Chilton & Bain (2018) A Textbook of Community Nursing-Routledge
Chilton & Bain (2018) A Textbook of Community Nursing-Routledge
Chilton & Bain (2018) A Textbook of Community Nursing-Routledge
Community Nursing
A Textbook of Community Nursing is a comprehensive and evidence-based introduction covering the full range
of professional topics, including professional approaches to care, public health, eHealth, therapeutic relationships
and the role of community nursing in mental health. The new edition has been updated throughout, including
new guidelines and policies. It also provides a stronger focus on evidence-based practice.
This user-friendly and accessible textbook includes the following:
• Current theory, policy and guidelines for practice. All chapters are underpinned by a strong evidence base.
• Learning objectives are provided for each chapter, plus exercises and activities to test current understanding,
promote reflective practice and encourage further reading.
• Case studies and examples from practice which draw on all branches of community nursing are provided to
illustrate practical application of theory.
This is an essential text for all pre-registration nursing students, students in specialist community nursing
courses and qualified nurses entering community practice for the first time.
Sue Chilton, Senior Lecturer/Academic Course Leader in the School of Health and Social Care, University of
Gloucestershire, Gloucester, UK
Heather Bain, Academic Strategic Lead: Academic Programmes, School of Nursing and Midwifery, Robert
Gordon University, Aberdeen
A Textbook of
Community Nursing
Edited by
SUE CHILTON and HEATHER BAIN
First published 2018
by Routledge
2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN
and by Routledge
711 Third Avenue, New York, NY 10017
The right of the editor to be identified as the author of the editorial material, and of the authors for their individual chapters, has been asserted
in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means,
now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission
in writing from the publishers.
Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation
without intent to infringe.
an often forgotten army of nurses who provide a critical service in the co-ordination
and delivery of care for patients at the end of their lives, every day. This happens in
every village, town and city around the United Kingdom and yet is rarely given the
attention it deserves in the media.
The ways in which nursing is embracing technology to enhance patient care are
illustrated in their leadership of new ways of working and a nuanced understanding
of patients’ responses to such opportunities.
Reading this cleverly woven set of chapters provides a reminder of the unique
combination of autonomous and team working that is the joy of serving a
community as a highly skilled, creative and resourceful nurse. It provides essential
reading to those who are new to a rewarding nursing career in the community and
a welcome invigoration for those nurses who have been privileged to serve their
communities for many years.
Dr Crystal Oldman
Chief Executive
The Queen’s Nursing Institute
INTRODUCTION
This book has been designed to support staff who may be new to working in a
community setting and is an essential guide to practice. We envisage that it will
be useful for pre-registration students on community placement, community staff
nurses and nurses moving from an acute work environment to take up a community
post. The aim of the book is to develop and support nurses to work safely and
effectively in a range of community locations.
Community nurses work in a great diversity of roles and a variety of settings –
including schools, the workplace, health clinics and the home (Naidoo and Wills,
2016). They empower individuals, families and communities to have control over their
health and to improve their wellbeing. They also work across the lifespan, and with a
range of social groups that include those who are vulnerable, experience inequalities
and are socially excluded. Not only do community nurses work autonomously
in leading, managing and providing acute and long-term health and social care,
anticipatory care and palliative care, but they also have a public health remit. They
have a pivotal role in health protection, ill-health prevention and health improvement.
Community practice is dynamic, forever changing and in a constant state of flux.
Baguley et al. (2010) have conceptualized community nursing in Figure I.1, which
illustrates that, in the promotion of optimum health and wellbeing, community
Individual
th
essm
Ass
Community Family
Int
e
ath
rve
De
nti
on
Lea my
der
ship ono
Aut
FIGURE I.1 Promotion of optimum health and well-being. (Reproduced from Baguley
et al., Concept of Community Nursing, Aberdeen: Robert Gordon University, 2010.)
xii Introduction
Chapter 14 – Providing quality care at the end of life – Highlights the importance of a holistic and timely
assessment in order to effectively manage the end-of-life care needs.
Chapter 15 – Organisation and management of care – Critically analyzes work organisation and care
delivery in the community setting with particular reference to prioritization, delegation and skill mix.
