HSE HR Circular 028/ 2014 23rd December 2014

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Oifig an Stiúrthóra Náisiúnta, Acmhainní Daonna Feidhmeannacht na Seirbhísí Sláinte Ospidéal Dr. Steevens Baile Átha Cliath 8 Office of the National Director of Human Resources Health Service Executive Dr. Steevens Hospital Dublin 8 All Queries to Info.t@hse.ie Tel: (01) 662-6966 HSE HR Circular 028/ 2014 23rd December 2014 To: Each Member of the Directorate and Leadership Team HSE Each ISA Manager, HSE Each Assistant National Director, HR Each Employee Relations Manager, HR, HSE Re: Policy on 2015 Certification of Registration of Nurses and Midwives with the Nursing and Midwifery Board of Ireland. Dear Colleagues, The Nursing and Midwifery Board of Ireland (NMBI) has issued revised arrangements for the registration of nurses and midwives in the Divisions of the Register maintained by Nursing and Midwifery Board of Ireland. Please see attached the NMBI document on Annual Registration Fee process 2015. As a result of the revised arrangements the HSE is issuing this circular and attached policy in respect of 2015. The purpose of this revised policy and procedure is to protect patients, service users and HSE employees and to provide evidence in support of good governance. This new document outlines the policy of the Health Service Executive (HSE): to employ and to maintain in employment nurses and midwives who on appointment furnish the HSE with proof of their appropriate registration in the relevant division of the register maintained by the Nursing and Midwifery Board of Ireland to require nurses and midwives to provide proof of registration with the Nursing and Midwifery Board of Ireland and to certify by the 30 th April 2015, by way of the Patient Safety Assurance Certificate (PSAC), Appendix 1 that they are appropriately registered in the relevant division/s of the register maintained by The Nursing and Midwifery Board of Ireland that they will advise the HSE without delay if there is any change in their registration status by way of restrictions or conditions placed on their practice or through erasure from the register or any other change to their professional status the name under which they are registered with The Nursing and Midwifery Board of Ireland and their Personal Identification Number (PIN)

that they have advised the Nursing and Midwifery Board of Ireland of any change in their professional or personal information (reference Section 46 (2), (a), (b) of the Nurses and Midwives Act 2011 Implementation of the policy and procedure requires: nurses and midwives to complete the Patient Safety Assurance Certificate (PSAC) by the 30 th April 2015 the verification of the information received by accessing the website of the Nursing and Midwifery Board of Ireland and, the entering of specified data into the SAP HR system or other appropriate employee records system where SAP HR has not been implemented. The operation of the policy and procedure will be reviewed in September 2015 by nominees from the Office of Nursing and Midwifery Service Director, Quality and Patient Safety Directorate, the AND of HR, Health Business Services and the HR Directorate. This policy is effective from the 5 th of January 2015. Please bring this policy to the attention of all relevant staff in your area of responsibility. The policy will be available on the HSE Intranet and Website at the following links: http://hsenet.hse.ie/intranet/working_in_the_hse/resources/?importurl=http://localhost:82/eng/s taff/resources/hrppg/ http://www.hse.ie/portal/eng/staff/resources/hrppg/policiesprocedures.html Queries in respect of registration with the Nursing and Midwifery Board of Ireland should be directed to the Nursing and Midwifery Board of Ireland, 18/20 Carysfort Avenue, Blackrock, Co. Dublin, telephone 01 266 9777 or e-mail registration@nursingboard.ie Queries in respect of HSE nursing and midwifery issues should be directed to Dr. Michael Shannon, Director of Nursing & Midwifery Services & Assistant National Director, Clinical Strategy & Programmes Division, HSE Tel:01 635-2471 or by e-mail michael.shannon@hse.ie Any HR queries in respect of this Circular or policy should be directed to Mr. Paddy Duggan, WPAI, HR Directorate, HSE, Oak House, Millennium Park, Naas, Co. Kildare. 045 880400 or by e-mail to paddy.duggan2@hse.ie Yours sincerely, Ian Tegerdine National Director of Human Resources

HSE Policy on Certification of Registration of Nurses and Midwives with the Nursing and Midwifery Board of Ireland for 2015 Document HR Directorate developed by Revision number 1 Document approved by Approval date Revision date 23 rd December 2014 Responsibility for implementation Responsibility for review and audit Ian Tegerdine, Interim National Director of Human Resources As specified in Section 6 As specified in Section 8 Table of Contents 1.0 Policy 2.0 Purpose 3.0 Scope 4.0 Legislation/other related policies 5.0 Glossary of Terms and Definitions 6.0 Roles and Responsibilities 7.0 Procedure/Protocol/Guideline 8.0 Revision and Audit 9.0 References 10.0 Appendices

