A concern has been raised

By a patient, a family, your employer or the NMC, and you need something behind your response. Speak to your union or indemnity provider first.

An NMC investigation is open

Section 6 covers the actions the NMC can take and the remediation steps that answer a concern before it escalates.

The concern is about escalation

A deteriorating patient, a colleague’s practice, or a staffing level you knew was unsafe. The situation most specific to this profession, and the one this page leads with.

You are a nursing associate

You are on the NMC register in your own right, the Code applies to you in full, and so does the fitness to practise process. This course is written for you as much as for nurses and midwives.

You are applying for readmission or restoration

You are struck off, or your registration lapsed, and you are working towards returning. The NMC calls this readmission where most regulators say restoration — the two mean the same thing here. What you did in the meantime is the heart of the application, and you do not need to be registered to take this.

You are building your CPD

Two verifiable hours you can complete and record today, with a certificate showing the title, the hours and the date.

Record-keeping

The single commonest subject of nursing concerns. Notes made late, made thin, or made to look better afterwards — the last of which is the one that escalates. Our Professionalism in Documentation course covers records as evidence in depth.

Medicines

Administration errors, omitted doses, controlled drugs and countersigning — and, as always, what happened in the hour afterwards.

Consent and capacity

Care given to someone who could not consent, or who could and was not properly asked.

Confidentiality and social media

Information shared without a basis, discussions overheard, and posts that identify a patient or a workplace even without naming them.

Delegation and supervision

Work delegated to someone not competent for it, or accepted when you were not — and where accountability sits when it goes wrong.

Failure to escalate

A deteriorating patient, a colleague’s practice, or a staffing level you knew was unsafe and did not formally raise.

Professional boundaries

Relationships that drifted over a long admission or a caseload, contact outside work, accepting gifts, and conduct towards colleagues. Nursing and midwifery involve sustained closeness and personal care, so boundaries erode by accumulation rather than by decision.

Overview of healthcare ethics

Three lessons: what ethics means in healthcare, why it matters in nursing and midwifery specifically, and the NMC’s role in setting and enforcing standards.

The core ethical principles

Four lessons: autonomy, beneficence and non-maleficence together, justice, and confidentiality.

Integrity, candour and records

Three lessons: maintaining honesty and integrity, the duty of candour, and documentation and record-keeping — the single commonest subject of nursing concerns.

Patient-centred care and shared decisions

Two lessons: informed consent and communication with the people in your care.

Professional boundaries and conduct

Two lessons: maintaining appropriate boundaries, and NMC guidance on where they sit, including digital professionalism and social media.

Breaches of ethical standards

Four lessons and the part that answers a live concern: the common breaches, their consequences, the actions the NMC can take, and the steps to take to remediate.

Conclusion and assessment

Conclusion and takeaways, followed by a post-course assessment. Your certificate is issued on completion.

Escalation

Taking a concern further when raising it once has not resolved it. It is not a single act but a duty that continues while the risk does — and it can require going outside your immediate line of management.

Accountability

You are answerable for your own practice and for what you delegate. Accepting a task you were not competent for, and delegating one to someone who was not, are both your accountability rather than only the other person’s.

Contemporaneous record

An entry made at the time or as soon as possible afterwards. Record-keeping is the commonest subject of nursing concerns, and a note written late is a very different thing from a note altered later.

Anonymised

Stripped of anything identifying a patient, a colleague or a workplace — including detail that makes them recognisable to someone who knows the case. It applies to anything you write down about your practice, and it matters most when you are reflecting on the incident behind a concern.

Duty of candour

Telling the person in your care promptly when something has gone wrong, apologising, and explaining what happened and what will be done about it. Whether it was done, and how quickly, is often more decisive than the original error.

Readmission

The NMC’s term for the route back onto the register, where most regulators say restoration. Worth using correctly in anything you write, and worth knowing that a lapsed registration is a common and non-disciplinary way of coming off the register.

Professional boundary

The limit that keeps a professional relationship therapeutic rather than personal, held in place by you rather than by the person in your care. In nursing and midwifery it is tested by sustained contact and personal care, and where someone in your care initiates, the responsibility for holding it still rests with you.

Raise it at the time, to the person making the decision

The Code requires you to act if you believe someone is at risk. A concern first voiced after the event, however genuine, is much harder to evidence and much less protective of the patient.

If it is not resolved, escalate

Being overruled is not the end of your obligation. Where the risk remains, the duty is to take it further — and the seniority of the person who disagreed does not discharge it.

Write down what you raised, and when

“I did raise it” is only a defence if there is a record. A contemporaneous entry or an email costs nothing and is the difference between an account and an assertion.

Follow it through

Escalation is not a single act. If nothing changes and the risk persists, the Code expects you to keep going, including outside your immediate line of management if that is what it takes.

Registered nurses

The largest group, and the one carrying most delegation decisions. Concerns often turn on what was handed over, to whom, and whether the accountability for that was understood at the time.

Midwives

Autonomous practitioners with their own caseloads, where escalation across professional boundaries — to an obstetrician, in an unfolding situation — is the recurring ethical pressure.

Nursing associates

On the NMC register in their own right since 2019, and the group most likely to assume a course titled for nurses and midwives excludes them. It does not. The Code applies in full, and so does fitness to practise.

Newly registered and internationally educated

The two groups most exposed to the escalation problem, because raising a concern with a senior colleague is hardest when you are new, or when the hierarchy you trained in worked differently. The obligation is identical.

Bank, agency and temporary staff

Working somewhere you do not know, often without knowing who to escalate to. Finding that out at the start of a shift is a small habit that answers a large category of concerns.

Students and returners to practice

Welcome, and it is more useful before you need it. Universities and return-to-practice programmes apply professionalism expectations built on the same Code.

Hospital wards and theatres

A senior nurse and a doctor are usually on site, so the hard part is rarely finding someone. It is raising it with a person more senior than you and going further when they disagree.

Care homes

Often no doctor on site and sometimes one registered nurse on shift. Escalation means out of the building — to a GP, to 111, to the manager, to safeguarding — and knowing which of those applies before you need it is the whole of the preparation.

District and community nursing

You are alone in someone’s home with no colleague to ask. Concerns about capacity, safeguarding and the conditions a person is living in have to be recognised and raised by you, from there, without a second opinion in the room.

Mental health and learning disability

Capacity, consent and restrictive practice arise routinely rather than exceptionally, and decisions are often taken in a multidisciplinary meeting where disagreeing means disagreeing with a team.

Midwifery and health visiting

Autonomous caseloads where escalation crosses professional boundaries — to an obstetrician, to children’s social care — and where the person you are escalating about may not be the person in front of you.

General practice and primary care

Working alongside GPs rather than within a nursing hierarchy, which makes raising a clinical disagreement a conversation with a different profession rather than a step up a line of management.

Prisons and secure settings

Clinical judgement sits alongside a security regime that is not yours to direct, and the route for a concern about care may be different from the route for a concern about the regime.

Bank, agency and unfamiliar placements

The common thread across all of the above. If you do not know who to escalate to, ask at the start of the shift — it takes thirty seconds and it is the reason a great many concerns were raised late or not at all.

Before anything else: do not amend the records

Not to clarify, not to complete, not to add the observation you know you made. Electronic systems log every amendment with a timestamp and a user, and a note altered after a concern has been raised turns a record-keeping problem into an honesty one — which is the category that escalates. If something genuinely needs adding, take advice and add it openly as a new, dated entry.

Put your escalations in writing

An entry in the notes or a short email to the person you raised it with. It takes a minute, it is the difference between an account and an assertion, and it is the single most useful habit on this page.

Pair the context with your own part in it

Not the staffing alone, and not an unqualified apology alone. What the conditions were, what you did, what you should have done instead, and what you now do when it happens again. That shape is what insight looks like on paper, and our Module on Insight covers it in depth.

Find out who you escalate to, at the start of a shift

Especially on bank, agency or an unfamiliar ward. Not knowing is the reason a great many concerns were raised late or not at all, and it is fixed in thirty seconds.

Anonymise everything you write about your practice

No patient, colleague or workplace identifiable, including by detail rather than by name. It matters most when you are reflecting on the incident behind a concern, which is exactly when identifying detail creeps in.

Discuss it with someone who knows what is alleged

A colleague, a practice educator or your manager, told the real version rather than a sanitised one. It produces third-party evidence of the change, which your own account of your own improvement never will.

The pair to this course: how you conducted yourself, where this one covers how decisions were reached.

Records as evidence — the commonest subject of nursing concerns, in depth.

Being open when something goes wrong, and apologising properly — the hour after the error.

Where the concern involves medicines — administration, omission and controlled drugs.

Working within your competence, delegation, and what to do when pressure pushes you past it.

The element assessed in almost every case, and the one most often described as lacking.

How to write reflection that reads as understanding rather than regret — useful for your CPD record too.

Turning insight into concrete, evidenced change somebody else can verify.