Chapter 16 – Leading quality, person-centred care in the community – Explores the role of leadership and
clinical governance at practice level within community nursing.
Chapter 17 – eHealth – Defines the terminology used in telehealth and telecare and appraises its potential
use in community nursing practice.
Chapter 18 – Development of community nursing in the context of changing times – Identifies contemporary
political influences and discusses new ways of working and responding as community nurses.
Within each chapter, further reading and resources are suggested. We hope you find this book informative
and inspirational in developing your professional practice.
REFERENCES
Baguley F, Bain H and Cowie J (2010) Concept of Community Nursing. Aberdeen: Robert Gordon University.
Naidoo J and Wills J (2016) Health Promotion, 4th edn. Edinburgh: Elsevier.
Timmins N (2013) The Four UK Health Systems. London: King’s Fund.
ACKNOWLEDGEMENT
The editors would like to thank colleagues from the Association of District
Nurse Educators (ADNE), many of whom have contributed to the book. The ADNE
(www.adne.co.uk) is committed to raising the profile of district nursing and its
purpose is the educational preparation and support of district nurses and other
health professionals working in primary and community care across the United
Kingdom. At various stages along the way, members of this professional group have
offered guidance and support.
CHAPTER
1 Nursing in a community
environment
Sue Chilton
LEARNING OUTCOMES
• Compare and contrast definitions of ‘community’, exploring the contexts
in which the term is used and, specifically, how it is interpreted within
community nursing.
• Explore the environmental, social, economic, professional and political
factors influencing the delivery of community healthcare services and
critically appraise ways in which local services aim to be responsive to the
specific needs of their population.
• Develop insight into the complex nature of the environment of community
healthcare.
• Identify the skills and qualities required of nurses working in community
settings.
INTRODUCTION
This chapter considers the complex environment within which community nurses
practice and offers some definitions of ‘community’ and ways in which the term is
used. It explores the wide range of factors impacting upon the services community
nurses provide for patients and discusses ways of tailoring care to respond to
local needs. Key skills and qualities currently required by community nurses are
identified and discussed.
DEFINITIONS OF ‘COMMUNITY’
Changes in terms of the location and nature of community nursing care provision
have occurred over the years in response to a variety of influencing factors. More
recently, we have seen a distinct shift of services from the hospital setting to primary
care and community locations (Turnbull, 2017; McGarry, 2003). Current health and
social care policy directives indicate that still more services will be provided within
the community context in the future (Scottish Government, 2013; Welsh Assembly
Government, 2013; Scottish Government, 2010; DHSSPSSNI, 2011; NHS England,
2014). In order to provide the required administrative and managerial infrastructure
to accommodate these changes, several major organisational reconfigurations have
2 Nursing in a community environment
taken place across the United Kingdom in recent years. In England, for example,
general practitioner (GP) fundholding was replaced by primary care groups, which
then developed into primary care trusts (DH, 1997). Further changes quickly
followed with the largest structural reorganisation of the National Health Service
(NHS) since its inception in 1948, involving the development of GP consortia (DH,
2010a), which have wide-ranging responsibilities for commissioning services and
manage the vast majority of the NHS budget. Over the last few months, there has
been the development of ‘Sustainability and Transformation Plans’ (STPs) which
involve partners working together in ‘place-based systems of care’ to transform
health and social care delivery within local populations. These plans are focused
on improving quality and developing new ways of working; improving health and
well-being; and improving the efficiency of services in hospitals and the community
(Alderwick et al., 2016). Political analysts have recognised the potential value of
STPs in supporting new care models and promoting collaboration between
key stakeholders but also advise caution and the need for close monitoring and
evaluation in testing whether service changes and related financial plans are viable
(King’s Fund, 2017).
Although, from an academic perspective, the notion of ‘community’ has been
discussed widely across a range of disciplines, including sociology and anthropology
(Cohen, 1985), clarity with regard to a definitive definition eludes us.
BAL ECOSYSTEM
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AL ENVIRONMENT
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ACTIVITIES
AL ECONOMY
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, Wa
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Working, Shop
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-life balance
etworks
The determinants of
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Figure 1.1 The health map. (From Barton H and Grant M., Journal of the Royal
Society for the Promotion of Health, 126, 152–253, 2006.) The determinants of health
and well-being in our neighbourhoods.
6 Nursing in a community environment
Buck and Gregory (2013) recognise the need for a clear purpose and ‘robust local
framework based on outcomes-focused partnerships and commitment to systematic
health impact assessment’ to improve the public’s health and tackle health inequalities.
To this end, information is required regarding disease patterns (epidemiology) and
public health in a particular area (locality/community/neighbourhood) as well as
data regarding local environmental factors/resources (knowledge base/experience of
community service providers), in other words, a combination of ‘hard’ (statistical/
research-based/quantitative) data and ‘soft’ (experiential/anecdotal/qualitative) data.
Qualitative information may include newspapers; meetings of agencies; diaries,
meeting notes of local workers; projects undertaken by students on programmes of
study; photographs and videos. Quantitative data will be obtained from a variety
of sources but will consist mainly of statistical evidence and research-based studies
(Hawtin and Percy-Smith, 2007).
Three key approaches to health needs assessment described by Coles and
Porter (2008) are epidemiological, comparative and corporate. A comprehensive
assessment would normally incorporate more than one of these approaches.
Explore the different sources of data available to inform a health and social needs
assessment of your local community. Much information can be obtained from the
local council, libraries and Internet sources (see Further Resources list).
In capturing the ‘essence’ of a locality, the term ‘community profile’ is frequently
used to describe an area in relation to its amenities, demography (characteristics of the
population), public services, employment, transport and environment. Traditionally,
health visitors, in particular, have been required to produce community profiles as a
form of assessment during their training.
‘Community profiling’ can be defined as
There are three interacting levels identified within profiling, which are
• Community – Assessment of need within a locality/neighbourhood
• Practice – Assessment of need within a GP practice
• Caseload – Assessment of need within a health professional’s caseload
Meeting the Needs of the Local Population 9
Any attempt to analyse the series of complex processes that makes up a living
community without the participation of local residents/consumers is a fairly fruitless
exercise. In gathering information from a large community population, a variety
of methods may prove useful. An approach entitled Participatory Rapid Appraisal
has been described elsewhere (Coles and Porter, 2008) and involves community
members in the collection of information and related decision making. Originally
used in developing countries to assess need within poor rural populations, it has
been employed in deprived urban areas. A wide variety of data-collection methods
is used and Participatory Rapid Appraisal involves local agencies and organisations
working together. By working in partnership with local residents, action is taken
by community members who have identified issues of local concern/interest and
discussed potential solutions. Clearly, Participatory Rapid Appraisal could be used
to help tackle specific issues as well as large-scale assessments.
Current government policy (DH, 2010a,b) stresses the importance of a localised
approach to community healthcare service provision. Each locality is different in terms
of its characteristics, which might include its demography, geographical location,
environment, amenities, transport systems, unemployment levels, deprivation scores,
work opportunities and access to services, for example. As a result of these potential
variations, it is important to interpret national guidelines according to local needs.
Each locality will have its own individualised local targets for public health tailored
to the specific requirements of the local population. Such targets are usually chosen
following an examination of local information sources, such as epidemiological data
collected by the relevant Public Health Department, general practice profiles and
caseload analysis data obtained from local healthcare practitioners, for example.
Roberson (2016), following a comprehensive review of the literature relating to
caseload management by district nursing teams, concludes that effective and efficient
caseload management is essential in improving the quality of care to patients, and
ensuring that limited valuable resources are used in the most appropriate way.
By systematically reviewing local information sources and working within
government/professional guidelines, community nurses have an opportunity to
develop practice and more collaborative ways of working.
Example 1.1
From general practice profile information, one locality identified a significantly
high percentage of the older population with dementia. As a result, the community
psychiatric nurse team working with older people in the locality liaised with the
district nurses and practice nurses across the identified GP practices with a view to
discussing the provision of support for the carers involved.
presents community nurses with the challenge of redefining their services to more
accurately respond to the needs of their particular patient group. Responding
more appropriately is not an easy task as many of these unmet needs often require
seeking out and might exist within the more disadvantaged sectors of society. It
is not unreasonable to assume that many community nurses will require a greater
understanding of different cultural issues and social value systems before they are
able to identify specific unmet needs. The inverse care law means that, ironically,
the more advantaged people in society tend to receive better healthcare services
(Acheson, 1998; Marmot Review, 2010). Current NHS policy is attempting to
rectify this anomaly and end the ‘postcode lottery’, which suggests you are able to
determine your health status from the place where you live.
Although National Service Frameworks (NSFs) are national guidelines produced
to encourage the dissemination of best practice in relation to particular conditions
or client groups, it is the responsibility of frontline staff to implement them locally
and interpret them according to local conditions.
• Make a list of the identified health and social care needs of all those people
involved.
• Were all of the needs addressed or met? If not, why not?
• Who was involved in meeting these needs?
• Consider the different sources of support, information, care, treatment and
advice offered and given. Was the overall package of care well co-ordinated?
• Were there other potential sources of help that were untapped at the time?
• Were sources of care and support readily available or did they need seeking out?
• Were self-care strategies employed in any way?
• With hindsight, how would you rate the quality of care and support received/
obtained?
• What do you consider to be the most important elements of high-quality care
provision?
On reflecting on the above activity, you may have identified service providers from
statutory, voluntary or charitable agencies and organisations. Individuals responsible
for assessing, planning, delivering and evaluating care based on apparent needs
may have been professionally qualified or not. Sources of support may have come
from recognised services or consisted of more informal networks. Information
to help you make sense of the experience could be accessed in a variety of ways.
Frustrations, concerns and reassurance at the time will probably have linked to a
range of factors – such as interpersonal communication, transport, accessibility of
services, effectiveness of treatment, information available and financial issues, for
example.
The National Nursing Research Unit (NNRU, 2011) has conducted research
measuring patient experience in the primary care sector that included patients with
different illnesses/conditions. Generic themes that were important to patients included
being treated as a person; staff who listen and spend time; individualised treatment
and no labelling; feeling informed, receiving information and given options; patient
involvement in care-efficient processes; and emotional and psychological support.
The authors highlight the need for policy makers to start to consider the relational
12 Nursing in a community environment
In the early 1990s, the United Kingdom Central Council for Nursing, Midwifery
and Health Visiting United Kingdom Central Council for Nursing, Midwifery and
Health Visiting (UKCC) conducted the PREP project to clarify the future training
requirements for post-registration nurses in terms of education and practice. At the
time, eight community specialist practice disciplines were identified and included
occupational health nursing, community children’s nursing, community nursing
learning disability, community mental health nursing, general practice nursing,
school nursing, health visiting and district nursing. The UKCC (1994) proposed
a common core-centred course for all specialities, which was to be at first degree
level at least and 1 year in length. According to the UKCC (1994), the remit of
community specialist practice embraces ‘clinical nursing care, risk identification,
disease prevention, health promotion, needs assessment and a contribution to the
development of public health services and policy’. Clearly, a higher level of decision
making is involved in specialist community nursing practice.
Community Nurses: Keeping the Focus on Person-Centred Care 13
A brief synopsis of each of the eight community specialist practice nursing roles
is offered below. For a more detailed discussion of the roles of these community
nurses, please refer to Sines et al. (2013b).
What is clear within learning disability nursing and services is the demand
for leadership in the quest for improving the quality and effectiveness of
services across health and social care.
The authors discuss the need to pursue a framework- such as the Promoting
Action on Research Implementation in Health Services (PARiHS) model – that
promotes and focuses on integrating knowledge transfer into services for people
with a learning disability and the inherent challenges.
School nursing
School nurses have been employed within the school health service for more than
100 years and are seen as central to child-focused public health practice (Jameson
and Thurtle, 2009).
Key aspects of the school nurse’s role include the assessment of health needs of
children and school communities, agreement of individual and school plans and
delivery of these through multidisciplinary partnerships; playing a key role in
immunisation and vaccination programmes; contributing to personal and health
and social education and to citizenship training; working with parents to promote
positive parenting; offering support and counselling, promoting positive mental
health in young people and advising and co-ordinating healthcare to children with
medical needs.
School nurses holding an appropriate qualification are eligible for registration on
the third part of the NMC register for SCPHN:
Health visiting
The health visiting service has been in existence for more than 100 years and has
its roots in public health and concern about poor health. The overall aim of the
service is the promotion of health and the prevention of ill health. According to the
Council for the Education and Training of Health Visitors (CETHV, 1977), the four
main elements of the health visitor’s (HV) role include the search for health needs;
stimulation of awareness of health needs; influence on policies affecting health; and
facilitation of health-enhancing activities.
HVs holding an appropriate qualification are eligible for registration on the third
part of the NMC register for SCPHN.
HVs need to engage actively in public health work, with individuals, families,
groups and communities working collaboratively with the full range of community
services (Sines et al., 2013b). Recent government directives (DH, 2010a) have
highlighted the need for HVs to maintain a focus on children and families. At the
same time, the profession is keen to develop their future roles in consultation with
the public they serve.
District nursing
District nurses (DNs) can trace their roots back to the mid-1800s at least, and
the historical development of the service is well recorded. They used to work in
relative isolation but are more likely nowadays to work within a team. The role
of the district nurse has evolved over time in response to political influences
Community Nurses: Keeping the Focus on Person-Centred Care 17
and the changing needs of the populations served. Although it is acknowledged
that the role of the district nursing service is not clearly defined, it involves the
assessment, organisation and delivery of care to support people living in their own
homes. Current research, however, by Jackson et al. (2015), using the Cassandra
Matrix Activity tool, has the potential to assist community and district nurses in
demonstrating the complex nature of their work in the near future. The current
work of the district nurse includes responsibility for providing pathways of nursing
care during acute, long-term (Carrier and Newbury, 2016) and terminal illness and
is detailed in the new vision and model for district nursing (DH/NHS/QNI, 2013).
The majority of people on the district nurse’s caseload tend to be from the older
generation – an often vulnerable and marginalised group of people within society.
Again, like their GPN colleagues, DNs have clear guidance in England, following
the development and publication of the District Nursing Service Education and
Career Framework by Health Education England (HEE, 2015). In addition, the
Queen’s Nursing Institute (QNI) and QNI Scotland have developed and published
updated Voluntary Standards for District Nurse Education and Practice (QNI/
QNIS, 2015).
With the current pressures on health and social care, there has been renewed
attention on the pivotal role of the DN in leading and managing complex care at home
(Chalk and Legg, 2017). The value of the DN’s role in caring for patients at home,
avoiding unnecessary hospital admissions, cannot be underestimated. Equally,
DNs are central to ensuring effective discharge planning (QNI, 2016). The King’s
Fund Report entitled ‘Understanding Quality in District Nursing Services’ (Maybin
et al., 2016) highlights the dissonance between the policy incentive to promote care
in community settings and the capacity problems being experienced in district
nursing services, and, among its recommendations, proposes the development of
a rigorous framework to assess and monitor the quality of care in the community
(Quaile, 2016b). Ongoing work by the QNI on what constitutes a safe caseload to
protect staff well-being while also ensuring high-quality and safe patient care –
comprising holistic care and care continuity – within current resources will further
inform the debate (While, 2016).
In addition to the community specialist practitioner nursing roles identified
above, there are, of course, many other community nursing roles. Numerous
specialist nurses work within the community environment and these include roles
that link specifically to a particular condition or illness (such as the specialist nurse
for diabetes) or to a group of conditions, such as long-term conditions (Community
Matron). Other community nurses work with specific client groups, such as homeless
or older people. A range of different titles exists for various roles and often the terms
‘specialist’ or ‘advanced’ practitioner are applied. Such a plethora of titles can cause
confusion and form part of the wider ongoing specialist-generalist debate within
community nursing circles.
Begley et al. (2014) conclude from their research that healthcare policy makers
believe that specialists and advanced practitioners contribute to higher quality
patient/client care, particularly at a strategic level, and could make an important
18 Nursing in a community environment
FURTHER RESOURCES
www.ons.gov.uk – Independent information to improve our understanding of the UK’s
economy and society
www.neighbourhood.statistics.gov.uk – Detailed statistics within specific
geographical areas
www.imd.communities.gov.uk
www.census.gov.uk – Index of Multiple Deprivation – statistics available at ward level
www.poverty.org.uk – UK site for statistics on poverty and social exclusion
www.direct.gov.uk – Public services all in one place – according to postcode
www.ic.nhs.uk – NHS Information Centre for health and social care
www.qof.ic.nhs.uk – Quality and Outcomes Framework – GP practice results database
www.marmotreview.org – Baseline figures for some key indicators of the social
determinants of health, health outcomes and social inequalities for specific
geographical areas
http://content.digital.nhs.uk/social-care – Information on adult social care for planning,
delivering and monitoring services
www.hse.gov.uk/Statistics/industry/healthservices/index.htm – Health and Safety
Executive – Health and Social Care sectorhttps://digital.nhs.uk/ – New name for
Health and Social Care Information Centre
www.ninis2.nisra.gov.uk/public/Theme.aspx?themeNumber=134 – Statistics and
information on public health, health services, social care and health and safety at work
in Northern Ireland
www.gov.scot/Topics/Statistics/Browse/Health – Range of information on health and
social care – Scottish Government
https://statswales.gov.wales/catalogue/Health-and-Social-care – Comprehensive set of
information on health, health services and social services in Wales
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CHAPTER
LEARNING OUTCOMES
• Examine the principles of public health, health and well-being.
• Explore the relevance of public health to community nursing.
• Appraise the concept of health and ways of determining health need.
• Critically analyse opportunities for nurses to positively influence health and
well-being of populations, families and individuals in the community setting.
INTRODUCTION
This chapter explores public health, identifies the relationship between health and
well-being and discusses the relevance to community nursing. The intention is to
reaffirm the importance and highlight the opportunities nurses have to positively
influence the health of the public and to promote well-being at individual or
community (population) levels.
Throughout the chapter there are activities presented to support learning
and development; they are also intended to act as a catalyst to foster a deeper
understanding of public health through reflection and informed discussion.
Health
The World Health Organization (WHO) defines health as
a state of complete physical, mental and social well-being and not merely the
absence of disease or infirmity.
(WHO, 1946: 2)
26 Public health and the promotion of well-being
While the word ‘complete’ might render the definition as idealistic and perhaps
unattainable, the definition does acknowledge that health is a multidimensional
issue, with well-being as an integral part, including the physical, mental and
social aspects. Subsequent WHO publications have contextualised the definition
and presented it in light of the importance of recognising underpinning health
determinants and influencing factors such as income, education and social
exclusion/inclusion (WHO, 2006).
According to Raymond (2005), health can be conceptualised from several
perspectives as shown in Box 2.1.
In their discussion paper, Huber et al., (2011) identify the physical, mental and social
aspects of health and the assessment of health. Discussion takes place around the
definition of health and introduces the concept of health being the ability to change and
self-direct. Concepts can be applied to individuals, groups or communities and could
be seen to relate directly the concepts of empowerment and resilience on several levels.
Naidoo and Wills (2015) challenge the adequacy of the preceding perspectives and
suggest that no single theory sufficiently explains the health experience. Moreover,
they state that health is considered to be the unique experience of the individual while
at the same time being influenced by external factors (Naidoo and Wills, 2015).
From the above it is clear that defining what health is can be complex and wider
than a lack of disease.
ACTIVITY 2.1 Consider the relevance of these definitions to the role of the nurse in relation
to the nurse as an
• Empowering agent
• Enabler
• Supporter of self-managed care and wellness to people in their care and
people in the local community
Well-being
When reading the WHO definition of health above is it noteworthy that the concept
of well-being is integral. Well-being as a notion applies to all individuals, regardless
of their physical or psychological state (Sines et al., 2013). The term ‘well-being’ was
analysed by the Sustainable Development Research Network (SDRN, 2005), who
conclude that the term encompasses the concepts of life satisfaction (happiness,
Social Determinants of Health 27
quality of life), physical health, income and wealth, relationships, work and leisure,
personal stability and lack of depression. You may wish to consider at this point
whether one of those mentioned is more significant to well-being than another, or
whether and how they relate.
The idea of health and well-being being closely related is embedded in government
policy. The Organization for Economic Co-operation and Development (OECD,
2013) report that lower income countries do well in relation to subjective perceptions
of well-being and overall work-life balance, while higher income counties struggled
with work-life balance and within these higher income counties poorer educated
and low income populations do less well – resulting in poorer health and social
isolation. Why would this be? The role of expectation and perception links clearly to
the emotional well-being of populations and their emotional health. These ideas of
lifestyle influence on health are discussed by Hanlon et al., (2012), who consider the
challenges of modernity on well-being. For example, culture, inequality, obesity,
addictions and population changes all influence well-being and health, and vice
versa. Hanlon et al., in their discussion suggest well-being and the perception of it
vary at an individual level, and the measurement of it often occurs at a community
level to enable organisations to identify key issues and strengths that can be
prioritised for the good of the majority, therefore, targeting areas of concern or
priority and concentrating resources.
ACTIVITY 2.2 Using the SWOT (strengths, weaknesses, opportunities, threats) analysis tool
below, consider your own health and well-being/lifestyle. What are negative
and positive influencing factors?
Develop these thoughts and consider the influencing factors of income, peer
group, upbringing, culture, genetics and education.
Consider your perceptions and expectations.
What do you measure yourself against?
STRENGTHS WEAKNESSES
OPPORTUNITIES THREATS
cultural conditions. Such factors can directly influence health, or have a bearing on
the lifestyle decisions we make and our ability to make such choices. Dahlgren and
Whitehead’s (1991) widely accessible model introduced in Chapter 1 demonstrates
how health is influenced, either positively or negatively, by a variety of factors.
In the United Kingdom, inequitable opportunities and variations in health exist
between sectors of the population. This conclusion has been well documented in
key studies of the nation’s health identified below:
• Black Report (1980)
• Acheson Report (1998)
• Wanless Report (2004)
• Equally Well (Scottish Government, 2008)
• Marmot Review (2010)
The above reports (which are detailed below) indicate that socio-economic
factors are strong indicators for health and well-being, with low socio-economic
status leading to disadvantage which can take on many forms, for example, poverty
of opportunity, poor education and emotional disease.
Within healthcare there is recognition and understanding of the importance
of the wider determinants of health and health inequalities. There is also
acknowledgement that addressing these root causes of ill health requires public
health to be everyone’s business and responsibility, including community services
and nurses (NMC, 2015; RCN, 2012; Wilkinson and Marmot, 2003). People are
presently living longer and also often living longer with one or more long-term
conditions. Moreover, populations are living in the home setting and receiving care
in that setting or between home, hospital or charitable organisation (Department
of Health, 2014; Scottish Government, 2011), often caring for or being cared for by
other family or community members (see Chapter 9) with significant consequences.
For all of the above, the root cause of ill health and ‘dis-ease’ on several levels is
significant for care managers and providers to understand.
PUBLIC HEALTH
Public health seeks to protect and improve the health of communities, identifying
causes of poor health, disease and illness in populations and examining it from
the wider social and economic standpoints. The four underpinning tenets of public
health are health protection, health promotion, illness prevention and reducing
inequalities (Skills for Health, 2008).
The concept of health and, conversely, illness has been the subject of much debate
in society, both before and after the inception of the National Health Service (NHS)
in 1948. In modern times the association between health and social determinants
can be traced back in policy to some of the work of the early social reformers. Edwin
Chadwick, one of the more well known, produced a report in 1842 entitled Report
of the Sanitary Conditions of the Labouring Population of Great Britain (Chadwick,
1965) in which the relevance of social conditions of the poor and their ability to
Public Health 29
influence their plight were made explicit in relationship to individuals’ health. This
report to the poor law commissioners resulted in the first Public Health Act in 1884.