1.0 Policy Statement 1.1 It is the policy of the Health Service Executive (HSE) to employ and to maintain in employment nurses and midwives who on appointment furnish the HSE with proof of their appropriate registration in the relevant division/s of the register maintained by the Nursing and Midwifery Board of Ireland. 1.2 It is the policy of the HSE to require nurses and midwives to provide proof of registration with the Nursing and Midwifery Board of Ireland and to certify by the 30 th April 2015, by way of the Patient Safety Assurance Certificate (PSAC), Appendix 1: 1.2.1 That they are appropriately registered in the relevant division/s of the register maintained by the Nursing and Midwifery Board of Ireland 1.2.2 That they will advise the HSE without delay if there is any change in their registration status by way of restrictions or conditions placed on their practice or through erasure from the register or any other change to their status 1.2.3 The name under which they are registered with The Nursing and Midwifery Board of Ireland and the Personal Identification Number (PIN). 1.2.4 That they have advised the Nursing and Midwifery Board of Ireland of their particulars as required by the Nurses and Midwifery Board of Ireland (reference Section 46 (2), (a), (b) of the Nurses and Midwives Act 2011.) 1.3 It is the policy of the HSE to suspend from employment any nurse or midwife who does not provide the PSAC by the 30th April annually to their head of discipline or service manager. 1,4 It is the policy of the HSE to manage any nurse or midwife who is removed from the register of nurses or midwives maintained by the Nursing and Midwifery Board of Ireland in accordance with HSE HR Circular 012/12 Policy on Erasures and Sanctions issued by Regulatory Authorities against HSE employees. 1.5 The HSE reserves the right to report to An Garda Siochana, in support of sections 39 and 44 of the Nurses and Midwives Act 2011 (see 7.5 below), any employee of the HSE who presents themselves as a nurse or midwife to the HSE or practices as a nurse or midwife in the HSE without the appropriate registration in the relevant division/s of the register maintained by the Nursing and Midwifery Board of Ireland. 2.0 Purpose The purpose of this policy and procedure is to protect patients, service users and HSE employees and to provide evidence in support of good governance. 3.0 Scope This Policy and procedure applies to: 3.1 Each individual employed as a nurse or midwife by the HSE

3.2 Each person employed in a position that requires a nursing or midwifery qualification, e.g. Bed Managers in certain hospitals and those employed in education or research 3.3 The Directors of Nursing/Midwifery 3.4 Any nurse or midwife who is normally employed in a non-nursing role but who practices as a nurse or midwife on an occasional basis e.g. relief cover at weekends, holidays etc. 3.5 Managers of Services, who are not Directors of Nursing/ Midwifery who are responsible for managing nurses and midwives 3.6 Each National Director, Hospital Group CEO, Community Health Organisation Chief Officer, Assistant National Director of Human Resources at Regional level, Assistant National Director of Human Resources Health Business Services and the individuals designated by them for the purpose of ensuring compliance with this policy and procedure 4.0 Legislation/other related policies: The relevant primary legislation is the Nurses and Midwives Act 2011. Specifically but not limited to Part 6, Registration and Practice Other relevant legislation: Data Protection Act 1988 and amendment Act 2003 HSE related policies: HR Circular 012/12 Policy on Erasures and Sanctions issued by Regulatory Authorities against HSE employees Disciplinary Procedure for Employees of the Health Service Executive HSE 5.0 Glossary of Terms and Definitions: The Act - The Nurses and Midwives Act 2011 Division/s The Division/s of the Register maintained by the Nursing and Midwifery Board of Ireland HBS Health Business Services Other staff record systems - As SAP HR has not been deployed in HSE South it will use its existing staff record system to comply with this policy and procedure PIN - The Personal Identification Number assigned by the Nursing and Midwifery Board of Ireland to each registered nurse and midwife PSAC - Patient Safety Assurance Certificate Proof of registration with the Nursing and Midwifery Board of Ireland; -.Original registration certificate for the current year

Regional - Refers to former HSE Dublin Mid Leinster, Dublin North East, West AND South Service Manager - A manager who is not a Director of Nursing / Midwifery but has responsibility for managing nurses or midwives AND of HR Assistant National Director of Human Resources 6.0 Roles and Responsibilities 6.1 The individual nurse or midwife is, as a condition of their employment, personally responsible and accountable for maintaining appropriate registration in the relevant Division/s of the register maintained by The Nursing and Midwifery Board of Ireland. 6.2 The individual nurse or midwife is personally responsible for completing the PSAC by the 30th April 2015. 6.3 The Director of Nursing/Midwifery or Service Manager with responsibility for nurses or midwives is responsible for: 6.3.1 Requesting each nurse and midwife to complete the PSAC by the 30th April 2015 6.3.2 Advising each nurse or midwife that failure to provide the proof of registration and to complete the PSAC by the appointed date may result in suspension from employment and investigation under the HSE s Disciplinary Procedure 6.3.4 Storing a copy of proof of registration and the completed PSAC in the local site 6.3.5 Validating the registered name, the PIN number and registration in the Division/s of the register supplied on the PSAC using the website of the Nurses and Midwifery Board of Ireland 6.3.6 Ensuring that the information contained in the completed PSAC is entered into the SAP HR system, or other staff record systems (HSE South), using the local personal administration procedures for amending employee information, see 7.3 6.3.7 Advising the relevant Regional AND of HR, or National Director in the case of Corporate employees, through local HR managers where they exist, of the names of the nurses and midwives who fail to provide proof of registration or to complete the PSAC by the 30 th April 2015 6.3.8 Advising any nurse or midwife who fails to provide proof of registration or to completed the PSAC by the appointed date that, on the grounds of patient safety, they may be suspended from employment pending further investigation of their registration status in compliance with this policy and procedure 6.4 The Divisional HR Managers, Regional AND of HR and the AND HR of HBS shall:

6.4.1 Establish a process within their Region or Service that will ensure that the required information is recorded on the SAP HR system or other staff record system (HSE South) by the 31 st July annually 6.4.2 Ensure that a failure to provide proof of registration or to complete a PSAC is managed in compliance with this policy and is investigated using the HSE s Disciplinary Procedure 6.4.3 Report on an on-going basis to the nomination of the relevant Division details of the reported failures to complete the PSAC, the actions taken in respect of these failures and the outcome of these actions 6.5 Each National Director is responsible for ensuring that this Policy and Procedure is implemented in their Directorate. Each National Director is also responsible for identifying and implementing the necessary systems and processes within their Directorate in support of this policy and procedure. 6.6 The Nursing and Midwifery Services Director shall: 6.7.1 Send by e-mail this notice to each Director of Nursing/Midwifery for the information of nurses and midwives in their services 6.7.2 Have this policy and the PSAC form published on the Office of the Nursing and Midwifery Services section on the HSE s intranet and website. 7.0 Procedure 7.1 Annual completion of the PSAC The relevant Director of Nursing/Midwifery or Service Manager will by the 31 st January 2015 request each nurse or midwife to supply proof of registration and to complete and return the PSAC to them by the 30th April 2015. 7.2 A copy of the completed and validated PSAC will be sent, using local procedures, by the Director of Nursing / Midwifery or relevant Service Manager to the local SAP HR / other staff records system office. A copy will be maintained locally by the relevant Director of Nursing/Midwifery or Service Manager for audit purposes. 7.3 The following information will be entered into the SAP HR system or other staff record system by the designated personal administration section, Information required SAP HR field Name of the statutory regulatory authority (ID Type) Individual s PIN (ID number) PSAC expiry date of the 31 st December annually (Valid to) Renewal date in all cases 1 st January ` (Renewal date) Birth name (Birth name) Nurses or midwives who submit the PSAC will have the status Active entered in their record in the Application Status field on SAP HR. A similar description will be entered in the appropriate field in other staff record systems. 7.4 The names of the nurses and midwives who by the 30th April have not supplied proof of registration or the PSAC will be forwarded by the Director of Nursing/Midwifery or relevant Service Manager, through local HR managers where they exist, to the Regional Assistant National Director of HR, or National Director in the case of corporate employees.

7.5 Following a preliminary review of the facts by the Regional AND of HR and the Director of Nursing/Midwifery or relevant Service Manager, the nurse or midwife may be suspended from employment pending a full investigation using the HSE s Disciplinary Procedure. 8.0 Revision and Audit: The operation of the policy and procedure will be reviewed in September by nominations from the Office of Nursing and Midwifery Service Director, Quality and Patient Safety Directorate, the AND of National HR Services and the HR Directorate. 9.0 References/bibliography: N/A 10.0 Appendices: Appendix 1: The Patient Safety Assurance Certificate

Appendix 1 Patient Safety Assurance Certificate for Nurses and Midwives Statement to be completed by the 30th April 20 I Employee Number D.O.B. Birth name (if different from above) employed by the HSE in (service and location) in the capacity of (title and grade) am appropriately registered for the current year in the following division (s) of the active register maintained by The Nursing and Midwifery Board of Ireland. a) b) c) d) My registered name with The Nursing and Midwifery Board of Ireland is I confirm that I will advise the Health Service Executive without delay should there be any change in my registration status with The Nursing and Midwifery Board of Ireland during the year. I understand that change in status means non registration, any restriction, conditions, censure, admonishment or removal from the register under Part V of the Nurses Act 1985. I confirm that I will advise the regulatory authority of any change in my professional or personal information (reference Section 46 (2), (a), (b) of the Nurses and Midwives Act 2011). I make this statement so as to provide assurance to patients, service users and fellow employees. I also acknowledge that should I practice as a nurse or midwife without appropriate registration that I may be prosecuted under section 39 and 44 of the Nurses and Midwives Act 2011. PIN: Signed: Date: Print name: Validated by: Title: Date: