Today’s correspondent is

… a Paramedic and RN currently employed by a small business, contracted in Afghanistan. I’ve been advised that “[the company] is subject to the laws of all countries associated with the contract but ultimately it is our decision how we adapt to our environment”. This came about as Australian and New Zealand paramedic staff raised concerns about drug management practices and the lack of “Australian” standards being applied to our practice here. In other employment both in hospitals and in the ambulance service, we keep a drug register of all drugs, and whenever a drug is administered we record the details of administration in the book along with ePCRs or other clinical documentation. The company has decided that the drug register is no longer needed and that a simple “handover” sign off sheet is sufficient.

Given that I am an Australian registered nurse (and paramedic), employed for my Australian registration, and work for an Australian organisation, should Australian law and standards be applied here – given that the standard here is non-existent? Additionally given that I feel this practice is not in line with Australian standards – can my registration be at risk should something untoward occur due to poor accountability and drug management practices?

In answering this question I’ll focus on my correspondent’s status as a nurse as paramedics are not yet registered in Australia.

As an Australian registered nurse it must be the case that conduct when overseas would be relevant to professional registration.  An Australian registered nurse, working for an Australian organisation who demonstrated sub-standard skills or engaged in conduct that demonstrated that they were not a fit and proper person to be a nurse (eg offending against patients in their care) could and should expect that this would impact upon their registration.

Health Practitioner Regulation National Law

However the provisions of the drugs or poisons legislation in each state is not part of the nursing standard.  If we look at the Health Practitioner Regulation National Law (which is Schedule 1 to the Health Practitioner Regulation National Law Act 2009 (Qld) but which has been adopted in all Australian states and territories) it refers to ‘unprofessional conduct’ and ‘unsatisfactory professional performance’.  Unprofessional conduct means:

… professional conduct that is of a lesser standard than that which might reasonably be expected of the health practitioner by the public or the practitioner’s professional peers, and includes—

… (c) the conviction of the practitioner for an offence under another Act, the nature of which may affect the practitioner’s suitability to continue to practise the profession;…

Unsatisfactory professional performance means ‘the knowledge, skill or judgment possessed, or care exercised by, the practitioner in the practice of the health profession in which the practitioner is registered is below the standard reasonably expected of a health practitioner of an equivalent level of training or experience.’

Handing out scheduled drugs, in Afghanistan, without completing the paperwork that would be required in one’s home state would not be contrary to the Australian law.  The relevant law would be the Afghan law (if there is one).   Assuming the conduct is not in breach of any Afghan law then paragraph (c) of the definition of ‘unprofessional conduct’ won’t be relevant.

The critical issue is what can be expected from a ‘health practitioner of an equivalent level of training or experience’ operating in those circumstances.  And the experience of being in Afghanistan is part of the relevant experience.   For example is completing a drug register and patient record helpful if the drugs aren’t recorded ‘in’ and ‘out’ and if no-one is ever going to read the patient record documents?

The Code of Professional Conduct for Nurses in Australia

There are professional standards.  The Code of Professional Conduct for Nurses in Australia (Nursing and Midwifery Board, effective date 7 May 2013) Conduct Statement 2[2]) says that:

Nurses practise in accordance with wider standards relating to safety and quality in health care and accountability for a safe health system, such as those relating to health documentation and information management, incident reporting and participation in adverse event analysis and formal open disclosure procedures.

And (Conduct Statement 2[3]) “Nurses’ primary responsibility is to provide safe and competent nursing care.”  But what is ‘safe’ and ‘competent’ has to take into account all the circumstances including, in my correspondent’s case, that they are working in Afghanistan and not Australia.  That would mean that as a nurse they still need to take responsibility for their own conduct in providing ‘safe and competent nursing care’ (Conduct Statement 1[1])) which in turn would require them to put the patient’s interests first and ‘practise nursing reflectively and ethically’ (Conduct Statement 10).   My correspondent is clearly practising ‘reflectively and ethically’ by actually reflecting on the practice in Afghanistan and considering whether or not it meets the relevant standard expected of a nurse.

Documents like the Code of Professional Conduct for Nurses in Australia are not meant to be prescriptive.  They do not say that a nurse must complete this or that record, rather they set out general principles that a reflective and ethical nurse has to consider and apply in the infinite number of circumstances in which nursing occurs.

Discussion

Conduct Statement 3[1] says

Nurses are familiar with relevant laws and ensure they do not engage in clinical or other practices prohibited by such laws or delegate to others activities prohibited by those laws.

For my correspondent the relevant laws are the laws of Afghanistan.  If convicted of administering drugs contrary to those laws that could well impact upon Australian registration, but the implication of the question is that there are no relevant laws or perhaps no meaningful way in which to comply with them.  Let us assume that is not an issue.

In that case my correspondent still has to practice ethically and reflectively and try to maintain safe and competent nursing care.    If my correspondent is actually in a war zone and under fire, keeping records may be irrelevant.  If however they are somewhere where the facilities are sub-standard and nursing staff are coping as best they can, some minimal record keeping may be required but it won’t be the case that the nurse is expected to practice nursing as they would if they were in one of the tertiary teaching hospitals in any of the Australian capital cities.  The fact that nurse can’t provide the level of care or meet the standards that the Australian community would expect if they were in an Australian hospital cannot, of itself, represent unprofessional conduct in nursing.

Just as the standards for other areas of care cannot be imported into Afghanistan, there is no reason to think that the standards for patient and drug records can be imported.  Without having been to Afghanistan, it surely has to be the case that Australian law and standards cannot be applied there.

So the nurse has to consider what can be done to provide, to the best of their ability, ‘safe and competent nursing care’.   Merely transferring the drug register from an Australian state to Afghanistan won’t do that – that’s form over substance.

I would think the answer lies in the Code of Professional Conduct for Nurses in Australia, Conduct Statement 2[3] which says, in full:

Nurses’ primary responsibility is to provide safe and competent nursing care. Any circumstance that may compromise professional standards, or any observation of questionable, unethical or unlawful practice, should be made known to an appropriate person or authority. If the concern is not resolved and continues to compromise safe and competent care, nurses must intervene to safeguard the individual and, after exhausting internal processes, may notify an appropriate authority external to their employer organisation.

If the ‘company has decided that the drug register is no longer needed and that a simple “handover” sign off sheet is sufficient’ that is not the end of the matter if, thinking about all the circumstances, the nurses involved think that is not safe and competent. Here it would be for a nurse, practising ‘reflectively and ethically’ to consider what are the risks and is there a better way to deal with it.  If they think that there is a better way then they need to raise that with their employer.  A mere assertion ‘but we wouldn’t do it that way at home’ is, I expect unhelpful.  But a statement ‘this is unsafe because of ….  What is required is [some modified process, perhaps modelled on the practice in Australia but taking into account the reality on the ground]’ might well help.  If the nurse feels that the practice the employer is asking them to adopt is unsafe and unreasonable in all the circumstances then the nurse has to ‘after exhausting internal processes … notify an appropriate authority external to their employer organisation’ or reconsider their position as an employee of that agency.

 Conclusion

The fact that my correspondent is practising nursing in Afghanistan does not mean that the Australian nursing standards do not apply.  As an Australian registered nurse, working for an Australian organisation, providing care in Afghanistan because of the Australian registration, the Australia Health Practitioner Regulation National Law and the Code of Professional Conduct for Nurses in Australia will continue to be relevant. Conduct that demonstrates lack of ethical practice or that the person is not a fit and proper person to remain registered as a nurse will be relevant whether that conduct occurs in Australia or in Afghanistan.

But that does not mean that the nurse in Afghanistan has to practice nursing as if they were in Australia.  What is appropriate conduct has to take into account all the circumstances and local laws.  To focus on the actual practice in Australia and try to apply Australian practice in Afghanistan is to miss the point of the code of conduct and what is meant by ethical practice.  It is impossible to apply Australian standards in Afghanistan – the hospitals are not the same, the nature of the practice is not the same, the access to drugs, technology, referral services etc cannot be the same. The overriding obligation is to practice safely, ethically and reflectively – so identify where the suggested practice is unsafe and how it can be improved.  The relevant question has to be not ‘Are we practising as we would in Australia?’ but ‘Are we practising in a way that is as safe and beneficial as we can make it?’