Nursing in theCommunity

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Nursing in theCommunity

An essential guide to practice

Edited by

Sue Chilton BNurs, RN, DN, HV, MSc, PGCE, DNT

Senior Lecturer, University of Central England in Birmingham and Staff Nurse, District Nursing Service, Cotswold

and Vale Primary Care Trust, UK

Karen Melling MA, PGCEA, RDNT, PWT, DN, RN

Senior Lecturer, University of Gloucestershire, Cheltenham, UK

Dee Drew RN, DN, MSc

Senior Lecturer, University of Wolverhampton, Wolverhampton, UK

Ann Clarridge MSc, BSc (Hons), PGCEA, DNT, RN, DN

Principal Lecturer, London South Bank University, London, UK

A member of the Hodder Headline Group

LONDON

First published in Great Britain in 2004 byArnold, a member of the Hodder Headline Group,338 Euston Road, London NW1 3BH

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© 2004 Arnold

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ContentsList of contributors vii

Foreword by Sarah Mullally ix

Acknowledgements x

Note on terminology and abbreviations xi

Chapter 1Setting the scene: an introduction 1Dee Drew, Sue Chilton, Ann Clarridge and Karen MellingSocial and political influences – demographic influences – community specialist practice

Chapter 2New ways of working 7Anne SmithChanges in service delivery – organisational culture – leadership – managing change

Chapter 3 Nursing in a community environment 17Sue ChiltonFactors influencing community nursing – health needs assessment – responding to localneeds – roles of specialist community nurses – ensuring quality of care

Chapter 4 Personal safety in the community 29Dee DrewPreparation for home visits – personal safety – non-confrontational behaviour – manualhandling – reporting of incidents

Chapter 5 Therapeutic relationships 41Patricia Wilson and Sue MillerThe features of therapeutic relationships – maintaining boundaries – promoting apositive experience – the nature of care – the impact of policy changes

Chapter 6 Working collaboratively 53Ann Clarridge and Elaine RyderRelevant government policy – defining collaboration – the interface of collaborative care– collaborative skills and attitudes

Chapter 7Conceptual approaches to care 63Milly SmithPhilosophies of care – conceptual models – application to practice – evidence-basedpractice – reflection

Chapter 8 Professional issues in community nursing 75Jenny Parry and Judith ParsonsProfessional approaches to care – decision making – innovations in practice

Chapter 9 Nursing for public health 85Sue Rouse, Sandra Baulcomb and Sandra BurleyDefining public health – development of the public health movement – roles withinpublic health – the nursing contribution

Chapter 10Developing health promotion practice 95Karen Melling, Judy Gleeson and Karen HunterPrinciples of health promotion – core competencies of health promotion – strategies forhealth promotion – application to practice

Index 103

vi Contents

ContributorsSandra Baulcomb RN, RM, DN Cert, PWT Cert, Cert Ed, RDN Tutor, BA (Hons), MSc

Lecturer, University of Hull, Hull, UK

Sandra Burley BA (Hons), RN, RM, DN, RNT

Lecturer, University of Hull, Hull, UK

Sue Chilton BNurs, RN, DN, HV, MSc, PGCE, DNT

Senior Lecturer, University of Central England in Birmingham and Staff Nurse, District Nursing Service,Cotswold and Vale Primary Care Trust, UK

Ann Clarridge MSc, BSc (Hons), PGCEA, DNT, RN, DN

Principal Lecturer, South Bank University, London, UK

Dee Drew RN, DN, MSc

Senior Lecturer, University of Wolverhampton, Wolverhampton, UK

Judy Gleeson MA, BSc (Hons), PG Dip Nursing (Education), RHV, RN

Senior Lecturer, University of Gloucestershire, Cheltenham, UK

Karen Hunter BA (Hons), RHV, RN

Clinical Governance Coordinator, South Warwickshire Primary Care Trust, Warwickshire, UK

Karen Melling MA, PGCEA, RDNT, PWT, DN, RN

Senior Lecturer, University of Gloucestershire, Cheltenham, UK

Sue Miller RN, RSCN, Dip Nursing, DNCert, Cert Ed, BSc (Hons) Nursing Studies, MSc Child Health Nursing

Senior Lecturer, University of Hertfordshire, Hatfield, UK

Jenny Parry MSc, RN, RM, NDN, PWT, DNT, NP

Principal Lecturer, Canterbury Christ Church University College, Canterbury, UK

Judith Parsons MSc, BA, RN, DNT, DNCert, PWT, NP

Senior Lecturer, Canterbury Christ Church University College, Canterbury, UK

Susan Rouse BSc (Hons), RN, RHV, Postgrad Dip Child Protection HETC

Lecturer, University of Hull, Hull, UK

Elaine Ryder RN, NCDN, CPT, Cert Ed, RNT, DNT, BA, MSc, ILT

Principal Lecturer, Oxford Brookes University, Oxford, UK

Anne Smith BSc (Hons) (Dist. Nurse) PGCE, RN

Lecturer in Primary Care, University of Reading, Reading, UK

Milly Smith MSc, Cert Ed, SRN, QIDN, CPT

Principal Lecturer, School of Health, University of Wolverhampton, Wolverhampton, UK

Patricia Wilson RN, NDN, PWT, BEd (Hons) Nursing Education, MSc

Senior Lecturer, University of Hertfordshire, Hatfield, UK

viii Contributors

ForewordNurses working in all community settings are experiencing unprecedented change. It is driven by manyfactors: demographic shifts, higher rates of chronic disease, health policy, increasingly better engagedpatients, social and economic developments, and progress in medical and other technologies and in nursingpractice – to name the key factors. The interplay of these variables is dynamic and inter-dependent. Healthpolicy, for example, addresses the impact of changes in the demographic make-up both in the populationand in the workforce, while changing social mores and expectations demand health policies that recognisethe primacy of the patient at the heart of decision making and choice. For nurses, each of the factors ispowerful enough in its own right to prompt significant change: together, they form an irresistible force.The demand for nurses and expectations of nursing will rise exponentially as the new world unfolds. Morenurses will be working outside of hospitals; more of them will have specialist or expert skills; many willcontinue as generalists offering flexible and accessible care in a variety of settings including the home.Nurses will practice in multi-disciplinary teams as members and as leaders; their work will crossorganisational boundaries, and will be built on partnerships – none more vital than the partnerships withtheir patients and the communities they serve. They will help patients understand the choices available tothem, and in expanding their skills and expertise, they themselves will increase the options on offer. Weshall see more nurse entrepreneurs offering family health services or primary care for vulnerable groups.We shall see nurses as care managers, overseeing all aspects of provision for at-risk older people.

This book provides a timely resource on the context and processes of working in the community for thosenew to this environment, and is an important reminder for those not so new. As is made clear, nursingoutside of hospital isn’t just a change of setting. It is a different way of thinking, of acting and of beingwith local people and communities so that capacity and resources for health are increased and enhanced.

Though we speak of future needs, let us not be daunted by how much there is to do. Let us instead beencouraged by how far we have come. This book reflects powerful developments in nursing practice in thecommunity that have taken place in recent years. It shows that none are more likely to adapt to and adoptchange than community nurses themselves, who understand more than most what will best improve thecare of their patients.

Sarah Mullally 2004

AcknowledgementsThe idea for this book originated from the many enquiries that members of the Association of DistrictNurse Educators (ADNE) received requesting further information on working and ‘surviving’ in thecommunity. With this in mind, all the contributors hope that this guide to practice will prove useful.

The book could not have been written without the ongoing support of the members of the Association ofDistrict Nurse Educators (ADNE) www.adne.com and from experts representing the various disciplinesfrom the community specialist pathways.

Note on terminology and abbreviationsBelow is an explanation of some of the terms favoured in the text of this book.

Patient: It is recognised that some groups of community nurses use other terminology in preference topatient, such as client or user.

Community specialist nurses: This term is intended to include occupational health nurses, health visitors,public health nurses, community children’s nurses, community learning disability nurses, communitypsychiatric nurses, school nurses, district nurses, and general practice nurses. These practitioners haveundertaken further programmes of education, which have been registered or recorded with the Nursingand Midwifery Council.

Community staff nurses: These qualified nurses work in teams under the guidance of a communityspecialist nurse.

She: Nurses are referred to throughout as she, although it is recognised that there are many malecommunity nurses working in Britain. The use of both he and she would have been clumsy, and to use ‘he’by preference would have seemed inappropriate when most nurses are female.

The following sets of initials have been used in the text when making reference to literature published bythese bodies: BMA: British Medical Association; CPHVA: Community Practitioners and Health VisitorsAssociation; DHSS: Department of Health and Social Security; DOE: Department of Education; DOH:Department of Health; HMSO: Her Majesty’s Stationery Office; HSE: Health and Safety Executive; HVA:Health Visitors Association; NHS: National Health Service; NHSME: NHS Management Executive; NMCNursing and Midwifery Council; RCGP: Royal College of General Practitioners; RCN: Royal College ofNursing; UKCC: UK Central Council for Nursing, Midwifery and Health Visiting.

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These are exciting and challenging times forcommunity nurses. Liberating the Talents (DOH2002) provides a framework for the expansion ofclinical roles and calls for greater freedom toencourage creativity. This book has been designedto support staff who may be new to working in acommunity setting and is an essential guide topractice. We envisage it will be useful forcommunity staff nurses and nurses moving from anacute work environment to take up a communitypost. These ‘front-line’ nurses might be working inany of the following disciplines: occupationalhealth nursing, health visiting, communitychildren’s nursing, community learning disabilitynursing, community psychiatric nursing, schoolnursing, district nursing and general practicenursing. Such nurses are not only responsible forpersonal care of patients and for a range of clinicalinterventions, but also for the assessment of healthneeds, planning, delivery and evaluation of directcare for individuals and groups of patients. Inaddition, they may be responsible for mentoringstudents, and directing and supervising the work ofsupport workers.

The aim of the book is to develop and support apractitioner so she can function safely andeffectively in a range of primary care/communitysettings. The authors take an inclusive approach,working from a health and social needs perspectiveand demonstrating the involvement of patients,professionals and non-professionals.

A range of topics relating to professional issues incommunity nursing is addressed. The text reflectsrecent and current government health and socialcare policy reforms and the effect of these on theroles and responsibilities of community nurses.

Community nursing is seen in the context ofpolitical, social and environmental influences.Interpersonal and practical skills, as well as theknowledge base required by community nurses, arecritically analysed and linked to relevant theory.Examples and exercises relating to the range ofcommunity disciplines are included throughout thebook to stimulate the reader’s creative thinking.

Topics covered include new ways of working,nursing in a community environment, personalsafety, therapeutic relationships, workingcollaboratively, conceptual approaches to care,professional issues in community nursing, publichealth and health promotion.

SOCIAL AND POLITICAL INFLUENCESUPON COMMUNITY NURSING

The economic crisis of the 1970s led to the first realmajor reforms in the National Health Service(NHS). The centralisation of administrative powerled to dissatisfaction amongst NHS employees. In1976 the Resource Allocation Working Partyreviewed the allocation of funds and began themove away from the focus upon London hospitals.The then government advocated a change ofbalance in services, emphasizing the need toprioritise older people, people with learningdisabilities and the mentally ill (DHSS 1977). Theimportance of strengthening service provisionwithin the community was clearly stated. In 1979Margaret Thatcher’s Conservative government waselected to power. The Conservative electionmanifesto made no statement relating to healthpolicy.

1Setting the scene: an introductionDee Drew, Sue Chilton, Ann Clarridge and Karen Melling

With underpinning values of efficiency savingsand cost improvement, the NHS in the early 1980swas bureaucratic and seriously underfunded(Lawton et al. 2000). In 1982, Roy Griffiths, asuccessful manager but with limited experience ofhealth care management, was charged with thereview of the management of the NHS. It waswidely thought by the government that poormanagement was behind the failings of the HealthService.

In the published report (1984) Griffithsproposed the introduction of general managers,who, in his view, would be able to lead servicesmore cost-effectively. It was intended that keymembers of the disciplines they managed wouldprofessionally advise these managers. For thenursing profession this meant that line managerswere no longer experienced nurses, which causedconcern relating to professional issues and to therepresentation of community nursing views inpolicy making and community planning (Thornton1995).

The introduction of general managers wasfollowed in 1991 by internal market reforms. Thisstep was intended to improve services byintroducing competition and a purchaser–providersplit. In theory, purchasers would ‘shop around’ forthe best deal. General practice (GP) fund-holderswere allocated an annual sum of money to buy adefined range of services for patients.

The mixed economy of health care was intendedto restrain the bureaucracy of the ‘nanny state’ andincrease input from voluntary and privateorganisations (Pierson 1998). The result was anincrease in the amount of time and effort spentliaising with a great number of people, but it didalso create opportunities for flexibility.

In May 1997 a large majority elected the Labourgovernment to power under the leadership of TonyBlair – signalling the end of the long Conservativehold on government. Frank Dobson led a well-prepared team into the Department of Health.Policies began to be issued almost immediately(Hyde 2001). A key feature of the health policies ofthis Labour government was that they were ‘joinedup’ with those of education and employment. Indocuments such as Saving Lives: Our HealthierNation (DOH 1999), links between health andissues such as poverty, housing and employment

were acknowledged. Nurses, who daily witness theeffects of these links, welcomed this approach.

The Labour government continued the workbegun by the Conservative administration inshifting the balance of care delivery into theprimary care sector, to create a primary care-ledNHS.Within 9 months of Labour gaining office, TheNew NHS: Modern, Dependable (DOH 1997), a 10-year plan for health, had been published. Thisheralded the introduction of health improvementprogrammes (HIPs) and the development ofprimary care groups (PCGs) into primary caretrusts (PCTs), which are, in effect, based aroundclusters of general practice surgeries. A majorradical reform of the NHS was in prospect.

PCTs were fully established in England by April2002. The equivalent bodies in Scotland are alsocalled primary care trusts; in Wales they areknown as local health boards; in Northern Irelandas local health and social care groups (Savage2003). PCTs are responsible for assessing, planningand delivering health services, improving thehealth of the defined population, and workingtowards the proposed public health agenda (DOH1999). They work collaboratively with localpartners, such as Social Services, and the localcommunity. Working alongside the PCTs, on acontractual basis, are the NHS trusts. The role ofthe health authorities has changed significantly:the recently formed strategic health authorities arelarger organisations than the previous authorities,and provide overall management for both PCTsand NHS trusts. The equivalent organisations inother parts of the UK are: in Scotland, unifiedhealth boards; in Wales, health authorities; and, inNorthern Ireland, health and social services boards(Savage 2003).

Alongside these structural changes, governmentpolicy focused on the needs of patients and theircarers, and advocated patient participation in care(DOH 2001a). A First Class Service: Quality in theNew NHS (DOH 1998) considered the quality ofservices offered, and launched clinical governance asa new framework for ensuring efficient and effectivecare within the NHS. Nurses were, on the whole,more receptive to the idea than their medicalcolleagues, who have traditionally monitoredthemselves. Many community nurses have taken thelead in issues of clinical governance. Quality is high

2 Setting the scene: an introduction

on the agenda, and various structures are in place toensure the optimum standards, including nationalservice frameworks (NSFs),the National Institute forClinical Excellence (NICE),and the Commission forHealth Care Audit and Inspection (DOH 2000). InJuly 2000 the government published The NHS Plan,which sets the agenda for health care services centredon the patient and tailored to the patient’s needs.The onus is on PCTs to implement nationalguidelines to meet the needs of their respective localcommunities.

The PCTs form the hub of the new NHS and arepolitically and financially powerful. Nurserepresentatives appointed to PCT boards need to beassertive, astute, have effective leadership skills anda clear vision of the future for community nursing.

CHALLENGES AND OPPORTUNITIES FORCOMMUNITY NURSING

The NHS Plan (DOH 2000) committed to theextension of nursing roles in all settings. Thedevelopment of such initiatives as rapid response,intermediate care, early discharge and nurse-ledclinics offer challenges and opportunities forcommunity nurses. In 2001 the Department ofHealth published a report, Shifting the Balance ofPower, which set out a programme of changedesigned to empower patients and the workforce todeliver this ambitious plan.

Politicians recognise the enormity of the task setbefore people and acknowledge that a huge culturalshift is necessary together with effectivecommunication at all levels of the NHS organisation.Effective implementation of clinical governance ispivotal to the development of innovative communitynursing practice and different ways of working.Aftermore than 50 years of domination by the acute,specialist, hospital-based service, these changes areradical. Liberating the Talents (DOH 2002) calls fora transference of power to the front-line staff and –even more radically – to patients. There does seemto be a real attempt to change the status quo. So, itwould appear that, after decades of being theCinderella service, community health care has nowgained a pivotal position in the NHS.

Community care and community nursing are byno means new phenomena. Looking back over time,

health care has been delivered in various ways andin a wide range of locations. The actual setting inwhich care occurs is directly influenced by thepredominant form of health care at that time. This,in turn, develops as a result of the wider societalinfluences of the day (Tinson 1995).

Community nurses work in a great variety ofsettings – clinics, health centres, people’s homes,schools, workplaces and private homes.Additionally, they work with different groups ofpeople. For example, school nurses tend to focusupon children and adolescents and occupationalhealth nurses care for a specified workforce. Somecommunity nurses may care for all age groups, butspend much of their time with a particularsubgroup. The majority of district nurse visits tendto be to older people (Audit Commission 1999).Community nurses work together with other teammembers. Collaboration and team working areessential for effective patient care. These issues areaddressed in Chapter 6.

DEMOGRAPHIC ISSUES

The United Kingdom has been described as anageing society, in which the number of people overthe age of 80 years is set to increase by almost halfas many again by 2025 and the number of peopleover 90 years of age is predicted to double (DOHb2001). The needs of older people and their carersare often complex, and assessment of these requiresa high level of knowledge and skill (Ryder 1997).Effective community care depends on the co-ordination and integration of health and social care.

To ensure that appropriate and effective healthand social care is available for those older peoplewho become frail or ill will become one of thecommunity services’ greatest challenges. It isequally important to acknowledge the greatpotential older people have to contribute towardscommunities and to encourage their participationin designing and developing services.

There are, of course, other groups of people whoneed to be considered carefully. It is important notto stereotype individuals, but planning to meet theneeds of people with common characteristics canproduce very effective initiatives. Good examples ofthese can be found in the government’s ‘Sure Start’strategy (DOE 1998).

Demographic issues 3

A tool, which may be of great help in assessmentof local needs, is a community profile. This can aidthe identification of health needs and shouldinvolve the general public’s viewpoint. Professionalgroups and less formal agencies may work togetherto produce a health needs assessment to assist inprioritising. These important issues are addressed inmore detail in Chapters 3 and 10.

COMMUNITY SPECIALIST PRACTICE

Policy directives and patient choice, amongst otherfactors, have led to the development today of aprimary care-focused NHS. According to Clarke(1999), community specialist practitioners workwith individuals, families and communities towardsthe achievement of independence. Communitynurses work within a network of complex processesin particular localities – not just in a differentcontext from their colleagues in institutional oracute care settings. Community nursing involvesmuch more than a change of location. From anexploration of the literature, it soon becomesapparent that the term ‘community’ itself isextremely difficult to define, as it can be interpretedin a variety of ways. Three commonly identifiedelements associated with ‘community’ are locality,solidarity and significance. In beginning to grasp thedynamic nature of a community, we must embraceall three elements and gain insight into the complexsocial relationships that exist between people,families and the community as they experiencehealth and illness (Clarke 1999).

Community nursing is a fairly unique area ofpractice, embracing a philosophy of care that relatesto primary, secondary and tertiary prevention, to awide range of different interventions, and to healtheducation (McMurray 1993). The ‘client’ can be anindividual, family or community. Advanced clinicalskills are required to fulfil the role of communityspecialist practitioner, including highly developedinterpersonal skills, critical thinking, decisionmaking, creative management and leadership, and ahigh degree of self-awareness (Clarke 1999). Eachmember of the community nursing team provides avaluable contribution to the delivery of high-qualityeffective care.

Nurses are now delivering care in a variety ofdifferent ways within the community, and new

initiatives within primary care include walk-incentres and nurse-led personal medical services(PMS). Nurses are increasingly becoming the‘gatekeepers’ of health services in the community.In general practice, the patient’s first point ofcontact is often a nurse.

As their roles develop in response to the currentNHS reforms, community nurses are required toexpand their repertoire of skills and expertise.Earlier hospital discharges and more sophisticatedtreatment regimes mean that nurses are engaged inmore technical and complex packages of care.‘Hospital at home’ services, often co-ordinated bycommunity specialist practitioners and their team,provide early hospital discharge for specific groupsof patients – for example, those recovering fromorthopaedic surgery. Many community hospitalsprovide respite care in nurse-led beds and ‘rapidresponse’ teams prevent hospital admissions, forexample, for chest infections and stroke (Thomas2000).

‘Intermediate care’ refers to ‘that range ofservices designed to facilitate transition fromhospital to home, and from medical dependence tofunctional independence, where the objectives ofcare are not primarily medical, the patient’sdischarge destination is anticipated and a clinicaloutcome of recovery (or restoration of health) isdesired’ (Steiner and Vaughan 1997).

Wade and Lees (2002) suggest that now is anideal time for a review of current health careprovision, with appropriate intermediate careservices providing an opportunity for practicedevelopment which can incorporateinterdisciplinary working and build bridgesbetween the acute and community sectors. There ispotential for a more needs-led and person-centredapproach to care.

Intermediate care can be delivered in a variety ofsettings, including community hospitals, hospital athome schemes, community assessment andrehabilitation schemes, social rehabilitationschemes, and hospital hotels. An interdisciplinaryapproach is called for in which nurses, socialservices personnel, therapists and medical staffwork together. Within the framework for nursing inprimary care, nurses, midwives and health visitorshave been given three core functions: first contact,continuing care and public health. Community

4 Setting the scene: an introduction

nurses will have a key role in delivering this excitingagenda (DOH 2002). In conclusion, the followingchapters further develop the issue raised in thisIntroduction.

REFERENCES

Audit Commission (1999) First Assessment: A Review of DistrictNursing in England and Wales. London: Audit Commission.

Clarke, J. (1999) Revisiting the concepts of community careand community health nursing. Nursing Standard, 14(10):34–6.

Department of Education (1998) Primary School LeagueTables. London: The Stationery Office.

Department of Health (1997) The New NHS: Modern,Dependable. London: The Stationery Office.

Department of Health (1998) A First Class Service: Quality inthe New NHS. London: The Stationery Office.

Department of Health (1999) Saving Lives. London: TheStationery Office.

Department of Health (2000) The NHS Plan. London: TheStationery Office.

Department of Health (2001a) Shifting the Balance DOH:London: The Stationery Office.

Department of Health (2001b) National Service Framework forOlder People. London: The Stationery Office.

Department of Health (2001c) The Expert Patient : A NewApproach To Chronic Disease Management in the 21stCentury. London: The Stationery Office.

Department of Health (2002) Liberating the Talents: HelpingPrimary Care Trusts and Nurses to Deliver the NHS Plan.London: The Stationery Office.

Department of Health and Social Services (1977) The WayForward: Priorities in Health and Social Services. London:HMSO.

Department of Health and Social Services (1983) NHSManagement Enquiry (Chair: Sir Roy Griffiths). London: HMSO.

Hyde, V. (ed.) (2001) Community Nursing and Health Care:Insights and Innovations. London: Arnold.

Lawton, S., Cantrell, J. and Harris, J. (2000) District Nursing:Providing Care in a Supportive Context. London: Arnold.

McMurray, A. (1993) Community Health Nursing: PrimaryHealth Care in Practice. London: Churchill Livingstone.

Pierson, C. (1998) Beyond the Welfare State? The New PoliticalEconomy of Welfare (2nd edn). Cambridge: Polity Press.

Ryder, E. (1997) Needs of older people. In S. Burley, E.E.Mitchell, K. Melling, M. Smith, S. Chilton and C. Crumplin,Contemporary Community Nursing. London: Arnold.

Savage, C. (2003) Where is the best place to nurse? NursingTimes, 99(10): 22–6.

Steiner A. and Vaughan, B. (1997) Intermediate Care. Adiscussion paper arising from the King’s Fund seminar held30 October 1996. London: King’s Fund.

Thomas, S. (2000) The changing face of community nursing.Primary Health Care, 10(5): 21–4.

Thornton, C. (1995) The changing face of management. In P.Cain, V. Hyde and E. Howkins (eds), Community Nursing:Dimensions and Dilemmas. London: Arnold.

Tinson, S. (1995) Assessing health need: a communityperspective. In P. Cain, V. Hyde and E. Howkins (eds),Community Nursing: Dimensions and Dilemmas. London:Arnold.

Wade, S. and Lees, L. (2002) The who, why, what of intermediatecare. Journal of Community Nursing 16(10): 6–10.

References 5

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Rapid changes have occurred within the NHSsince the return of the Labour government topower in 1997. This commenced with The NewNHS: Modern, Dependable (DOH 1997) and hasbeen consolidated in The NHS Plan (DOH2000a). Health and social policy have provided thedriver for change and health care professionalshave been required to respond. Clinicalgovernance and quality issues (see DOH 1999d)have impacted on the organisation of the healthservice and the delivery of services. The aim of thischapter is to consider the effect of these changes.The focus of the discussion will be an analysis ofhow they have affected community care, and thenew ways of working required to accommodatethem.

THE CHANGING PERCEPTION OFSERVICE DELIVERY

Previously the NHS has been service-led, with anauthoritarian, ‘top–down’ approach. The medicalmodel of health care has predominated (Burke2001). In recent years there has been a paradigmshift in the underpinning philosophy of care

delivery, and the focus is now on providing apatient-centred service based on local need (DOH2000a), which is identified through exercises suchas community profiling. There has been aconceptual shift away from illness orientation tohealth promotion (Naidoo and Wills 2000). Thereis a greater focus on the social aspects of people’slives that may affect their health. The individual,whilst being consulted over services, is also beingexpected to take some responsibility for his/herown health. However, it is recognised that healthpromotion strategies need to be targeted beyondthe individual’s behaviour, as the health of thegeneral public is affected by many factors overwhich they have no personal control: for example,global warming and air pollution.

ExerciseReflect on factors that affect your health overwhich you have no control. Consider yourcontribution to maintaining your localenvironment.

2New ways of workingAnne Smith

Learning outcomes

• Define the changing perception of service delivery in respect of the modernisation agenda.• Examine the influence of the organisational culture on practice development.• Identify new ways of working and delivering services in accordance with local targets.• Analyse the need for skills development in leadership and management of change for practitioners

at all levels.

The government’s commitment to supportinghealthy living initiatives is demonstrated through theintroduction of services such as smoking cessationclinics (DOH 1999b). This particular initiative hasbeen placed within the remit of health visitors,districtnurses and practice nurses. Their autonomy in thisarea has been further recognised by their beingpermitted to prescribe the relevant nicotinereplacement therapy for the patients involved.Evidence suggests that this activity is one of the mostinfluential health-promoting activities, and providesa measurable impact on health.The National Institutefor Clinical Excellence has published guidelines toendorse this (2002). One example of a simple buteffective innovation is described by Roberts (2002),who, in consultations, used three key questions todetermine patients’ readiness to give up smoking.Theanswers given by the patient indicate whether theyare definitely resolved, or are considering ‘quitting’but require more support to do so.This then enablesthe practitioner to arrange a suitable follow-upappointment to provide that support.

The new agenda is being directed by publicationssuch as The NHS Plan (DOH 2000a) and Shiftingthe Balance of Power (DOH 2001a), which haveevolved from The NHS: Modern, Dependable(1997). It will be influenced further by theforecasted demographic trends over the next 20years – trends that have been substantiated in the2001 census. This identified a greater proportion ofthe population being over the age of 60 than under16 for the first time.The implications of this fact areenormous, together with the evidence that suggeststhat a quarter of the health care accessed during aperson’s life is accessed during the final years(Wanless 2001).

The infrastructure of the NHS has been radicallyaltered. Primary care trusts (PCTs) have nowemerged as the main provider of services. Revenuereleased from the Department of Health givesPCTs control of 75 per cent of the total healthbudget (DOH 2002b). Services are being deliveredin innovative ways: for example, walk-in centres,NHS Direct. PCTs are now commissioning servicesat a local level, sensitive to the specific needs oftheir communities (DOH 2002b). Personal medicalservices (PMS) demonstrate this concept, and walk-in centres provide quick and effective access forclients, especially those who, because they are

working full-time, may have found surgery hoursprohibitive.

These initiatives have also led to an expansion ofnurse-led services, and the timely extension of nurseprescribing has enhanced nurses’ contributions tothis target.Other examples of innovations have beenin operation over a longer period of time.‘Intermediate care’ (DOH 2001b) is well establishedin many communities and offers a service thatreduces pressure on acute beds, whilst meeting theneeds of clients more effectively than previousarrangements, which were less flexible. This hasprovided the opportunity for targeting localproblems with the appropriate services, building onprevious initiatives evidenced by health action zones(HAZ) and health improvement programmes (HIPs)(DOH 1997). More recent publications (e.g. DOH2002c) provide guidance on the priorities that localorganisations are required to consider when planningfuture developments in community services. Themain theme of this document echoes the underlyingphilosophy of service delivery in acknowledging theperspectives of all parties involved, including thepatient. The public health agenda has also beenemphasised, as each PCT is required to have a publichealth professional on the board. This emphasis isfurther demonstrated by the development of rolesfor health care professionals that are concerned withpromoting public health. Within some communityspecialist nursing disciplines this has engendered anew conceptual base to the provision of services,particularly significant within the realms of schoolnursing and health visiting. Historically the schoolnursing service has been responsible for duties thathave mimicked a medical model of care concernedwith the completion of school medicals and healthscreening and surveillance. This image is swiftlychanging, following the publication of SchoolNursing:A National Framework for Practice (CPHVA2000),which identifies the school nurse as a dynamicmember of the multi-disciplinary team, more

ExerciseConsider what experience you or members of yourfamily have as patients accessing these services.

8 New ways of working

involved than previously in issues of healthpromotion and education. A clear example of suchinnovation has been provided in Liberating the Talents(DOH 2002a), in which a school nurse describes herdevelopment of a profiling tool that identifies healthand social issues within the school population so thatthese can be targeted to improve health.

It is increasingly obvious that the way that healthcare is delivered has been influenced by a shift infocus and this is common to all communitydisciplines. The practitioner’s role is increasinglyevolving as one with political and ethical dimensions.One clear example of the public’s behaviour beingaffected by the media and their own interpretationof risk has been demonstrated through the MMR(measles, mumps and rubella) vaccination debate.Clinical staff were in a prime position to offer adviceand influence behaviours. The health consequencesresulting from the non-uptake of this vaccine werenot clearly defined and therefore the public may nothave been fully informed as to the implications oftheir decisions.The outcome has been that now thereare unvaccinated infants susceptible to contractingthese communicable diseases and the ‘herd’immunity relied upon to control them is lost(Lewendon and Maconachie 2002). The publichealth issues underpinning this debate and the publichealth dimension that has become an expectationwithin every professional’s remit will be exploredfurther in Chapter 9.

Currently practitioners are trying to understandand manage transition. New roles have beencreated, job descriptions reconfigured andemployees are reorientating to their newresponsibilities within the emerging structures.These events have taken place against a backdrop ofquality enhancement and clinical governance(DOH 1999d). There is a focus on measuring andjustifying the delivery of services whilst ensuring

that the patient’s perspective is sought anddocumented (DOH 2002c). For those engaged indelivering services and providing continuity of carewhilst all the reorganisation is occurring there is asense of unease and instability. These behaviourscan be clearly related to Tuckman’s (1965) model ofgroup life in which the group of individuals passthrough several stages of ‘forming’ and ‘storming’prior to settling into any type of team formationthat is able to perform effectively.

However, it is an environment that can provideopportunities for those who feel enabled. Otherpractitioners may resist change by raising barriers toprevent any development being successful. Theseissues will be considered later, and coping strategiesdiscussed.

Other major influences on the delivery of care arethe monitoring procedures established to measureperformance and the penalties incurred for failingto achieve targets. The National Institute forClinical Excellence and the Commission for HealthImprovement are both involved with ensuringquality in health care delivery underpinned by theimplementation of research and evidence-basedpractice.

One key element of the new approach to thedelivery of health care has been the emphasis onwidening access. The changing perception thereforerelates to both patients and staff as new initiativesare operationalised. The intention is that patientssee a health service that is responding moreappropriately to individual need and staff areincreasingly aware that the provision of care isbecoming more patient focused.

The new public health agenda has a strongemphasis on involving, inspiring and supportinglocal communities to undertake projects in whichthey, the public, propose and lead the changes(James and Barker 2001).

It may be useful to view this concept in relationto the principles of ‘social marketing theory’, firstdescribed by Kotler and Zaltman (1971, cited inLefebvre 1992 ). Lefebvre’s (1992) definition statesthat social marketing is ‘a method of empoweringpeople to be totally involved and responsible fortheir wellbeing: a problem-solving process that maysuggest new and innovative ways to attack healthand social problems. It is not social control.’ Theprinciples are adapted from a business base but

ExerciseReflect on how issues concerning a public healthapproach have influenced your own views ofservice delivery. Has it influenced the way that youwork with your patients?

The changing perception of service delivery 9

have relevance to the introduction of healthpromoting behaviours from a micro and a macroperspective. (See Chapter 10 for further discussionof this concept.)

THE ORGANISATIONAL CULTURE

Central to the notion of patient-centred care is thefact that a new approach is necessary. The structureof the whole organisation has been radically alteredto facilitate this. Care cannot be delivered in avacuum so the devolving of decision making andcommissioning to localities should assist in theprovision of services sensitive to local need (DOH2002b).

However, these policy initiatives cannot beintroduced without a consideration of the staff whowill be implementing them. Many of the changeshave already caused confusion as new roles havebeen established and new services developed.Sometimes this has been done without consideringthe services already in place. Poole (2002) advocatesthat real working in primary care necessitates anunderstanding of the complex issues involved. Thenature of the work concerns investing inrelationships and dealing with people who do notfunction in a predictable way like machines.Consequently staff must also adapt to the situationsin which they find themselves and be aware of theloss of control that might be experienced. Theauthoritative or ‘top–down’ model of health caredelivery has been succeeded by a more democratic,negotiated model. Poole offers some practicalstrategies for coping. She suggests that thosedelivering the services should invest time indeveloping relationships rather than focusing onroles and functions. Other essential considerationsare flexibility in structuring working practice and,underpinning this, a sound communication system.

Community nurses are central to the delivery of

the change process. The clinical governance agendastrongly influences working practice, with auditbeing an important component of practice. Thenurses’ contribution to the development of a ‘newNHS’ was documented in Making a Difference(DOH 1999a). This publication outlined theleadership qualities necessary to manage a swiftlychanging service and initiated programmes such asthe LEO (leading empowered organisations)programme to prepare nurses for their pivotal role(Garland, Smith and Faugier 2002).

A culture shift has also been experienced asbudgets were amalgamated between health andsocial services. This was to promote the provision ofa seamless service and to encourage integratedworking, necessitating the removal of professionalboundaries. One practical example of theDepartment of Health’s commitment to suchinitiatives is the ‘Single Assessment Process’outlined in National Service Framework for the OlderPerson (DOH 2001b). This has requiredprofessionals to co-operate in new ways to deliverappropriate care. Wild (2002) comments that atruly person-centred approach will only beachieved when professional boundaries have beendissolved.

Public service management styles require to beanalysed in order to understand the philosophyunderpinning the change of emphasis. Theevolution of PCTs has ensured that the hierarchicaland bureaucratic structures formally associatedwith health service management are becomingflatter and more democratic, with decisions beingtaken by those who are closer to the point ofdelivery and more aware of the outcomes.

The NHS bears little resemblance to theorganisation it was even a decade ago. Confusionpersists over the new structural components androle definitions. Job titles appear creative andexpansive as boundaries and expectations have notbeen clearly identified. ‘Skill mix’ has become aterm encompassing innovative strategies to developmembers of the workforce to enable them to offersupport in a variety of ways; for examplereceptionists who are also trained as phlebotomistsand ECG (electrocardiogram) technicians.

Localities operate in very different ways, andmoving from one area to another can provide aculture shock in itself. The sense of change in the

ExerciseWhat evidence are you aware of concerningpatient participation in the decision making inyour area? Identify examples of how thesedecisions have affected services.

10 New ways of working

organisational culture is devolved to a very personallevel. However, the reorganisation of communitycare is a constant feature throughout. The driversfor change are also similar, but the interpretation ofhow the agenda will be met may vary enormouslyaccording to the location in which the care isdelivered.

NEW WAYS OF WORKING

The NHS Plan (DOH 2000a) has outlined a 10-yearplan of investment and reform in order tomodernise the NHS. The workforce is central tothat plan. As previously noted, the NHS mustacknowledge that a culture shift is required.Bureaucratic management concentrating on serviceprovision dictated by resource allocation is nolonger acceptable. A dynamic and flexible approachis advocated, which places the emphasis on patientparticipation in decision making. This approachmust be transparent, and a variety of options havebeen developed to facilitate this.

The introduction of local patient forums and theformation of patient advisory liaison services(PALS) indicate that the public are being consulted(Chapman 2002). Collaborative working must beembraced in its widest sense – to include therecipient of care. Further evidence of thegovernment’s commitment is clearly demonstratedby the introduction of the white paper The ExpertPatient (DOH 2001c). Whilst acknowledging thatmany patients with chronic diseases have a more in-depth knowledge of the personal management oftheir particular condition than the professional, italso conveys the message that patients are able to bemore independent if encouraged to take control ofthe management. This relates to the theorydescribed by Rotter (1954) concerning ‘locus ofcontrol’. It is also aligned to the concept prevalentin the government documents that the patientshould remain in control of the decisions abouttheir health and treatment.

Health promotion strategies to prevent the onsetof chronic diseases such as coronary heart diseaseand diabetes are also advocated. Again thegovernment’s commitment to this has beendemonstrated by the publication of national serviceframeworks, for example DOH 2000c and 2001b,which prescribe standards, respectively, for the careof individuals suffering from coronary heart disease,and for the care of older patients, in order toprovide equity of care throughout the country.Integral to these frameworks are initiativesconcerned with providing both primary andsecondary prevention. An example of respondingwith a team approach is quoted by Fairhead (2003),who describes how a community mental healthnurse worked alongside a practice nurse to developher expertise in managing patients with depression.The general practitioners and patients gave a verypositive response, when surveyed, to the resultingimprovement in services.

New ways of working are emerging in response tothe demographic influences within the workforce.The shortage of nurses is already apparent, and is setto get worse, particularly as the profile of communitynurses indicates an ageing population. The problemwas identified in 1999 (DOH 1999a) and a responseby the government was to provide more trainingplaces. However this was not sufficient to resolve theproblem. Other solutions have been considered,various of them initiated by the document A HealthService for All Talents (DOH 2000b). Cadet schemeshave been reinstated. Further incentives have beenprovided for those workers (health care assistants)with NVQ qualifications to undertake more in-depthtraining. These schemes are supported by theiremployers and delivered in the workplaceenvironment whilst they continue with theiremployment. This has several advantages in that theworkforce is not depleted whilst the care assistantsare training and they continue to receive a salarywhilst extending their knowledge and skills. Oncetrained, their employment status will be enhanced tothat of ‘assistant practitioners’.They will also qualifyacademically with a foundation degree (GreaterManchester Workforce Development Confederation2002). The intention is to initiate a ‘skills escalator’,which practitioners will be able to ‘step on’ and ‘stepoff’, to provide flexible learning and training,accessible to all individuals at all grades (DOH 2003).

ExerciseConsider which government initiatives have beenimplemented in your locality.

New ways of working 11

The government has pledged its commitment toinitiatives to educate the workforce and support life-long learning for all sectors of the workforce, andsuch initiatives as this demonstrate the commitment.

Flexible working is further enhanced by ‘family-friendly policies’ advocated in such documents asImproving Working Lives (DOH 2002d) Theemphasis is on recruiting and retaining staff byoffering working hours that complement domesticresponsibilities.

As previously discussed, the different communitydisciplines are challenged by a variety of demandsaccording to their roles, although some issues arecommon to all. This is considered within specialistpractitioner degree courses. All community nursingprofessionals are educated within a core coursewhich includes a specialist element to reflect theirspecific discipline. This demonstrates the valueplaced on all these professionals’ contributions tothe primary health care team in fulfilling the healthimprovement agenda.

The NHS Plan (DOH 2000a) placed greatemphasis on the development of integrated teamsand this was to include practice nurses, whohistorically have been set apart from theircommunity nursing colleagues due to theiremployment contracts with GPs. In many instancesthese arrangements are changing following theformation of PCTs.

New ways of working and managing care arecontinually being influenced by advances intechnology and the health service’s attempt toembrace them. Examples of such influences are theincreasing use of telemedicine and thecomputerisation of patient records. Theimprovement in communication provided by thesesystems with their ability to transfer information,

particularly between hospitals, laboratories andsurgeries has an impact on patient care.

KEY SKILLS FOR LEADERSHIP ANDMANAGEMENT OF CHANGE

The community environment is changing beyondrecognition and there is a requirement forpractitioners to change their ways of working tomanage it. Practice development can be achieved inmany different ways and the success of it dependson the management of change.As previously stated,examples of innovative schemes have beenpublished in the document Liberating the Talents(DOH 2002a). This publication describes creativeways in which health care can be delivered,acknowledging the fact that 90 per cent of patientjourneys involve a contact in primary care(O’Dowd 2002).

Unsworth (2001) contends that within the NHSprofessionals are expected to plan and implementchange in practice, often with very little support.Business organisations meanwhile will importexperts to manage the change process. Theseapproaches to managing change refer to ‘external’or ‘internal’ change agents (Broome 1998).

However, change management is a complexprocess for which practitioners need adequatepreparation. The requirement for preparation wasclearly identified in Making a Difference (DOH1999a) and reinforced in the recommendations ofThe NHS Plan (DOH 2000a), in which nurses wereproposed as the main implementers of the newagenda in practice. A national nursing leadershipproject, initiated by the Department of Health, isproviding training for those considered best placedto move practice forward, advocating anempowering approach. Well established in this areais the LEO (Leading an Empowered Organisation)programme (Garland, Smith and Faugier 2002).

The Department of Health has invested in avariety of measures to ensure that leadershiptraining is devolved to all levels of staff, sinceleadership qualities do not necessarily only existwithin those staff in positions of seniority. Clinical‘change agents’ do not need to be team leaders butany practitioner who is supported to changepractice.

ExerciseConsider the skill mix of the team in which youwork. What sort of roles do the members of theteam adopt? Are people adopting different roles?Is the team delivering services in a different way?Are the patients seeking the service for differentreasons than they were two years ago?

12 New ways of working

Certain approaches need to be considered ifchange is going to be effective and smoothlyimplemented. A primary consideration is that ofplanning the change and providing a soundrationale for the need to change. If this is clearlyarticulated and agreed by the team members thechances of success are more likely.

The nature of current change is that it isgovernment-led and -driven, which means that it isdifficult for the practitioner to see the need forchange or take responsibility for it. This often leadsto resistance and hostility. It is vital to consider theperceived benefits of change. SWOT analysis is auseful exercise that will help practitioners do this(Adams 2000). It involves compiling a list ofstatements that identify the effects of the changeunder four headings: strengths, weaknesses,opportunities and threats. It must be rememberedthat the type of change mainly associated with thenew arrangements is ‘imposed change’, oftenunplanned and swiftly introduced, and with thosepeople who will be most affected are not beingconsulted over the best means of implementation.Unless SWOT analysis shows obvious benefits to allconcerned, practitioners will continue to lackenthusiasm and motivation.

It is clear that change cannot be effectivelymanaged unless certain procedures are followed toidentify the need for it: for example, audit, research,reflection, SWOT analysis (Adams 2000). Theseprovide the evidence for change, after whichplanning the change process must be undertaken. Ifthe ideas of those who will be involved areincorporated, or their comments sought, they aremore likely to support rather than resist the change.‘Planned change’ is generally better received andmore likely to succeed than ‘unplanned change’(Broome 1998).

It is worthwhile pausing here to consider thecomponents of change management theorydiscussed by Lewin (1951), as these underpin anystrategy that may be devised to manage change in

the working environment. Lewin describes a three-stage approach: unfreezing, moving (or changing)and refreezing. The unfreezing stage concernsrecognising that a change is necessary. This needmay be identified through reflective practice orexamining research that promotes different ways ofworking. The change requires planning in order toachieve the proposed outcomes. Finally, once thechange has been implemented refreezing occurs asthe new practice is adopted. As with any newinitiatives there will be those who are motivated tochange and those who are cynical and less keen;enthusiasts ready to accept and implement change;but equally ‘laggards’, who are difficult to convince.Managing these ‘laggards’ is the real challenge, andthe leadership style of the person who is facilitatingthe change is relevant to success. Styles ofleadership vary according to the character of theindividual and their position in the organisation.

The above is an extremely simplified explanationof the change management process. In reality, thesuccessful implementation of a change in practice isa complex task.

Mulhall’s text (1999) examines various theoreticalperspectives. Ultimately however, the culture of thepractice environment has a strong determininginfluence on whether the change is effectivelyintroduced and adopted. Therefore practicedevelopment is the remit of all staff, and to achievesuccess in this area requires an inclusive approach,in which everyone feels they can contribute.

CONCLUSION

It is necessary and indeed the responsibility of allNHS employees, in order to meet the demandsplaced upon them, to become involved in providinga service that sets the patient at the centre. It is alsoimportant that health professionals are responsiveto the feedback offered by the patient (Hollins2002). If the targets of the NSFs are to be met,practice innovation and new ways of working arerequired in which individuals are empowered to beself-supporting in taking responsibility for theirpersonal health and wellbeing and that of theircommunity. Models of community health practice(Chalmers and Kristajanson 1989) and practicedevelopment (Page 2002) can provide a frameworkfor this activity.

ExerciseVisit the nursing leadership website and explorethe educational opportunities that it offers atwww.nursingleadership.co.uk.

Conclusion 13

The community nurse’s role is multi-faceted andthe approach must be adaptable in order to respondto the variety of caring, supportive, or pro-activeroles that she may be required to adopt in thisdiverse area.

The Chief Nursing Officer summed up thediverse roles of primary health care practitionerswhen briefing PCT lead nurses:

It isn’t just what you do that matters, it is alsohow you work that is important – putting thepatient and community first, empowering frontline staff and working in partnership across healthand social care.

(Mullally 2002)

FURTHER READING

Iles, V. and Sutherland, K. (2001) Managing Change in the NHS.Organisational Change: A Review for Health Care Managers,Professionals and Researchers. London: National Co-ordinating Centre for NHS Delivery and Organisation R and D.

Mulhall, A. (1999) Changing Practice: The Theory. NursingTimes Clinical Monograph No 2. London: Nursing TimesBooks.

Rink, E. (2000) Integrated Nursing Teams in Primary Care.Nursing Times Clinical Monograph No 49. London: NursingTimes Books.

REFERENCES

Adams, C. (2000) Clinical Effectiveness: A Practical Guide forNurses. London: Community Practitioners and HealthVisitors Association.

Broome, A. (1998) Managing Change. London: Macmillan.Burke, W. (2001) Can you feel the force? The importance of

power in practice development. In S. Spencer, J. Unsworthand W. Burke (eds), Developing Community NursingPractice. Buckingham: Open University.

Chalmers, K. and Kristajanson, L. (1989) The theoretical basisfor nursing at the community level: a comparison of threemodels. Journal of Advanced Nursing, 14: 569–74.

Chapman, L. (2002) Involving patients in the new NHS. PrimaryHealth Care, 12(21): 10–12.

Community Practitioners and Health Visitors Association(2000) School Nursing: A National Framework for Practice.London: CPHVA.

Department of Health (1997) The New NHS: Modern,Dependable. London: The Stationery Office.

Department of Health (1998) A First Class Service: Quality inthe New NHS. London: The Stationery Office.

Department of Health (1999a) Making a Difference:Strengthening the Nursing, Midwifery and Health VisitingContribution to Health and Health Care. London: TheStationery Office.

Department of Health (1999b) Smoking Kills. London: TheStationery Office.

Department of Health (1999c) Sure Start. London: TheStationery Office.

Department of Health (1999d) Clinical Governance: Quality inthe New NHS. London: The Stationery Office.

Department of Health (2000a) The NHS Plan: A Plan forInvestment, A Plan for Reform. London: The StationeryOffice.

Department of Health (2000b) A Health Service for AllTalents: Developing the Workforce. London: The StationeryOffice.

Department of Health (2000c) National Service Framework forCoronary Heart Disease. London: The Stationery Office.

Department of Health (2001a) Shifting the Balance of Power:The Next Steps. London: The Stationery Office.

Department of Health (2001b) National Service Framework forOlder People. London: The Stationery Office.

Department of Health (2001c) The Expert Patient: A NewApproach to Chronic Disease Management in the 21stCentury. London: The Stationery Office.

Department of Health (2002a) Liberating the Talents. London:The Stationery Office.

Department of Health (2002b) Delivering the NHS Plan. London:The Stationery Office. And see: www.doh.gov.uk/deliveringthenhsplan/index/htm

Department of Health (2002c) Improvement, Expansionand Reform: The Next Three Years. London: The StationeryOffice. And see: http://www.doh.gov.uk/planning2003-2006/improvementexpansionreform.pdf

Department of Health (2002d) Improving Working Lives for theAllied Health Professions and Health Care Scientists.London: The Stationery Office.

Department of Health (2003) Human Resources Skills Escalator. London: The Stationery Office. And see: www.doh.gov.ukhrinthenhs/section4b/skillsescalatorhomepage.htm

Fairhead, C. (2003) A new role in managing depression. PrimaryHealth Care, 13(21): 18–20.

Garland, G., Smith, S. and Fuagier, J. (2002) Supporting clinicalleaders in achieving organisational change. ProfessionalNurse,17(8): 490–2.

14 New ways of working

Greater Manchester Workforce Development Confederation(2002) Developing the Modern Workforce: Annual Report2001/2002. See: www.gmconfed.org.uk

Hollins, M. (2002) The opportunity for nurses to managethemselves. Primary Health Care, 12(4): 10–12.

Hyde, V. and Cotter, C. (2001) The development of communitynursing in the light of the NHS Plan. In V. Hyde (ed.),Community Nursing and Health Care: Insights andInnovations. London: Arnold.

Iles, V. and Sutherland, K. (2001) Managing Change in the NHS.Organisational Change: A Review for Health Care Managers,Professionals and Researchers. London: National Co-ordinating Centre for NHS Delivery and Organisation R and D.

James, T. and Barker, E. (2001) Community development. In D.Sines, F. Appleby and E. Raymond (eds), Community HealthCare Nursing (2nd edn). Oxford: Blackwell Science.

Lefebvre, C. (1992) Social marketing and health promotion. InR. Bunton and G. Macdonald (eds), Health Promotion.Disciplines and Diversity. London: Routledge.

Lewendon, G. and Maconachie, M. (2002) Why are children notbeing immunised? Barriers and risks to immunisation uptakein South Devon. Health Education Journal, 61(3): 212–20.

Lewin, K. (1951) Field Theory in Social Science. New York:Harper & Row.

Mulhall, A. (1999) Changing Practice: The Theory. NursingTimes Clinical Monographs No 2. London: Nursing TimesBooks.

Mullally S. (2002) Special Edition: Chief Nursing OfficerBulletin July 2002. And see: www.doh.gov.uk/cno/pctbulletinspecialjuly02.htm

Naidoo, J. and Wills, J. (2000) Health Promotion: Foundations

for Practice (2nd edn). Edinburgh: Baillière Tindall inassociation with the Royal College of Nursing.

National Health Service Centre for Research andDissemination (1999) Effective Health Care Bulletin, 5(1):9–14. And see: www.york.ac.uk/inst/crd

National Institute for Clinical Excellence (2002) Guidance on theUse of Nicotine Replacement Therapy (NRT) and Bupropionfor Smoking Cessation. Technology Appraisal Guidance No 39.

O’Dowd, A. (2002) The primary care revolution. Nursing Times,98(47): 1–11.

Page, S. (2002) The role of practice development inmodernising the NHS. Nursing Times, 98(11): 34–6.

Poole, J. (2002) Complexity in primary care. Primary HealthCare,12(1): 16–17.

Roberts, J. (2002) Kicking the habit. Primary Health Care, 12(9):27–32.

Rotter, J. (1954) Generalised expectations for internal v. externalcontrol and reinforcement. Psychological Monographs, 80.

Tuckman B. (1965) Developmental sequences in small groups.Psychological Bulletin, 63: 384–99.

Unsworth, J. (2001) Managing the development of practice. InS. Spencer, J. Unsworth and W. Burke (eds), DevelopingCommunity Nursing Practice. Buckingham: Open University.

Wanless, D. (2001) Securing our Future Health : Taking a Long-term View. London: HM Treasury.

Wild, D. (2002) The single assessment process. Primary HealthCare, 12(1): 20–1.

Woodward, V. (2001) Evidence-based practice, clinicalgovernance and community nurses. In V. Hyde (ed.),Community Nursing and Health Care: Insights andInnovations. London: Arnold.

References 15

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This chapter considers the context in whichcommunity nurses practise, and addresses the widerange of factors that impact upon the services theyprovide for patients. Demand-driven and needs-ledservices are compared,and ways of tailoring provisionof care to fit local need are discussed. The roles andresponsibilities of the eight community specialistpractice disciplines are outlined and the key strategiesfor ensuring high-quality care are identified.

FACTORS INFLUENCING THE DELIVERYOF COMMUNITY HEALTH CARESERVICES

Community nurses face many challenges within theirevolving roles. The transition from working in aninstitutional setting to working in the community canbe quite demanding at first. As a student oncommunity placement or a newly employed staffnurse, it soon becomes apparent that there is a widerange of factors influencing the planning and deliveryof community health care services. Within the

home/community context, the issues that impactupon an individual’s health are more apparent.Peopleare encountered in their natural habitats rather thanbeing isolated within the hospital setting.Assessmentis so much more complex in the community as thenurse must consider the interconnections betweenthe various elements of a person’s lifestyle.

Defining health is complex as it involves multiplefactors. According to Blaxter (1990), health can bedefined from four different perspectives: an absenceof disease, fitness, ability to function and generalwellbeing. The concept of health has many

ExerciseMake a list of all those factors that might have animpact upon a person’s health. It might be helpfulto think about it on different levels: individual/family factors, community factors and societal/governmental factors.

3Nursing in a community environmentSue Chilton

Learning outcomes

• Discuss environmental, social, economic and political factors influencing the delivery ofcommunity health care services.

• Differentiate between a demand-driven and a needs-led approach to community health careservice provision.

• Explain ways in which local services aim to be responsive to the specific needs of their population.• Describe the role and key responsibilities of the eight community specialist practitioner nursing

disciplines.• Identify those mechanisms which need to be in place to ensure services are effective and efficient.

dimensions: physical, mental, emotional, social,spiritual and societal. All aspects of health areinterdependent in an holistic approach. It is prudentto view an individual within the context of their widersocio-economic situation when considering issuesrelating to their health. There are acknowledgedinequalities in health status between different peoplewithin society and major determinants include socialclass, culture, occupation, income, gender andgeographical location. The Acheson report (1998),which informs the present national public healthagenda,provides a fairly comprehensive review of theliterature/research available on inequalities in health.

DOH (1998a) summarises some of the factorsinfluencing health as follows:

• Fixed: genes, sex.• Social and economic: poverty, employment and

social exclusion.• Environmental:air quality,housing,water quality,

social environment.• Lifestyle: diet, physical activity, smoking, alcohol,

sexual behaviour and drugs.• Access to services: education, NHS, Social

Services, transport and leisure.

These different categories of influences upon healthcan be particularly useful in providing promptswhen considering the health status of a localpopulation of people.

Dahlgren and Whitehead (1991) present acomprehensive model consisting of four levels:

• Level 1: General socio-economic, cultural andenvironmental conditions.

• Level 2: Living and working conditions – housing,health care services, water and sanitation,unemployment, work environment, education,agriculture and food production.

• Level 3: Social and community networks.• Level 4: Individual lifestyle factors.

The authors state that all four levels impact uponthe health status of the individual, for whom age,sex and hereditary factors are also significant.

The increased emphasis lately on thedevelopment of a primary care-led NHS has comeabout in response to demographic, technological,political and financial influences amongst others.An

increasing population of older people, shorterhospital stays, improvements in technology andpatient preference have all contributed to themovement of resources from the acute to theprimary care sector. The development of newcompetencies to provide services away from hospitalsettings (Thomas 2000) means that an increasingnumber of people with both acute and chronicconditions will eventually receive care at home or ina range of other locations within the community. Itis envisaged that hospitals will mainly providediagnostic and specialist services in the future.

HEALTH NEEDS ASSESSMENT

A quote from Community-oriented Primary Caresummarises the principles underpinning a needs-led, as opposed to a demand-led, service:

Needs assessment requires more thanepidemiological data on geographically definedpopulations. To be responsive to users, it requiresthe involvement of front-line service providers,particularly those based in the community. Theseinformation sources are complementary, and bothneed to be integrated to plan and deliverappropriate health services. Linking rigorous needsassessment to service definition and the iterativecycle of service assessment and revision requiresclose collaboration between commissioners andproviders. Primary care professionals are closer toservice users than most other providers, and havea key role in identifying health care needs.

Primary health care teams (PHCTs) are beingrequired to assess their practice populations’needs to guide practice and to achieve targets inareas such as health promotion. Systematicapproaches to these tasks are required.

Primary care organisations of the future willhave to retain their capacity to provide qualitypersonal care and develop a populationorientation if they are to move from a demand-led service – however responsive – to needs-ledpractice, and a better integration of primaryhealth care, secondary care, social services andthe voluntary sector.

(King’s Fund 1994: p.1)

18 Nursing in a community environment

This approach to primary health care is just asrelevant today, particularly as we are now providingservices to defined populations within primary caretrust (PCT) boundaries. It is clearly important thatwe consider the actual/potential needs of our givenpopulation – regardless of our discipline – if we areto provide services that are relevant and efficient.

Bradshaw’s taxonomy of need (1972), whichdescribes four types of need,provides a useful startingpoint when addressing this subject: (1) ‘normative’need is need as defined by professionals;(2) ‘felt’ needis a want as perceived by the population; (3) an‘expressed’ need is a demand for a felt need to be met;and (4) a comparative need is defined by comparingservices provided to individuals/populations withsimilar characteristics. In order for services to targetneeds appropriately, they need to respond to felt andexpressed needs rather than normative need.Providing ‘needs-led’ services can be somewhatchallenging for community nurses as it may wellinvolve a greater empowerment of the client and awillingness on the part of the community nurse to re-examine their own motives/reasons for providing thecurrent service in the way they do. This may lead toa fairly major change in the organisation of the servicefor the future, which will require regular evaluations.

In a review of the district nursing services acrossEngland and Wales, the Audit Commission (1999)recognised that at least one in ten referrals to districtnurses (DNs) are inappropriate.It is recommended thatDNs define more clearly the service they provide. Oneof the major reasons for inappropriate referrals appearsto be a misunderstanding on the part of colleagueswithin the primary health care team regarding the roleand the responsibilities of DNs. In response,DNs couldaddress this issue in a number of ways.

Community nurses can identify the needs of theirgiven population by conducting a health needsassessment,which is a process of gathering informationfrom a variety of sources in order to assist the planningand development of services. As society is constantlychanging, health needs assessment is not a staticexercise. According to the extract from Community-oriented Primary Care (King’s Fund 1994) quotedabove, data is required regarding disease patterns(epidemiology) and public health in a particular area(PCT or locality within PCT), as well as informationregarding local environmental factors/resources(knowledge base/experience of community serviceproviders). In other words, a combination of ‘hard’(statistical/research-based/quantitative) data and ‘soft’(experiential/anecdotal/qualitative) data.

In capturing the ‘essence’ of a locality, the term‘community profile’ is frequently used to describean area in relation to its amenities, demography(characteristics of the population), public services,employment, transport and environment.Traditionally, health visitors, in particular, have been

ExampleConsider the area/team in which you are workingat present. What sources of information wouldhelp to inform you regarding the specific needs ofyour client group/population. Make a list and tryto divide the information into either ‘hard’ or ‘soft’data.

ExampleA district nursing team working within a particularlocality of a PCT might decide to actively markettheir service. They may produce guidelines forreferral (for GPs, hospital staff, other professionalcolleagues and patients/families). Serviceaims/objectives would reflect the needs of theirspecific client group (felt/expressed need) and notbe based solely on normative need. Comparisonswith other DN service guidelines might be carriedout (comparative need) but variations in thecharacteristics of the different populations wouldneed to be taken into account.

ExampleAn occupational health nurse working in a factorythat produces chemicals may engage in healthchecks for new employees and respond to staffhealth problems on a daily basis. In addition,however, he/she might take part in screeningactivities with employees in order to identifypotential physical/psychological health problemsrelated to the nature of the work in question.

Health needs assessment 19

required to produce community profiles as a formof assessment during their training.

Any attempt to analyse the series of complexprocesses that make up a living community withoutthe participation of local residents/consumers is afairly fruitless exercise. In gathering information froma large community population, a variety of methodsmay prove useful.An approach known as participatoryrapid appraisal has been described elsewhere (Chiltonand Barnes 1997) and involves community membersin the collection of information and in decision makingrelated to this information. Originally used indeveloping countries to assess need within poor ruralpopulations, it has been employed in deprived urbanareas (Cresswell 1992). A wide variety of datacollection methods are used and participatory rapidappraisal involves local agencies and organisationsworking together.By working in partnership with localresidents,action is taken by community members whohave identified issues of local concern/interest anddiscussed potential solutions. Clearly, participatoryrapid appraisal could be used to help tackle specificissues as well as large-scale assessments.

MEETING THE NEEDS OF THE LOCALPOPULATION

Current government policy (DOH 1997, 2000a,2001) stresses the importance of a localised approachto community health care service provision. EachPCT is different in terms of its characteristics, whichmight include its demography, geographical location,environment, amenities, transport systems,unemployment levels, deprivation scores, workopportunities and access to services, for example. Asa result of these potential variations, it is importantto interpret national guidelines according to localneeds. Each PCT has its own individualised localtargets for public health identified within a HIP andtailored to the specific requirements of the localpopulation.Such targets are usually chosen followingan examination of local information sources, such asepidemiological data collected by the public healthdepartment within the health authority, generalpractice (GP) profiles and caseload analysis dataobtained from local health care practitioners.

By systematically reviewing local informationsources and working within government/professionalguidelines, community specialist practitioners havean opportunity to develop practice and morecollaborative ways of working.

DOH (2001) highlights the importance of front-line staff taking responsibility for implementingmany of the recent changes in the NHS. This willinvolve community nurses becoming more activelyinvolved in health needs assessment. It has beenrecognised that there are populations whose healthcare needs are unmet (Latimer and Ashburner 1997),which presents community nurses with the

ExampleFrom GP profile information, one locality within aPCT identified a significantly high percentage ofthe older population with dementia. As a result,the community psychiatric nurse team workingwith older people in the locality liaised with thepractice nurses across the identified GP practiceswith a view to discussing the provision of supportfor the carers involved.

ExampleIn a PCT, the local health improvement programme(HIP) target is to reduce teenage pregnancies. Aparticipatory rapid appraisal approach to the issuemight involve pregnant teenagers, health visitors,school nurses, school teachers, practice nurses,midwives, family planning clinic personnel, localhospital maternity services etc. Followinggovernment guidelines in the form of the SocialExclusion Unit’s report (1999) on teenagepregnancies, data collection methods could includesemi-structured interviews with key individuals,focus group interviews, written reports and harddata. By working together with teenagers who arepregnant in an appraisal of their needs, professionalsmay develop greater understanding of the keyissues. A more co-ordinated approach to thechallenge of reducing teenage pregnancies may bedeveloped, which might necessitate changes to theresponsibilities of the different disciplines involved.In promoting a collaborative initiative such as this,there is a greater awareness of the roles of othercolleagues and duplication can be avoided.

20 Nursing in a community environment

challenge of redefining their services to moreaccurately respond to the needs of their particularpatient group.Traditionally,many community nurseshave responded to referrals, which are frequentlyinappropriate and often do not represent the mosturgent needs of the population in terms of priority.

Responding more appropriately is not any easy task,as many of these unmet needs often require seekingout and might exist within the more disadvantagedsectors of society. It is not unreasonable to assume thatmany community nurses will require a greaterunderstanding of different cultural issues and socialvalue systems before they are able to identify specificunmet needs. The inverse care law means that,ironically, the more advantaged people in society tendto receive better health care services (Acheson report,1998). Current NHS policy is attempting to rectifythis anomaly and end the so-called ‘postcode lottery’,which suggests that health status can be determinedon the basis of where a person lives.

Although national service frameworks (NSFs) arenational guidelines produced to encourage thedissemination of best practice in relation to particularconditions or client groups, it is the responsibility offront-line staff to implement them locally andinterpret them according to local conditions.

Ensuring that local NHS organisations worktogether with local authorities, especially withregard to social care, is fundamental to the newways of working, and PCTs are in an ideal positionto facilitate this collaborative approach.

Clearly, there are differences between PCTs in termsof the locations in which community health careservices are offered to patients. Provision will varyconsiderably between a rural and an urban PCT. Forexample,in a rural location,there might tend to be morecommunity hospitals,providing accessible local services

that are not of a specialist nature, whereas walk-incentres,for example,tend to be located in more denselypopulated locations, such as city centres and airports.

In order to provide high-quality care to patients,community nurses need the necessary skills,knowledge and expertise and it is the responsibilityof individual practitioners and their employingauthority to ensure that the appropriate training isorganised. Working alongside their local workforceconfederation, PCTs or other employing authoritiesplan for the future recruitment and training of newstaff and the continuing professional developmentof existing staff. PCTs will also develop and updatepolicies and procedures in relation to the clinicalresponsibilities of community nurses and theseshould relate to the latest benchmarking criteriaand government/professional guidelines.

Under the present government, it is suggestedthat patients should have an influence on theprovision of health care services. Patients’ viewsshould therefore be considered by board membersof the PCT, who are charged with the responsibilityof ensuring patient participation.

COMMUNITY HEALTH CARE NURSINGDISCIPLINES

A new understanding of community care as ‘process’rather than ‘context’ is proposed by Clarke (1999)to enable us to value community nursing as advancedspecialist practice in its own right, rather than asinstitutional or acute care nursing in another setting.Eng et al. (1992) encourage an ‘understanding thata community is a ‘living’ organism with interactivewebs of ties among organisations, neighbourhoods,families and friends’.

Community nursing takes place in a wide varietyof settings.

ExerciseList as many different locations as you can wherecommunity nurses provide care. This might helpyou to identify particular client groups and go onto name some of the eight community specialistpractice disciplines identified by the UK CentralCouncil (UKCC) in 1994.

ExerciseIn relation to the locality in which you are basedin the community, find out about ways in whichthe NSFs are being implemented at a local level.Gather information regarding local initiatives andexamples of any community nurses working incollaboration with other individuals/organisations/agencies in addressing the NSF guidelines.

Community health care nursing disciplines 21

Recent government reforms in terms of thestructures and systems that form the NHS (e.g.DOH 1997, 2000a, 2001) have led to anacknowledgement by community specialistpractitioners that their roles and responsibilitiesneed to be examined and redefined in preparationfor the new challenges ahead. Leadership, practicedevelopment and partnership working are keyelements within the roles of all communityspecialist practitioners (DOH 2001). The Nursingand Midwifery Council (NMC) are currentlyattempting to redefine the role of the specialistpractitioner. In the early 1990s, the UKCCconducted the PREP (post-registration educationand practice) project to clarify the future trainingrequirements for post-registration nurses. At thetime, eight community specialist practicedisciplines were identified: occupational healthnursing, community paediatric nursing,community learning disability nursing,community mental health nursing, generalpractice nursing, school nursing, health visitingand district nursing.

The UKCC (1994) proposed a common core-centred course for all specialities, which was to be atfirst degree level at least, and one year in length.According to the UKCC, the remit of communityspecialist practice embraces ‘clinical nursing care,risk identification, disease prevention, healthpromotion, needs assessment and a contribution tothe development of public health services andpolicy’. It is perhaps particularly pertinent in thecurrent context of partnership working that weembrace those common aspects of our practice ascommunity specialist practitioners. In espousing theuniqueness of the individual disciplines, there is anacknowledged danger that nurses will miss out onopportunities to influence a primary care-led NHS(Quinney and Pearson 1996)

Occupational health nursing (OHN)

OHN is a relatively new nursing discipline that hasdeveloped from its origins in ‘industrial nursing’ inthe mid-19th century, when the role was mainlycurative rather than preventative (Chorley 2001).

Occupational health nurses work within thewider occupational health services and play apreventive role in advising employers, employees

and their representatives on health and safety issuesin the working environment, and the adaptation ofthe working environment to the capabilities of theemployees (RCN 1991).

The role of the OHN is concerned withpreventing ill health which affects the ability towork, and ill health caused by employment, andalso with promoting good health and developinghealth promotion strategies in the workplace.OHNs’ responsibilities are as varied as theindustries/businesses in which they are employed.

Chorley (2001) identifies five elements of theOHN role as being professional,managerial,business,environmental and educational responsibilities.

Many factors influence the future role of theOHN, including political, economic and publichealth care strategies. However, Chorley (2001)argues that OHNs can professionally influence keyareas of their practice by assessing future healthcare trends through analysing research, reviewingepidemiological data and conducting needsassessment.

Community children’s nursing (CCN)

According to the Royal College of Nursing (RCN2002b), the past few decades have seen considerablegrowth and innovation for CCN services. In 1987,there was a total of 25 services in the UK; currently,there is a total of 150 CCN teams in England alone.There are very few areas (mainly rural) without aservice.

The development of the CCN services has beensupported by a number of pertinent reports (DOH1991; DOH/NHSE 1996, Audit Commission1993). The Department of Health and the NHSExecutive (1996) agree that ‘CCN services shouldbe led, and predominantly staffed, by nurses whopossess both registrations as a children’s nurse andexperience of community nursing’.

There are three key elements within the deliveryof CCN services: (1) first contact/acute assessment,diagnoses, treatment and referral of children; (2)continuing care, chronic disease management andmeeting the imperatives of the Children’s NSF; and(3) public health/health protection and promotionprogrammes – working with children and familiesto improve health and reduce the impact of illnessand disability (DOH 2002).

22 Nursing in a community environment

Community learning disability nursing(CLDN)

According to Barr (2001), there was a recognitionof the need for more community-based services tobe provided for people with learning disabilitiesliving at home and their families in the mid-1970s.Around this time, different models of service weredeveloping around the notion of ‘normalisation’,which is the underlying philosophy of many of theservices provided for people with learningdisabilities. Normalisation may be defined as ‘acomplex system which sets out to value positivelydevalued individuals and groups’ (Race 1999).

Service principles for learning disability servicesshould be based on an individual’s assessed needs;flexible and sensitive in service provision; equitableand integrated with an accessible range of servicesthat offer priority to those in the greatest need;prompt, effective and comprehensive and evaluatedby the degree to which they provide privacy,dignity, independence, rights and fulfilment forpeople with learning disabilities (DHSS 1995).

CLDNs often work closely with other membersof the multidisciplinary team. Bollard and Jukes(1999) stress the importance of CLDNs clarifyingtheir working relationships with other communityspecialist practitioners and members of the primaryhealth care team in order that people with learningdisabilities do not fall between services or receiveconflicting advice.

Community mental health nursing(CMHN)

The CMHN service has been well documentedsince its inception in the mid-1950s. The expertiseof the CMHN lies in assessing the mental health ofan individual within a family and social context.CMHNs may be located in health centres, GPpractices, voluntary organisations and accident andemergency departments. They represent peoplewith mental health needs and provide high qualitytherapeutic care (Long 2001). Four elementsunderpin the professional practice of CMHNs. Firstis a guiding paradigm, which involves respecting,valuing and facilitating the growth unique to eachindividual (Rogers 1990). Second, therapeuticpresence is needed to restore clients’ dignity and

worth as healthy, unique human beings. Third, thetherapeutic encounter, which is essential for healingand growth. Finally, the principles of CMHN, whichinclude the search for recognised and unrecognisedmental health needs; the prevention of adisequilibrium in mental health; the facilitation ofmental health-enhancing activities; therapeuticapproaches to mental health care and influences onpolicies affecting mental health (Long 2001).

Although several models are emerging in theorganisation, delivery and evaluation of communitymental health services, the guiding principlesremain the same. Community profiling andcollaborative working are considered by Long(2001) to be pivotal in promoting the mentalhealth of the nation.

General practice nursing (GPN)

Nurses have been working in general practice formore than 80 years (Hyde 1995). Since the early1990s, the number of practice nurses has grownconsiderably in response to the demands of generalpractice. The service expanded from 1515 nurses in1982 to 10198 in 1998 (RCGP 2000). At the sametime, the range of services they provide has alsodeveloped rapidly.

Practice nurses frequently fulfil the role of‘gatekeeper’ and are relatively easily accessible andacceptable to patients as they are located within GPsurgeries. The role of the practice nurse is wide-ranging and covers all age groups within thepractice population (Saunders 2001). The types ofservice provided might include tasks such as earsyringing and venepuncture through to nurse-ledchronic disease management programmes operatedwithin agreed protocols. The expansion of nurseprescribing will enhance the provision of care forpractice nurses working within clinics such as these(DOH 2000b). Chronic disease management andscreening/secondary prevention programmes areareas of expertise for practice nurses, which couldbe further developed (Eve and Gerrish 2001). Morerecently, practice nurses have become involved inthe implementation of NSF guidelines at a locallevel and often play a key role in establishing nurse-led clinics to tackle public health targets. Forexample, clinics for people with coronary heartdisease.

Community health care nursing disciplines 23

School nursing

School nurses have been employed within theschool health service for more than 100 years buthave not been afforded, despite their importance,the same status as their community specialistpractice colleagues, according to Thurtle (2001).

DeBell and Jackson (2000) state that theassessment of the specific health-care needs ofschool age children in the community is essential inthe development of the school nursing service.Theyalso emphasise that ‘school nursing is committed tothe health improvement of children and youngpeople of school age’.

In addition to delivering core health surveillanceprogrammes within schools, school nurses considerthemselves to have particular responsibility forpromoting healthy lifestyles and healthy schools;for child and adolescent mental health; chronic andcomplex health needs; and for vulnerable childrenand adolescents (Obeid 2001).

DOH (1999a, p.13) emphasises that schoolnurses are ‘playing a vital role in equipping youngpeople with the knowledge to make healthylifestyle choices’. Key aspects of the school nurse’srole include the assessment of health needs ofchildren and school communities, agreement ofindividual and school plans and delivery of thesethrough multi-disciplinary partnerships; playing akey role in immunisation and vaccinationprogrammes; contributing to personal and healthand social education and to citizenship training;working with parents to promote positiveparenting; offering support and counselling,promoting positive mental health in young peopleand advising on and co-ordinating health care tochildren with medical needs.

In addition to this the DOH (1999b) identifiesschool nurses as public health practitioners with aspecific role in the healthy school programme,tackling teenage pregnancy and working withfamilies

Health visiting (HV)

The health visiting service has been in existence formore than 100 years and has its roots in publichealth and concern about poor health. The overallaim of the service is the promotion of health and

the prevention of ill health. According to theCouncil for the Education and Training of HealthVisitors (CETHV 1977), the four main elements ofthe health visitor’s role are the search for healthneeds; stimulation of awareness of health needs;influence on policies affecting health; andfacilitation of health-enhancing activities.

Although health visitors (HVs) will continue tomaintain their public health role, they are alsodeveloping a much wider role in primary care.Traditionally, the focus of their work has been onmonitoring the development of the under-fives.Several documents (Acheson 1998; DOH1999a,1999b) have defined a new health agenda forthe future, in which health visitors have a key role.A statement from Making a Difference (DOH1999a, p. 132) reads: ‘we are encouraging [healthvisitors] to develop a family-centred public healthrole, working with individuals, families andcommunities to improve health and tackle healthinequality’. Family health maintenance, childprotection and community outreach withvulnerable groups are examples of the type of workHVs undertake.

Appleby and Sayer (2001) stress the importanceof health visitors finding new ways of measuring theeffectiveness of their work, which tends to havelong-term benefits for society but has always beennotoriously difficult to quantify.

District nursing (DN)

District nurses can trace their roots back to the mid-1800s at least and the historical development of theservice is well recorded. District nurses used towork in relative isolation but are more likelynowadays to work within a team (Thomas 2000).The role of the district nurse has evolved over timein response to political influences and the changingneeds of the populations served. Although it isacknowledged that the role of the district nursingservice is not clearly defined, it involves theassessment, organisation and delivery of care tosupport people living in their own homes (AuditCommission 1999). The three major elements ofthe role are that of clinical expert, manager andteacher (Clarridge et al. 2001). District nurses carefor people with acute and chronic illnesses as wellas those requiring palliative care. The majority of

24 Nursing in a community environment

people on the district nurse’s caseload tend to befrom the older generation.

According to the RCN (2002a), the value of thedistrict nursing service comes from its holisticapproach to patient need and its ability toimplement a package (often complex) of treatmentthat transcends health and social care. Districtnursing work is complex and wide ranging.Intermediate care, rehabilitation, rapid responseand prevention of admission teams are currentinitiatives within the modernisation programme.District nurses are playing key roles in developingmany of these innovative services.

Integrated nursing teams

Integrated nursing teams are ‘teams of community-based nurses from different disciplines, workingtogether within a primary care setting pooling theirskills, knowledge and ability in order to provide themost effective care for their patients within apractice and the community it covers’ (HVA 1996).

According to the Department of Health (1999a),integrated nursing teams are beneficial as theypromote greater understanding of each other’sroles, help to reduce duplication and allow for moretargeted use of specialist skills.

Considering the acknowledged importance oftailoring services to patient need, an approach thatresponds to and addresses nursing/health issuesidentified as part of an individual or population-based health needs assessment exercise is preferable.

Beech (2002) explores the potential for integratednursing teams in primary care settings and recognisesthat, at present, very little research-based evidence

exists in relation to integrated nursing teams,particularly in terms of patient outcomes. Shebelieves that all those people with a vested interestneed to be consulted prior to the establishment ofintegrated teams and a structured approach isrequired for successful practice development.

GUARANTEEING A QUALITY SERVICE

With the launch of their new manifesto for healthin 1997, the Labour government stressed theimportance of delivering quality standards withinthe NHS:

Professional and statutory bodies have a vital rolein setting and promoting standards but shiftingthe focus towards quality will also requirepractitioners to accept responsibility fordeveloping and maintaining standards withintheir local NHS organisations. For this reason, theGovernment will require every NHS Trust toembrace the concept of ‘clinical governance’ sothat quality is at the core, both of theirresponsibilities as organisations and of each oftheir staff as individual professionals.

(DOH1997)

The DOH (1998b) reinforces the importance ofensuring that the services provided by health careprofessionals are of a high quality. The presentgovernment have established a number oforganisations and initiatives designed to support aculture of excellence in health care: the NationalInstitute for Clinical Excellence (NICE), nationalservice frameworks (NSFs), the Commission forHealthcare Audit and Inspection (CHAI), theNational Performance Framework, a NationalSurvey of Patient and User Experience, and clinicalgovernance (CG).

NICE provides advice on best practice withregard to existing treatments and evaluates newhealth interventions. In so doing, it encourages theuse of the most appropriate treatments in terms ofclinical and cost effectiveness.

NSFs are evidence-based national guidelinesissued in relation to the treatment of specific clientgroups or disease categories. They act to ensure thatpeople receive integrated, safe and clinically

ExampleA young child diagnosed with learning disabilitiesand who has associated physical health problemswill require a comprehensive package of care.Working in alliance with a core integrated nursingteam, which would include a health visitor,specialist services could be provided by acommunity children’s nursing service andcommunity learning disability nurses, ideallyworking in collaboration.

Guaranteeing a quality service 25

effective care (RCN 2002c). Collaborative practiceis a prerequisite for the successful implementationof the NSFs. NSFs include strategies to supporttheir implementation and establish performancemilestones against which progress, within an agreedtimescale, can be measured. NSFs form one of anumber of initiatives designed to raise quality anddecrease variations in service. There are plans topublish only one new framework annually. Anexternal reference group (ERG) consisting of healthprofessionals, service users and carers, health servicemanagers, partner agencies and other advocatesassists in the development of the NSFs with thesupport and supervision of the DOH. Since itslaunch in April 1998, the NSF programme hasembraced established frameworks on cancer andpaediatric intensive care and developed the mentalhealth NSF (September 1999), the coronary heartdisease NSF (March 2000), the national cancer plan(September 2000), the older person NSF (March2001), the diabetes NSF (2001) and the children’sNSF (2003). NSFs are being prepared for renalservices and long-term neurological conditions.

The Commission for Healthcare Audit andInspection (CHAI) is due to replace theCommission for Health Improvement (CHI), thenational body that supports and monitors thequality of clinical governance and of clinicalservices. CHAI will be a more powerful healthinspectorate, responsible for both public and privatesectors. CHAI’s other responsibilities will includeconducting ‘value for money’ audits; determiningstar ratings for all NHS bodies and recommendingspecial measures where necessary; validatingperformance assessment data, including waiting listinformation; reporting on NHS organisations’performance; providing independent scrutiny ofpatient complaints and reporting annually toparliament on health care progress and the resourcesthat have been used. There are plans to create asingle Commission for Social Care Inspection at thesame time as CHAI, with a legal obligation on thetwo bodies to co-operate.

The National Performance Framework is designedto give a rounded picture of NHS performance andwill address six areas: health improvement; fairaccess to services; effective delivery of appropriatehealthcare; efficiency; patient/carer experience andhealth outcomes of NHS care.

The National Survey of Patient and UserExperience is conducted annually to elicit theopinions of people in relation to care provided bythe NHS.

The current government has proposed a 10-yearmodernisation programme for the NHS, whichincorporates clear national standards, local delivery,statutory duty, life-long learning and professionalself-regulation, monitoring of services throughCHAI and the NHS Performance Framework andUser survey. Clinical governance (CG) is the centralconcept that embraces all of these elements. It is aframework through which NHS organisations areaccountable for continuously improving the qualityof their services.According to Bennett and Robinson(2002), clinical governance is the vehicle foridentifying not only excellence in care but also thoseaspects of practice that require further development.

The RCN (2002c) describes three main elementswithin clinical governance: quality improvement,risk management and management of performanceand systems for accountability and responsibility.Quality improvement includes standard setting,clinical audit and evidence-based practice.Standards are devised in line with national/localclinical guidelines and evidence-based best practiceand then implemented. Clinical audit is conductedto evaluate whether care meets the requiredstandards and, where necessary, improvements aremade, implemented and re-audited. Riskmanagement involves all of those activities designedto promote best practice and avoid detrimentalevents happening. Individual practitioners areencouraged to view critical incidents and patientcomplaints positively and to learn fromexperiences, supported by a ‘no blame’ culture. Inthe clinical area, this involves clinical supervision,continuing professional development and effectiveclinical leadership. Within the wider NHSorganisation, risk management systems mightinclude incident reporting procedures andstrategies/protocols to prevent adverse events.Systems for accountability and responsibility placea statutory responsibility for care within all NHSorganisations. PCTs, and more specifically the chiefexecutive, are responsible for the quality of careprovided within their organisations. A clinician isappointed within each NHS organisation withresponsibility for the implementation and

26 Nursing in a community environment

evaluation of the CG framework. A spirit ofteamworking and commitment to high standards ofcare is essential if CG is to be effective.

According to Zeh (2002), CG needs to beconsidered alongside professional self-regulationand continuing professional development.Increasingly, community specialist practitioners arebeing encouraged to develop their practice bydiscussing and sharing experiences with colleaguesand regularly updating their skills, knowledge andexpertise. In addition, there is a requirement tovoice any concerns regarding compromised careand actively link into the wider organisational CGframework. Community nurses are accountable tothe Nursing and Midwifery Council (NMC) andthe public for the duties they perform. With CG,there are increased opportunities for patientinvolvement in decisions about care and moreexplicit mechanisms in place to make complaintsand put forward their views.

FURTHER READING

Sines, D., Appleby, F. and Raymond, E. (eds) (2001) CommunityHealth Care Nursing (2nd edn). Oxford: Blackwell Science.

Watson, N. and Wilkinson, C. (2001) Nursing in Primary Care.Basingstoke: Palgrave.

REFERENCES

Acheson, D. (1998) Independent Inquiry into Inequalities inHealth Report. London: The Stationery Office.

Appleby, F. and Sayer, L. (2001) Public health nursing: healthvisiting. In D. Sines, F. Appleby and E. Raymond (eds),Community Health Care Nursing. Oxford: Blackwell Science.

Audit Commission (1993) Children First: A Study of HospitalServices. London: HMSO.

Audit Commission (1999) First Assessment: A Review ofDistrict Nursing Services in England and Wales. London:Audit Commission.

Barr, O. (2001) Community learning disability nursing. In D.Sines, F. Appleby and E. Raymond (eds), Community HealthCare Nursing. Oxford: Blackwell Science.

Beech, M. (2002) The way forward? Journal of CommunityNursing, 16(3): 46–8.

Bennett, J. and Robinson, A. (2002) Developing leadershipcapacity in community nursing: the context of change.Journal of Community Nursing,16(12): 4, 5.

Blaxter, M. (1990) Health and Lifestyles. London: Routledge.Bollard, M. and Jukes, M.J.D. (1999) Specialist practitioners

within community learning disability nursing and theprimary health care team. Journal of Learning Disabilitiesfor Nursing, Health and Social Care, 3(1): 11–19.

Bradshaw, J. (1972) The concept of social need. New Society,30: 640–3.

Cain, P., Hyde, V. and Howkins, E. (1995) Community Nursing:Dimensions and Dilemmas. London: Arnold.

Council for the Education and Training of Health Visitors(1977) An Investigation into the Principles of HealthVisiting. London: CETHV (reprinted 1993, London: ENB).

Chilton, S. and Barnes, E. (1997) Assessing health needs in thecommunity. In S. Burley, E.E. Mitchell, K. Melling et al. (eds),Contemporary Community Nursing. London: Arnold.

Chorley, A. (2001) Occupational health nursing. In D. Sines, F.Appleby and E. Raymond (eds), Community Health CareNursing. Oxford: Blackwell Science.

Clarke, J. (1999) Revisiting the concepts of community careand community health care nursing, Nursing Standard,14(10): 34–6.

Clarridge, A., Boran, S. and Bninski, M. (2001) Contemporaryissues in district nursing. In D. Sines, F. Appleby and E.Raymond (eds), Community Health Care Nursing. Oxford:Blackwell Science.

Cresswell, T. (1992) Assessing community health and socialneeds in North Derbyshire using participatory rapidappraisal. Community Health Action, 24.

Dahlgren, G. and Whitehead, M. (1991) Policies and Strategiesto Promote Social Equity in Health. Stockholm: Institute forFuture Studies.

DeBell, D. and Jackson, P. (2000) School Nursing: A NationalFramework for Practice. Consultation document. London:CPHVA.

Department of Health (1991) The Welfare of Children andYoung People in Hospital. London: HMSO.

Department of Health/NHS Executive (1996) Child Health inthe Community: A Guide to Good Practice. London: HMSO.

ExampleIn relation to your own organisation, considerways in which the three elements of clinicalgovernance – quality improvement, riskmanagement and accountability, and responsibility– are implemented at a local level.

References 27

Department of Health (1997) The New NHS: Modern,Dependable. London: The Stationery Office.

Department of Health (1998a) Our Healthier Nation: AContract for Health. Consultation document. London: TheStationery Office.

Department of Health (1998b) A First Class Service: Quality inthe New NHS. London: The Stationery Office.

Department of Health (1999a) Making a Difference:Strengthening the Nursing, Midwifery and Health VisitingContribution to Health and Healthcare. London: TheStationery Office.

Department of Health (1999b) Saving Lives: Our HealthierNation. London: The Stationery Office.

Department of Health (2000a) The NHS Plan: A Plan forInvestment, A Plan for Reform. London: The StationeryOffice.

Department of Health (2000b) Consultation on Proposals toExtend Nurse Prescribing. London: The Stationery Office.

Department of Health (2001) Shifting the Balance of Powerwithin the NHS – Securing Delivery. London: The StationeryOffice.

Department of Health (2002) Liberating the Talents: HelpingPrimary Care Trusts and Nurses to Deliver the NHS Plan.London: The Stationery Office.

Department of Health and Social Security (1995) Review ofPolicy for People with a Learning Disability. Belfast: DHSS.

Eng, E., Salmon, M.E. and Mullan, I. (1992) Communityempowerment: the critical base for primary health care.Family and Community Health, 15(1): 1–12.

Eve, R. and Gerrish, K. (2001) Roles, responsibilities andinnovative capacity: the case of practice nurses. Journal ofCommunity Nursing, 15(9): 4–6, 8.

Health Visitors’ Association (1996) Integrated Nursing Team:Initial Information. Professional Briefing 1. London: HVA.

Hyde, V. (1995) Community nursing: a unified discipline? In P.Cain, V. Hyde and E. Howkins (eds), Community Nursing:Dimensions and Dilemmas. London: Arnold.

King’s Fund (1994) Community-oriented Primary Care.London: King’s Fund.

Latimer, J. and Ashburner, L. (1997) Primary care nursing: Howcan nurses influence its development? Nursing TimesResearch, 2(4): 258–67.

Long, A. (2001) Community mental health nursing. In D. Sines,F. Appleby and E. Raymond (eds), Community Health CareNursing. Oxford: Blackwell Science.

Obeid, A. (2001) School health nursing review andrecommendations for future practice. Journal of CommunityNursing, 16(12): 6, 8, 10, 12, 15.

Quinney, D. and Pearson, M. (1996) Different Worlds, MissedOpportunities: Primary Health Care Nursing in a North-western Health District. Liverpool: Health and CommunityCare Research Unit, University of Liverpool.

Race, D.G. (1999) Social Role Valorisation and the EnglishExperience. London: Whiting & Birch.

Rogers, C.R. (1990) Client Centered Therapy. London:Constable.

Royal College of General Practitioners (2000) The Primary CareWorkforce: An Update for the New Millennium. London: RCGP.

Royal College of Nursing (1991) A Guide to an OccupationalHealth Nursing Service: A Handbook for Employers andNurses. Middlesex: Scutari Projects Ltd.

Royal College of Nursing (2002a) District Nursing: Changingand Challenging. A Framework for the 21st Century.London: RCN.

Royal College of Nursing (2002b) Community Children’sNursing. Information for primary care organisations,strategic health authorities and all professional workingwith children in community settings. London: RCN.

Royal College of Nursing (2002c) RCN Information: Guidancefor Nurses on Clinical Governance. London: RCN.

Saunders, M. (2001) General practice nursing. In D. Sines, F.Appleby and E. Raymond (eds), Community Health CareNursing. Oxford: Blackwell Science.

Social Exclusion Unit (1999) Teenage Pregnancy. London:Social Exclusion Unit.

Thomas, S. (2000) The changing face of community nursing.Primary Health Care, 10(5): 21–4.

Thurtle, V. (2001) School nursing. In D. Sines, F. Appleby and E.Raymond (eds), Community Health Care Nursing. Oxford:Blackwell Science.

UK Central Council (1994) Standards for Specialist Educationand Practice. London: UKCC.

Zeh, P. (2002) Clinical governance and the district nurse.Journal of Community Nursing, 16(4): 4, 6, 8, 11.

28 Nursing in a community environment

INTRODUCTION

Working in the community provides manychallenges and opportunities. When placed in non-hospital settings as a student nurse or embarkingupon a career as a community staff nurse, it istimely to reflect upon personal safety. This chapteris not intended to deter nurses from choosing towork in a community setting, but to ensure thatpractical and reasonable steps are taken to ensuretheir safety.

The first section of this chapter examines safetyrelating to the prevention and management ofviolence and aggression.The second part focuses uponmanual handling, as the safety of both nurse andpatient may be compromised if careful thought is notgiven to this issue before home visiting.The principlesremain the same wherever the nurse is working, butsome consideration needs to be made when movinginto community settings. Finally, issues of reportingand bringing incidents to a resolution will be explored.

SAFETY AT WORK

The 1974 Health and Safety at Work Act and the1992 Health and Safety at Work Regulations charge

employers and employees with responsibilities inrisky situations. Assessment of risk is a requirementto minimise potential harm and community nursesneed to consider safety issues from both practicaland professional perspectives.

Sadly, violence and aggression are an increasingproblem in hospitals around the United Kingdom(Health Services Advisory Committee 1997, RoyalCollege of Nursing 1998, Whittington and Wykes1996).This is also the case for those nurses working inthe community who are often working alone (Jackson,Clare and Mannix 2002) despite the Zero ToleranceCampaign launched in 1999 by the government.

This campaign sought to reduce the incidence ofviolence against nurses by 20 per cent. It has proveddifficult to achieve (RCN 2001). It is very importantto spend time considering how to prepare forcommunity work and be aware of potential problems.

4Personal safety in the communityDee Drew

Learning outcomes

• Explain the importance of preparation needed prior to visiting patients and clients in their homes.• Discuss considerations relating to personal safety when working in the community.• Analyse interpersonal relationships in terms of non-confrontational behaviour.• Discuss manual handling principles and their application to community settings.• Clearly understand the importance of reporting incidents involving risk.

ExerciseConsider the differences between hospital workingand being community-based. What health andsafety issues may be encountered by communitynurses?

BEING STREETWISE

This includes developing knowledge of the area ofwork, developing self-awareness and understandingwhy and how aggression can escalate.

First, learn the geography of the area, whetherthat is a town, clinic or surgery. Become familiarwith the layout of rooms and buildings and notethe position of exits. Find out what is known aboutthe community. Without falling into the trap ofstereotyping people, investigate what reputationthe area has, find out about crime rates, forexample. Talk to your colleagues about safety. It isstrongly recommended (Leiba 1997) that visiblesecurity measures, involving personnel andtechnology, should be evident in health centres andclinics.

There may be areas within the surroundinglocality that are considered to be high risk.Sometimes community staff visit these in pairs.Find out if the remit of the post involves visitingafter dark. It is good practice to gather as muchinformation as is possible before setting off to apatient or client’s house.

PREPARATION FOR HOME VISITING

This section will focus particularly upon homevisits, as there are particular features that could,

potentially, compromise personal safety. Bearingthis in mind, read carefully any records or notespertaining to the visit. Talk to colleagues, who mayknow the situation and should make sure thatconcerns are shared. Look at the location of the visit– think about how you will get there.

Always remember that home visits, howeverwelcome to the patient or client, are an invasionof that individual’s space. Table 4.4 outlines someof the things that should be considered whenarriving at someone’s home.

The community nurse is a visitor in the patient’shome and must wait to be invited in. It is goodpractice to discourage patients from leaving notes(for example: ‘Please come round to the back – dooropen’) and hanging keys on strings behindletterboxes. These, obviously, put patients at riskfrom unscrupulous opportunists. In addition tothese measures, the community nurse should offerpersonal identification.

Compare the visits in the following example.

The first visitor makes a number of assumptions.When a nurse gets to know the patient well, over aperiod of time, this kind of approach could be moreacceptable, but remember that being in position ofprofessional authority does not override commoncourtesy.

When visiting in other people’s homes, self-

ExampleVisit number 1

‘Hello, I’m the nurse’ (stepping over the thresholdof the door). ’I’ll just put my coat here and go andwash my hands.’

Visit number 2

‘Hello, I’m Staff Nurse Winter from GreendaleHealth Centre’ (showing her identification card). ‘May I come in, Mrs Henry?’ (enters on invitation). ‘Is there somewhere that I could put my coat?’ (waits for a reply). ‘I need to wash my hands. Would it be OK to use yourbathroom?’

ExerciseThe Ladybridge Estate is known to be a verydeprived area with a high crime rate. Car theft andmuggings are increasing.

List the precautions that could be taken by thecommunity staff nurse prior to visiting a patienton the estate. Discuss your list with anexperienced colleague/mentor.

30 Personal safey in the community

How could potential risks be minimised? Makenotes of your ideas and keep them to refer to lateron in this chapter.

awareness is crucial. The conditions in which somepeople live can be upsetting. Monitoring facialexpressions and choosing words carefully are a must(Leiba 1997). This may not prove to be easy. If so,take the opportunity to discuss your feelings withother members of the team after visits that leaveemotions heightened.

The majority of home visits are very welcome tothe patient or client. Relationships betweencommunity staff and the people that they care forcan be very positive and a rewarding aspect ofworking in primary care. With thought, observationand self-awareness many potential problems may beavoided.

Preparation for home visiting 31

Table 4.1 Entering a patient’s home

Considerations Rationale

Remember that you are the visitor. It is the patient’s space that you are invading – it is unknown what isor has recently been happening in that person’s home.

State clearly who you are and why you Don’t assume that the person will recognise a uniform (if one is have come. Show your identity badge. worn) or will be expecting the visit. It is good practice to encourage

patients and clients to ask to see identification. This protects them aswell as the professional.

Wait to be invited into the house and ask Being pushy can make people irritated and angry. It may not be in which room the patient or client would convenient for the patient or client to allow you into a particular like you to carry out the purpose for your room. This may be for good reason, e.g. if an unpredictable dog is visit. shut in there!

Note the layout of the house – exits, In case a speedy exit is required. telephones.

Be careful with people’s property – Spillages, breakages or rough treatment of belongings will irritate – protect their belongings. remember the visitor status.

Be alert – monitor moods and expressions Changes in the demeanour of the patient or client could indicate during the visit. potential conflict developing.

Be self aware – monitor the manner in The nurse should not provoke feelings of anger. Remember that this which information is given and care carried is the patient’s home. out. Do not react to conditions, which may seem unacceptable – dirty, smelly environments, for example.

Trust instinctive feelings. If it feels that Often assessment of situations takes place on many levels. If leaving quickly is the thing to do – go. uncomfortable feelings are building up don’t wait until there is an

incident.

If prevented from leaving – try not to It may be possible for you to de-escalate the situation.panic – see the section relating to interpersonal relationships.

CAR SAFETY

Working in a community setting involves beingmobile. In some localities bicycles may be anentirely appropriate way to get around; in busycities public transport is often the best option. Formost community staff, however, it would beimpossible to function effectively without a car.

Some practical measures need to be undertakenrelating to car safety (Table 4.2). Areas between carparks and clinic/surgery buildings should be well lit.

In addition to the above, it is helpful to plan theroute to the destination with care.As the geographyof the area becomes more familiar, this will becomeeasier. Try not to give the impression that you areunsure of the way. Some police experts are nowrecommending that car doors are kept locked whilstdriving in more dangerous areas. Good preparationfor the journey makes it more likely that the nursewill arrive feeling calm. It is better to avoid roadrage – especially if it is your own.

Walking between car and house,community nursesshould appear purposeful, confident and in control.Walk towards the kerb side of the pavement and awayfrom alleyways and hedges. Footwear should becomfortable and allow for speed, if necessary. It is nota good idea to wear jewellery at work for manyreasons. Chains may catch or be pulled; rings and

wristwatches are a hazard to patients and clients ifphysical care is needed. In addition to these (wellknown) considerations,wearing jewellery could catchthe attention of muggers.

INTERPERSONAL RELATIONSHIPS ANDNON-CONFRONTATIONAL BEHAVIOUR

In spite of the preparations suggested above, it maybe that tensions rise whilst visiting. Confrontationmay occur between patient or carer and nurse.Communication skills are crucially important in allfields of nursing; however, some issues need carefulthought when visiting patients and clients in theirown homes.

Households vary tremendously and staff new tocommunity working may be surprised or shockedby the conditions in which some people live. Anopen mind needs to be cultivated in terms of thepossible relationships that may be encountered –there are many variations of family life. It isnecessary to communicate respect for all patientsand clients, whatever thoughts may be experienced.Nabb (2000) found many incidences of family andcarers assaulting nurses – remember that the givingand receiving of information should always becarried out courteously and sensitively.

32 Personal safey in the community

Table 4.2 Car safety

Consideration Rationale

It makes sense to ensure the vehicle is Not only is it inconvenient, it may be hazardous to break down in a well maintained. remote place after dark. Well worth the expense of servicing and

looking after the car.

Try not to run out of petrol. The car will not be happy and again this could leave you stranded inremote or unsavoury places.

Park with thought. Look for safe parking places. In the dark it is helpful to find astreetlight to park under. Try to park near to your destination.

Take out breakdown cover. At least someone is coming to assist you. Always state that you arealone and make it clear if you are female.

Keep any nursing bags out of view – in Some people may believe that nurses carry drugs in their bags – addition to any personal valuables. prevent temptation.

Table 4.3 suggests guidelines for non-confrontational behaviour to minimise the risk ofprovoking or encouraging aggression or violence.Some of the suggestions may appear to be‘common sense’. In situations of potential conflict,however, it is easy to feel anxious and behaveinappropriately. Try to think carefully about theconsiderations and rationales before a difficult visitoccurs.

Remember that there may be indicators that aperson is potentially aggressive, such as using araised voice, clenching their fists and threateningassault (Leiba 1997).

ExerciseMr Grainger is very annoyed. David, the chargenurse, had told him that he would be visited onTuesday. On Wednesday morning Mr Grainger rangthe Health Centre to complain that no-one hadbeen.

Consider the approach that should be taken whenvisiting Mr Grainger on Wednesday afternoon.Make notes of your decisions and discuss thesewith your team leader.

Non-confrontational behaviour 33

Table 4.3 Interpersonal relationships – non-confrontational behaviour

Considerations Rationale

Be aware of how you are feeling and how If you appear worried or defensive you may cause worry or fear. you may appear to others.

Try to look calm and relaxed. Never try to domineer or act in an arrogant fashion. Attempts tobelittle those who are angry are extremely dangerous.

Speak clearly and quietly – speak in a Shouting or talking over others will provoke a response.low pitch if possible.

Listen to responses. Use non-verbal This is a two-way process. Demands and commands should not be communication (such as nodding the issued.head) to convey understanding.

Try to accept how the other person is Even if the issue is difficult to empathise with, people own their feeling. Ask for further clarification. feelings. Don’t argue.

Be polite in the face of provocation. Avoid becoming over-emotional. It is better to be brief andprofessional if tensions are mounting.

Try to ensure that the other person If people are angry and feel crowded or cornered, aggression can be has an escape route. triggered.

Stay seated if the other person is seated. It can be dangerous to tower over others – the aim is not to provoke.

Don’t stand too close. Leave reasonable personal space to avoid crowding.

Watch carefully to plan your exit. Try to close the conversation if possible.

Aggression has been defined as:

Any incident in which a health professionalexperiences abuse, threat, fear or the applicationof force arising out of the course of their work,whether or not they are on duty.

(RCN 1998: p.3)

This definition is useful, as actual abuse does nothave to occur in order for aggression to be felt. Fearis a powerful enough experience to warrant action.The Royal College of Nursing’s definition also doesnot differentiate between on- or off-duty situations.It is important to remember that insurance coverfrom employers relates to the duration of the shift.

ORGANISATIONAL SUPPORT

Under the 1974 Health and Safety at Work Act,employers have a duty to provide a safe workingenvironment. Along with the responsibilities foremployers there are also requirements, which needto be carried out by employees. Firstly, locate anypolicies and procedures, which exist locally relatingto health and safety (RCN 1994). Study thesecarefully and note the reporting arrangements thatare laid down for staff to follow.

Many primary care trusts (PCTs) offer training inassertiveness and dealing with aggression andviolence. The Health and Safety at WorkRegulations (1992) charge employers withprovision of training in these fields. Take up theopportunities on offer. If there doesn’t seem to beany training available ask if this could be arranged.

It is good practice to contact the work base at theend of the day to let someone know that visits arecomplete. The team leader will delegate visits toeach member of staff and will co-ordinate the team.The order in which visits are carried out may not bepredictable, but someone knows where each nurseshould be visiting on a daily basis.

Many community nurses have the use of a mobiletelephone, which can be useful in difficultsituations. It may not be possible, however, to accessthe phone at the very time that you may need it.Mobile phones do not ensure safety, but they help.The use of personal alarms may be useful, to

frighten, disorientate and debilitate an attacker. TheSuzy Lamplugh Trust (see useful addresses) advisesholding up the alarm directly to the ear of theattacker and running away as fast as possible.

In addition to all of the above, there is a potentialthreat (even in a ‘caring profession’), which may notmanifest itself in the homes or streets of the communityserved. Personal safety may be at risk in situations ofharassment and bullying. Reported incidents are rising(Jackson, Clare and Mannix 2002; Rippon 2000) andit is important to be aware of ways to deal with bullies.

Bullying has been defined as the misuse of poweror position (RCN 2001) and includes aggressivebehaviour, ridiculing or humiliation, public criticismand exclusion from opportunities open to others.

Bullying may occur in any NHS setting and is,unfortunately, becoming more prevalent in manysocieties (Jackson, Clare and Mannix 2002). Manystudies have found that aggression between staff ismore upsetting and difficult to deal with thanassaults from patients (Farrell 1999, 2001).

It is important not to keep bullying quiet – talk toother people (family, friends, trusted colleagues)and document what is happening. Employers arecharged with the task of developing a culture ofintolerance towards bullying and to deal withincidents effectively (DOH 2002). It is alwaysbetter to try to address issues informally anddirectly at first – the person may not realise theeffect that they are having. If, however, this does notwork, then a formal complaint may be made. It isstrongly advised that advice be sought from unionrepresentatives if a formal complaint is to be made.

A further requirement of the 1992 Health andSafety at Work Regulations is that of risk assessmentin the workplace, which should be followed byplanning, organising and monitoring bothprotective and preventive measures. The Healthand Safety Executive (HSE) have issued a five-stageframework for risk assessment. This applies to allsituations, which could lead to harm and is used alsoto evaluate needs relating to manual handling.

HSE’S FIVE STAGES OF RISKASSESSMENT

These apply to all situations that have potential forrisk. It is the case that many interventions carried

34 Personal safey in the community

out by nurses carry risks of harm to patients, thenurse and the general public. Dale and Woods(2001) state that these risks include clinical issuessuch as infection control, needlestick injury,inappropriate skill mix and staffing levels. There hasbeen a rise in MRSA (methicillin-resistantStaphylococcus aureus) infections in communitysettings (Cookson 2000). This is of great concernand should mean that the highest standards aremaintained in terms of hygiene.

Measures such as hand cleansing need to becarefully considered, particularly in patient’shomes – not every household will have hotrunning water and soap, for example. Consult localpolicies for advice as to how to deal with thisproblem. There are many solutions for handcleansing, in addition to traditional soap and water– these should be used as prescribed by themanufacturers. Uniforms and clothes worn forwork need to be changed daily and launderedproperly (RCN 1999b) to protect nurses andpatients alike. Chronic understaffing puts nurses atrisk. In addition to personal safety issues, healthand safety within clinics and patient’s homes needsconsideration.

We shall now look at, each of the five stages ofrisk assessment and relate them to potentiallythreatening situations of violence or abuse.

1. Identify the hazards

This includes reports of threats and abuse, not onlyof actual physical violence, by patients, carers orothers. Remember that this could be whether thenurse is on duty or not. The community staff nursemust report any incidents by following localpolicies.

2. Identify who is at risk

Specify who could be harmed by the risk. Thiscould include other members of the nursing team,other professionals and lay people.

3. Evaluate the risk

Assess the seriousness of the situation. Identifywhat can be done to minimise or eliminate the riskto protect those who could be harmed. Seniornurses will carry out the assessment of the risk withcontributing evidence from the team. However, it iseveryone’s responsibility to identify and reportpotentially hazardous situations.

4. Record the findings

Decisions taken and workable measures to minimisethe risk will be documented.This provides a workingplan for staff and managers outlining all of the abovein addition to steps,which may still need to be taken.Be sure to record events accurately (NMC 2002).

Poor communication of risk can result inmisunderstanding and failure to pass on vitalinformation to other colleagues. Documentationneeds to be comprehensive and accurate, containinga full account of intervention and assessment of thesituation (NMC 2002, Woods 2002). Avoid the useof jargon and abbreviations.

5. Review and revise the assessment

Assessment is a dynamic process. It is important torevisit the document, particularly after incidents arereported. Staff training and communications shouldalso be reviewed.

It has been said that a major source of risk isuncertainty by members of staff about what isexpected of them, especially in emergencysituations (Dale and Woods 2001). Policies andprocedures need to be current, available to thosewho need them, and comprehensive.

In order not to compromise patient care, careplans need to be regularly reviewed and updated sothat staff are clear what has been found onassessment and what interventions are required.

The above stages also apply to other areas ofpractice – in the interests of patients and nurses it is

ExerciseSelect one of the identified hazards above. Locate local policies and procedures relating tothat hazard and read them. Work through thestages of risk assessment with the chosen topic in mind. Discuss your thoughts with your teamleader.

HSE’s five stages of risk assessment 35

important to think about manual handlingsituations arising in non-institutional settings.

MANUAL HANDLING IN THECOMMUNITY

The potential for safety to be compromised inmanual handling situations in patients’/clients’homes is very real.The inclusion of this issue withinthis chapter is in recognition of the fact that over 30per cent of nurses suffer work-related back paineach year (Institute of Employment Studies 1999).

Although the principles of manual handlingremain the same wherever the nurse is working,community visiting gives rise to particular issues. Byrevisiting the five tenets of manual handling someof these are presented.

The task

There will be manual handling issues in manynursing procedures undertaken in the home (seeTable 4. 4). These include moving patients in bed,helping patients get out of bed and standing up.

Toileting and dressing should be approached withthought, as should bathing and washing procedures.

The load

As in many settings, patients can be heavy andunpredictable. Paralysis, confusion or pain maymake the patient a particular challenge.

When handling a load it is important to hold thatload as close to the trunk as possible. Think about apatient in the middle of a double bed. This bed islow and not very firm. Immediately problems forsafety (both for nurse(s) and patient) are apparent.

The environment

Nursing patients in their home environment is verydifferent from doing so in a hospital ward. Hazardscould include cluttered rooms with little space formanoeuvre, slippery polished floors, loose rugs andpoor lighting. These are a problem for both patientsand staff. It is important to address these hazardousconditions with tact and sensitivity. When rapportand trust have been developed between patient andnurse, suggestions for improving home safety willbe better received.

The worker

Nurses come in all shapes and sizes. The same istrue of carers, who tend to be more involved ingiving direct care in home settings. Older people

ExerciseIdentify whose responsibility it is to review thehealth and safety policies in your area. Find outwhere these are kept and how often they areupdated.

36 Personal safey in the community

Table 4.4 Occasions when manual handling procedures must be carefully considered

1 Moving patients in bed

2 Helping them to sit or stand up

3 Toileting and dressing

Note the following:

A full assessment will be carried out as required according to the Manual Handling Operations Regulations 1992.

The sister or charge nurse will assess patients. Measures to reduce the risk of potential injury will be put in place, e.g. ahospital bed may need to be provided.

The assessment will be documented in the care plan. Any changes in circumstances must be reported to the teamleader.

who are carers may not be in the best of healththemselves. It is important not to make assumptionsabout the abilities of others.

The organisation

Policies and procedures relating to manual handlingmust be studied carefully (Chambers 1998).Mandatory updates in PCTs are necessary to ensurethe safety of staff and patients. There may beunfamiliar equipment in patients’ homes. Don’t useunknown manual handling aids until training hasbeen carried out.

Inadequate staffing levels can put nurses at risk.The number of staff at any given time will affectdirectly the workload of each nurse. Tired staff aremore vulnerable to injuries, accidents and mistakes(RCN 1996, 1999a).

In addition to the above, keeping fit and healthycan reduce the possibility of back problemsdeveloping. By valuing and safeguarding his/herown health the community nurse can contribute tothe risk reduction process.

REPORTING INCIDENTS

Nurses are required to report issues relating tosafety under the Health and Safety at work Act(1974). If injury occurs as a result of manualhandling procedures, then this must be reported.

There is evidence that a large majority of nursesbelieve that a certain level of aggression is part ofthe job (Leiba 1997, Unison 1997). Thisacceptance of abuse seems to be particularlywidespread amongst older nurses. In theircampaign to ‘stamp out violence’, the NursingTimes received 1000 replies to a questionnaire onthe subject (Coombes 1998). In nurses aged over55 years, 92 per cent felt that violence andaggression was part of the nurse’s lot. Amongstnurses aged between 26 and 34 this view was heldby 76 per cent. Undoubtedly this leads to anunderreporting of incidents, which is worrying. Itwill not be possible to gauge the size of theproblem if nurses are reluctant to speak up. It isalso unfair to colleagues to keep quiet. Todaymight have included verbal abuse from a relative,tomorrow (particularly if the situation is poorlyhandled) may lead to something much worse.

The report should be made as soon as is possible.Events should be clearly and comprehensivelystated.

SUPPORT AND COUNSELLING

People who have been involved in aggressive orviolent incidents need to be supported at work.Reporting the events can be traumatic and it ishelpful to have assistance from a colleague whencompleting the necessary documentation (RCN1998). It may be helpful to discuss what hashappened with other members of staff. A debriefingshould take place with the people concerned. Theactual events should be explored, including anypossible triggering factors and the feelings of thosewho took part. Ways of preventing recurrenceshould be considered.

Commonly, following verbal abuse or physicalattack feelings of fear, guilt or anger may beexperienced. These can manifest themselves intaking the ‘blame’ for provoking aggression,wondering if the experience will be repeated oranger towards the aggressor, the organisation oreven oneself.

It may take time for a victim of abuse or violenceto regain the confidence to visit alone again.Support may be offered by occupational health,professional organisations or counselling services.Support may also be needed for others involved,including the aggressor.

CONCLUSION

After careful consideration of the issues addressedwithin this chapter, turn back to the learningoutcomes at the beginning and think about eachone in turn. Look back at the notes made for thefirst exercise at the beginning of this chapter. Is

ExerciseFind out the procedure for reporting incidents ofabuse within your primary care team. Who couldbe helpful in these situations? Locate theOccupational Health Department and explore theservices offered by its staff.

Conclusion 37

there anything that you would like to add tothem?

If this chapter has raised any concerns forpractice, it is important that they are discussed withan experienced community nurse, either informallyor through clinical supervision channels. Someuseful addresses can be found at the end of thissection.

Remember that the majority of staff working incommunity settings enjoy a close partnership withtheir patients and clients. The health centre orsurgery is at the heart of the local community andrelationships may build over a number of years.Visiting patients and clients in their homes is aprivilege that greatly enhances the experience ofcommunity nursing. Taking practical precautionsand taking time to think about safety can betterprepare the community nurse for difficult situationsthat could arise.

FURTHER READING

Anderson, L.N. and Clarke, J.T. (1996) De-escalating verbalaggression in primary care settings. Nurse PractitionerAmerican Journal of Primary Health Care, 21(10): 95.

RCN (2002) Code of Practice for Patient Handling. London:Royal College of Nursing.

REFERENCES

Chambers, N. (1998) The experience of being the registerednurse on duty: managing a violent incident involving anelderly patient. Journal of Advanced Nursing, 2: 429–36.

Cookson, B. (2000) Methicillin-resistant Staphylococcus aureusin the community – new battlefronts or are the battles lost?Infection Control Hospital Epidemiology, 21(6): 398–403.

Coombes, R. (1998) Violence, the facts. Nursing Times, 94(43):12–14.

Dale, C. and Woods, P. (2001) A risk assessment andmanagement strategy for community nursing. BritishJournal of Community Nursing, 5(6): 286–91.

Department of Health (2002) Improving Working Lives.London: DOH. www.doh.gov.uk/iw/index.htm

Farrell, G.A. (1999) Aggression in clinical settings – a follow-upstudy. Journal of Advanced Nursing, 29: 532–41.

Farrell, G.A. (2001) From tall poppies to squashed weeds: whydon’t nurses pull together more? Journal of AdvancedNursing 35(1): 26–33.

Health and Safety at Work Act (1974). London: HMSO.

Health and Safety at Work Regulations (1992). London: HMSO.Health Services Advisory Committee (1997) Violence and

Aggression to Staff in Health Services. Sheffield: HSE Books.Institute of Employment Studies (1999) Royal College of

Nursing. Unpublished data from RCN membership survey.Jackson, D., Clare, J. and Mannix, J. (2002) Who would want to

be a nurse? Violence in the workplace – a factor in recruitmentand retention. Journal of Nursing Management 10(1): 13–23.

Leiba, T. (1997) Tackling aggression and violence in theworkplace. Managing Clinical Nursing, 129–34.

Nabb, D. (2000) Visitors’ violence: the serious effects ofaggression on nurses and others. Nursing Standard, 14:36–8.

Nursing and Midwifery Council (2002) Guidelines for Recordsand Record keeping. London: NMC.

Rippon, T. (2000) Aggression and violence in health careprofessions. Journal of Advanced Nursing 31(2): 452–60.

Royal College of Nursing (1994) Violence and Community Staff– Advice for Managers. London: RCN.

Royal College of Nursing (1996) Manual HandlingAssessments in Hospital and the Community. London: RCN.

Royal College of Nursing (1998) Dealing with Violence againstNursing Staff. London: RCN.

Royal College of Nursing (1999a) Changing Practice –Improving Health: An Integrated Back Injury PreventionProgramme for Nursing and Care Homes. London: RCN.

Royal College of Nursing (1999b) Taking a Uniform Approach:An RCN Guide to Selecting the Right Clothing for Nurses.London: RCN.

Royal College of Nursing (2001) Working Well: A Call toEmployers. A Summary of the RCN’s Working Well Surveyinto the Well-being and Working Lives of Nurses. London:RCN.

Unison (1997) Violence at Work: Health Staff Survey. London:Unison.

Whittington, R. and Wykes, T. (1996) An evaluation of stafftraining in psychological techniques for the management ofpatient aggression. Journal of Clinical Nursing, 5: 257–61.

Woods, C. (2002) The importance of good record–keeping fornurses. Nursing Times, 99(2): 26–7.

USEFUL CONTACTS

Victim SupportCranmer House39 Brixton RoadLondonSW9 6DZTel. 0171 7359166

38 Personal safey in the community

Victim Support14 Frederick StreetEdinburghEH2 2HBTel. 0131 2258233

The Suzy Lamplugh Trust14 East Sheen AvenueLondonSW14 8ASTel. 020 83921839

Royal College of Nursing Counselling ServiceTel. 0345 697064

www.freedomtonurse.co.ukFreedom to NurseP.O. Box 37WorksopNottinghamS80 1ZT

Useful contacts 39

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This chapter will focus upon the relationship that existsbetween the nurse, patient and their family. It isrecognised that such a relationship should betherapeutic, and indeed this would seem essential tothe delivery of effective nursing care. However, it isunwise to assume a therapeutic relationship willautomatically occur, as there are many challenges inestablishing and maintaining such a relationship incommunity settings. In this chapter the key features ofa therapeutic relationship will be identified and someof the challenges of maintaining that relationship in acommunity setting will be discussed.This will lead thereader to consider some of the issues of particularrelevance to her patient group, and to explore some ofthe consequences of failing to establish and maintainrelationships. In conclusion, the current and potentialchanges in health care delivery will be reviewed withparticular reference to the way these changes mightimpact on the nurse/patient/family relationship.

THE FEATURES OF A THERAPEUTICRELATIONSHIP

The recognition of the importance of thetherapeutic relationship is not a new phenomenon.

Peplau’s (1952) theory of nursing is based upon theimportance of the relationship between the nurseand the patient, and she asserts this is the way inwhich all nursing care is delivered. The importanceof this relationship has continued to be widelyacknowledged and indeed McMahon and Pearson(1998) suggest that it is central to patient health,well-being and recovery. Since a therapeuticrelationship is so important, it is essential toconsider what features characterise such arelationship. In reviewing various definitions itbecomes apparent that the important factors are:

• appropriate boundaries are maintained• meets the needs of the patient• promotes patient autonomy• positive experience for the patient.

Appropriate boundaries are maintained

A boundary, as defined in the dictionary (Chamber,1993) is: ‘a limit, a border, termination or finallimit’. Within the therapeutic relationship,boundaries define how far the nurse is willing to goto meet the needs of the patient and his family.

5Therapeutic relationshipsPatricia Wilson and Sue Miller

Learning outcomes

• Identify the features of a therapeutic relationship.• Discuss some of the challenges for community nurses in establishing a therapeutic relationship.• Recognise some of the issues that may arise when trying to establish a therapeutic relationship

with specific patients.• Explore some of the possible consequences of failing to establish a therapeutic relationship.• Analyse the impact of changes in policy on the development of therapeutic relationships.

Therefore it is important that the nurse, patient andfamily are clear regarding their relationship andwhat is reasonably expected of each party. This willprotect all those involved in the relationship. Apublication from the UK Central Council (1999:p.5) on this subject states that: ‘boundaries definethe limits of behaviour which allow a client andpractitioner to engage safely in a therapeutic, caringrelationship’. The practitioner has the responsibilityto maintain appropriate professional boundaries atall times (UKCC 1999). However, the process offinding the boundaries of care is far from automatic(Totka 1996), as will be discussed later in thischapter.

Meets the needs of the patient

The purpose of the relationship between the nurseand patient is to meet the nursing needs of thatpatient. It is therefore important that the nursingneeds of the patient are discussed at the outset ofthe relationship in order that mutually identifiedgoals can be set and each person within therelationship can be clear as to their role in theachievement of those goals. This might include thenurse, patient, family members, other professionalsand carers. This will require expert communicationskills on the part of the nurse in order that arelationship of trust can develop. Whilst therelationship exists to meet the needs of the patientit is likely that the nurse will experience satisfactionin helping the patient to meet those needs. This isentirely appropriate. However, it is important thatnurses do not allow their personal needs for positiveself-esteem, control and belonging to underminethe professional relationship (Jerome and Ferraro-McDuffie 1992). This requires the nurse to be self-aware and open to seeking support from otherswhen the need arises.

Promotes patient autonomy

Autonomy is the right to self-determination. Self-determination can be defined as an ability tounderstand one’s own situation, to make plans andchoices and to pursue personal goals (McParland etal. 2000). This further supports the need forexcellent communication skills on the part of thenurse in order to assist the patient to understand

their own situation. Within a relationship thatpromotes patient autonomy the patient willcontribute to the achievement of personal goalsand will move towards independence.

Positive experience for the patient

The experience of participating in a therapeuticrelationship will be positive for the patient asnursing needs will be met, in a way that is mostappropriate to the patient and their family. Trulytherapeutic relationships can empower the patient,the family and the nurse.

These features are embodied in the Code ofProfessional Conduct, which states:

You must at all times, maintain appropriateprofessional boundaries in the relationships youhave with patients and clients. You must ensurethat all aspects of the relationship focusexclusively upon the needs of the patient orclient.

(NMC 2002: Clause 2.3)

CHALLENGES OF DEVELOPINGTHERAPEUTIC RELATIONSHIPS INCOMMUNITY SETTINGS

Having considered the features of a professionalrelationship, some of the challenges of achievingsuch a relationship in the community setting will bediscussed. Professional relationships with thepatient are influenced by a number of factors –illustrated in Figure 5.1.

ExerciseThink about entering a patient’s home andestablishing a therapeutic relationship. What skillsdo you have that would enable you to achievethis? What skills need further development? Howcan you develop your skills further? Discuss yourideas with your mentor/preceptor.

42 Therapeutic relationships

Location of care

The delivery of care within the home can provide afeeling of security for the patient and his carer/s asthey are on familiar territory.This can make it easierto develop a good relationship, such that they areable to share their concerns and worries. It is alsoprobable that patients and carers will be able tolearn new skills more readily as they are likely tofeel more relaxed within their ‘normal’environment.

In this example the benefits of home visiting areapparent. These opportunities could be lost ifhealth visitors change their mode of practice togive more care in clinic settings, as has beenreported by Normandale (2001). However, caringin the home environment can leave the nursefeeling vulnerable. A nurse who has recently left ahospital-based job to work in the community canfeel very isolated. Despite the use of mobilephones and pagers it is more difficult to seek theadvice of a colleague, and help may not beinstantly at hand. A nurse who feels vulnerable andisolated will find it more difficult to inspire theconfidence of patients.

Working in the relative isolation of the home canprovide challenges to nurses in maintainingstandards of care. If the relationship is not‘therapeutic’ it can be difficult for the nurse toidentify this herself, particularly if the situation hasdeveloped over time. The support and guidance ofcolleagues is essential, as is the willingness of thenurse to be open to that support. Totka (1996)notes that peers often recognise unhealthysituations before the nurse involved, but find itdifficult to discuss the situation with theircolleague.

Care given by the nurse within the workplacewill also be different from the more traditionalhospital setting. The occupational health nurseworks within a three-way relationship betweenthe employer, employee and the nurse (Atwell1996).

Developing therapeutic relationships may alsobe affected by a clinic or surgery setting, where

ExampleAlthough stress in the workplace is beingincreasingly recognised as a legitimateoccupational health issue (Health and SafetyExecutive 2000), many employees will stillconsider it unwise for their career prospects toreport mental health needs to their occupationalhealth nurse. The challenge for the nurse withinthis context is to promote trust with theemployees in order to facilitate a therapeuticrelationship.

ExampleConsider Mrs Patel, whose 2-year-old son hasrecently been in hospital suffering from anasthmatic attack. Mrs Patel speaks some Englishbut found the experience of her son being inhospital very stressful. When the health visitormade a visit to the home Mrs Patel was unsurehow to use the prescribed medication, particularlythe use of the spacer device to administer theinhalers. Teaching Mrs Patel at home is likely to bemore successful, as she will be more relaxed and itwill be possible for the health visitor to reinforceany aspects of the care at a later date if this isnecessary.

Developing therapeutic relationships 43

Factors affectingprofessional andpatient relationship

Location of care:e.g. GP sugery or clinic,workplace, home

Nature of care: e.g. one-off visit, long-term input

Patient expectation:e.g. past experiences,values and assumptions

Patient needs:e.g. mental health,life-threatening condition,level of dependence onnurse

Figure 5.1 Factors affecting the therapeutic relationship

the patient may gain the impression of busyworkloads inhibiting the time they spend with thenurse. Paterson (2001) identified lack of time as amajor inhibitor in developing a participatoryrelationship between professional and patient, andalthough the nurse is likely to be as busy, if notmore so, when undertaking home visits theinteraction may be less distracted than in a busyclinic.

In other cases the relative anonymity the surgeryor clinic provides may be of benefit in facilitatingthe development of a therapeutic relationship.Initial assessments are often the first point ofcontact between community nurse and patient andthe nurse must develop skills to enable a conduciveenvironment in order to establish the start of atherapeutic relationship (Bryans and McIntosh1996).

Working in the community, many nurses find thatnot wearing a uniform removes an unnecessarybarrier, which makes the development of atherapeutic relationship an easier task. It does,however, require skills on the part of the nurse togain access to the patient’s home, gain the patient’strust and explain her nursing role, since a symbol,which for many carries some degree of status, hasbeen lost.

For those community nurses who do wear auniform other challenges arise. Wearing of a

uniform can enable almost instant entry to somehomes, but may present a barrier to acceptance bysome people. This may be especially apparent withchildren, who have perhaps learnt to associateuniforms with pain and discomfort. In thesesituations it will take time to address priorconceptions before a therapeutic relationship canbe established.

If nurses do not wear a recognised uniform it isparticularly important to consider theappropriateness of the clothing that is worn.Entering a home inappropriately dressed may causeoffence and prevent establishment of a relationship.Perhaps this might require the nurse to cover herarms and legs if visiting Asian families, or maybe toremove shoes prior to entry into some homes. Inorder to meet the needs of individual families thenurse must enquire as to family preferences and bewilling to adapt behaviours to respect valuesdifferent from her own, in order to facilitate goodrelationships.

A final point about dress code: whether wearinguniform or not, it is essential to carry identificationat all times in order to protect the wellbeing ofpatients.

Nature of care

A key element in the nature of the therapeuticrelationship with all patient groups is the durationof the relationship. Morse (1991) describes threeappropriate relationships. Firstly, she describes theone-off clinical encounter that, for example, apractice nurse may have with a patient in a travelclinic. There are also encounters that last longer butfocus on a specific need, such as maintenance ofhormone replacement therapy. Both of theserelationships are mutual and appropriate to certainsituations but Morse argues that within a much

ExerciseHave you cared for a patient over a long period oftime? How did your relationship with the patientdevelop? Did you find yourself becoming ‘closer’ tothe patient? How did this make you feel? Discussthis with your mentor/preceptor.

ExerciseDo you wear a uniform when working in thecommunity? What are the advantages anddisadvantages of wearing a uniform? If you had achoice would you wear a uniform?

ExampleConsider the scenario of the new mother trying toexplain her depression to the health visitor andhow much harder this might be in a busy babyclinic rather than in the privacy of her own home.

44 Therapeutic relationships

longer-term nurse–patient relationship there shouldbe a different focus, with the development of whatMorse terms as a connected relationship. Morsesuggests that the key characteristic of a connectedrelationship is that the nurse views the patient as aperson first rather than a patient.

Whilst for many families and professionals this canonly be positive, there is a potential to step overthe professional boundary and it is essential tomaintain the appropriate balance within thetherapeutic relationship. The consequences of notmaintaining the balance will be explored later inthe chapter.

In the home environment the patient and hiscarer could be perceived to have greater controlwithin the relationship. Should the patient decidenot to concur with recommended treatment, thismay not be immediately evident as the nurse is

spending only a short period of time within thehome environment. Parkin (2001) notes thatprofessionals are unable to control the homeenvironment. If, unbeknown to the nurse, thepatient has not adhered to the recommendedtreatment, the therapeutic relationship isthreatened, since a relationship based on trust nolonger exists. Within a therapeutic relationshipthe patient should be able to tell the nurse of hisintentions. This might allow treatment to bemodified such that the patient feels able tofollow the regimen, but even if this is not thecase at least the nurse is aware of the truesituation and can modify her nursing careaccordingly.

Further exploration of the current and futurecontext of concordance can be found in the lastsection of this chapter.

Patient expectations

Expectations of the nurse and of the communitynursing service may also impact on therelationship between the nurse and adult patient.Over the past 25 years there has been a rapid risein consumerism (May and Purkis 1997), with acorresponding rise in expectations of the HealthService. In community nursing this can be seen bythe use of time bands in allocating home visitsand the proliferation of charters and missionstatements displayed on clinic and surgery walls.

ExampleSusie is 14 years old and has been diabetic for 3years. She is supposed to record her blood glucoselevels once daily, varying the time of day she takesthe readings, but she finds this requirementtiresome and does not do it. Prior to thecommunity children’s nurse’s visit she wonderswhat to do – should she make up some values tokeep the nurse happy or should she tell the truth?Hopefully if Susie and the nurse have a goodrelationship she can be truthful and they can worktogether on what care Susie can reasonably beexpected to give herself.

ExerciseHave you ever cared for a patient who did notfollow the recommended treatment programme?Why did the patient not adhere to the treatmentregimen? How did it make you feel?

ExampleA district nurse has been visiting an elderly ladyfor several years. The visits now may often includea chat over a cup of tea about how thegrandchildren are progressing or other issues inthe patient’s life on which the nurse hasdeveloped a wealth of knowledge over the years.Although it may be a venous ulcer that initiatedthe referral to the district nurse, the connectedrelationship that has developed with time allowsthe nurse to deal with other issues that may be farmore important to the patient, such as feelings ofloneliness. During the chat a skilled nurse will beable to assess for signs of depression or otherpsychosocial needs that are common in chronicillness.

Developing therapeutic relationships 45

Many patients have clear ideas on the service theyexpect from community nurses with a consequentialdetrimental effect on the therapeutic relationshipwhen these expectations are either not met or areunrealistic.

However, despite trends in healthy ageing andparticipation in health care (Lorig et al. 1996),many older adults were bought up in a societywhere medicine was seen to have all the answersand the public was expected to be the passiverecipient of care (Dukes Hess 1996). There is someevidence that not all adult patients wish to be anactive partner in the therapeutic relationship(Waterworth and Luker 1990) and there may be asignificant number of patients who feel morecomfortable with the paternalistic model of care(Roberts 2001). The nurse ‘doing for’ the patientrather than enabling them to self-care contradictsthe current trend towards empowerment(Copperman and Morrison 1995), which is acentral theme in the National Service Framework forOlder People (DOH 2001a). The community nursemay find a challenge in helping some patients indeveloping the confidence and ability to self care,and again the therapeutic relationship will befocused on trust and the facilitation of realisticindependence.

Patient needs

The main purpose of the nursing or health visitingintervention may also have a significant impact onthe therapeutic relationship. The patient within therelationship may have significant physical andemotional needs, such as happens in palliative care.The relationship in such cases may be based onintensive input by the nurse (Goodman et al.1998).In contrast, the practice nurse or occupational healthnurse may see a person for health screening with lessobvious health needs as the focus of the intervention.

The substantial shift of care from hospitals to thecommunity for those with mental health needs(Brooker and Repper 1998) has resulted in a rapidlydeveloping role for community nurses in supportingthis group. With approximately one in six people atany one time suffering from mental illness in theUnited Kingdom (DOH 1999a) the role isconstantly evolving. The National Service Frameworkfor Mental Health (DOH 1999a) is firmlyunderpinned by a patient focus. However,empowering patients with mental health needs isoften challenging, not least because of concernsfrom society and professionals as to whether somepatients have the capability of making decisionsover their care and treatment (Feenan 1997).

46 Therapeutic relationships

Table 5.1 Responses to caring role

Response to caring role Features of response

Engulfment mode • Cannot articulate needs as a carer• No other occupation• Generally female spouse• Total sense of responsibility and duty

The balancing/boundary • Have a clear picture of themselves as carers (e.g. how they save nation money)setting mode • Generally male

• Often adopt language of an occupation – treat role as a job• May emotionally detach themselves from recipient

Symbiotic mode • Positive gain by caring• Does not want role taken away

Adapted from Twigg and Atkin (1994)

The therapeutic relationship with this group isessential in empowering patients to activelyparticipate in decisions about their care. Peplau’s(1952) developmental model is often used as theframework for developing a therapeuticrelationship (Collister 1986) with the assessment(or orientation) phase focusing on the developmentof mutual trust and regard between nurse andpatient, as well as data gathering. Addressinganxiety is the overarching aim of the therapeuticrelationship (Aggleton and Chalmers 2000), andthe community nurse may take on a number ofroles to facilitate this including that of counsellor,resource, teacher, leader or surrogate. All nursesworking in the community develop knowledge oflocal resources and other agencies and facilitatingthe patient to access these may be the keycomponent within this relationship.

It should also be acknowledged that thetherapeutic relationship in the community setting isnot only formed between nurse and patient, butwill often encompass an informal carer. In theUnited Kingdom there are approximately 6 millioninformal carers who are the primary carers for arange of patients ranging from young people withlearning disabilities, to the frail elderly (Bond et al.1999). The Carers Recognition and Services Act(DOH 1995) and the Carers and DisabledChildrens Act (DOH 2000) enshrined the principlethat carers should be assessed and acknowledged asan individual rather than simply an adjunct to thepatient. For the community nurse this reinforcesthat an individual therapeutic relationship mustalso be developed with the informal carer, but thisposes a number of challenges.

First, a significant number of informal carers areunknown to the community nurse, with Henwood(1998) estimating that only half of all carers receiveany support from community nurses. Second, themore an informal carer does for the patient, the lessintervention there will be from the communitynurse (Pickard et al. 2000). Consequently, theinformal carers most likely to benefit from atherapeutic relationship are less likely to be visitedby the community nurse. Third, there are oftenmisguided assumptions by many professionals thatinformal carers should undertake the caring roleand that the role is taken on very willingly (Procteret al. 2001).

Finally, studies have shown that many informalcarers have significant health needs of their ownwhich often are unrecognised (Henwood 1998) andundertake very complex and technical tasks (Pickardet al. 2000). All too frequently community nursesfirst meet an informal carer when there is a crisis andthe nursing input is a short-term measure to help thepatient and carer over this period. However, thetherapeutic relationship with informal carers shouldideally be long-term, with the nurse aiming toprovide information and acting as a resource(Seddon and Robinson 2001) and responding to therole the carer is happy to undertake.

Twigg and Atkin (1994) describe three differentresponses by individuals to the informal caring role,given in Table 5.1.

It is important for the community nurse torecognise the informal carer’s response to theirsituation.

Another frequently met scenario is that of thehusband caring for his wife. He has every detailorganised and is business-like in his approach to thecommunity nurse.Again, this may hide a number ofphysical and emotional needs, and the communitynurse must develop a therapeutic relationship inorder to enable him to express these. The needs ofinformal carers are only now being recognised andthe community nurse must develop a relationshipand provide intervention appropriate to both thepatient and informal carer as individuals.

ExampleImagine the case of Lily, a 75-year-old mothercaring for her son Ted, who has Down’s syndrome.She is devoted to her son and has no other lifethan caring for him. The General Practitioner hasreferred Ted for a wound assessment but when thenurse arrives it is apparent that Lily is exhausted byher role. The challenge for the nurse is to establisha relationship that enables Lily to acknowledge herindividual needs and helps her to accept helpwithout feelings of guilt. This may involvedeveloping a long-term relationship and not simplythe organising of respite, which many informalcarers do not want (Pickard et al. 2000).

Developing therapeutic relationships 47

WHEN THE BALANCE IS NOTMAINTAINED: FAILURES INTHERAPEUTIC RELATIONSHIPS

In reality it is hard to learn about boundaries unlessone is involved in setting them, and extendingbeyond the therapeutic boundary may only beapparent once it has been breached.

It may be that it is in the interests of the patientand his carer to encourage the professional todevelop a relationship of friendship since this hasthe potential to ‘normalise’ the patient, as it is‘normal’ to have friends who visit. This is perhapsmore likely to occur if nurses do not wear uniforms.Families may be keen that friendships do developsince a friend is likely to respond to requests forhelp, perhaps more swiftly than a detachedprofessional. Therefore nurses must consider theiractions carefully in case actions are misinterpreted,

as perhaps was the case when Ann attended John’sparty.

Hylton Rushton et al. (1996) describes over-involvement as a lack of separation between thenurse’s own feelings and that of the patient.Typically the nurse may spend off-duty time withthe patient (Barnsteiner and Gillis-Donovan 1990),appear territorial over the care (Morse 1991), ortreat certain patients with favouritism (Wilson2001a). Consequences for the patient are an over-dependence on that particular nurse and a lack ofsupport in reaching therapeutic goals. For thecommunity nurse the implications are oftensignificant stress and deterioration in job satisfaction(Hylton Rushton et al. 1996) and an inevitabledetrimental effect on team working.

Of course, the balance in the therapeuticrelationship may be tipped the other way. Thedetached, cold nurse who seems indifferent to herpatient’s emotional needs may be familiar to thereader. The results of under-involvement are a lackof understanding by the nurse of the patient’sperspective, conflict, and standardised rather thancontextually dependant care (Hylton Rushton et al.1996). It has been suggested that the overwhelmingfeelings that a nurse may have for a patient’ssituation can lead to dissociation by the nursewithin the therapeutic relationship (Crowe 2000).Within the community setting the feelings of beingthe last resort in care has also been linked to under-involvement within the therapeutic relationship(Wilson 2001a). The consequences of under-involvement for the patient is that the nurse has alack of insight into the patient’s perspective and isunable to facilitate the patient in meetingtherapeutic goals.

ExerciseThink of a likeable patient who you have recentlycared for. Reflect on the following: What were thecharacteristics of this patient and their care thatmade it a positive experience for you? If othercolleagues were involved do you think they felt thesame way? Was the care you gave this patientaffected by these feelings? Are there anyconsequences for yourself, the patient, your otherpatients?

ExampleConsider the case of Ann who is John’s communitychildren’s nurse. Ann has cared for John, aged 5,for the last 2 years and supported Gill, his singlemother, through some difficult times, as John hasreceived treatment for acute lymphoblasticleukaemia. During Ann’s recent visit to the homeGill and John invite her to John’s 6th birthdayparty the following weekend. Ann considers thisbriefly and agrees to come. At the end of the partyGill asks Ann if she would be willing to baby-sitfor John, as she’s the only person she feels she cantrust to care for John. What should she do now? Itwould appear the edges of the professionalboundary have become significantly blurred suchthat Gill feels it is appropriate to ask Ann to baby-sit.

ExerciseHow do you define friendships? Have you everbeen in a situation when a patient wanted to beyour friend? What would you do if a patientwanted to develop a friendship with you? Discussyour ideas with a professional colleague.

48 Therapeutic relationships

Maintaining a therapeutic relationship isparticularly challenging in the community nursingcontext because of the commonly intense nature ofcare, duration of contact and the non-clinicalenvironment. Reflection with colleagues andclinical supervision become invaluable tools tofacilitate the nurse in developing the appropriaterelationship with patients.

THE INFLUENCE OF THE CURRENT ANDFUTURE CONTEXT ON THERAPEUTICRELATIONSHIPS

Long-term interventions within the communitysetting will continue to increase with an ageingpopulation and rise in chronic illness (Kalache1996; Wellard 1998; DOH 1999b), and thischapter has already explored the impact ofduration of care on the therapeutic relationship.One response by policy makers to the rise in long-term conditions is the facilitation of individuals toself-manage their own conditions. The expertpatient programme (DOH 2001b) recognises thatindividuals often have significant expertise abouttheir chronic illness which has developed overyears through experience and the aim of theprogramme is to further develop this expertise inorder to promote symptom control, quality of lifeand effective use of health resources (Wilson2001b). Within all spheres of community nursing,nurses are now dealing with far moreknowledgeable patients not least because ofthe readily available access to information viathe Internet (Timmons 2001). Therapeuticrelationships in the current climate must be basedon an acknowledgement that the patient may haveconsiderable expertise in their own condition,exceeding that of the nurse. There has been somedebate as to how comfortable community nursesare with this (Wilson 2002), but there can be littledoubt that a therapeutic relationship that fails totake into account the knowledge that both nurseand patient bring will fail.

The expert patient programme is one example ofa policy that is based on partnership andresponsibility (Wilson 2001b). Another example isthe move towards concordance (RoyalPharmaceutical Society of Great Britain 1997),

where the patient’s views are considered of equalimportance in treatment plans.

Community nurses are required to demonstrateevidence-based practice (Woodward 2001) and thechallenge of today’s therapeutic relationship is tobalance this with informed choice by the patient(Wilson 2002). There is a balance to be maintainedbetween the rights of the child (dependant on theirage and understanding) and rights of the parents indecision-making, against the risks of significantharm that might result from the treatment. Theparents in the above scenario should be advised toensure the advice regarding the complementarytreatment comes from a registered practitioner.Community nurses need to assess their ownknowledge base regarding complementary therapyand seek specialist advice if necessary. Within atherapeutic relationship the nurse will be aiming tofacilitate an atmosphere where the parents feel ableto be honest about the treatments the child iscurrently receiving, and should be able to directpatients and their families to sources of appropriateinformation.

A final feature of the current context of care thatmay have an effect on the therapeutic relationshipis the fragmentation of care. In particular thedivision of health and social care (DOH 1990)means that patients within the community oftenhave to deal with a vast array of professionals, whichcan inhibit the development of a therapeuticrelationship (Hyde and Cotter 2001).

CONCLUSION

In this chapter features of a therapeutic relationshiphave been identified, leading to an exploration of

ExerciseA child has severe eczema that has not respondedwell to normal treatments. The parents insist ontrying a complementary remedy recommended tothem by a self-help group. How would you feelabout this? What issues would you need to takeaccount of? What are the implications for thetherapeutic relationship?

Conclusion 49

some of the challenges community nurses face inestablishing therapeutic relationships. In futurecommunity health care provision, challenges will beshaped by an increasingly multi-cultural, ageing andinformed population. The growing provision ofhealth care in the community only serves toreinforce the need to establish appropriaterelationships with patients, their families and othercarers. Current government policy emphasisespartnership in care at all levels; the challenge for thecommunity nurse is to develop this opportunity ineveryday working practice.

FURTHER READING

Smith, P. (1992) The Emotional Labour of Nursing. Basingstoke:Macmillan.

REFERENCES

Aggleton, P. and Chalmers, H. (2000) Nursing Models andNursing Practice (2nd edn). Basingstoke: Macmillan.

Atwell, C. (1996) Health in the workplace. In S. Twinn, B.Roberts, and S. Andrews (eds), Community Health CareNursing: Principles for Practice. Oxford: Butterworth-Heinemann, 260–75.

Barnsteiner, J.H. and Gillis-Donovan, J. (1990) Being relatedand separated: a standard for therapeutic relationships.Maternal Child Nursing Journal, 15: 223–8.

Bond, J., Farrow, G. and Gregson, B.A. et al. (1999) Informalcare-giving for frail older people at home and in long-termcare institutions: who are the key supporters? Health andSocial Care in the Community, 7(6): 434–4.

Brooker, C. and Repper, J. (eds) (1998) Serious Mental HealthProblems in the Community: Policy, Practice and Research.London: Ballière Tindall.

Bryans, A. and McIntosh, J. (1996) Decision making incommunity nursing: an analysis of the stages of decisionmaking as they relate to community nursing assessmentpractice. Journal of Advanced Nursing, 24: 24–30.

Chambers (1993) The Chambers Dictionary. Edinburgh:Chambers Harrap.

Collister, B. (1986) Psychiatric nursing and a developmentalmodel. In B. Kershaw. and J. Salvage (eds), Models forNursing. Chichester: John Wiley.

Copperman, J. and Morrison, P. (1995) We Thought We Knew:Involving Patients in Nursing Practice. London: King’sFund.

Crowe, M. (2000). The nurse–patient relationship: aconsideration of its discursive context. Journal of AdvancedNursing, 31(4): 962–7.

Department of Health (1990) The NHS and Community CareAct. London: HMSO.

Department of Health (1995) Carers Recognition and ServicesAct. London: HMSO.

Department of Health (1999a) National Service Framework forMental Health. London: The Stationery Office.

Department of Health (1999b) Our Healthier Nation: SavingLives. London: The Stationery Office.

Department of Health (2000) Carers and Disabled Children ActLondon: HMSO.

Department of Health (2001a) National Service Framework forOlder People. London: Department of Health.

Department of Health (2001b) The Expert Patient: A NewApproach to Chronic Disease Management for the 21stCentury. London: The Stationery Office.

Dukes Hess, J. (1996) The ethics of compliance: a dialectic.Advances in Nursing Science, 19(1): 18–27.

Feenan, D. (1997) Capable people: empowering the patient inthe assessment of capacity. Health Care Analysis, 5(3): 227–36.

Goodman, C., Knight, D., Machen, I. and Hunt, B. (1998)Emphasizing terminal care as district nursing: a helpfulstrategy in a purchasing environment? Journal of AdvancedNursing, 28(3): 491–8.

Health and Safety Executive (2000) Stress is a Workplace Issue– HSE begins Publicity Drive. Press Release E206:00. London:HSE.

Henwood, M. (1998) Ignored and invisible? Carers’ Experienceof the NHS. London: Carers National Association.

Hyde, V. and Cotter, C. (2001) The development of communitynursing in the light of the NHS Plan. In V. Hyde. (ed.),Community Nursing and Health Care: Insights andInnovations. London: Arnold.

Hylton Rushton, C., Armstrong, L. and McEnhill, M. (1996).Establishing therapeutic boundaries as patient advocates.Pediatric Nursing, 22(3): 185–9.

Jerome, A. and Ferraro-McDuffie, A. (1992) Nurse self awarenessin therapeutic relationships, Pediatric Nursing, 18(2): 153–6.

Kalache, A. (1996): Ageing worldwide. In S. Ebrahim and A.Kalache (eds), Epidemiology in Old Age. London: BMJPublishing Group.

Lorig, K., Stewart, A., Ritter, P. et al. (1996) Outcome Measuresfor Health Education and Other Health Care Interventions.Thousand Oaks, CA: Sage.

May, C. and Purkis, M.E. (1997) Editorial: exploringrelationships between professionals, patients and others.Health and Social Care in the Community, 5(1): 1–2.

50 Therapeutic relationships

McMahon, R. and Pearson, A. (1998) Nursing as Therapy (2ndedn). Cheltenham: Stanley Thornes.

McParland, J. Scott, P. Arndt, M. et al. (2000) Autonomy andclinical practice, 1: identifying areas of concern. BritishJournal of Nursing, 9(8): 507–13.

Morse, J.M. (1991) Negotiating commitment and involvementin the nurse–patient relationship. Journal of AdvancedNursing, 16: 455–68.

Normandale, S. (2001) A study of mother’s perceptions of thehealth visiting role. Community Practitioner, 74(4): 146–50.

Nursing and Midwifery Council (2002) Code of ProfessionalConduct. London: NMC.

Parkin, P. (2001) Covert community nursing: reciprocity informal and informal relations. In Hyde, V. (ed.), CommunityNursing and Health Care: Insights and Innovations. London:Arnold.

Paterson, B. (2001) Myth of empowerment in chronic illness.Journal of Advanced Nursing, 34(5): 574–81.

Peplau, H.E. (1952) Interpersonal Relations in Nursing. NewYork: Putnam.

Pickard, S., Shaw, S. and Glendinning, C. (2000) Health careprofessionals’ support for older carers. Ageing and Society,20: 725–44.

Procter, S., Wilcockson, J., Pearson, P. et al. (2001) Going homefrom hospital: the carer/patient dyad. Journal of AdvancedNursing, 35(2): 206–17.

Roberts, K. (2001) Across the health-social care divide: elderlypeople as active users of health care and social care. Healthand Social Care in the Community, 9(2): 100–07.

Royal Pharmaceutical Society of Great Britain (1997)Compliance to Concordance: Achieving Shared Goals inMedicine Taking. London: RPSGB.

Seddon, D. and Robinson, C.A. (2001) Carers of older peoplewith dementia: assessment and the Carers Act. Health andSocial Care in the Community, 9(3): 151–8.

Timmons, S. (2001) Use of the Internet by patients: not a threatto nursing, but an opportunity? Nurse Education Today,21(2): 104–9.

Totka, J. (1996) Exploring the boundaries of paediatric practice:nurse stories related to relationships. Pediatric Nursing,22(3): 191–6.

Twigg, J. and Atkin, K. (1994) Carers Perceived. Buckingham:Open University.

United Kingdom Central Council (1999) Practitioner–ClientRelationships and the Prevention of Abuse. London: UKCC.

Waterworth, S. and Luker, K.A. (1990) Reluctant collaborators:do patients want to be involved in decisions concerningcare? Journal of Advanced Nursing, 15: 971–6.

Wellard, S. (1998) Constructions of chronic illness.International Journal of Nursing Studies, 35: 49–55.

Wilson, P.M. (2001a) Being the Last Resort: A criticalethnography of district nurses and their patients with long-term needs. Unpublished MSc thesis, University ofManchester, RCN Institute.

Wilson, P.M. (2001b) A policy analysis of the ‘expert patient’ inthe United Kingdom: self-care as an expression of pastoralpower? Health and Social Care in the Community, 9(3):134–42.

Wilson, P.M. (2002) The expert patient: issues and implicationsfor community nurses. British Journal of CommunityNursing, 7(10): 514–19.

Woodward, V. (2001) Evidence-based practice, clinical governanceand community nurses. In V. Hyde (ed.), Community Nursingand Health Care: Insights and Innovations. London: Arnold.

References 51

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Collaborative working has become a significantfeature of current and future practice. This chapterseeks to define collaboration and to explore anumber of its different aspects. It includes theattitudes and skills required, the issues surroundinginterprofessional relationships and some of theconstraints and barriers that can arise. The aim is toassist those nurses who choose to work in primarycare to understand more fully the complexities ofcare delivery within this setting. It will mention therange of professionals and agencies who work withpatients to meet their needs.

INTRODUCTION

The ability to work collaboratively has beenhighlighted in the professional Code of Conduct (NMC2002a) as an essential part of a nurse’s role.There is anexpectation that a nurse will work co-operatively withother professionals,respecting their skills,expertise andcontributions.Additionally,a nurse must communicateeffectively to share knowledge, skills and expertise inorder to work efficiently with other team members,whilst maintaining high standards of care (NMC2002a). Nurses who seek to enrich their practice need

to have a greater understanding of what it means towork collaboratively, not just with other professionalsbut primarily with patients and their carers (Fatchett1996).This active involvement of patients in their carelies at the heart of current government policy (DOH2001a, 2001b). Whilst the aim of collaborativeworking is that it should lead either to health gains orimproved patient outcomes,it must be noted that thereis,according to Ross and Mackenzie (1996),insufficientevidence to date to substantiate this view – aninteresting finding given that policy and practice placesuch emphasis on collaborative working.

The following case study of a hypothetical familyin receipt of primary care will be used tocontextualise the issues being discussed.

6Working collaborativelyAnn Clarridge and Elaine Ryder

Learning outcomes

• An understanding of why collaborative working is so essential in terms of the government policy.• An understanding of what is meant by collaboration.• An appreciation of the issues relating to the interface of collaborative working.• A recognition of the skills that are required in order to collaborate effectively. • An acknowledgement of the interprofessional relations, including some of the barriers and

constraints, that can affect collaborative working.

ExampleElmer King, aged 35 years, is black British ofCaribbean origin but grew up in London. He isunemployed, suffering from schizophrenia andcarries sickle cell trait. His partner Ann, aged 32years, is white British. She also carries sickle celltrait. She has a part-time night cleaning job for alarge local firm.

In considering issues relating to Elmer, Ann andtheir family there is the potential for a number ofdifferent people to be involved in order to providethe appropriate services to meet the family’s healthand social needs.

IMPLICATIONS OF GOVERNMENTPOLICY FOR COLLABORATION

Over the past 15 years, government health andsocial policy has constantly reinforced the need forprimary health care and teamwork to meet thechallenges of a changing population and of ‘life-style related disease in the community’ (Ross andMackenzie 1996: p.78). In 1986 the CumberlegeReport (DHSS 1986) noted that numerous healthand social care professionals were ‘beating the samepathway’ to patients. The results were confusion forthe patients and their carers and duplication of

services. It was considered that the service provisionwas fragmented and the potential for missing healthneeds was significant. Through a series ofgovernment policies (DOH 1987, 1989a, 1989b,1990, 1996, 1997, 1999a, 1999b), teamwork,collaboration and a partnership approach to carehave become central to the provision of care in thecommunity. There is recognition of a need to moveaway from the traditional boundaries of health andsocial care towards the development of multi-professional teams working throughout hospitaland primary care settings.

The NHS and Community Care Act 1990 broughttogether the social services and health services toprovide ‘seamless care’ to people in their own homesor in homely settings. The Act provided a ‘planningframework’ to enable different agencies to worktogether, to consult and collaborate at every level(Audit Commission 1992). This ‘bringing together’was further strengthened in the subsequentgovernment report, Primary Care-Led NHS (DOH1996). It was envisaged that multi-disciplinary,multi-professional, inter-agency teams of peoplewould be working together. In a time of diminishingresources and increasing demand they would providean effective, high-quality care that would be needsled and not merely a blanket provision.

It was the change of government in 1997 thatbrought about recent changes of policy in theNational Health Service, but the need forpartnership and collaborative working has remaineda significant feature – in fact has been emphasisedmore strongly. One of six key underpinningprinciples outlined in The New NHS: Modern,Dependable (DOH 1997) was to involve theNational Health Service in partnership with otheragencies in the provision of social and health care,with the needs of the patient at the centre of thecare process. The increasing emphasis on the role ofprimary health care teams has come about as aresult of ever-increasing hospital costs alongsidegovernment recognition of their importance asgate-keepers to health care (Fatchett 1996). Themore recent NHS Plan (DOH 2000) hascontributed to this shift in emphasis to a needs-ledservice – one that encompasses collaboration, jointworking and partnership. Fatchett (1996) hasattributed the increase in popularity tocollaboration to a number of causes.

54 Working collaboratively

Malcolm Roberts, aged 13 years, is the son ofAnn’s first partner. He is timid and small for hisage. He ‘gets picked on’ by other children at schooland has recently been complaining of stomachaches and not wanting to go to school.

Louise King, aged 8 years, has sickle cell diseaseand has had a lot of absence from school becauseof sickle cell crises.

Alice King, aged 11 months, is wheezy and suffersfrom severe infantile eczema. She was bottle-fedfrom birth and weaned very early. She hasattended for developmental checks. Her hearingand vision are satisfactory but there is concernabout delayed motor development.

Ann recently scalded her leg badly. She says sheaccidentally knocked over a full pot of freshlymade tea. She has been self-treating the woundfor a few days and has only just visited her generalpractitioner (GP) as the wound is now ‘rathersmelly’ and her leg is very red.

The family live in an urban area of a large city.Their accommodation, which they rent, is a smallterraced house with two bedrooms and a smallgarden at the rear.

• A growth in the complexity of health and welfareservices.

• Expansion of knowledge and subsequent increasein specialisation.

• A perceived need for the rationalisation ofresources.

• A need to reduce the duplication of care.• The provision of a more effective, integrated and

supportive service for both users and professionals.

The greater complexity of technology andtreatment has placed tremendous pressure uponpractitioners to have the necessary knowledge andcompetencies to meet the needs of patients withcomplex care needs. There have been a number ofrecent public inquiries into incidents involvingpeople who have been diagnosed as mentally ill.Government response has been to seek to improvethe co-ordination of care for such individuals, withan increased emphasis on the role of the primaryhealth care teams (Secker et al. 2000).

DEFINING COLLABORATION

As highlighted in the previous section, the reasonsgiven for collaborative working would seem to beextensive and significant, but what does it actuallymean? The word ‘collaborate’ is derived from theLatin collaborare which means ‘to labour together’.This notion of working together has beenhighlighted by Ovretveit (1997) in the sense ofcollaboration between organisations or individualsworking together or acting jointly. In addition, thenotion of exchange is evident in Armitage’sdefinition (1983), defining collaboration as beingthe exchange of information between individualsinvolved in the delivery of care, which has thepotential for action or joint working in the interestsof a common purpose.

This definition would seem to be quitestraightforward, but it could also be seen to bereferring exclusively to professionals delivering care

without reference to the patients and their carers.Interestingly enough, the issue about beingprofessionally driven could be inferred from policydocumentation (DOH 1992). Here collaboration isseen as a ‘partnership of individuals andorganisations formed to enable people to increasetheir influence over the factors that affect theirhealth and well being’, a view more recentlyexpressed in The NHS Plan (DOH 2000) andLiberating the Talents (DOH 2002).

The issue of collaboration having the potential tobe professionally driven is of particular importancewhen considering a partnership approach betweenpractitioners, patients and their carers. Henneman etal. (1995) suggest that when individuals areinvolved in collaboration their relationship is non-hierarchical. Power is shared on the basis ofknowledge and expertise rather than role or title. Inother words, collaborative working needs to involvea redistribution of power within the health careteam (Soothill et al.1995).

THE INTERFACE OF COLLABORATIVECARE

In considering the needs of Elmer, Ann and theirfamily there will be a need to relate to and workwith each member of the family as well asnetworking with a range of diverse groups,including social services, and voluntary agencies.The interface may be at different levels, accordingto the actual requirements of care. Armitage (1983)identified a taxonomy of levels of collaboration thatmoves from a situation where people communicatewithout meeting to a situation where people worktogether. For example, issues of child protection andbullying that could be associated with Alice andMalcolm might be dealt with by the health visitorand the school nurse, who might also involve suchother agencies as social workers, the police and the

ExerciseCollaborative working can be seen as a multi-faceted concept. Identify the skills and knowledgeneeded by the practitioners for effectivecollaborative working.

ExerciseWhich agencies might be involved in supportingElmer, Ann and their family?

The interface of collaborative care 55

judiciary. The GP and the practice nurse may beinvolved with the care of Ann’s wound and forElmer’s maintenance medication. In this wayreferrals from one agency to another regarding thefamily might occur without any need for a meeting.However, if the care is to be effective it might bethat each of the agencies involved would need tocome together and meet with the family to resolvedifficulties, duplication and problems. Similarly, twoagencies might be more involved than others andtake the lead in the care whilst informing theremaining agencies of progress.

A framework for classifying collaboration by Gray(1989, cited in Huxham 1996) suggests that thereare two dimensions: factors that motivate people tocollaborate and the goal or anticipated outcome ofthe collaboration. Gray further suggested that thereare four types of collaboration: appreciativeplanning, dialogues, collective strategies andnegotiated settlements.Although Gray is concernedspecifically with business organisations, herclassification of the four types of collaboration couldalso be applied to health care situations.

The different types of collaboration as identifiedby Gray can be seen at a micro level, as in the Kingfamily.The exchange of information is one of the keyfeatures in the King family’s situation (appreciativeplanning). Each of the different practitionersinvolved with Elmer, Ann and the family care needto communicate (dialogues) their knowledge of thesituation in order to arrive at a shared vision. Theyneed to provide an arena for exploring solutions tothe problems identified by the patients and theircarers, resolve difficulties (negotiated settlements) andreach agreement about a plan of care (collectivestrategies). Thus the collaborative process will passthrough three phases: problem solving, directionsetting and implementation (Gray 1989, cited inHuxham 1996).

At a broader macro level, working in partnershipand collaborative care means ensuring that thestructure of the organisation is sufficiently flexibleto support patients and enable them to function.The implementation of health improvementprogrammes (HIPs) is seen as providing the‘strategic glue’ that binds the different servicestogether in new working partnerships between usersand health service providers, including statutory andnon-statutory (Gillam and Irvine 2000). In

addressing the needs of local populations throughHIPs there is an emphasis upon primary care staff towork across practice and professional boundarieswith colleagues in Social Services, Education andHousing. In this way, people with the relevantknowledge and skill, including the patients and theircarers, will be able to carry out the appropriate care.

SKILLS NEEDED TO COLLABORATEEFFECTIVELY

Previous sections of this chapter have discussedwhy it is important to work collaboratively, what itmeans to collaborate and with whom we need tocollaborate. This section is about how wecollaborate – in particular the skills needed tocollaborate effectively. Using the case study ofElmer,Ann and their family, scenarios will be drawnout to demonstrate the range of skills that arefundamental to effective collaboration.

Hornby and Atkins (2000) are clear in establishingthat the sole purpose of collaboration is to provideoptimum help. In their discussion on collaborativeprocesses and problems, they identified a range ofattitudes and skills necessary for good practice. It isthese that will be identified and integrated in anexamination of this complex family situation.

Thompson (1996) states that working withothers involves engaging with other people person-to-person. However, before we can do this we haveto have a good understanding of ourselves in termsof ‘how we are perceived by other people, ourcharacteristic responses and reaction and our ownneeds’ (p. 234).

Collaborative attitudes

Hornby and Atkins (2000) suggest that collaborativeattitudes may be clustered under the concepts:reciprocity, flexibility and integrity.

ExerciseIf the King family were on your caseload, whatprocesses would you need to establish to meettheir needs?

56 Working collaboratively

• Reciprocity is based on respect and concern forindividuals and the development of mutualunderstanding and mutual trust.

• Flexibility is the readiness to explore new ideasand methods of practice and an open attitude tochange. It is about working in partnership withclients and colleagues and not about positions ofpower.

• Professional integrity places the client’s needs firstand not those of the individual practitioner.Integrity, according to Hornby and Atkins,demands that practitioners examine their owndefensive practices and separatist tendencies.

This scenario highlights the importance ofcollaborative attitudes. In considering the issues ofreciprocity, flexibility and professional integrity, youmay have covered the following issues.

Reciprocity. The practice nurse has shown genuineconcern and empathy for Elmer. She has begun tobuild up a relationship with him during his routineappointments and her knowledge of his conditionhas led her to feel genuine concern. In the busyschedule demanded by the appointment system atthe surgery, it would be easy to label Elmer as a ‘DNA’(did not attend) and be somewhat dismissive of anyfollow-up. Mutual trust is beginning to developbetween the practice nurse and Elmer and the factthat she has been unable to contact him on the phone,has led her to feel that ‘something is wrong’.

Flexibility. The practice nurse has shown by heractions that she sees Elmer as an equal partner in hiscare. Her approach is one of working towards

concordance (see DOH 2001a) as opposed tocompliance. She would be keen to consider othermethods of practice, depending on Elmer’s needs.

Professional integrity. The practice nurse hasdemonstrated the importance she places onmeeting Elmer’s needs – it would have been easy forher to become irritated by Elmer’s ‘DNA’. In termsof her role within the practice and the otherpatients she has been more prepared to considerwhat is wrong with Elmer than her own position atthat time. However, she should also realise that sheis not alone in being able to provide support forElmer. She is a member of a wider primary healthcare team, some of whom might be better placed tofollow up Elmer’s situation. In this way she wouldbe demonstrating her awareness of her own role andits boundaries whilst respecting the roles of theothers in the team.

Elmer’s community mental health nurse wouldprobably be the first colleague to contact regardinghis schizophrenia and depot medication. She mightalso want to discuss the situation with her healthvisitor colleague, who would know the familybecause of visiting Ann and baby Alice. Both thesecolleagues would be able to discuss Elmer’sfinancial situation with him and seek furthersupport from the social worker, should he wish it.She could also contact the school nurse responsiblefor the schools that Louise and Malcolm attend justto ensure that the children have the opportunity toshare any concerns if they wish and to monitor theirsituation.

In summary, this scenario demonstrates howimportant it is to have a positive attitude tocollaboration not only with patients but also withcolleagues.

Collaborative skills

In addition to collaborative attitudes, Hornby andAtkins (2000) highlight the importance of

ExerciseWho do you think the practice nurse couldcollaborate with regarding Elmer’s situation?

ExerciseConsider what reciprocity, flexibility andprofessional integrity would mean in relation tothe following scenario.

Elmer usually attends the health centre for hisregular depot injections from the practice nurse.He has not attended for the second injection andthe nurse is very concerned about Elmer. She hastried to contact him by telephone but the numberis unobtainable – in fact it has been cut off due tonon-payment of bills.

Skills needed to collaborate 57

collaborative skills and see these as relational,organising and assessment skills – all essentialelements for effective collaborative working.

Relational skills include open listening, empathy,communicating and a helping manner, in other wordsputting people at their ease.

Open listening means hearing without stereotyping,and using direction purely for the purpose of hearingmore rather than less. It requires the ability to toleratedistress and anxiety without resorting to copingmethods that restrict the client’s communications. Itmeans being alert to the feelings that may be involvedwhen individuals seek and receive help and being awareof the effect on people of finding themselves as a serviceuser. It is about facilitating the expression of relevantemotions and being able to empathise whilst at thesame time retaining the necessary objectivity whenmeeting patients’ needs.

Empathy, according to Thompson (1996), is theability to appreciate the feelings and circumstancesof others even though we do not necessarily sharethem. It is about being sensitive to differences andavoiding making stereotypical assumptions. In orderto avoid discrimination and disadvantage, it isessential that patients’ differing requirements aremet.

Clements and Spinks (1994) stress the importanceof treating others,whether as individuals or in groups,fairly,sensitively and with courtesy,regardless of whothey may be. Further, they identify the followingskills, knowledge and attitudes, which are applicableto almost any situation:

• empathy• keeping within the law• thinking about the consequences• not believing myths• a desire to be fair• openness to different ideas• reflective thinking• sensitivity• using appropriate language• knowing about the issues• treating people as individuals• not seeing alternative cultures as a threat.

Open communicating means conveying whatseems to be relevant, including feelings as well asfacts and opinions, without becoming defensive.

Where trust is lacking, defensive processes andprotective devices are likely to come into operation.Open communicating also relates to the need forprofessional confidentiality (NMC 2002b). Forfurther information about confidentiality seeCornock (2001).

A helping manner, according to Hornby andAtkins (2000), is the ability to manifest personalconcern and professional confidence withoutsuperiority, thus enabling patients, carers andpractitioners to function at their best in a workingrelationship. The role of carers should not be takenfor granted nor undervalued: the practitioner mustbe as concerned for their wellbeing as for that of thepatient. This feeling of being valued may notautomatically result in an increased participationbut it can at least bring emotional benefit to bothcarer and patient. Facilitating patients’ and carers’expressions of their feelings is a skill which canoften increase understanding of a situation, resolveblocks to progress and relieve tension and distress.

You may have considered some of the followingpoints. At the initial referral it would have been

ExerciseIn terms of relational skills, for example openlistening, communication and a helping manner,what do you feel are some of the issues in thefollowing scenario?

The district nurse has received a referral from theGP regarding visiting Mrs King, who has recentlyscalded her leg. She has been self-treating thewound for several days and it has now becomeinfected. The district nurse has not had anyprevious contact with Mrs King.

Mrs King has a night-time cleaning job for a largelocal supermarket and with her familycommitments is not able to attend the healthcentre. The district nurse knocks hard on the doorand eventually Mrs King appears in her nightie,looking cross. She was asleep and Elmer, whoshould have been looking after baby Alice, hasgone out.

58 Working collaboratively

helpful if the GP had indicated that Mrs Kingworked ‘nights’. Even though she could not confirmher visit by telephone the district nurse should havebeen able to make a visit at a time more convenientfor Mrs King which intruded less on her need tosleep during the day. It might have averted theinitial ‘angry’ meeting. However, once in thissomewhat confrontational position, the districtnurse needs to be able to acknowledge the situationas a whole and her role in it. She needs to bereceptive to Mrs King’s irritation and demonstrateher open listening skills. It would be easy to becomedefensive and use closed questions as a means ofrestricting Mrs King’s communication. Skills inopen communication are essential in order to builda trusting relationship between practitioner andpatient. A helping manner is demonstrated byconcern for the individual patient within the widerfamily context. This example shows how importantit is for the practitioner to view a situation from aholistic perspective rather than from a limited taskviewpoint. In an uncomfortable atmosphere thepractitioner could well have undertaken a specifictask and then left, limiting her concern solely to MrsKing’s leg.

Organising skills identified by Hornby andAtkins (2000) are those required to implementthe principles of essential collaboration. Theseinclude establishing networks, setting upmeetings, devising appropriate patient/carerreferral systems, and managing changes within thework context. Professional boundaries need to beclearly defined and agreed. Henneman et al.(1995) maintain that collaboration requiresindividuals to have both a clear understanding oftheir own role and an understanding and respectfor the roles of others.

When individual team members are clear abouttheir own roles and boundaries and those of othersin the team, the most appropriate person can thensupport Elmer and his family – otherwise gaps intheir support could appear. The complex situationpresented by Elmer’s family requires an effectiveapplication of skills. The family, the GP, practicenurse, receptionist, community mental healthnurse, district nurse and school nurse have alreadybeen indicated as each having a role to play. Clearly,networking with others in such a situation iscrucial. The primary health care team meeting

could prove to be a valuable forum where issueswould be shared, future support for the familyclarified, and the key worker identified. A lack oforganisational skills could prevent a full andaccurate picture of the family’s needs beingcompleted.

Assessment skills represent the final element ofcollaborative skills as identified by Hornby andAtkins (2000). Assessment, according to Thompson(1996), is a complex and multi-faceted process. Ahigh level of interpersonal skills is required whenundertaking a holistic assessment, and in complexsituations assessment skills involving a range ofperspectives may be appropriate. When differentagencies have overlapping boundaries sometimesthe patient can experience difficulty in finding thatwhich is most suited to meeting his/her needs. Atthe same time it is not always possible for onepractitioner to have sufficient in-depth knowledgeof the various contributions of other agencies.Practitioners need to know enough about a range ofservices to be able to select the most appropriateone for any given situation and also when to referthe patient. Thus, the demands on the practitionerinclude not only a wide range of knowledge and ahigh level of assessment skills but also a freedomfrom defensive or separatist attitudes (Hornby andAtkins 2000). Whilst there is a desire to movetowards a single assessment process, currentlydifferent professionals have their own methods fordocumenting assessment (NMC 2002b). It is thepooling of this information that is so important toensure that all the pieces of information fittogether.

INTERPROFESSIONAL RELATIONS

The final section of this chapter focuses oninterprofessional relationships, thus drawingtogether some of the wider issues already alludedto.

ExerciseWithin your area of practice, identify a complexfamily situation and identify potential barriers andconstraints to collaborative working.

Interprofessional relations 59

Mackay et al. (1995) have asserted that workinginterprofessionally involves crossing traditionalprofessional boundaries, being prepared to beflexible in considering a range of views and having awillingness to listen to what colleagues from otherdisciplines are saying. Each group brings differentskills and solutions to the health care problem withwhich they are presented. In some decisions thecontribution of one professional group needs totake precedence over others, which underlines theneed for flexibility in decision making.Interprofessional working, as mentioned earlier,raises the question of redistribution of power withinteams. So many fundamental changes are takingplace within primary care that perhaps now is anopportune moment to challenge established andentrenched attitudes.

Collaboration between professionals and betweenservice agencies is currently regarded as thecornerstone of the development of community carein the UK. However, only recently have mechanismsof collaboration been subject to evaluation as a meansof demonstrating effectiveness. Molyneux (2001)attempted to do just this in her study ofinterprofessional team-working by identifying andevaluating the positive characteristics of teamworking. Three main themes emerged:

• Motivation and flexibility of staff. Personal qualitiesof staff such as flexibility, adaptability and lack ofprofessional jealousy enabled team members towork across professional boundaries.

• Communication within the team. Findingsidentified regular and frequent team meetings andagreement on the communication strategies, forexample shared records, within the team ascentral to effective team working.

• Opportunities for creative development of workingframeworks. Encouragement and opportunitiesneed to be provided for staff working together toenable them to develop creative methods ofworking which meets their patients’ needs.

It is in the sharing of knowledge and skills in acollaborative way that the common goal of holisticcare is more likely to be achieved with ultimatebenefits to the patient and family. (Shields et al.1995). Essential to the success of collaborativeworking is a defined mechanism for making

decisions. Problems can occur where a team doesnot have a clear and agreed process. Ovretveit(1993) points out that conflict can arise unlessdifferences are aired and worked through in acreative and fair way. Unstructured decision makingprocedures waste time, cause conflict andresentment and can lead to team break down.

In summary, collaborative working is an ideal thatessentially seeks to ensure that the best interests ofthe patient are protected. It is a never-endingprocess in which the patient, relatives and carersmust increasingly be supported to play a centralrole in making their own contribution to decisionsaffecting their lives. Collaborative working is,therefore, one step on the way to fully informeddecision making in meeting the needs of patientsand their carers and delivering effective andefficient community health care.

REFERENCES

Armitage, N.H. (1983) Joint working in primary health care.Nursing Times, 79:75–8.

Audit Commission (1992) Homeward bound: A New Course forCommunity Health. London: HMSO.

Clements, P. and Spinks, T. (1994) The Equal OpportunitiesGuide. London: Kogan Page.

Cornock, M.A. (2001) Ethical and legal considerations ofcommunity nursing. In V. Hyde (ed.), Community Nursingand Health Care. London: Arnold.

Department of Health (1987) Promoting Better Health.London: HMSO.

Department of Health (1989a) Working for Patients. London:HMSO.

Department of Health ( 1989b) Caring for People. London: HMSO.Department of Health (1990) The NHS and Community Care

Act. London: HMSO.Department of Health (1992) The Health of the Nation.

London: HMSO.Department of Health (1996) A Primary Care-Led NHS.

London: HMSO.Department of Health (1997) The New NHS: Modern,

Dependable. London: The Stationery Office.Department of Health (1999a) Saving Lives. London: The

Stationery Office.Department of Health (1999b) Making a Difference. London:

The Stationery Office.Department of Health (2000) The NHS Plan. London: The

Stationery Office.

60 Working collaboratively

Department of Health (2001a) Shifting the Balance of Power.London: The Stationery Office.

Department of Health (2001b) The Expert Patient. London: TheStationery Office.

Department of Health (2002) Liberating the Talents. London:The Stationery Office.

Department of Health and Social Security (1986) NeighbourhoodNursing: A Focus for Care (Cumberlege report). London: HMSO.

Fatchett, A. (1996) A chance for community nurses to shapethe health agenda. Nursing Times, 92: 40–2.

Gerrish, K. (1999) Teamwork in primary care: an evaluation ofthe contribution of integrated nursing teams. Health andSocial Care in the Community, 7(5): 367–75.

Gillam, S. and Irvine, S. (2000) Editorial: Collaboration in thenew NHS. Journal of Interprofessional Care, 14(1): 5–7.

Gray, B. (1989) Collaborating: Finding Common Ground forMultiparty Problems. San Francisco, CA: Jossey-Bass.

Henneman, E.A., Lee, J.L. and Cohen, J.I. (1995) Collaboration: aconcept analysis. Journal of Advanced Nursing, 21:103–9.

Huxham, C. (1996) Creating Collaborative Advantage (1st edn).London: Sage.

Hornby, S. and Atkins, J. (2000) Collaborative Care. Oxford:Blackwell Science.

Mackay, L., Soothill, K. and Webb, C. (1995) Troubled times:the context for interprofessional collaboration. In Soothill,

K.L., Mackay, L. and Webb, C. (eds) InterprofessionalRelations in Health Care. London: Arnold.

Molyneux J. (2001) Interprofessional teamworking: what makesteams work well? Journal of Interprofessional Care,15(1): 29–35.

Nursing Midwifery Council (2002a) Code of Conduct. London:NMC.

Nursing Midwifery Council (2002b) Guidelines for Records andRecord Keeping. London: NMC.

Ovretveit, J. (1993) Co-ordinating Community Care.Buckingham: Open University Press.

Ovretveit, J. (1997) Interprofessional Working for Health andSocial Care. London: Macmillan.

Ross, F. and Mackenzie, A. (1996) Nursing in Primary HealthCare Policy into Practice. London: Routledge.

Secker, J., Pidd, F., Parham, A. and Peck, E. (2000) Mental healthin the community: roles, responsibilities and organisation ofprimary care and specialist services. Journal ofInterprofessional Care, 14(1): 49–58.

Shields, G., Hoelzle, L. and Schondel, C. (eds) (1995) Socialwork and nursing collaboration: a case study in assessingand meeting patient and family needs. Journal ofInterprofessional Care, 9(1):21–9.

Soothill, K., Mackay, L. and Webb, C. (eds) (1995)Interprofessional Relations in Health Care. London: Arnold.

Thompson, N. (1996) People Skills. London; Macmillan.

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INTRODUCTION

The term ‘nursing model’ was probably introduced toyou in your basic education, and used for assignmentwork. Nursing models are supposed to be used inpractice but in reality they are generally not used well,and appear to serve more as checklists for care plansrather than to inform the direction of nursing care.Youmay now be questioning the value of models of nursing,if they are simply used as a theoretical exercise in nurseeducation and a checklist in routine practice, butnursing models can, properly used, facilitate thinkingabout care and the philosophy that underpins it.

Most nurses have used one or more nursing models.You are likely to be familiar with the Activities ofLiving model (Roper, Logan and Tierney 1980, 2000)and the Self Care model (Orem 1971, 1991). Thereare many models that can inform nursing and healthpractice. Models are not simple; they have been veryrigorously contemplated by experts and each oneserves as a representation of nursing. An interestingpoint about nursing models is the way in which theyvary quite considerably, so that the purpose andintention of one, and the way in which it informs

nursing,is quite different from these aspects in anothermodel, and each is helpful to different branches ofnursing.This will be discussed as the chapter develops.

ExerciseThink of a particular patient you have seen for thefirst time recently and use this person for the allthe exercises in this chapter.

Imagine for a moment that models had neverbeen developed. How would nurses approachpatient care, what would inform actions anddecisions in everyday practice?

You may or may not have been the first person toassess your patient’s health state. If you were yourdecisions and actions about the care of the patientwill be fundamental to all care following theinitial assessment. Spend a few minutesconsidering what influenced the decisions thatyou made. It would be helpful to write down yourideas.

7Conceptual approaches to careMilly Smith

Learning outcomes

• Discuss the underlying principles from which nursing care is developed.• Explore the meaning of conceptual approaches to care.• Explore conceptual approaches that are in common use in community nursing.• Discuss and critically apply the concept of evidence-based practice to aspects of community

nursing.• Review the concept of reflection as a means of learning and establish as a concepts of sound

practice.

PHILOSOPHIES OF CARE

It is unlikely that anyone has a blank sheet,mentally, when approaching patient care, and thisindicates that professionals take a consideredapproach in this matter. There are several labels forthese general approaches. One approach to nursingis known as task-orientated – referring to the clinicaltask being carried out in isolation from any otheraspects that influence the patient’s condition. Thusthe nurse dresses the wound and does not considerother factors that could influence the healing of thewound or the patient’s comfort. Most nurses haveheard the term biomedical model, which refers totreating the medical condition of the patient inisolation from the patient as a person. For instance,the patient’s heart condition would be treated buttheir excess weight and sedentary lifestyle, and theanxiety they might have about their health, wouldbe ignored. Pearson et al. (1996) consider that manynurses still use the biomedical model as the basis fortheir practice.

A term that is often used in relation to ageneral philosophy of care is holistic. The holisticapproach takes into account a range ofphysiological and personal considerations for eachindividual and also places them in the context ofcontemporary society and of current health careprovision. Holism is concerned with balance, i.e.with balancing the physical, psychosocial, andeconomic relationships of the person, with theenvironment in which they live (Aggleton andChalmers 2000). Some branches of nursing, forexample the nursing of those with learningdisabilities, are more likely to take a holisticapproach, as clients are not perceived in terms ofa medical condition.

The underlying philosophy of our approach tonursing very much reflects our individuality.‘Philosophy’ refers to the beliefs and values thatshape the way each of us thinks and acts. You willcertainly have heard the word used in the context ofphilosophy to life. Some common sayings exemplifysuch philosophies: Live now pay later; A short lifebut a good one; You reap what you sow. Thesesayings demonstrate our use of the term philosophyin this context: how our beliefs and values shapethinking and influence actions. It is to be expectedthat life experiences, education, professional

socialisation and professional experience will shapea nurse’s philosophy of care. Thus our underlyingphilosophy of care says something about us asindividuals with unique personal experience.

CONCEPTUAL MODELS

Nurse theorists have examined the concept ofnursing and have illustrated their ideas throughnursing models.The full term is ‘conceptual model’,differentiating this kind of model from the sort thatare exact miniatures of real objects – model cars,boats, buildings, for example. Each of these can beperfectly recreated as a working model. Is it possibleto build such a model of nursing? The answer is, ofcourse, No; and the reason for this is that nursing isa concept. A concept is a collection of images andideas that help to classify things and it is notpossible to build anything material from images andideas. The notion of a concept can be explainedthrough something that is familiar, for example theconcept of spring. There are certain aspects thatembody spring: lambs, daffodils, buds on trees,sunshine and warmer days. Put all these togetherand a set of images that creates a picture of theseason of spring comes to mind. Nursing is aconcept that is built around a set of images.

Your concept may involve images about caring,knowledge about health and illness, prevention of ill

ExerciseStop for a minute and consider what the conceptof nursing suggests to you.

ExercisePut your personal philosophy of nursing intowords and take a few minutes to consider some ofthe experiences that have influenced thisphilosophy.

Work out which general approach your philosophyreflects: does it reflect a biomedical or a holisticmodel?

64 Conceptual approaches to care

health, rehabilitation and enabling people to helpthemselves, partnerships with patients and otherhealth workers, the list goes on. When nursing isviewed in this way it is easy to determine whymodels of nursing are conceptual. It would beimpossible to build such a set of images into avisible working model.

It is possible to see that models may differ quiteconsiderably because nurses think differently andhold divergent views about the concept. Thedifference in views will also reflect the variedconcepts that are embodied in the differentspecialities of nursing. Take, for example, theconceptual difference between mental health andacute nursing. The concepts that make up the tworoles will vary because the nature of nursing isdifferent in each role; mental health nursingtreating psychological disorders and imbalanceswhile acute nursing is concerned with physicalillness or disability. As conceptual models aredeveloped for the nursing role it is logical that theywill differ in accordance with the differencesbetween branches of nursing.

Fawcett (1984) identified some common groundby analysing four key concepts that are embodied inall nursing models. These are: (1) the person orindividual; (2) the environment in which nursingtakes place; (3) health; and (4) nursing itself.Whatever other concepts make up a particularmodel, these four are found in all. Nurse theoristshave attempted to build conceptual models thatillustrate ‘systematically constructed, scientificallybased, and logically related sets of concepts whichidentify the essential components of nursingpractice’ (Riehl and Roy 1980: p. 6).

Building nursing models

Models must be put down in writing/text to enablethem to be shared and used by other nurses. It is inthis state that you have probably encounterednursing models. You might imagine how difficult itis to represent a complex set of concepts in writing.All models require to be portrayed through thewritten word and with the use of diagrams.

Before any model can be effectively used it mustbe interpreted and understood. It may take time towork through some of the terminology, but this isnecessary if the is model to be used as intended.You

can see that Orem’s model (1980) is based on theability of people to care for themselves. The modelrepresents a balance between what people need tobe able to do, which Orem refers to as ‘universal selfcare needs’ and a person’s ability to perform theircare, which Orem refers to as ‘self care’. The modelalso lists areas where, for various reasons, anindividual may require nursing intervention andsuggests, under methods of helping, the form thatsuch intervention might take.

The model proposed by Orem has severalcomponents that relate to self care, starting with thepremise that individuals wish to be independent andlisting areas where people normally meet their ownself care needs.There are health-related reasons thatinterfere with people’s ability to be independent andto care for themselves. The model looks at generalreasons why a person may need help and makessuggestions about ways in which a nurse may supporta patient in their striving for self care. The overallphilosophy is to support self care and independence,and this sets the tone of this particular model andthe direction that nursing care will take.

Representing this conceptual model is not easyand Orem supports the concepts embodied in themodel with detailed explanatory text. To use anymodel well, the whole model should be applied,with all concepts captured, in its application topatient care. Nurses tend to take what they considerto be the useful ideas from models and apply themin isolation. A prime example of this is the use ofthe Activities of Living model (Roper, Logan andTierney, 1980, 2000), where the list of daily livingactivities is used as a checklist against which careplans are developed. This action ignores the essenceof the model.

You should now have an understanding of thenature and purpose of a nursing model. One or

ExerciseIt would help you at this point to refer to a textthat deals explicitly with nursing models andexplore Orem’s model to understand generalphilosophical approach and the particular featuresof the model.

Conceptual models 65

more models should be used by a care team toguide the process of care, and the model(s) must besupported by all members. The team leader hasresponsibility to ensure that all team members aresufficiently knowledgeable to be able to use thechosen model(s) competently to follow through theplanned programme of care. Effective caring using anursing model is a team effort.

Models with differing philosophies

You may not feel that a Self Care model is suitablefor the patient that you have in mind or for yourbranch of nursing. There are other options toexplore, some similar to the ideas expressed inOrem’s model, others very different. A similarmodel was developed by Roper, Logan and Tierney(1980, 2000), informed by earlier work fromHenderson, who offered a definition of nursingbased on 14 activities of daily living (Henderson1966).The Activities of Living model is well knownand much used in the British Isles. It approachesnursing care by considering the activities of livingthat are common to all people, and how these canbe influenced by a range of factors, the origins ofwhich might be physical, psychological, social,cultural, environmental, political or economic.Other aspects that come into the model are the ageof the person and the degree to which they are ableto lead an independent life. The model focusesstrongly on the many factors that influenceactivities of daily living and requires nurses to takethese into consideration in making judgementsabout nursing care.

Self care and activities of living tend to beconcerned with planning nursing care in order tomeet physical health deficits, which is why thesetwo models are widely used to nurse patients withacute and chronic illnesses. They are equallysuitable for wider use. Aggleton and Chalmers(2000) illustrate this point by applying theActivities of Living model to bereavement.

Other models take a very different philosophicalapproach. Roy (1976) proposed a model based onadaptation. It works from the premise that eachperson is constantly adapting to an ever-changingenvironment. Roy suggests that an altered state ofhealth requires a person to adapt to cope withchanged circumstances. She sees the role of thenurse as one of facilitating adaptation in the patientby adopting a systematic series of actions, directedtowards the goals of adaptation. The role of thenurse in this model is to facilitate the patient toadapt to their altered health circumstances andthrough adaptation learn to cope with the change.This explanation is much over-simplified but itindicates yet another conceptual approach.

Neuman’s Systems model (Neuman 1989) takesa very different conceptual approach, based onwellness. It is concerned with the patient’s responseto stressors in the environment. Each persondevelops a range of responses to cope with normalcircumstances, with some people appearing to copebetter than others with everyday life. There are,however, situations that occur in the lives of allpeople that deviate from normal and producestressors that are very difficult to cope with.Neuman defines stressors as inert forces that havethe ability to impact on the patient’s steady state(Neuman 1989: pp. 12, 24). Some situations may bepositive and enabling whilst others may bedetrimental. This model views the nurse’s role asintervening to enable the patient to maintain anoptimal state of wellness. There may beopportunities in primary care practice to capitaliseon facilitation and enable the patient to managestressors that face them in order to attain anoptimum state of health. Such a model may be wellsuited for use in school nursing, health visiting andoccupational therapy.

In Peplau’s Interpersonal Relations model(Peplau 1988) the key components are theinterpersonal process, nurse, patient and anxiety.Peplau considers that people are motivated towardsself-maintenance, reproduction and growth bybiological, psychological and social qualities. Themodel views the interpersonal relationship betweennurse and patient as the focal point of interface thatwill produce benefits for the patient’s health. Thereare elements of adaptation and coping in this modelwith the main thrust of nursing intervention

ExerciseConsider if and how Orem’s Self Care model couldbe used for the patient you have in mind.

66 Conceptual approaches to care

coming through the nurse–patient relationship as atherapeutic interpersonal process. A model such asthis, based on interpersonal relationships, may bewell suited to mental health and learning disabilitynursing.

The conceptual models that have beenmentioned in this chapter serve to illustrate thewide and varying approaches that contribute to thedevelopment of models of nursing. The differingapproaches afford choice in decisions that are takenabout delivery of care, and consideration should begiven by the care team to the most suitable choiceof model for the patient. The models are complexand to use any one effectively it will be necessary torefer to texts where the model under considerationis fully examined. It will also be necessary to makesure that others involved in the care know andunderstand the model in all its aspects.

THE NURSING PROCESS: A MEANS OFIMPLEMENTING NURSING MODELS

The vehicle for implementing a nursing model isthe nursing process, a functional approach to theorganisation of nursing care. Yura and Walsh (1967)identified a number of stages in nursing care withwhich all nurses have some familiarity: assess, plan,implement, evaluate. The four stages of the processare used in conjunction with a nursing model andits philosophy. Using Orem’s model as an example,the four stages of the nursing process could beapplied as follows.

The assessment stage of the nursing process wouldtake into consideration:

• the philosophy that people are normally self caring• the ability of people to care for themselves, using

universal self-care needs to guide the assessment• recognition of the reasons an individual may

require nursing intervention• recognition of the way in which lifestyle and the

patient’s environment influence the situation.

The care plan would detail:

• the actions that need to be taken to meetidentified needs in relation to the patient’s normallifestyle and wishes

• interventions that could be used to achieve selfcare, whether they are the responsibility of thenurse, the patient or others

• the type of intervention needed: for example,teaching how to carry out care, or giving care, andproviding aids to living that enable the patient toregain independence

• ways in which the planned actions would beevaluated.

The planned care would then be given(implemented), bearing in mind that:

• planned care is given according to good practice;• current knowledge that is evidence-based

underpins the care• lifestyle and the environment are accommodated

in the provision of care• care given is evaluated against changes in the

patient’s physical, psychological and socio-economic condition.

Evaluation of care takes place to determine itseffectiveness. This is:

• carried out as an ongoing practice at each visit• includes, at regular predetermined intervals, an

objective review of the care with reference tochanges in condition, treatment effectiveness,introduction of new treatments

• leads to an adjustment of the care plan, ifnecessary, updating it in accordance with theevidence of the review.

Thus the nursing process, systematically applyinga model, connects theory to what is done on apractical level; and the nursing process and model(s)of care offer a care team a more supportive structurethan can be provided by a task-oriented approach tonursing.They enable systematic, logical organisationof care to be developed around a philosophical focus.

Though we are here referring to ‘nursing process’,in fact the four-stage process outlined above can beapplied to any situation that requires organising. Itis a tool that can be just as useful for organising acharity walk or planning a teaching session.

Through the use of models of nursing and thenursing process there is good support on which tobase nursing and health care practice, in a well

The nursing process 67

planned manner. All nurses must be thoroughlyconversant with models and process, but althoughthese provide a philosophy of care and givestructure to care, what else is needed to providesound practice? Evidence from patient surveyssuggests that patients would want competent andcaring practitioners (Carey and Posovac 1982) andthe next part of this chapter is concerned withcompetent practice.

EVIDENCE-BASED PRACTICE (EBP)

You are taught in formal and informal situations.Youread professional journals, books, literature frommedical suppliers and drug companies. You observethose who you work with,some of whom you admireas role models. As you progress through your careeryou gain from experience.Many things that you havedone have worked well and the patient has hadpositive outcomes from your care. These positiveoutcomes are sources of learning: you learned fromsomething that went well. Learning can also takeplace following a poor experience. If something didnot work well or went wrong a great deal can begained from reflecting on the event, identifying whatwent wrong and considering measures that could betaken to improve the situation.

Objectivity in nursing practice

Learning takes place in a variety of ways andeveryday work provides a mixture of objective andsubjective learning experiences. Information that isevidence-based has been based on research studies,and this is objective knowledge, gained fromsystematically established evidence. Subjectiveknowledge is gathered from observations made inpractice, from conversations with colleagues andsometimes from teaching sessions. The problemwith knowledge gained in this way is that it may not

be reliable, and could even be unsound anddangerous. It is important that care is planned onthe basis of objective evidence, and this means thatknowledge that is gained subjectively must bechecked to see that it supported by evidence.

EBP, a key concept in modern health care, is oneelement of clinical governance (DOH 1999), aframework for the continual improvement ofservices and quality in the NHS, the purpose ofwhich is to ensure that clinical decisions are basedon the most up-to-date evidence and that clearnational standards are set to reduce local variationsin access to and outcomes of health care. Clinicalgovernance has the following key elements:

• To set national standards for health servicesthrough development of national serviceframeworks and the National Institute for ClinicalExcellence (NICE).

• To provide mechanisms for assessing localdelivery of high-quality services, reinforced by anew statutory duty to quality.

• To provide support for life-long learning.• To develop effective systems for monitoring the

delivery of quality standards in the form of theCommission for Health Improvement, the NHSPerformance Framework and surveys ofpatient/user experience (DOH 1999).

All health professionals are accountable for theirindividual practice and are responsible for makingsure that their knowledge and skills are current.This implies that any care given is based on themost up-to-date knowledge available.

EBP forms an essential element in the quality ofhealth care and is directly related to clinical care inthat clinically effective practice is based on nationalstandards, frameworks and research.

A systematic approach to acquiringevidence

Systematic acquisition of evidence provides theinformation from which standards and protocols forcare are developed. Standards and protocols relatedto the provision of care are written by employers toguide the process of care. Health trusts use nationalguidelines based on the work of the National

ExerciseThink again about your patient. How do you knowthat what you are doing is correct? Where do youacquire the evidence on which you base yournursing practice?

68 Conceptual approaches to care

Institute for Clinical Excellence (NICE) andevidence from research as the basis for protocols.Each employee has a duty to keep up-to-date with,and refer to, guidelines that are supplied by theiremployer to inform their specific area of care, andto work to protocols.

Research is the means of gathering evidence, andthus the source of guidelines and protocols. Nursesshould have a working knowledge of the researchprocess to enable them to appraise and understandthe evidence that is presented as the basis for care,and be able to make a judgement on validity.

McInness et al. (2001) suggest that evidence isnot easily integrated into practice. The reasons thatthey offer for this are that research literature canbe poorly organised and not easy to read, making itparticularly hard for busy practitioners to access.The same authors also acknowledge the poorquality of some research. These comments make itclear that evidence is not always easy toaccess/understand, neither is it always sound.Health professionals must be able to interpret theinformation that is given to them to enable themto question evidence when it is unclear orunconvincing. The application of EBP lies witheach health professional who must exercisejudgement about the applicability of knowledge,whether it is evidence-based or subjective. Seniormembers of the team should have sufficientknowledge to support less experienced nurses, butall registered nurses should have a workingknowledge that equips them to question thesoundness of practice.

A part of professional life must be the acquisitionof knowledge that informs patient/client care.Access to information through electronic journalsand websites makes information readily accessible.Most health trusts have access points for internetsearches and this makes it so much easier for nursesto keep informed and current in their practice.

Evidence-based care or patientpreference?

There may be some instances where a treatment orpractice, even though based on evidence, may notbe appropriate for a patient. Thought andconsideration are required to be given by

practitioners at each care intervention. This makesthe argument for evidence-based practice turn onitself. You may reasonably ask why objectiveevidence cannot be applied in all cases when it islikely to be effective. The response to this rests inthe nature of health care practice, which isdescribed by McCormack et al. (2002) as practicethat takes place in a variety of settings, communitiesand cultures. To add to this complexity, there areother relevant influences, for example psychosocialand economic factors. Taking all these factors intoaccount it is reasonable to assume that thoughtneeds to be given to the application of practice.While practice should be based on evidence, it isalso important to establish that the patient is suitedto this care, and willing to accept the proposedtreatment.

Informed decisions and patient choice

One example of advocated treatment being foundunacceptable to the patient, would arise in the caseof a family who do not wish to have their childvaccinated with the triple measles, mumps andrubella (MMR) vaccine. The family might holdstrong views about the safety of triple vaccine. Herethe parents’ wishes might conflict with those ofprofessionals, who have convincing reasons whychildren should be protected from childhoodinfections. There are no easy answers to this type ofproblem, and decisions taken must be carefullyconsidered in the light of evidence that is presentedfrom a range of sources.The patients’, or in this casethe parents’, wishes are vital. When decisions aboutcare are to be made the nurse’s role is to provideinformation that can enable the patient to make aninformed decision, but in the end the choice restswith the patient.

Planning decisions about care are normallyconsidered by the care team, and a long-termtreatment plan, though initially developed by onenurse, would not rest with a single individual. Theplan would be discussed by the team to ensure thatit was suitable and allow all team members tounderstand the goals and process of care. Dailyevaluation of circumstances would, however, restwith an individual and would rely on informeddecision making.

Evidence-based practice 69

Professional practice relies on nurses beingcompetent in a range of specified outcomes (UKCC2001), successful achievement of which equipsnurses to practice. Practice requires that decisionsare made, and that implies that each professionalshould be knowledgeable in their subject area andhave the ability to translate their knowledge tosupport practice. Knowledge in itself has onlylimited value if it is used without due considerationof the effect that it might have on a situation. Thusa key aspect of professional practice is the ability tointerpret and apply knowledge in widely varyingcircumstances. It is around the varyingcircumstances that decisions must be made thatassure that care is appropriate and each nurse isaccountable for the decisions that they make aboutpatient care (NMC 2002).

LEARNING THROUGH REFLECTION

Many of the issues raised in this chapter illustratethe complexity of nursing practice and demonstratehow thinking skills and decision making are essentialto good practice. Not only is nursing practicecomplex it is also dynamic, and changes withdevelopments in health policy and scientificknowledge. For nurses this means that every patientcontact is unique and that over a period of time agreat deal of experience is generated from nursingpractice. Nursing practice, taken in its widest sense,means working with other health and social carepractitioners to provide the assessment, organisationand management of holistic care for patients.

Reflection is a great way to learn. It enables nursesto capitalise on what they do well and see how toimprove the aspects of care that did not go so well.Taylor (2000) stresses this by stating how theunconsidered life is transformed, through theprocess of reflection, into one that is consciouslyaware, self-potentiating and purposeful.All recently

qualified nurses will have been taught to usereflection as a method of learning, for just as EBP isa key concept in current nursing practice, so isreflection. Reflection has particular value to learningin nursing because of the richness of experience inpractice and the direct observation that nurses areable to make about how the care that they and thehealth care team give affects patients.

Reflection and practice

Reflection can and should take place during theprocess of practice. Schon (1983) refers to this as‘reflection in action’. It also takes place after theevent, which Schon refers to as ‘reflection onaction’. Sometimes reflection is private, at othertimes it is shared with colleagues or may even formpart of a team meeting.

The exercise that you have undertaken is anillustration of reflecting on practice, learning from itand using the learning to inform and develop futurepractice. This is why reflection is so beneficial innursing. In part it is explained because of theuniqueness of each situation demands new thinkingand reasoning and this accumulates over time asexperience increases.

Reflecting on action is a deliberate event. It canbe a very effective learning experience for theindividual nurse or for the team. Each nurse shouldregularly take time to reflect on their practice,considering their knowledge and skills, the evidencebase from which care is given and the manyinfluences that impinge on care.

Group reflection probably occurs informally inmany teams at hand-over meetings when care isdiscussed. Reflection by the team in a more formalsense provides opportunity for review of patient

ExampleThink about your chosen patient, and reflect onone aspect of care that you feel pleased with.Identify what was good about this particularaspect of care and why it was good. Also make alist of the ‘good’ parts that could be transferred tobenefit the care of future patients.

ExampleIn the case of your patient, can you deduce anyreason why a proposed treatment that is known tobe based on the best available evidence may notbe suitable?

70 Conceptual approaches to care

care on a planned and regular basis. Like theindividual nurse, the care team considers theirknowledge and skills, the evidence base from whichcare is given, the influences on care, that are raisedin models of nursing, and take a general reflectiveview of the care provided for each patient. Groupthinking can be productive, with each membercontributing an individual perspective, andeveryone learning from the others in the group.Shaw (1981) suggests that groups make better-quality decisions than individuals, which hasparticular significance when so much is at stake forpatients. However, some caution needs to beexercised when a group reflects, on account of aphenomenon known as groupthink, wherebypressures for conformity and for keeping within theboundaries of accepted practice stifle creativethinking (Robbins 1986).

Learning often occurs when something happensthat is disappointing or does not turn out the rightway. It is this type of experience that mostfrequently makes people think about what theyhave or have not done and how it could have beenmore effectively achieved. It is not enough only toreflect and recognise where things went wrong: thatis evaluation of the incident. Reflection is more thanevaluation – it involves new learning. For learning tooccur it is first necessary to identify what, in thecase of a negative experience, went wrong. It is thenessential to take the necessary steps to remedy thedeficit and put it right. It may be as simple asrecognising that work has been done withoutsufficient thought and that corners have been cut.In this instance the practitioner knows what shouldbe done but has failed to do it correctly. Thelearning will be in the nature of accepting thathowever great the pressures, sufficient time must begiven to each patient and procedure. It may,however, be that new learning needs to take place,perhaps a new skill needs to be learned, maybe froma colleague who has the necessary expertise.Sometimes knowledge is out of date and must beupdated by reading or by attending study days. Veryoften in primary care nurses come across healthproblems that are new to them and they have tofind the information that is needed to enable themto provide effective care. As you can see, learninginvolves taking some action. The purpose ofreflective practice is to actively enable learning so

that it becomes integral to routine practice. If anurse constantly reflects on practice, learns from itand changes practice in response to learning,practice will not become static and out of date.

Aids to reflection

A number of frameworks have been designed tohelp the process of reflection. Many nurses areintroduced to reflection by using the staged processadvocated by Gibbs (1988). Gibbs’s model offers acycle to guide nurses through the reflective process:

• describe what happened• explore the thoughts and feelings that occurred

as part of the experience• evaluate what was good and bad about the

experience• analyse the experience in order to better

understand it• consider what else could have been done, and

finally• make an action plan to determine how the

situation would be handled should it occur again.

This cycle of steps gives an easy-to-follow process,guiding the nurse through reflection. There areother frameworks that facilitate the reflectiveprocess, for example Burnard (1991), Boud, Keoghand Walker (1985) and Goodman (1984).Goodman’s approach focuses on levels of reflection,suggesting three levels of increasing complexity.Thefirst level consists of a simple approach that involvesconsidering how the job was done with regard totechnical efficiency and effectiveness, and in termsof accountability. The second level takes a widerview, looking at the implications and consequencesof the nurse’s actions and beliefs, which includes theunderlying rationale for practice. The third, mostcomplex, level draws on all the considerations inlevels one and two, and adds ethical and politicalconsiderations and developments.

There are distinct differences between theapproaches that are taken by Gibbs and Goodman.Gibbs offers a framework to facilitate structuredthinking while Goodman pushes the boundaries ofthinking to levels of considerable complexity.Examination of different approaches helps nursesto choose the one most suited to the situation. As

Learning through reflection 71

with models of nursing the most suitable approachto reflection may vary with differing experiencesand so it is beneficial to have a range of approachesto draw upon.

CONCLUSION

This chapter has covered some of the key factorsthat influence and inform professional practice innursing. This should create awareness of sources ofnursing knowledge and reinforce earlier learningthat introduced the nature and purpose of nursingmodels. There is no doubt that practice is complexand nurses can only truly attempt to meet theneeds of patients if they are able to understand andmanage complexity. The value of models ofnursing is that, in representing the complex natureof practice, they act as prompts. Because eachmodel is presented in diagrammatic form it enablesthe same detailed process of assessment, planning,implementation and evaluation to take place forevery patient. Professional skill comes into play asinfinitely variable information is analysed andinterpreted into personal and individual plans ofcare that take account of very differing needs. Theskill of the nurse is needed to manage patientinformation and translate it, with the patient’scollaboration, into meaningful and appropriatedelivery of care. Nurses must therefore beknowledgeable and skilful. The dynamic nature ofhealth care means that new knowledge isconstantly emerging, and health practitioners areobliged to keep up to date with the latestdevelopments.

Knowledge and the validity of information arerequirements for planning effective, economic care.Quality in care is high on the government agendafor improving the National Health Service (DOH2000). Receiving care that is based on objectiveinformation is an essential part of provision;application of care without thought orconsideration of the individuality of people wouldgo against the ethos of professional practice(Norman and Cowley 1999). Norman and Cowleystate that knowledge based on evidence is valuableand should underpin protocols and guidelines.Information that is collated and current greatlyassists practitioners. Blind acceptance of evidenceis not, however, consistent with professional

practice, one criterion of which is autonomy.Reflective practitioners who are constantlylearning on the job are fundamental to theprofession – nurses who can plan appropriate careon an individual basis, with the patient, and areable to be justify their decisions.

REFERENCES

Aggleton, P. and Chalmers, A. (2000) Nursing Models andNursing Practice (2nd edn). London: Macmillan.

Boud, D., Keogh, R. and Walker, D. (1985) Reflections: TurningExperience into Learning. London: Kogan Page.

Burnard, P. (1991) Improving through reflection. Journal ofDistrict Nursing, May:10–12.

Carey, R.G. and Posovac, E.J. (1982) Using patient informationto identify areas for service improvement. HMC Review, 7(2):42–8.

Department of Health (1999) Clinical Governance: Quality inthe New NHS. London: DOH.

Department of Health (2000) The NHS Plan: A Plan forInvestment, A Plan for Reform. London: The Stationery Office.

Fawcett, J. (1984) Analysis and Evaluation of ConceptualModels of Nursing. Philadelphia, PA: F.A. Davis.

Gibbs, G. (1988) Learning by Doing: A Guide to Teaching andLearning Methods. Oxford: Oxford Polytechnic FurtherEducation Unit.

Gibbs, G. (1997) Improving Student Learning: Theory andPractice. Oxford: Oxford Brookes University, Centre for Staffand Learning Development.

Goodman, J. (1984) Reflection and teacher education: a casestudy and theoretical analysis. Interchange, 15(3): 19–26.

Henderson, V. (1966) The Nature of Nursing. London: CollierMacmillan.

McCormack, B., Kitson, A., Harvey, G., Rycroft-Malone, J., Titchen,A. and Seers, K. (2002) Getting evidence into practice: themeaning of context. Journal of Advanced Nursing, 38(1):94–104.

McInness, E., Harvey, G., Duff, L., Fennessy, G., Seers, K. andClark, E. (2001) Implementing evidence-based practice inclinical situations. Nursing Standard, 15: 40–4.

Neuman, B. (ed.) (1989) The Neuman Systems Model. Norwalk,OH: Appleton & Lange.

Norman, I. and Cowley, S. (eds) (1999) The Changing Nature ofNursing. Oxford: Blackwell Science.

Nursing and Midwifery Council (2002) Code of ProfessionalConduct. London: NMC.

Orem, D.E. (1980) Nursing: Concepts of Practice. New York:McGraw Hill.

72 Conceptual approaches to care

Pearson, A., Vaughn, B. and Fitzgerald, M. (1996) Models forNursing Practice (2nd edn). Oxford: Butterworth–Heinemann.

Peplau, H.E. (1988) Interpersonal Relations in Nursing.Basingstoke: Macmillan Education.

Riehl, J. and Roy, C. (eds) (1980) Conceptual Models forNursing Practice (2nd edn). Norwalk, CT: Appleton-Century-Crofts.

Robbins, S.P. (1986) Organisational Behaviour: Concepts,Controversies and Applications (3rd edn). Englewood Cliffs,NJ: Prentice Hall.

Roper, N., Logan, W.W. and Tierney, A.J. (1980) The Elements ofNursing. Edinburgh: Churchill Livingstone.

Roper, N., Logan, W.W. and Tierney, A.J. (2000) Roper–Logan–Tierney Model of Nursing: The Activities of Living Model.Edinburgh: Churchill Livingstone.

Roy, C. (1976) Introduction to Nursing: An Adaptation Model.Englewood Cliffs, NJ: Prentice Hall.

Schon, D. (1983) The Reflective Practitioner. New York: BasicBooks.

Shaw, M.E. (1981) Group Dynamics (3rd edn). New York:McGraw-Hill.

Taylor, B.J. (2000) Reflective Practice: A Guide for Nurses andMidwives. Buckingham: Open University.

UK Central Council for Nursing, Midwifery and Health Visiting(2001) Fitness for Practice and Purpose. London: UKCC.

Wells, J.S.G. (1999) The growth of managerialism and its impacton nursing and the NHS. In I. Norman and S. Cowley (eds),The Changing Nature of Nursing. Oxford: Blackwell Science.

Yura, H. and Walsh, M. (1967) The Nursing Process. Norwalk,CT: Appleton-Century-Crofts.

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INTRODUCTION

This chapter will examine the professional issues thatimpact on the nurse working in the community.Many of the skills that a nurse uses in an acute settingare transferable to community nursing, but the focusof the work tends to be different, because it relatesto people in their everyday lives, either in their ownhomes, general practice, school, work, clinic or otherfamiliar environments. Some of the skills acquiredpreviously in the acute setting are transferable, butthere is a need to develop new approaches andadditional knowledge in order to function efficientlyand effectively.

WHAT ARE PROFESSIONALAPPROACHES TO CARE?

Nursing practice in the United Kingdom (UK ) iscurrently regulated by the Nursing and MidwiferyCouncil (NMC). The nurse has responsibilitieswithin these regulations towards clients, the public,the profession, the employer and to themselves.

In the community the nurse is potentially

responsible to a wider spectrum of clients andprofessionals on a day to day basis. They are adiverse group of people because of the range ofclient groups, professionals and voluntary agencieswith whom she may come into contact. Legislationmay also impact upon the role; for example: theMental Health Act 1983, the Children Act 1989,and the Human Rights Act 1998. Nursing practicein the community differs from that in the hospital,in that it is not necessarily observable by anotherprofessional, but is often only seen by clients, theirfamily and informal carers. This gives moreautonomy to the community nurse but places moreresponsibility on them, which will require them todevelop sophisticated decision making skills. Theextent to which this takes place will be affected byjob descriptions, clinical grade and expectations andthe requirements of the nursing team and thetrust/employer.

One area of community nursing practice wherestaff nurses may find significant differences betweenhospital and community nursing is in the approachto the assessment of clients and families. This isclosely linked to the standards for community

8Professional issues in communitynursingJenny Parry and Judith Parsons

Learning outcomes

• Identify the use of professional approaches in community nursing practice.• Analyse the similarities and differences between hospital and community nursing.• Recognise the complex nature of decision making within a community setting.• Discuss contemporary innovations in community nursing practice.

specialist practice (UKCC 1994). This may meanthat some staff nurses will not be undertaking initialassessments of clients or families as they wouldhave done routinely in hospital. Role activities willvary considerably between different disciplines ofcommunity nursing and areas within the UK. Anexample of this might be a staff nurse working in ahealth visiting team who could be undertakingroutine child development work related toassessment and screening, whilst a staff nurse in adistrict nursing team may not be undertaking anyinitial assessment work. It is vital that all levels ofstaff in this environment, where the clients are notmonitored in the same way as on a hospital ward,carry out continuous assessment. This demonstrateshow closely the role of the community staff nurse isassociated with that of the specialist practitionerand the way in which teams function (Vanclay1998). It is discussed in more detail in Chapter 6.These different approaches to care can be exploredmore closely from a professional perspective, as inthe past roles were very clearly defined andsupported by legislation. This meant for examplethat the core activities associated with particularlyhealth visiting could only be carried out byregistered health visitors (Nurses, Midwives andHealth Visitors Act 1979). As health care demandshave become more complex and sophisticated newroles have evolved, such as that of the nurseconsultant, whilst the role of community specialistpractitioners continues to develop and change withstaff nurses being integral to this policy (DOH1999a, 2000a, 2002a). Thus there is a need todefine clearly the essential requirements of anycommunity nursing service (Audit Commission1999), and at the time of writing many changes aretaking place (DOH 2002a.).

KNOWING WHAT YOU ARE DOING

All nurses come to community nursing bringing theskills and knowledge that they have used in theacute setting (Canham and Moore 2002). In theacute working environment, when the nurse hasuncertainties there are other members of the teamnearby to call upon. Usually knowledge and clinicalskills that are used within a familiar environmentwill enable the nurse to be confident and competentin her nursing interventions. It is important for any

nurse working in a new environment to recognisethe skills that they bring with them. These cancontinue to be used and are known as transferableskills. It is equally important for nurses in a newsetting to identify the new skills they may need toacquire. These can be obtained in different waysand there are a number of resources that the nursecan draw on:

• The senior nurse/line manager will be a resourcefor relevant policies and protocols, and could bethe relevant person to assist staff in identifying theareas of practice that need further development.They may be in a position to enable staff to accessappropriate study days and short courses tofacilitate continuing professional development.

• Clinical supervision is increasingly available. Itshould provide the opportunity for staff toexplore and develop best practice within a safeenvironment (Butterworth et al. 1998).

• Code of Professional Conduct (NMC 2002) is auseful aid to check the standards that are required.

• The individual approach can be to use the SWOTanalysis (Hannagan 2000), which enables thenurse to identify opportunities and threats or,more simply, to list strengths and weaknesses.

• The use of reflection can aid all of the aboveactivities, but can be particularly useful in helpingto identify areas of practice that have worked welland find ways of approaching other areas wherefurther professional development is required(Johns 1995). Reflection is explored in greaterdetail in Chapter 7.

ExerciseIt would be useful if you firstly reviewed youractual/potential professional responsibilities in thecommunity nursing environment. Consider thesetting in which you meet clients – home, clinic,health centre, GP surgery, workplace.

Reflect on and list the key differences you findpractising in this setting. Using the information onkey differences, list your transferable skills andthose that may need further development. List thenew knowledge and skills that you need toacquire.

76 Professional issues in community nursing

Some of the points identified could include issuessurrounding the need not only to transfer and adaptskills, but also to provide care in a flexible andinnovative way. Professional competence is acomplex set of knowledge and skills, whichintegrates knowledge, judgement, reasoning,personal qualities, skills, values and beliefs. Thismeans that the transference of skills and knowledgemay need to be interpreted in a more flexiblemanner, where the environment or situation is lessclinical than has been worked in previously, aswould be the case, for example, in a refugee centre,where there is little understanding of the UK healthcare system and therefore the client expectationsare different.

This may often mean adapting to the needs of theclient and responding in a more holistic manner totheir needs than might have occurred in a hospitalenvironment. The nurse’s response will beconcerned with information giving to enable theclients to understand the differences in the UKhealth and welfare system.Working as a communitynurse means starting out as a novice in this newsetting but very quickly transferring and adaptingexisting skills and acquiring new ones so as todevelop into a competent and ultimately proficientpractitioner (Benner 1984).

A useful exercise is to observe the senior nursewho is accountable for the caseload or client groupand identify the different ways in which theyinteract with clients and respond to needs(McIntosh 1996). Experienced and skilled nurseswill practise with confidence and competence andprovide a flexible and innovative service, and theycan be considered expert nurses (Benner 1984).This level of expert practice, which draws on theirexperience, education and evidence, is often calledprofessional artistry (Schon 1991).

Whilst staff nurses or student nurses cannot beexpected to work at this level there are severalimportant points associated with this way ofpractising. These expert practitioners arecomfortable within their roles and with time,experience and education staff nurses can beexpected to use some of the same skills within theirown practice. The extent to which these can bedeveloped may depend on employers. It is alsoimportant to remember that staff nurses arenormally part of a team and, whilst not fulfilling the

same role as the community specialist practitioner(UKCC 1994), will complement the service offeredto the clients. Nursing in this context requires apractitioner who is able to maintain safe highstandards of practice and be flexible and innovative.These can be seen to be centred around the set ofcore skills listed below:

• assessment of individuals, families and carers• decision making• clinical expertise• patient/client teaching• public health and health promotion• interest in and respect for the client community• effective communication skills, underpinning all

of the above.

These core skills recognise that practice takesplace in a real-life setting (Carr 2001) rather thanthe more focused acute sector of care. Nursing inthe community is multi-faceted, encompassingdiverse client needs. The power normally lieswith the client rather than the nurse. This isbecause clients potentially have more controlover care when receiving health services either intheir own home or in other familiarenvironments, such as their workplace or GPpremises. They usually feel more comfortable andare not normally functioning within the sick role(Parsons 1951).

DECISION MAKING

This should be based on information gatheredmainly from the initial assessment and fromongoing contact with the patient/family. It is notjust about interpreting medical diagnosis or clinicalinterventions, but taking the patient’s real lifeagenda into account. Decision making is influencedby many factors that can be seen to inter-relate,which increases the complexity of the task (seeFigure 8.1).

These factors may have different emphasesaccording to the practice area, but all can be foundin community nursing. They are evident in thefollowing example.

Decision making 77

When trying to make decisions in such a situationa holistic assessment needs to be undertaken. Any

nurse working in the community may have some ofthe knowledge required to work with this family,but how they prioritise the different factors willdepend on their experience and branch of nursing.It is likely that more information is going to berequired about Wayne and his mother, such as thefamily and its membership and whether any otherprofessionals are already involved.

Figure 8.1 demonstrates how the nurse assessingcare can ensure the wider context of communitynursing is addressed. This contrasts with nursing inan acute care setting, where the patient may be seenin the more limited context of daily living needs. Incommunity nursing, decisions cannot be made inisolation from the client‘s real-life situation (Carr2001), which reinforces the government’s agendaon working in partnership and empowering people(DOH 1998, 2000a). The client is central to anycare decisions that are to be made and should beconsulted about what their goals are for anyintervention by health and social care professionals

ExerciseCan you think of any other information you wouldlike if you were a member of the school nursingteam looking at Wayne’s case?

ExampleWayne, aged 13 years, has been truanting. Heturns up at a confidential drop-in session that theschool nurse runs. In conversation he tells her thathe looks after his mother, who has multiplesclerosis, and that this is the reason for hisabsences. He adds that his mother is entirelydependent on him for most of her care needs.

The factors the school nurse will need to considerinclude:

• the needs of the child• the mother–son relationship• client agenda – who is the client in this

situation?• confidentiality• her knowledge of child carers• the government agenda re truancy and care in

the community• the law• partnership working• available resources for this family’s needs.

78 Professional issues in community nursing

Resources

Decisionmaking

Clientagenda

Localagenda

Partnership

Professionalagenda

Governmentagenda

COMMUNITY

NURSING

K N O W L E D G E

Figure 8.1 Decision making in community nursing

or voluntary agencies, so that a collaborative carepackage can be developed (DOH 2002a).

As suggested by Figure 8.1, there are variousfactors that need to be considered. Whenundertaking this process the nurse must be skilledin needs assessment, goal setting, intervention andevaluating outcomes (Southard et al. 1994). Thenurse should examine the factors in each individualclient situation and consider the possible course ofaction and potential outcomes. This will enablethem to anticipate any unintended consequencesthat may impact on the family, carers, group orcommunity. The challenge to any assessing nurse isto find a mutual understanding of the needs of theirclient and attempt to meet them while taking intoaccount the local availability of resources. There arestudies in mental health using decision trees(Concoran 1986). This approach has been found byBonner (2001) to be time-consuming and complex,but the ideology of having alternative partnershipsof care can be utilised by the community nurse toensure that all factors have been considered. Theuse of the decision-making diagram in Figure 8.1provides an aid to assessment that is simpler to use.The client is central to the decision making, and byensuring that each factor has been addressed allneeds can potentially be met. A staff nurse mayalready have gained some knowledge of the client’ssituation, either through hand-over, medicalrecords, referral information, or previousassessment. These are all cues to identifying thereal-life situation for the client and their family(Carr 2001). They can be drawn upon to contributeto the decision making of potential interventionactivities, which may be required to meet theirneeds (Buckingham 2000). Benner et al. (1996)recognise how these cues shape decisions in relatingthem to previous knowledge.

Nurses use previous knowledge and experienceto support their decision making (Benner 1984).Clinical supervision can support nurses in theirdecisions, reinforcing quality of care throughreflection and can also enable them to identifydeficits in their knowledge base for professionaldevelopment (Butterworth et al. 1998).

The notion of concordance, that is negotiationbetween health care professionals and thepatient/client and family, is central to communitynursing. It is concerned with giving full informationand establishing a contract of care with the patient(Alder 1999). This can be achieved with effectiveinterpersonal skills, collaboration and consentwithin a patient-centred approach. The nurse willneed good understanding of client health beliefsand and awareness of the barriers tocommunication that can lead to ineffectivecollaboration in care.

The locality in which people live and work willhave identified resources that may meet the needsof the client group. The knowledge of theseresources can be accessed from a range of sources:community specialist practitioners, primary careand health and social care trusts or theirequivalents, local libraries, citizens advice bureaux,voluntary agencies and the internet. Part of the waythat community nurses can become familiar withlocal resources and needs is through health needsassessment and use of the community profile, whichhas been written about in Chapter 3 (see alsoRobinson and Elkan 1996;Worth 1996; Billings andCowley 1995).

CURRENT INNOVATIONS IN PRACTICE

Amongst the current innovations in practice is theuse of nurse prescribing to complement and providemore holistic client care. It can be seen as one of themajor changes that have occurred in nursing. Theconcept was first developed in community nursingas a response to the Cumberlege Report, whichidentified the need in 1986 (DHSS 1986).

The Medicinal Products Prescription by Nursesetc. Act 1992 gave district nurses and health visitorsindependent prescribing powers from a limitedformulary. This group of specialist nurses, whichincludes any practice nurse with either of these

ExampleA client presents for a routine cervical smearscreening. On discussion with the practice nurseshe states that she is ‘passing water a lot’ andseems very thirsty. Interpreting these clues, thepractice nurse would undertake basicinvestigations for diabetes.

Current innovations in practice 79

qualifications, has been trained since 1999. Nurseprescribing education is now within the qualifyingdegree programme for the health visitor and districtnurse specialities. The Review of Prescribing, Supplyand Administration of Medicines (DOH 1999a)suggested that prescribing powers might beextended to more nurses and after a 3-monthconsultation with professional organisations,ministers announced in May 2001 that nurseprescribing would be extended to more nurses andto a wider range of medicines. The Nurse PrescribingExtended Formulary (BMA and RoyalPharmaceutical Society of Great Britain 2002) hasincreased the prescription-only medicines intendedfor nursing care in four main areas; minor injuries;minor ailments; health promotion/maintenance andpalliative care. The formulary includes all GeneralSales List (GSL), the so-called over the countermedicines, and pharmacy-only (P) medicines.

The Review of Prescribing (DOH 1999a)recommended two types of prescriber:

• The independent prescriber, who is responsiblefor the assessment of patients with undiagnosedconditions and for the clinical management,which may include prescribing.

• The dependent prescriber, who is reponsible forthe continuing care of patients who have beenclinically assessed by an independent prescriber(doctor or dentist). This continuing care mayinclude prescribing from individual clinicalmanagement plans. It was also proposed thatpharmacists and other allied health careprofessionals would also become dependentprescribers (now referred to as supplementaryprescribers).

Supplementary prescribing has now become partof the extended nurse-independent prescribingcourse. Supplementary prescribing will enable thenurses and pharmacists to continue treatmentregimes within an agreed plan, prescribing frommost areas of the British national formulary.Scotland, Wales and Northern Ireland at the time ofwriting are to decide whether and when it will beimplemented in their countries.

Supplementary prescribing is intended to providepatients with a quicker and more efficient access tomedication (DOH 2003). The aim is for more

nurses and other allied professions to prescribe andis based on the intention to enhance patient/clientcare by providing continuity and using healthprofessional skills to their best effect.

Prescribing is a team activity in as much as theindependent prescriber utilises the knowledge andexpertise of all team members to enable andsupport their prescribing decisions. This supportspartnership working between health professionalsand gives a greater understanding of roles,responsibilities and accountability in patient care(Basford and Bowskill 2002).

The increase in prescribing powers has led tonurses taking a leading role in introducing newservices, such as nurse-led minor ailments clinics,and chronic disease management could be nurse- orpharamacist-led. This could be an area of care inwhich staff nurses in the future may be required todevelop knowledge and skills.

FUTURE CHANGES IN PRACTICE

Since 1997, when the Labour party returned togovernment, there have been many new approachesto the NHS, not least focusing on a primary care-ledservice (DOH 1997). These changes are detailedmore fully in social policy textbooks, but theircumulative impact is evident in The NHS Plan(DOH 2000a), a 10-year project for the delivery ofhealth care in England. This document summarisesgovernment health strategy, providing an umbrellaapproach to recent policies based on themodernisation agenda for health. Subsequentpapers (DOH 2001a, 2002b) detail the ways inwhich the NHS plan is to be implemented inprimary care. The new strategies have had animpact on community nursing and the ways inwhich nurses are expected to provide health care(DOH 1999b, 2002a). Other countries in the UKare at different stages of planning at the time ofwriting, but either have produced (ScottishExecutive Health Department 2000), or can beexpected to produce similar documents to meet theneeds of health and social care delivery withinScotland, Wales and Northern Ireland.

One of the most important changes that istaking place is the move towards a public healthagenda throughout all the countries of the UK.This degree of focus on public health has not been

80 Professional issues in community nursing

seen since the 19th century. It was in that periodand in response to that public health agenda thathealth visiting, occupational health nursing, districtnursing and school nursing first developed. So nowexisting community nursing services will have toadapt, and perhaps in some cases re-inventthemselves, in order to meet the public healthdemands of the 21st century. The Department ofHealth for England has identified new approachesto providing care, and new ways of working (DOH2000a). They include not only a public health andhealth promotion role for all nurses, but anemphasis on more effective assessment anddelivery of care, chronic disease management andthe implementation of the national serviceframeworks (NSFs). Resource packs have beendeveloped for health visiting and school nursing tohelp to facilitate staff in these new ways ofworking (DOH 2001b, 2001c). A range ofstrategies is being put in place by primary care andhealth and social care trusts to enable these newpolicy initiatives to be implemented. In the othercountries in the UK similar initiatives are beingadopted, particularly in Scotland (ScottishExecutive Health Department 2001). This meansthat all nurses working in the community will berequired to take on some of this new work, such asproviding more acute care at home and managingthe care of patients with a range of chronicdiseases. Specialist practitioners will be deliveringsome of these innovations in care, together withstaff nurses in their teams. In other instances staffnurses will be taking on new roles, enabling thespecialist practitioners to work in other ways.These developments enable community nursing todevelop practice in new and more flexible andinnovative ways. Liberating the Talents (DOH2002a) cites examples from around England ofhow all levels of community nurses can besupported in working in new ways. In Scotland, inorder to meet the health needs of the population,the Health Department of the Scottish Executivehave found new ways for nurses to deliver thepublic health agenda (Scottish Executive HealthDepartment 2001).

All community nursing staff will find themselvesworking to deliver the modernisation agenda. Oneof the ways this will take place in England isthrough the standards set by the NSFs. To date the

following have been published for: mental health(DOH 1999c), coronary heart disease (DOH2000b), cancer (2000c), older people (2001e), anddiabetes (DOH 2001f). The NSF for children isawaiting publication. The NSFs have been put inplace to ensure quality and equity of care. Theyprovide standards for care of the various groups andare concerned with health care delivery in both theacute and primary care sectors. Some, such as theones for mental health and older people, veryspecifically require collaboration with otheragencies. A good example of this is the singleassessment process highlighted in the NSF for olderpeople (DOH 2001e). This process will place thepatient at the centre of the assessment process,which will only take place once, no matter howmany health and social care professionals areinvolved. So community nurses may findthemselves relying on an assessment carried out bya care manager. The importance of respecting oneanother’s professional expertise and experience willbe very significant in this process (Ovretveit 1997).It will prevent clients undergoing repeatedassessments and suffering from assessment fatigue.

Other examples of flexible ways of deliveringhealth care to the population can be seen by theway in which the government has set up initiativessuch as NHS Direct. This 24-hour telephone helpline is staffed by specially trained nurses. It hasproved popular with the public (O’Cathain et al.2000), but initially received less favourable reviewsfrom doctors, who were concerned about thequality of the service (Hayes 2000). Recent signssuggest that some of these initial misgivings mayhave been resolved and that the service is now beingmore accepted (Sadler 2002). Another initiative isthe use of telephone triage in general practice,which is used to screen clients and decide who canbest meet their needs (Richards and Tawfik 2000).These services are normally undertaken by nursepractitioners or practice nurses who haveundertaken additional education. It is likely thatthis type of work will continue to increase andcommunity nurses are in key positions to take thisforward.

One of the other areas of innovation wherenurses are at the forefront of service delivery iswalk-in centres. These have been established inaccessible localities for local communities to offer

Future changes in practice 81

flexible health care (DOH 2002a). They arenormally staffed by a team of nurses led by anexperienced senior nurse, who is frequently a nursepractitioner or a community specialist practitionerin practice nursing. All these initiatives are teambased and will require a level of skill mix in order todeliver them efficiently and effectively.

In order to deliver these innovations in practicethere will have to be effective leadership fromsenior nurses. Research has shown that some of themost effective leaders are those who are found topossess emotional intelligence. They rise to the topof organisations (Goleman 1998). These skills maybe summed up as people skills used in amanagement context. Corning (2002) has shownhow skills such as employee development,teamwork, negotiation, self management, anddecision making enable effective leadership. Shealso adds other characteristics such as futuristicthinking, empathy and interpersonal skills. Whentaken in context with the way in which caredelivery is changing in community nursing thesecan be seen to be very desirable qualities for seniornurses to possess.

Emotional intelligence is associated withtransformational leadership, which is the way inwhich futuristic thinking can be developed. Theseattributes can be applied to change managementand Hill (2002) considers that there are certainfactors that need to be taken into account, forexample the importance of generating energy.

It is important for senior nurses to have theenergy to take the vision for the future ofcommunity nursing forward. This can sometimesbe difficult if staff feel threatened and demoralisedby constant change and teams are reluctant to co-operate with new ways of working. This is whentransformational leaders are needed to enable teammembers to share in the vision for the future andfacilitate staff in implementing change. Leaders

will be required to develop new ways of thinkingabout issues and problems, and to be very creativeand innovative, whilst also motivating their teams.At the same time change will have to take placewithin the constraints of the organisation, in thiscase the NHS. Hill (2002) indicates that it isimportant to set structures in place to allowchange to take place. Currently, this is provided bythe various health departments in the fourcountries of the UK.

CONCLUSION

Professional approaches to care in communitynursing can be identified by the need to becompetent and confident in settings that do notnormally provide the same level of immediatesupport to the nurse that is available within anacute setting. This means that the nurse is requiredto develop a range of skills that will enable her toprofessionally practise with confidence, establishingan environment of partnership with patients in areal-life situation. Some of these skills will havebeen acquired in the acute setting, whilst others willbe developed when working in community nursing.Assessment undertaken in the community looks atthe wider picture (see Figure 8.1) which entailsgreater complexity in decision making. Currentinnovations in the health and social care agenda willmean that all nurses will be required to adapt andbe flexible and open to change.

FURTHER READING

Bishop, V. and Scott, I. (2001) Developing clinical practice. InChallenges in Clinical Practice: Professional Developmentsin Nursing. (2nd edn). Basingstoke: Palgrave.

Johns, C. (2000) Becoming a Reflective Practitioner. Oxford:Blackwell Science.

REFERENCES

Alder, B. (1999) Psychology of Health: Applications ofPsychology for Health Professionals (2nd edn). Singapore:Harwood Academic Publishers.

Audit Commission (1999) First Assessment: A Review ofDistrict Nursing Services in England and Wales. London:Audit Commission for Local Authorities and the NHS inEngland and Wales.

ExerciseThink about the senior nurses or managers whohave inspired you. What did you like about theirleadership style?

82 Professional issues in community nursing

Basford, L. and Bowskill, D. (2002) Celebrating the present,challenging the future of nurse prescribing. In Topics inNurse Prescribing (British Journal of Community Nursingmonograph). Wiltshire: Mark Allen Publishers.

Benner, P. (1984) From Novice to Expert: Excellence and Powerin Clinical Nursing Practice. Boston, MA: Addison-Wesley.

Benner, P., Tanner, C. and Chesla, C. (1996) Expertise in NursingPractice: Caring, Clinical Judgment and Ethics. New York:Springer.

Billings, J.R. and Cowley, S. (1995) Approaches to communityneeds assessment: a literature review. Journal of AdvancedNursing, 22(4): 721–30.

Bonner, G. (2001) Decision making for health careprofessionals: use of decision trees within the communitymental setting. Journal of Advanced Nursing, 35(3): 349–56.

British Medical Association and Royal Pharmaceutical Societyof Great Britain (2002) Nurse Prescribing Formulary(2002–3). London: BMA and RPSGB.

Buckingham, C. and Adams, A. (2000) Classifying clinicaldecision making: interpreting nursing intuition, heuristicsand medical diagnosis. Journal of Advanced Nursing, 32(4):990–8.

Butterworth, T., Faugier, J. and Burnard, P. (1998) ClinicalSupervision and Mentorship in Nursing (2nd edn).Cheltenham: Stanley Thornes.

Canham, J. and Moore, S. (2002) Learning approaches in thepractice context. In J. Canham and J. Bennett (eds),Mentorship in Community Nursing: Challenges andOpportunities. Oxford: Blackwell Science.

Carr, S. ( 2001) Nursing in the community – impact on thepractice agenda. Journal of Clinical Nursing, 10(3): 330–6.

Children Act (1989) London: HMSO.Concoran, S. (1986) Decision analysis: a step-by-step guide for

making clinical decisions. Nursing and Health Care, 7.Corning, S. (2002) Profiling and developing nurse leaders.

Journal of Nursing Administration, 32(7/8): 373–5.Department of Health (1997) The New NHS: Modern,

Dependable. London: The Stationery Office.Department of Health (1998) Working in Partnership. London:

The Stationery Office.Department of Health (1999a) Review of Prescribing, Supply

and Administration of Medicines (Final Report). London: TheStationery Office.

Department of Health (1999b) Making a Difference. London:The Stationery Office.

Department of Health (1999c) National Service Framework forMental Health. London: The Stationery Office.

Department of Health (2000a) The NHS Plan. London: TheStationery Office.

Department of Health (2000b) National Service Framework forCoronary Heart Disease. London: The Stationery Office.

Department of Health (2000c) The National Cancer Plan.London: The Stationery Office.

Department of Health (2001a) Health and Social Care Act.London: The Stationery Office.

Department of Health (2001b) Primary Care General Practiceand the NHS Plan. London: The Stationery Office.

Department of Health (2001c) Health Visitor Practice ResourcePack. London: The Stationery Office.

Department of Health (2001d) School Nurse Practice ResourcePack. London: The Stationery Office.

Department of Health (2001e) National Service Framework forOlder People. London: The Stationery Office.

Department of Health (2001f) National Service Framework forDiabetes. London: The Stationery Office.

Department of Health (2002a) Liberating the Talents. London:The Stationery Office.

Department of Health (2002b) The Single Assessment Processfor Older People. London: The Stationery Office.

Department of Health (2002c) Improvement, Expansion andReform: The Next Three Years Priorities and PlanningFramework 2003–06. Available on line: www.Department ofHealth.gov.uk/planning2003-2006/index.htm

Department of Health (2003) Supplementary Prescribing byNurses and Pharmacists within the NHS in England: A Guidefor Implementation. London: DOH.

Department of Health and Social Services (1986)Neighbourhood Nursing: A Focus for Care. (CumberlegeReport). London: HMSO.

Goleman, D. (1998) Working with Emotional Intelligence.London: Bloomsbury.

Hannagan, T. (2000) Management: Concepts and Practices.London: Prentice Hall.

Hayes, D. (2000) The case against NHS Direct. Doctor (April):36–9.

Hill, M.H. (2002) Transformational leadership in nursingeducation. Nurse Educator, 27(4): 162–4.

Human Rights Act (1998). London: The Stationery Office.Johns, C. (1995) Framing learning through reflection within

Carper’s fundamental ways of knowing in nursing. Journalof Advanced Nursing, 22(2): 226–34.

McIntosh, J. (1996) The question of knowledge in districtnursing. International Journal of Nursing Studies, 33(3):316–24.

Medicinal Products: Prescription by Nurses Act (1992). London:HMSO.

Mental Health Act (1983). London: HMSO.Nurses, Midwives and Health Visitors Act (1979). London: HMSO.

References 83

Nursing and Midwifery Council (2002) Code of ProfessionalConduct. London: NMC.

O’Cathain, A., Munro, J.F., Nicholl, J.P. and Knowles, E. (2000)How helpful is NHS Direct? A postal survey of callers. BritishMedical Journal, 320: 1035.

Ovretveit, J. (1997) How to describe interprofessional working. InJ. Ovretveit, P. Mathias and T. Thompson (eds), InterprofessionalWorking for Health and Social Care. London: Macmillan.

Parsons, T. (1951) The Social System. London: Free Press.Richards, D.A. and Tawfik, J. (2000) Introducing telephone triage

into primary care nursing. Nursing Standard, 15(10): 42–5.Robinson, J. and Elkan, R. (1996) Health Needs Assessment:

Theory and Practice. Edinburgh: Churchill Livingstone.Sadler, M. (2002) NHS Direct audited. Letter. British Medical

Journal, 325: 164, 124.Schon, D. (1991) The Reflective Practitioner: How Professionals

Think in Action. Aldershot: Avebury.

Scottish Executive Health Department (2000) Our NationalHealth: A Plan for Change. Edinbugh: The Stationery Office.

Scottish Executive Health Department (2001) Nursing forHealth: A Review of the Contribution of Nurses, Midwivesand Health Visitors to Improving the Public’s Health inScotland. Edinburgh: The Stationery Office.

Southard, D., Certo, C. and Comass, P. (1994) Corecompetencies for cardiac rehabilitation professionals.Journal of Cardiopulmonary Rehabilitation,14: 87–92.

UK Central Council for Nursing, Midwifery and Health Visiting(1994) The Future of Professional Practice: Standards forCommunity Specialist Practice. London: UKCC.

Vanclay, L. (1998) Teamworking in primary care. NursingStandard, 12(20): 37–8.

Worth, A. (1996) Identifying need for district nursing: towardsa more proactive approach by practitioners. NT Research,1(4): 260–9.

84 Professional issues in community nursing

INTRODUCTION

Public health may by a relatively new topic formany nurses working in the community for thefirst time. This chapter seeks to develop thereader’s understanding of the concept of publichealth and explores the actual and potential rolefor nurses in contributing to the public healthagenda. It begins by defining public health and theevolution of public health care provision over thepast hundred years. The reason for the currentrenewed emphasis on public health work is thenconsidered by examination of some of the keypolicy developments, both international andnational, over the past few decades. It isacknowledged that the NHS must have a role incaring for health as well as responding to illhealth. The multi-disciplinary/multi-agencycontribution to be made to the improvement ofthe health of the population is then explored withparticular emphasis on the necessary and valuablerole for nurses, especially community nurses. Thisis followed by some more detailed considerationof specific ways in which nurses can and should beusing their skills and knowledge to contribute to

the public health agenda with some ideas abouthow these activities can be incorporated into day-to-day practice.

WHAT IS PUBLIC HEALTH?

9Nursing for public healthSue Rouse, Sandra Baulcomb and Sandra Burley

Learning outcomes

• Evaluate the historical development of public health and the legacy for modern public healthpractice.

• Explain the origins of modern public health priorities and the determinants of health.• Discuss the relevance of determinants of health to nursing practice.• Identify the skills required for the improvement of public health and the contribution to be made

by community nurses.

ExerciseFor this exercise you will need access to severaldifferent newspapers all published on the same day. For example, a broadsheet (Times, Telegraph,Guardian); a ‘blue top’ tabloid (Daily Mail, DailyExpress); a ‘red top’ tabloid (Mirror, Sun, Daily Star) and a local evening newspaper. These may be accessed on the Internet or available in libraries.

Look for reports in the newspapers of the samepublic health-related story – for example, the latestdata on the prevalence of AIDS, or how asylumseekers are being processed and integrated intocommunities.

The term ‘public health’ has come to be used in twoseparate but closely related ways. The first, refers tothe general state of health or wellbeing of thepopulation at large or the ‘public’. The second isused to describe those measures designed to carefor, maintain and promote such ‘health’ (Baggott2000).

The meaning of the term has, however, changedwith time. As pointed out by Ashton and Seymour(1988), both the general state of health of thepublic and those measures designed to care for ithave evolved in line with the current state oftechnological advancement and knowledge. Someunderstanding of the historical context of ‘publichealth’ may help to illustrate the modern usage ofthe term.

During the 17th century, following thepopulation changes after the Industrial Revolution,overcrowded and inadequate urban livingconditions led to the flourishing of infectiousdiseases. Early attempts to combat this, throughimprovements in housing, sanitation and educationabout the importance of hygiene and clean food andwater, constituted the earliest organised publichealth movement and included the appointment ofthe first medical officers of health in Britain.Following the discovery of germ theory and theearly availability of immunisation techniques duringthe late 19th century, measures designed to improvethe health of the population shifted towards themore personal preventive services. These servicesincluded contraception, immunisation and clinicservices, and the health of the population becameless dominated by the ravages of infectious andcontagious disease.

From 1930 onwards, the discovery of insulin andsulphonamides rendered a range of diseases moresusceptible to medical treatment and thedominance of a curative approach to health carebecame the reality. During this phase, the conceptof a population approach to public health measureslargely receded in favour of services focused on thehealth needs of the individual.

Eventually, during the 1970s, it became apparentthat the purely therapeutic approach offered bypublicly funded medical interventions was bothinsufficient and unsustainable in terms of cost andeffectiveness. There was a growing recognition thata large proportion of modern disease was the resultof lifestyle changes and factors that could beconsidered preventable prompted by a Canadianreport on the health of the population of Canada(LaLonde 1974).

The current phase of public health activity hasbeen coined ‘The New Public Health’ and isdescribed as a phase which returns to theconsideration of environmental issues andpopulation health alongside those personalpreventive and therapeutic services which are nowwell established (Ashton and Seymour 1988).There is acknowledgement of the importance of thesocial environment, policy and inequality asdeterminants of the public’s health experiences.

DEVELOPMENT OF THE PUBLIC HEALTHMOVEMENT

Table 9.1 shows the development of the publichealth movement. Over the last 150 years fourdistinct phases have emerged, reflecting changes insociety and developing knowledge and innovationin health care.Tuberculosis (TB) has been chosen toillustrate the change in emphasis over these phases.

Within the modern NHS, there is a recognition ofthe important role of primary care and communityservices in the prevention and promotion of healthas well as the treatment of disease (DOH 1997).There is also some recognition of the limitations ofmedicine alone in the provision of health care.Medicine has traditionally focused on diseases andtheir treatment using a physiological knowledgebase to underpin its practice. Nursing, on the otherhand, has tended to take a more holistic approach

86 Nursing for public health

Read these reports, compare and contrast the waythe reports are written. What type of language isused? Is blame apportioned to individuals orcollectively to institutions such as education, thehealth service or the welfare state? Can you discerna different approach or attitude towards theproblem? If so why do you think this is the case?Can this be explained in relation to the way issueson public heath are transmitted to the populationat large. What role can nurses play in ensuring thepopulation at large are well informed about publichealth issues?

to the care of individuals, incorporating broaderdefinitions of health into its approaches toassessment and care planning.

The publication of the Acheson Report on healthinequalities (1998) has prompted a newinvestigation into the determinants of ill healthamong the population at large. There is a renewedacknowledgement of the impact of factors such asemployment, education, and the availability andaccessibility of public services on the healthexperiences of both individuals and wholepopulations.The understanding of health in its widerform, beyond the presence or absence of disease andincluding social, emotional and spiritual factors isnow more apparent.The impact of crime, substancemisuse, homelessness, ethnicity and changing familypatterns either directly or indirectly on the health

experiences of the population, is acknowledged.Nurses, especially community-based nurses, are seenas having an important contribution to make to thecare and improvement of the public’s health. Thiscan be achieved through both the direct provision ofcare and through collaboration with others and theinfluencing of policies that affect health both locallyand nationally.

WHY PUBLIC HEALTH?

As indicated above, the limitations of a purelytherapeutic approach to addressing modern healthproblems has long been acknowledged.International, national and local policies haverecognised the need to combine programmes of

Why public health? 87

Table 9.1

Era Period Characterised by: Health gains achieved by:

Public health movement. To: Migration from Improvements in housing, sanitation and the Environmental change. 1870s countryside into towns. provision of safe clean water and food supplies

Poverty, overcrowding, help guard against the spread of TB.poor sanitation.Infectious diseases such as TB predominate.

Germ theory of disease. To: Emphasis now on Increased involvement of the state through Individualistic approach. 1930s personal preventive provision of hospital and clinic services leads to

medical services. improved individual health status and protection Immunisation, family against TB.planning.

Therapeutic era. To: Rising use of drugs and Move away from public health to hospital 1970s therapeutic interventions. services and teaching hospitals.

Sulphonamides used to treat TB.

New public health era. To: Escalating cost of health Re-emphasis on environmental and personal present care. preventive services alongside therapeutic day Technological innovation. intervention. Prevention of TB through

Increasing demand for immunisation and healthy public policy becomes health care. the new focus.Demographic changes, increase in elderly population.

ill-health prevention, health protection and healthpromotion alongside curative measures withinhealth care provision (WHO 1981, 1998; DOH1999a).

The World Health Organisation has beeninfluential in the development of world policy. Therole of primary health care services and the need forclose co-operation between health care providersand other sectors, both statutory and voluntary, inthe pursuit of improved public health is central tothe objectives of their Global Strategy for Health forAll by the Year 2000 (WHO 1981).The targets wererevised in 1998 in order to become applicable toEurope in the 21st century (WHO Regional Officefor Europe 1998).

The publication of The New NHS: Modern,Dependable (DOH 1997) heralded the latestapproach to improve health service provision inBritain. Building upon the recommendations of theAcheson Report (1998), along with subsequentguidance (DOH 2000), it emphasises the need forlocally focused public health provision, properconsultation with service users, and modernisationof existing services to meet new demands.

Within nursing itself, a further overhaul of theprofession and its approach to education outlinedwithin Making a Difference (DOH 1999b)acknowledges the need for nurses to be highlyeducated, flexible and multi-skilled in order tomeet the demands of modern health care. Morerecently, the government publication of Liberatingthe Talents (DOH 2002) has emphasised the needfor creative approaches to co-operative andcollaborative service provision, acknowledging thecentral role that specialist and generalistcommunity nurses will have in the improvementof population health.

It would seem that escalating costs and ever-improving and technological advances withinsecondary care,may lead to limitations in the need forever larger numbers of people accessing curativeinterventions. This represents a shift in favour of abroader and less costly population approach to thepromotion and maintenance of better health. Thisbecomes especially pertinent in the face ofdemographic shifts in population profiles, with feweryounger and middle-aged people available to care forthe growing number of their frail older and disabledcompatriots (www.statistics.gov.uk). It seems

imperative that those factors identified asdeterminants of poor health experiences andoutcomes should be addressed as soon and aseffectively as possible.This clearly means a widespreadand collaborative approach between many nationaland local policy makers and service providers.

It has been argued that the very technologicaladvances and publicly funded services thatcharacterise the modern NHS in Britain can be heldresponsible for the decline in the health of thepublic that we appear to be now experiencing(Illich 1977). The welfare state has been blamed forencouraging people to shrug off personalresponsibility for health status in the expectationthat the NHS, paid for through taxes, will meettheir health care needs as and when required.

The requirement for health needs assessment tobe carried out at a local level has been central toNHS policy since the introduction of the internalmarket within the NHS in 1991 (DOH 1990). Thishas meant that local NHS organisations have had todevelop the resources and expertise to enable themto obtain and analyse local health data. It isnecessary to consult with the public and carry outlocal research to determine those factors which, ifaddressed effectively, are likely to lead to the mostsignificant health gains. Since the eradication of theinternal market, this requirement has becomeincorporated into the remit of local primary caretrusts. The desire is to foster the production of localhealth improvement plans and focus healthspending on services most relevant to localpopulation health needs, including appropriatepublic health measures (DOH 1999a). Within suchpolicy is an opportunity for community nurses tocontribute to the gathering and interpretation oflocal data that will influence local policy (DOH1995). Community nurses are in close and regularcontact with users of primary care services and theirfamilies.This provides access to a rich source of dataand information on population health experiences,attitudes and priorities that should be influential indetermining local policy.

WHO HAS A ROLE IN PUBLIC HEALTH?

Perhaps the most readily identified role in publichealth is that of the Director of Public Health andthe team of public health doctors,nurses, statisticians

88 Nursing for public health

and researchers who work within the public healthdepartments of local primary care trusts. Thesepeople, along with the Health Protection Agencyhave a clear remit within public health identified bythe titles of their departments/services. Thecontribution of the work of local authorityenvironmental health departments on public healthpriorities such as food hygiene, pest control andpollution is also readily identifiable.

There is recognition that the health of the publicis affected by every aspect of their lives andenvironments. Factors which adversely affect thehealth of populations include those such as crime,substance misuse, transport and education. There is,then, a role for a wide range of services and agenciesin tackling the public health agenda. The list ofagencies with a significant contribution to make islikely to include every local authority department,including the police, education, transport, housingand social services as well as the more immediatelyidentifiable role of the environmental healthdepartment, as mentioned above. In addition, manyof the voluntary organisations which exist in anycommunity are likely to have a significant part toplay in promoting the health of the local population.Examples would include Homestart, Age Concern,National Society for the Prevention of Cruelty toChildren, to name only a selection. The promotion,protection, maintenance and restoration of thehealth of the local population is clearly a task whichmust involve a broad range of agencies with a varietyof roles and a range of expertise.

At the level of local health services, co-ordinatingthe promotion, maintenance and improvement ofthe health of the population is the remit of theprimary care trusts.This role clearly requires a set ofskills which are different from but complementaryto those required in the secondary care, curativeservices, sometimes most readily associated withmedical and health service provision and providedby hospital-centred NHS trusts. Some knowledge ofphysical and mental health and the contributoryfactors for ill health and disease can be a clearadvantage in some aspects of public health work,but the knowledge and expertise required goesbeyond these specialist areas.

Essentially, public health work must involve aprocess of population health needs assessment,including analysis and processing of data in order togain an understanding of the factors whichcontribute to both good and poor health. Publichealth work includes providing services orinfluencing service provision in such a way as to seekto eliminate adverse factors and to promote positiveones.As in all aspects of care and under the guidanceof clinical governance (NHSME 1999; Swage 2000)these processes must be followed by the carefulevaluation of outcomes in order to inform a cycle ofimprovement. This sequence of activities has muchin common with the systematic approach to nursingcare or ‘the nursing process’ taught to and used bynurses of every discipline. The major difference inusing the model for public health purposes is thatthe skills and knowledge involved in the assessment,planning, implementation and evaluation of caremust be applied to a population rather than anindividual. The direct provision of nursing care maybe replaced by the influencing or organisation ofcare/services at a more strategic level, often incollaboration with others. It is clear, however, thatthere is a correlation between the motivation(better health), skills (assessment, planning,implementation and evaluation) and knowledgebase (factors which affect health) of nurses and

ExerciseConsider the residents of your own street, town orvillage and/or your own group of friends orrelatives. In terms of their casual conversationsacross shop counters or at the bus stop what arethe factors that concern people most? List thesorts of topics you hear people talking about andconsider which of them may impact upon theirhealth and how.

Now, look at your list and decide which of thesetopics can be addressed by a health professional,or health services alone and which may need theexpertise of another service provider.

Who has a role in public health? 89

What proportion of the factors you listed can beaddressed using the expertise of healthprofessionals? What does this tell you about therange of agencies which have a role in thetackling of public health issues?

those required for public health work. Nurses’therefore are perceived as having a significant role toplay.

Government policy has clearly indicated the needfor nurses to become more involved in improving thehealth of the population and public health work.Relatively early policy documents made specificreference to the contribution that nurses could andshould make in the field of public health. In the lastdecade national strategies for improving the nation’shealth set out a clear role for nurses, among others,in health promotion and prevention of ill health,through provision of education and support andinfluencing policy (NHSME 1993; DOH 1992,1995, 1998, 2000, 2002).

It is clear that the health of the population andparticularly the huge inequalities experienced bypeople from different backgrounds and evendifferent geographical areas is determined by factorsother than the provision and/or quality of medicalor health services available (Acheson 1998). It is nowevident that people from the lower socio-economicgroups are more likely to suffer prematurely fromheart disease than those from the higher socio-economic groups, for instance. It is equally apparentthat the rates of morbidity and mortality are higherin the less affluent geographical areas of the countrythan the more affluent. Socio-economic variants,such as employment and housing, then, have animpact on life expectancy and general health status.

There have been concerted health educationcampaigns encouraging people to modify theirlifestyles in order to guard against the earlydevelopment of diseases such as coronary heartdisease and stroke. Nurses, alongside healtheducation/health promotion experts, are seen asbeing among those in the front line in terms of suchhealth education. Subsequently, it has become clearthat the very factors that characterise inequalities inhealth status also mitigate against the ability of peopleto make the desired lifestyle decisions. The focus ofpublic health campaigns has thus moved towards‘making the healthier choices the easier choices’(DOH 1998). This requires changes in policy in thefields of environment, the economy, education andtransport, among others in order for such a goal to beachieved. Nurse training stresses the importance ofeffective communication skills (NMC 2002a), withthe users of their services, each other and, the multi-disciplinary and multi-agency team members whocontribute to any health care plan. Nurses, therefore,already have in place networks of communicationthat can be strengthened and utilised at all levels inorder to enhance a multi-agency approach to theimprovement of health experiences both forindividuals and for communities.

Planning for public health needs access toknowledge about the health status of the localpopulation, factors that contribute to this, andevaluation of those services which are already inexistence to help improve people’s health. Nursesworking in the community in primary care settingshave access to people within their own livingenvironment. Such contact allows nurses access to

ExerciseThink about your role in assessment, planning,implementation and evaluation of care for anindividual patient or client you have cared for inthe past. What are the skills you needed to use ateach of these stages of the nursing process? Nowthink about how you would go about assessingthe collective health needs of the people living ona small local housing estate? What skills wouldyou need to use?

Did either of your lists include the following skills?

Assessment Planning

Communication CommunicationRecord-keeping TeachingListening NegotiationData analysis Application ofresearch Empathy knowledge topractice

Implementation Evaluation

Delegation Data analysisRecord-keeping SynthesisCommunicationClinical skillsLiaisonReferral

90 Nursing for public health

the ‘soft’ data which is required for a comprehensiveassessment of local health needs. This informationcannot be gathered from epidemiological studiesalone but must be enhanced by access to informationobtained directly from those people at risk of poorhealth experiences. There is, therefore, a significantinfluence which community nurses can exert uponlocal policy making by collating and providing suchessential data to inform local health improvementplans.

The combination of medical and nursing expertiseand data collection can thus provide a complementaryand effective way of working towards a local publichealth strategy. Efffective working relationships withthe local authority and voluntary organisations canensure the success of schemes such as ‘HealthySchools’ projects (www.wiredforhealth.gov.uk), SureStart (www.surestart.gov.uk), Healthy Cities (Daviesand Kelly 1992), and others.

The real expertise in terms of understanding andcontributing to their own health outcomes comesfrom the public itself. Recent developments in bothpolicy and practice acknowledge the value ofcommunity development initiatives as a way forwardin fostering the health of communities. Professionalstake on the role of facilitators in terms of engagingrepresentatives of local communities in bothdetermining their own health priorities and the localresponse. The result can take the form of directservice development or lobbying of policy makers tofund and provide services as determined by the localpopulation.There are some good examples of successin terms of community development which take truecognisance of the expertise of local people inunderstanding and taking responsibility forresponding to their own health needs; see Valois(2003) and Carter and El-Hassan (2003).

HOW CAN NURSES CONTRIBUTE TOPUBLIC HEALTH OUTCOMES?

Working in partnership with patients and clients andencouraging them to take responsibility for decision-making about their own health can lead to moreeffective ‘bottom-up’ solutions to experienced/anticipated health problems. Through negotiatingwith clients nurses can achieve better outcomes thancan be gained through a more prescriptive approach

to the provision of health care. For example theMedicines Partnership have done considerable workto encourage concordance in connection with theprescription of medicines as an aid to improvingoutcomes (Carter and Taylor 2003). This can befurther extended beyond work with individuals toworking with groups and communities in acommunity development way so that members of thecommunity themselves become engaged in and/orresponsible for identifying their own health needs anddesigning/commissioning their own interventions tomeet those needs. This ‘bottom–up’ way of workingreduces the wastage of resources on the developmentof expensive but unsuitable resources which aresubsequently unused or poorly used by the peoplefor whom they are intended. This has been a featureof health care provision for many years and wasremarked upon by Tudor Hart (1972), who observedthat services were often accessed most by those whowere likely to benefit least and remained inaccessibleto those who might most benefit and for whom theymay have been designed. Such a phenomenon hascontributed to the perpetuation of inequalities ofhealth as highlighted by Acheson (1998).

