to be able to deal with challenging issues such as reporting a colleague, whereas nurses without managerial experience may lack confidence in identifying impairment and be fearful of the consequences of reporting. Guidelines to facilitate identifying and reporting misconduct may overcome difficulties in reporting faced by nurses.

The findings of this study are limited by the use of quantitative data collected on hypothetical scenarios of professional misconduct. The use of qualitative methodology would provide an opportunity to explore reasons for difficulty in reporting and allow for a more comprehensive understanding of nurses' and other healthcare workers' experiences of professional misconduct.