ExampleWhen the issue of high rates of teenagepregnancy first came to the fore, there was aflurry of developments around specialistcontraception services in order to inform, educateand supply young people with access to bettermethods of contraception and thus seek to avoidunwanted pregnancies. However, comprehensiveholistic assessment and further research led to therealisation that some young people actuallyplanned their early pregnancies and sawparenthood as a way of gaining recognition bywider society in terms of access to suitablehousing and benefits and the ability to perform auseful social role with important and fulfillingrelationships. This, in turn has led to someinnovative schemes which seek to explore issuesabout relationships, parenthood and self-esteemamong young people and thus address some ofthe broader social factors associated withteenage parenthood.

How can nurses contribute to outcomes? 91

Nurses can also be instrumental in ensuring theoptimum use of local resources. By being aware ofand working alongside other agencies, bothstatutory and voluntary, community nurses canrefer patients/clients to receive the range of serviceswhich will best meet their identified health needsand can also influence the way in which localservices develop. For example, community nursescan work alongside agencies such as Age Concern todevelop Carer Support services and ensure thatpeople are appropriately referred and well-supported in their important caring roles.

Another way in which nurses’ regular and uniquecontact with people at home can contribute topolicy making is in helping to ensure appropriateconsumer involvement in decision making. Therehas been a growing trend in public policy (DOH1997, 2000) to involve users of services directly inthe decision making relating to local serviceprovision. Nurses can play a significant role inencouraging service users to become involved inconsultation exercises or by advocating for thoseunwilling to become directly involved.

The significant contribution to be made in thefield of public health by nurses has recently beenrecognised in the development of nurse consultantposts in public health. Increasing numbers of PCTpublic health departments now have one or morespecialist public health nurses within the team.These specialist senior and experienced nurses workalongside their medical and other colleagues toensure that nursing data and expertise is bothdeveloped and utilised in this field. The furtherdevelopment of the curriculum for public healthnurses (NMC 2002b) to re-establish the principlesof health visiting or public health nursing as thebasis for teaching and training is likely to reinforcethe role to be played by nurses in supporting publichealth developments for many years to come.

WHERE AND WHEN CAN NURSING FORPUBLIC HEALTH OCCUR?

All nursing interventions are aimed at contributingto health improvements, either for individuals orgroups. Activities that range from the treatment ofleg ulcers to the education and reassurance of youngteenage parents, all have the aim of improving

health in its widest sense. In this way, communitynurses have a daily contribution to make inimproving the public’s health.

They may use their contact with individuals andfamilies in their own homes to educate peopleabout those factors which may be affecting theirhealth and ways of dealing with them. This may becarried out directly through behaviour change orindirectly through referral to available services.Additionally this information can be used to informlocal health planning.

Analysis and interpretation of local health datamay indicate the need for community nursingservices themselves to be organised and delivereddifferently in order to make a greater impact uponthe health of the population (DOH 2002). Forexample, district nurses may be able to carry out anassessment of a client’s home environment andmedication status in order to put in place measuresdesigned to reduce the incidence of falls amongstolder people.This could take place at the same timeas responding to an established health need such aswound care or administration of medicines. Accessto appropriate health care services may beimproved by taking services to people who arelikely to benefit most from them rather thanexpecting them to visit a surgery or clinic. Forexample, services for older people may be providedin a local day centre or residential establishmentand services for children and families could beprovided from a nursery or play group premises. Inthis way, services may be rendered less threateningand more relevant to the everyday lives of theindividuals for whose benefit they are intended.

Providing valuable data to contribute to the localhealth needs assessment process and thus toinfluence service development and policy makingcan become a routine part of daily practice. Thisfunction could be greatly enhanced through the useof information technology systems designed for thepurpose of collecting and collating valuable healthdata.

ExerciseRevisit the questions raised in the first exercise. Onreflection in the light of your reading have yourviews changed?

92 Nursing for public health

Public health can be addressed through the dailynursing practice of all community nurses, once theyare aware of the contribution they can make and areable to adjust their practice to accommodate thisimportant social function.

FURTHER READING

Department of Health (2001) On the State of the PublicHealth. The Annual Report of the Chief Medical Office of theDepartment of Health. London: DOH.

Plews, C., Billingham, K. and Rowe, A. (2000) Public healthnursing; barriers and opportunities. Health and Social Carein the Community, 8(2): 138–46.

Websites

The following websites are useful sources of up-to-dateinformation on public health and associated nursing issues.

Department of Healthwww.doh.gov.uk/public.htmHealth Development Agencywww.hda-online.org.ukHealth Protection Agencywww.hpa.org.ukNational Healthy School Standard www.wiredforhealth.gov.ukNursing and Midwifery Councilwww.nmc-uk.orgPublic Health Laboratory Servicewww.phls.org.ukSurestartwww.surestart.gov.ukWorld Health Organisationwww.whodk/informationsources

REFERENCES

Acheson, D. (1998) Report of the Independent Inquiry intoInequalities in Health (Acheson Report). London: StationeryOffice.

Ashton, J. and Seymour, H. (1988) The New Public Health.Milton Keynes: Open University.

Baggott, R. (2000) Public Health: Policy and Politics.Basingstoke: Macmillan.

Carter, M. and El-Hassan, A.A. (2003) Between NASS and aHard Place: Refugee Housing and Community Development

on Yorkshire and Humberside. A Feasibility Study. London:Housing Associations’ Charitable Trust.

Carter, S. and Taylor, D. (2003) A Question of Choice: Compliancein Medicine Taking. London: Medicines Partnership.

Davies, J. and Kelly, M. (eds) (1992) Healthy Cities: Policy andPractice. London: Routledge.

Department of Health (1990) NHS and Community Care Act.London: HMSO.

Department of Health (1992) Health of the Nation: A Strategyfor Health in England (Cmnd 1986). London: HMSO.

Department of Health, Standing Nursing and MidwiferyAdvisory Committee (1995) Making it Happen: PublicHealth: The Contribution , Role and Development of Nurses,Midwives and Health Visitors. London: HMSO.

Department of Health (1997) The New NHS: Modern,Dependable (Cmnd 3807). London: The Stationery Office.

Department of Health (1998) Our Healthier Nation. London:HMSO.

Department of Health (1999a) Saving Lives: Our HealthierNation. London: The Stationery Office.

Department of Health (1999b) Making a Difference:Strengthening the Nursing, Midwifery and Health VisitingContribution to Health and Healthcare. London: TheStationery Office.

Department of Health (2000) The NHS Plan. London: TheStationery Office.

Department of Health (2002) Liberating the Talents. London:The Stationery Office.

Department of Health and Social Security (1976) Preventionand Health: Everybody’s Business. London: HMSO.

Illich, I. (1977) Limits to Medicine. Medical Nemesis: TheExpropriation of Health. London: Pelican.

LaLonde, M. (1974) A New Perspective on the Health ofCanadians. Ottawa: Government of Canada.

NHS Management Executive (1993) New World, NewOpportunities: Nursing in Primary Health Care. London: HMSO.

NHS Management Executive (1993) A Vision for the Future.London: HMSO.

NHS Management Executive (1999) A First Class Service:Quality in the New NHS. London: HMSO.

Nursing and Midwifery Council (2002a) Requirements for Pre-registration Health Visitor Programmes. London: NMC.

Nursing and Midwifery Council (2002b) Requirements for Pre-registration Nurse Programmes. London: NMC.

Swage, T. (2000) Clinical Governance in Health Care Practice.Oxford, Butterworth–Heinemann.

Tudor Hart, J. (1972) The inverse care law. Lancet: 405–12.Valois, N. (2003) Extend yourself. Community Care, 15 May:

32–5.

References 93

World Health Organisation (1981) Global Strategy for Healthfor All by the Year 2000. Geneva: WHO.

World Health Organisation Regional Office for Europe (1998)Health 21: The Health for All Policy Framework for theTwenty-first Century. Copenhagen: WHO.

www.statistics.gov.ukwww.surestart.gov.uk www.wiredforhealth.gov.uk

94 Nursing for public health

INTRODUCTION

It is acknowledged that you will have consideredaspects of health promotion theory and practicewithin your pre-registration training, however thischapter will explore a number of different aspectsof the current debate related to health promotion,following on from a brief review of the concept ofhealth.

Health promotion is part of a wider public healthagenda, which is discussed in detail in Chapter 9.Here we will be focusing on the approaches andcompetencies you will need to support the deliveryof effective health promotion interventions as onestrand of public health development. It is hopedthis will enable you to gain a better understandingof what health promotion is about, how it is ‘done’and what competencies you need to be able tointegrate health promotion into your on-goingpractice within the community.

It is beyond the scope of this chapter to coverthe theory of health promotion in detail. Thereforewe have included a range of further reading, whichyou may wish to pursue to expand yourunderstanding in this area and furthercontextualise your practice.

WHAT IS HEALTH?

Any attempt to define health promotionfundamentally needs to give some consideration tothe question, ‘What is health?’ The concept of‘health’ has long been a contested one, ranging fromMansfield’s view of health as personal fulfilment –‘by health I mean the power to live a full, adult,living, breathing life in close contact with what Ilove … I want to be all that I am capable ofbecoming’ (Mansfield 1977: p. 278) – through to amore specific medical model view which seeshealth predominantly as the absence of disease.

This, in the past, has been a dominant paradigmadopted by many health care professionals, althoughthere has been a shift towards the adoption of a moreholistic definition of health such as that of the WorldHealth Organisation:

[Health is] the extent to which an individual orgroup is able, on the one hand, to realiseaspirations and satisfy needs; and, on the otherhand, to change or cope with the environment.Health is, therefore, seen as a resource foreveryday life, not an object of living; it is a

10Developing health promotion practiceKaren Melling, Judy Gleeson and Karen Hunter

Learning outcomes

• Discuss definitions and underlying principles of health promotion.• Explore a range of core competencies of health promotion.• Review own levels of competence in health promotion and identify potential strategies for their

development.• Identify opportunities for applying the competencies into your current practice.

positive concept emphasising social and personalresources as well as physical capacities.

(WHO 1984)

The scope of this chapter does not allow for an in-depth consideration of this issue. For a wider debateon the contested concept of health further readingis suggested at the end of this chapter, includingSeedhouse (1997) and Naidoo and Wills (2000).

There are no right or wrong answers to thisquestion; your thoughts may have covered aspectsof physical,mental, spiritual, social and sexual healthand will have been influenced by your personal lifeexperiences. It is important to recognise theseinfluences and also how other people, bothprofessionals and lay people, may well experiencedifferent sets of influences which will colour theirperceptions of this concept of ‘being healthy’.

WHAT IS HEALTH PROMOTION?

There are numerous definitions of healthpromotion in the literature, reflecting both thebreadth of health promotion practice and also theissues around the contested concept of ‘health’. Itmay well depend on your preferred definition ofhealth as to which of the definitions of healthpromotion you are most comfortable with.

Here are two examples of definitions of healthpromotion for you to consider:

Health promotion is the process of enablingpeople to increase control over, and to improve,their health.

(WHO 1984)

Health promotion comprises the efforts to enhancepositive health and prevent ill-health, through theoverlapping spheres of health education,prevention and health protection. Empowerment isa cardinal principle of health promotion.

(Downie et al. 1996)

Both definitions indicate that health promotion issomething which is ’done’ to achieve a particulargoal or outcome, here defined in terms such as‘improving health, ‘enhancing positive health’ and‘preventing ill health’.

In considering the goals of health promotion youmay have come up with a number of differentreasons in your list, such as:

• to secure better health for people as individualsor as a community or wider population

• to reduce inequalities in health between groupsin the population

• to reduce the incidence of preventable diseasesuch as coronary heart disease or cancer

• to increase life expectancy within the population;• to enhance someone’s quality of life• to meet National Service Framework targets.

All of these broad goals would be seen as validreasons for undertaking some health promotionactivity and, indeed, all of them are embedded inthe current political agenda for health, as identifiedin documents such as Saving Lives: Our HealthierNation (DOH 1999), The NHS Plan (DOH 2000)and the various National Service Frameworks (DOH1999, 2000, 2001). (These policies are discussedfurther in Chapter 9.)

This chapter is written from the perspective thathealth promotion is an umbrella term which embracesactivities in one, some or all of the following areas:health education programmes, preventive healthservices, community-based work, organisationaldevelopment, economic and regulatory activities,environmental health measures and healthy publicpolicies (as identified by Ewles and Simnett 2003).

Within this diverse collection of activities thebreadth, level and depth of any activity is very wide-ranging – from an individual community staff nurseengaged in a one-to-one discussion with a patient,

ExerciseWhy do health professionals and others undertakehealth promotion activities? Take a moment toconsider, from your perspective, what the goals ofhealth promotion are.Exercise

What does ‘being healthy’ mean to you?

96 Developing health promotion practice

giving advice on healthy eating,to a nurse influencinghealth promotion issues at policy level: for example,a nurse member of the professional executivecommittee of a primary care trust developing healthyeating strategies for children and young people aspart of the local development plan.

In considering the opportunities forincorporating health promotion into your practiceit is important to bear in mind the principles onwhich health promotion should be grounded.Thesewere outlined by the WHO in 1984 as follows:

• Health promotion involves the population as awhole in the context of their everyday life, ratherthan focusing on people at risk of contractingspecific diseases.

• Health promotion is directed towards action onthe causes or determinants of health.

• Health promotion combines diverse, butcomplementary, methods or approaches.

• Health promotion aims particularly at effectiveand concrete public participation.

• While health promotion is basically an activity inthe health and social fields, and not a medicalservice, health professionals – particularly inprimary care – have an important role in nurturingand enabling health promotion.

The practice of health promotion will requireyou to look critically at your own values andattitudes in relation to health behaviours, both ofyour own and your clients. As in nursing practicethere is a need to be non-judgemental in yourapproach, working with individuals andcommunities to achieve ‘health’ as they determineit, not as you would impose upon them.As has beenidentified in the Tannahill’s definition of healthpromotion, quoted above, a fundamental element isthat of empowering individuals and communities toidentify their own health needs and set their ownagenda for health gain. This process will require anability to work with clients rather than directingthem in a particular direction.

It is important to take into account influencessuch as culture, religion, gender, sexual orientation,disability, socio-economic grouping and how theyimpact on the individual’s value system that may, inturn, impinge on their choices in relation to healthbehaviour.

In summary, you need to adopt an appropriateapproach and/or select a suitable activity, that isinclusive of the individual or client group, takingaccount of the influences impinging on health forthat individual or community.

As is indicated in the WHO principles of healthpromotion, it is important to recognise andacknowledge that no health promotion activity isthe exclusive responsibility of any one professionalgroup or discipline; working with others inpartnership and collaboration is an importantapproach to adopt. However, nurses working in thecommunity often have a role in facilitating and/orparticipating in many health-promoting activitieswhich, if applied appropriately, will work towardsachieving positive health outcomes for individualpatients or clients and within local communities.

WHAT COMPETENCIES DO YOU NEEDFOR EFFECTIVE HEALTH PROMOTION?

The breadth of health promotion requires diversecompetencies,related to the areas of activity in whichyou are engaged.Competencies include componentsof knowledge, skills and attitude. This chapter willnow go on to explore ways in which your existingcompetencies can be applied and developed furtherin relation to health promotion practice.

Many nurses working in the community have longrecognised the importance of health promotionwithin their role. However, when questioned theymay say that they do not ‘do health promotion’.Indeed, much health promotion takes place whilstother procedures or interventions are being carriedout: it is integral to the role and not seen as somethingdifferent or extra. However, it is perhaps worthreflecting on what within your work could beclassified as ‘health promotion’. Sometimes thechallenge is undertaking health promotion activitiesalongside other competing demands.

ExerciseConsider for a moment a client you have cared forrecently and bring to mind any health-promotingor health-enhancing activities you may haveundertaken. Reflect on which competencies youhave used.

What competencies do you need? 97

Within the field of health promotion Ewles andSimnett (2003) have identified a number of corecompetencies that can be built on and developed asyou have the opportunity and gain experience inintegrating health promotion into your practice.Although these have been identified as separatecompetencies they are closely interrelated andoften elements from each area of competence willbe drawn upon within a specific health promotionactivity or initiative.

• managing, planning and evaluating• educating• communicating• facilitating and networking• marketing and publicity• influencing policy and practice.

It is important to recognise that thesecompetencies are not exclusive to healthpromotion; indeed, it is acknowledged that you willhave developed many of them already throughinitial nurse education programmes, through lifeexperiences and, subsequently, in practice.However, you may wish to consider how thesecompetencies relate to health promotion practicewithin the community setting. In order to deliverthe health promotion agenda, you are likely to drawon, and develop further, skills and competence insome or all of these areas.

The following section will expand on each of theareas of competence, outlining some of the essentialelements and providing examples of how thecompetencies might be utilised in practice.

Managing, planning and evaluation

In any health promotion activity, it is important tobe clear about what you are trying to achieve andhow you are going to go about it. This requires youto plan and manage your activity systematically,setting realistic and clear aims and objectives,selecting appropriate methods of delivery and also,at an early stage, identifying your evaluation tools.Consideration also needs to be given to theresources you have available, including time, money,personnel and access to equipment and facilities. Inundertaking this you should be able to develop a

project plan that will incorporate a realistictimeframe for delivery.

Such planning may be done by an individual, asmall working group or team of staff, perhapsinvolving people from other disciplines or otheragencies who also have a role in promoting thehealth of the local population. This ‘workingtogether’ or working in partnership encourages asharing of ideas and resources and may expand thepotential opportunities within the activity beingplanned. It is important to identify who will ‘lead’the project or activity. Steering a boat without arudder is a recipe for disaster! Also remember tokeep notes of all decisions and actions to be taken,including who is responsible for each part of theproject so that everyone is clear about what isexpected of them. For more detail on the planningprocess in health promotion see Ewles and Simnett(2003) and Naidoo and Wills (2000).

Evaluation is an important part of any healthpromotion activity: it allows you to measure yoursuccess, learn from your experiences and plan forthe future. This need not be a complex or oneroustask but it is an important one. If possible shareyour potential evaluation methods with someone,such as a senior colleague, health promotionspecialist, line manager. There are numerous toolsand guides to evaluation which may be helpful toyou, for example see Peberdy (cited in Katz et al.2000).

Educating

Education is a key tool in promoting health, andhealth promoters will be using this competency in avariety of ways and settings, from the formal

ExampleA staff nurse in the health visiting team may beable to support the specialist practitioner indeveloping materials for display at the markethealth stall as part of a health fair promotinghealthy eating. The role would encompasselements of forward planning, implementationand evaluation, working alongside other teammembers.

98 Developing health promotion practice

teaching of large groups in schools to informal inputon a one-to-one basis in a clinic or nursing home. Inundertaking any educating role it is important toplan your input, make sure you are up-to-date withthe knowledge base, think about the mostappropriate style of delivery, such as a didacticapproach, where you have limited time and a largegroup, to a more Socratic approach, with a smallgroup in which interaction can be encouraged.Again, the measuring of success of your delivery isan important aspect of this intervention.Fundamental to this area of competence is effectivecommunication.

Communicating

This area of competence will not be new to you.Communication is a fundamental skill for allhealth professionals and one which is usedconstantly. It is also fundamental to healthpromotion practice. We can communicate with ourclients in many different ways and it is importantto select the most appropriate for the situation.How we communicate with people, when wecommunicate with people and what wecommunicate to people are all important aspectsto consider.

Health promoting messages can be deliveredthrough many media, but for maximumeffectiveness, it is important to match up theperson, the message and the method of

communication. Communicating health messagescan take many forms, including one-to-one advicefrom a health professional, group teaching inschools by school nurses, posters and leaflets, healthfairs, videos, NHS Direct, through the internet,telephone helplines, newspapers and magazines,television and radio.

Facilitating and networking

It is important to recognise how other people canhelp you in your health promoting role and howyou can help others. Sharing ideas, skills andknowledge is all part of this, particularly whenworking with local communities and groups andother organisations. Getting to know what ishappening locally and who is involved is animportant and useful process.

Working together with others on projects canhelp to enhance the effectiveness of the activity andhelps to share the workload. This is an importantaspect to consider when you want to incorporatehealth promotion work into an already busyschedule.

ExamplesA community mental health nurse working withcarers to establish a local carers’ self-help/supportgroup.

Attending the annual general meeting of a localsupport group to find out more about what ishappening and who is involved.

ExamplesThe use of the Smokebuster magazine/comic toencourage young people to quit smoking.

An E-grade nurse working in the community withthe district nursing team arranging for a local olderpeoples’ drama group to perform a play aboutreducing accidents in the home to clients attendingthe local Age Concern luncheon club and daycentre.

ExerciseHow many ways of communicating healthmessages can you think of?

ExampleA school nurse specialist may need support indeveloping a hand-washing programme forprimary school children. Here the E- or D-gradenurse may work with the school children to createplace mats with pictures depicting good hand-washing practices.

What competencies do you need? 99

Marketing and publicity

Raising awareness of your health promotionactivities can be important to support you insharing good practice, widening participation in theactivities and providing further opportunities forpromoting the health messages. This can be done ina variety of ways from an informal approach using aposter display in the local surgery through toseeking support from the local press for a majorhealth event in the town. There will be people inyour local primary care trust with particular skills inliaising with the press who can help you withdeveloping publicity materials. It may be necessaryto gain approval for any press releases you mightwant to make related to particular projects in whichyou are involved.

Influencing policy and practice

You may feel that your opportunities in this area arelimited. However, participating in audits, recordingactivities undertaken to identify trends in localpopulations, being involved in pilot projects, sharinggood practice and fully participating in local staffmeetings all provide the potential to influencepolicy and practice at a local level.

A focus on evidence-based practice is important,ensuring you and your work colleagues aredelivering a quality-based service to the localpopulation. (See Chapter 2 for a discussion ofclinical governance.)

Taking a pro-active approach to your healthpromotion activities can provide opportunities toinfluence practice and can lead to greatersatisfaction with your work. Why not find out ifyour trust offers a reward scheme for ‘good ideas’;many do.

There are also opportunities you can take as anindividual citizen, such as voting for your localcouncil representatives or standing as a

representative yourself, or participating in localconsultation processes, such as the closure of a localhealth facility.

HOW DO YOU DEVELOP THESECOMPETENCIES?

Developing competence in health promotionpractice often involves the enhancement of existingskills and knowledge, and incorporating them intonew or different ways of working. It is abouttransferring skills across into a new domain or areaof practice.

Self-assessment of levels of competence is notalways an easy task. You could be helped to do thisthrough a variety of channels including, forexample, preceptorship, clinical supervision,individual performance review or staffdevelopment review, reflective practice andfeedback from colleagues and clients.

Levels of competence and consequent learningneeds will vary from individual to individual,depending on previous experience and learningopportunities. You may have come into nursingfollowing a career in marketing, in which case your

ExerciseReflecting on the list of core competencies, inwhich areas do you feel you have existing‘transferable skills’ and where is there room fordevelopment?

Using a tool such as a SLOT analysis might assistyou in this task. A SLOT analysis encourages you toconsider the task, focusing on the following areas:strengths, limitations, opportunities and threats.

ExampleCommunity staff nurses supporting the runningand evaluation of a pilot scheme for acommunity-based leg ulcer clinic to influencefuture provision.

ExampleAn occupational health nurse developing anddisplaying publicity material on the fluvaccination campaign in their local workplace.

100 Developing health promotion practice

competence in that area may well be high whereasyour experience in educating others is very limitedOr you may have just completed your nurseeducation, having come direct from school, and theopportunities to date for you to develop yourcompetence in areas such as facilitating andnetworking have been limited, whereas yourcompetence in communicating with individualclients is high. Or you may have undertaken ahealth studies degree, which included modules onhealth promotion, that has given you a substantialgrounding in the area although this may focus moreon the theory and knowledge base rather than theapplication in practice.

Whatever the circumstances for you as anindividual, having assessed your competency levelsit is possible to look for opportunities to enhancethose competencies you identify as needingdevelopment.Again, how you achieve this will vary,depending on the area of competence, yourpersonal and work circumstances and the level ofsupport available to you through your workplace.

One effective way of developing competence isthrough experiential learning, by applying the skillsin practice, with support as necessary in the firstinstance, and to reflect on the process and theoutcome. This is perhaps best supported by a seniorcolleague or manager who is already experienced inthe field and who can coach or mentor you throughthe learning process.This will obviously require youto be given the opportunity to incorporate somehealth promotion practice into your workprogramme and this may need to be facilitated withsupport from other colleagues. Another source ofhelp and support could be through your localpublic health, health improvement or healthpromotion colleagues who should be able to offerspecialist advice and guidance in the field to helpyou in applying the skills to practice and providingthe appropriate evidence base to assist in directingyour practice.

Another opportunity that will almost certainlyoffer new experiences and perspectives from whichyou can learn and develop is through participatingin inter-agency projects or initiatives. As has beenindicated previously, working in partnership withothers is an important aspect of health promotionactivity and one which should be taken up wherefeasible. It is potentially a new and challenging

experience for many staff, but one that can berewarding and enriching, enabling you to expandyour existing competence and develop others.Again, if this way of working is new to you it issuggested you undertake such activity with supportand supervision from more experienced colleaguesin the first instance, and also take the opportunity toreflect on the process and practice. Use of areflective model, such as those of Gibbs (1988) orJohns (1996), may assist you in this task.

It may be that you have identified underpinningknowledge gaps, rather than specific skills gaps. Ifthis is the case the means of meeting your learningneeds will probably be different from thosesuggested previously. For example, you may benefitfrom undertaking some specific focused readingaround the topic concerned, attending an updatesession on falls prevention for the elderly (if that isthe area of knowledge deficit) or perhapspreparing a seminar paper for your colleagues onan area of work relevant to the team, such asreducing the problems of obesity among youngpeople. Again the specialist public health andhealth improvement/promotion staff should be agood source of help and support.

Opportunities for learning and enhancingcompetency levels in health promotion will varyacross the country and the suggestions made hereare only examples. You will need to clarify yourlearning needs, make those needs known to yourmanager and then seek appropriate opportunities tomeet those needs, based on the situation locally.

CONCLUSION

To meet the requirements of the current agendafor health improvement there is a need for staff ina wide range of roles and settings to adopt aproactive health promotion element in their work.We hope that this chapter has inspired you to feelconfident in developing your competencies toenhance the health of your client group and that ithas illustrated how health promotion can besomething that is integrated into your everydayactivity.

Engaging in health promotion can be many thingsfor you as a practitioner: challenging, exciting,frustrating, rewarding, at times overwhelming,enjoyable, innovative, empowering, satisfying, time-

Conclusion 101

consuming,skill-enhancing,self-actualising,stressful,but overall very worthwhile.Wherever and wheneverhealth-promoting opportunities arise we urge you toparticipate actively.

FURTHER READING

Ewles, L. and Simnett, I. (2003) Promoting Health: A PracticalGuide (5th edn). Edinburgh: Baillière Tindall/RCN.

Katz, J., Peberdy, A. and Douglas, J. (eds) (2000) PromotingHealth: Knowledge and Practice (2nd edn). Basingstoke:Palgrave in association with the Open University.

Naidoo, J. and Wills, J. (2000) Health Promotion: Foundationfor Practice Edinburgh: Baillière Tindall /RCN.

Seedhouse, D. (1997) Health Promotion: Philosophy, Prejudiceand Practice. Chichester; John Wiley.

REFERENCES

Downie, R.S., Tannahill, C. and Tannahill A. (1996) HealthPromotion: Models and Values (2nd edn). Oxford: OxfordMedical Publications.

Department of Health (1999) Saving Lives: Our HealthierNation. London: The Stationery Office.

Department of Health (1999) Mental Health National HealthService Framework. London: The Stationery Office.

Department of Health (2000) The NHS Plan. London: TheStationery Office.

Department of Health (2000) Coronary Heart Disease NationalHealth Service Framework. London: The Stationery Office.

Department of Health (2001) Older People National HealthService Framework. London: The Stationery Office.

Ewles, L. and Simnett, I. (2003) Promoting Health: A PracticalGuide (5th edn). Edinburgh: Baillière Tindall/RCN.

Gibbs, G. (1988) Learning by Doing: A Guide to Teaching andLearning Methods. Oxford: Oxford Polytechnic.

Johns, C. (1996) Visualizing and realising caring in practicethrough guided reflection. Journal of Advanced Nursing 24:1/35–43.

Katz, J., Peberdy, A. and Douglas, J. (eds) (2000) PromotingHealth: Knowledge and Practice. Basingstoke: Palgrave inassociation with the Open University.

Naidoo, J. and Wills, J. (2000) Health Promotion: Foundationfor Practice. Edinburgh: Baillière Tindall /RCN.

Seedhouse, D. (1997) Health Promotion: Philosophy, Prejudiceand Practice. Chichester: John Wiley.

World Health Organisation (1984) Health Promotion: ADiscussion Document on the Concept and Principles.Copenhagen: WHO Regional Office for Europe.

102 Developing health promotion practice

abbreviations and terminology xiaccess to health care 9Acheson Report (1998), health inequalities 87, 88, 91aggressive behaviour 34appreciative planning 56assessment skills 59, 75–6

needs assessment 18–20nursing process 90personal risk, HSE framework 34–6

assessment stage, Orem’s self-care model 67audit, Commission for Healthcare Audit and

Inspection (CHAI) 26

boundaries, therapeutic relationships 41–2

carers 46–7, 92case study, family situations 53–9CCNs see children’s nursing (CCN)change management

internal/external agents 12and leadership 12–13

childrenHealthy Schools projects 91rights 49

(community) children’s nursing (CCN) 22CLDNs see learning disability nursing (CLDN)clients see patientsclinical governance 2, 26–7

evaluation of outcomes 89–90key elements 68see also evidence-based practice (EBP)

clinical supervision 76CMHNs see mental health nursing (CMHN)Code of Professional Conduct (NMC 2002) 76collaborative working 53–61

attitudesflexibility 56–7professional integrity 56–7reciprocity 56–7

definition 55effective skills 56–9government policy implications 54–5interface of collaborative care 55–6interprofessional relations 59–60skills 57–9social services 53–61

collective strategies 56Commission for Healthcare Audit and Inspection

(CHAI) 26

communication skills, health promotion 90, 99community nursing/nurses 3

process vs context 21–2competencies, health promotion requirements 97–101conceptual approaches to care 63–73

evidence-based practice (EBP) 49, 68–70learning through reflection 70–2models 64–7philosophies of care 64see also nursing (conceptual) models

concordance 79consumer involvement, decision making 92contraception, teenage pregnancy issues 91counselling and support 37crime, personal safety, work areas/reputations 30

decision makingconsumer involvement 92MMR vaccine 69and patient choice, evidence-based practice (EBP)

69–70professional issues 77–9

demographic issues in UK 3–4dialogues 56district, personal safety, work areas/reputations 30district nursing/nurses 3, 24–5

assessment of patients 92inappropriate referrals 19

education, health promotion 98–9elderly patients, self-care, vs medical paternalism 46emotional intelligence (people skills) 82empathy, defined 58empowerment, self-care vs medical paternalism 46evidence-based practice (EBP) 49, 68–70

acquiring evidence 68–9informed decisions and patient choice 69–70objectivity 68vs patient preference 69

facilitating and networking, health promotion 99family situations, case study 53–9flexibility 56–7flexible working 12, 56–7, 60

general practice (GP) nursing 23telephone triage 81walk-in centres 81–2

group reflection 70–1

Index

hand washing 35, 99health, definitions 17–18, 95–6health care service delivery 17–18

access 92changes in perception 7–10innovations 8, 81–2walk-in centres 81–2

health promotion 95–102competencies required 97–101

communication skills 90, 99development 100–1educating 98–9facilitating and networking 99influencing policy and practice, development

100–1managing, planning and evaluation 98marketing and publicity 100

definition 96–7principles (WHO) 97

Health and Safety Executive (HSE), risk assessment,personal safety 34–6

Health Service for all Talents (DOH 2000b) 11health status model 18health visiting 24healthy living initiatives 8–9helping manner, defined 58history

development of public health movement 86–7recent, of NHS 1–3

holistic care 64home visiting, personal safety 30–1hygiene issues 35

implementation skills, nursing process 90Improving Working Lives (DOH 2002d) 12incident reporting 37individual responsibility 7–8innovations

current practice 79–80public health agenda 80–1service delivery 8walk-in centres 81–2

integrated nursing teams 25intermediate care 4, 8internal market 2interpersonal relationships and non-confrontational

behaviour 32–4interprofessional relations 59–60

leadershipemotional intelligence (people skills) 82and management of change 12–13

(community) learning disability nursing (CLDN) 23

Liberating the Talents (DOH 2002) 3lifestyle see healthy living initiatives; preventive

strategieslocal population, needs 20–1locus of control theory 11

Making a Difference (DOH 1999a) 10, 11managing, planning and evaluation, health promotion

98manual handling

load handling 36policies and procedures 37

manual handling situations 36–7marketing and publicity, health promotion 100medical paternalism, vs self-care 46Medicinal Products Prescription by Nurses Act

(1992) 79–80Medicines Partnership 91(community) mental health nursing (CMHN) 23MMR vaccine, decision-making 69modernisation

public health demands 87–8see also innovations

National Institute for Clinical Excellence (NICE) 2,25

National Performance Framework 26national service frameworks (NSFs) 2, 25–6, 81needs

local population 20–1taxonomy of 19

needs assessment 18–20negotiated settlements 56New NHS: Modern, Dependable (DOH 1997) 2, 7,

88new ways of working 11–12NHS Direct (phone line) 81NHS Plan (2000) 3, 11, 12, 80–1nursing

Making a Difference (DOH 1999a) 10, 11shortage of nurses 11

nursing (conceptual) modelsActivities of Living 66biomechanical model 64building models 65–6with differing philosophies 66–7implementation of models 67–8key concepts 65Neuman’s Systems model 66Orem’s self-care model 63–4, 65–6, 67Peplau’s Interpersonal Relations model 66task-oriented 64

nursing disciplines 21–5

104 Index

nursing processassessment skills 90vs context 21–2evidence-based practice (EBP) 49, 68–70Orem’s self-care model

assessment stage 67care plan 67evaluation 67planned care 67

reflection and practice 70–1

objectivity, evidence-based practice 68occupational health nursing (OHN) 22open communicating, defined 58open listening, defined 58organisational culture 10–11organising skills, defined 59

participatory rapid appraisal 20Patient Advisory Liaison Services (PALS) 11patient preference, vs evidence-based practice 69patients/clients

assessment of 75–6autonomy 42entering home, guidelines 31expectations and needs 42, 45–7Expert Patient (DOH 2001c) 11relationships see therapeutic relationshipsself-care 46–9

people skills (emotional intelligence) 82personal medical services (PMSs) 4, 8personal safety 29–39

aggression 34car safety 32interpersonal relationships and non-confrontational

behaviour 32–4manual handling 36–7organisational support 34reporting incidents 37risk assessment

hazard identification 35HSE framework 34–6recording findings 35review/revise assessments 35–6

safety at work 29–30support and counselling 37

planning skillsnursing process 90public health 90

postcode lottery, ending 21pregnancy, teenage pregnancy issues 91prescribing by nurses 79–80

types of prescriber 80

preventive strategies 11–12primary care trusts (PCTs) 2, 8–10, 19

personal safety, organisational support 34primary health care practitioners, roles 14primary health care teams (PHCTs) 18process vs context 21–2professional integrity 56–7professional issues 75–84

approaches to care 75–6current innovations in practice 79–80decision making 77–9future innovations in practice 80–2

public health 85–94choices, healthier 90contribution of nurses to outcomes 91–2definition 85–6development of public health movement 86–7key agencies 89modern health care demands 87–8provision and processes of care 88–91range of nursing services 92–3roles of workers 88–91websites 93

public health agenda 80–1

quality service, guarantees 25–7

reciprocity 56–7reflection

aids to reflection 71–2and practice 70–1, 76

relationships see therapeutic relationshipsresponses to caring role 46risk assessment, personal safety, HSE framework

34–6

safety at work 29–30safety issues see personal safetyschool nursing 8–9, 24self-assessment, core competencies 100self-care

Expert Patients Programme 49vs medical paternalism 46Orem’s model 63–4, 65–6

service delivery see health care service deliveryShifting the Balance of Power (2001) 3skills

collaborative working 57–9organising skills 59relational skills 58transferable skills 76–7see also assessment skills

skills escalator 11

Index 105

skills mix 10SLOT analysis, core competencies 100smoking 8social marketing theory 9social and political influences on health care 1–3social services

collaborative working 53–61government policy 54–5

socioeconomic groups, and health levels 90(community) specialist practice disciplines 4, 22stressors, defined 66SWOT analysis 13, 76

taxonomy of need 19teams 12teenage pregnancy issues 91telephone triage 81terminology xi

therapeutic relationships 41–51appropriate boundaries 41–2boundaries 41–2in community setting 42–7failures, over-involvement 48–9influence of current and future contexts 49location of care 43–4nature of care 44patient expectations 45–6patient needs 42, 46–7promoting patient autonomy 42

training and educationhealth promotion 98–9specialist practice disciplines 4, 22

transferable skills 76–7tuberculosis, history of public health measures 86–7

walk-in centres 81–2

106 Index