Since then public health has been part of the United Kingdom’s healthcare provision.
The United Kingdom has seen many different approaches to public health over the past
150 years, each reflecting a more detailed/broader understanding of health and illness
in society. Activities have included interventions to address inequalities on a population
level, through the provision of state education and increased employment opportunities,
to programmes of illness prevention through mass vaccination of children.
Acheson (1988) defined public health as ‘the science and art of preventing
disease, prolonging life and promoting health through the organised efforts of
society’. The vision of the collective efforts of society, empowering individuals and
groups was clearly expressed in the White Paper Saving Lives: Our Healthier Nation
(DH, 1999: 3), in which the strategic intent of government was set out as being to
improve the health of the population as a whole by increasing the length of life and
the number of years people spend free from illness; to improve the health of the
worst off in society and to narrow the health gap.
Wanless (2004: 27) defines public health as ‘the science and art of preventing
disease, prolonging life and promoting health through the organised efforts and
informed choices of society, organisation, public and private communities and
individuals.’ Wanless (2004) and Kerr (Scottish Executive, 2005) took the traditional
view of public health further and place responsibility on society, organisations,
communities and individuals to implement public health improvement through
their organised efforts (Crabbe and Hemingway, 2014).
In 2007, a major criticism of contemporary healthcare provision was made by Lord
Darzi, who observed that the NHS was still overwhelmingly concerned with treatment
of the sick, and that it should move from a ‘sickness service to a well-being service’ (Darzi,
2007: 37). Importantly, this inclusion of well-being in policy encourages services to place
greater emphasis on social health and emotional well-being. The emerging emphasis on
personal responsibility also signified the importance of the role of the individual and
not the healthcare practitioner when it comes to making lifestyle decisions.
The role of the healthcare practitioner (in this case the community nurse) can be
crucial to achieving health-related goals, as community nurses are often in a position
to assist individuals to either access services or support individuals, the family, groups
and communities in making informed decisions about their health and well-being.
through a culture which ‘mobilises the organised efforts of society’ (Skills for
Health, 2008) by empowering individuals and by tackling the wider social,
economic, environmental and biological determinants of health and well-being.
Policy is the definition and setting of goals, often made explicit in the form of
written legislation. Health policy influences us, as health professionals, in terms of
the institutions we work in and the practices we follow in delivering care. To act as
persons’ advocate we need to be aware of their rights as clarified in policy. Policy
can have either a negative or positive impact on health as it has direct and indirect
influence on all aspects of our lives. Public health policy is developed as a result of
networks of decisions involving a wide range of people and organisations at local,
national and international levels. Social policy traditionally includes public policy
in the areas of welfare benefits, unemployment, the NHS, personal social services,
education and training. However, despite this optimism and the inequality gap
continued to widen (Smith and Eltanani, 2014).
In their UK-wide study, Smith and Eltanani (2015) suggest that knowing what
works (significant for the development of policy and strategy) is complex and that
there exists little agreement among researchers about to what is effective in reducing
health inequalities. However, in their study they stated that there was ‘consensus
among researchers about the need for upstream, redistributive and public-service-
orientated approaches to reducing health inequalities’.
From the above it is evident that ongoing research and partnership working are
critical in the achievement of improving health and addressing inequalities. As the
contribution of health professionals to public health is widely acknowledged within
recent government policy across the United Kingdom, it is worth reflecting on
what this means for your role as a nurse. Governments within the United Kingdom
have clearly stated their commitment to public health, health and well-being in
documents including, a DoH white paper (DoH, 2010a); Equally Well (Scottish
Government, 2008) and Early Years Framework (Scottish Government, 2009), in
which they set out strategies for improving the nation’s health by taking preventative
measures. They continue to build on these in more recent policies in each of the four
UK Nations while staying true to the idea that promoting health and well-being
through prevention of illness is achievable through the collective efforts of society.
ACTIVITY 2.3 The idea of health and well-being has been embedded in government policy
for many years and continues to be. Additionally, health and well-being were
identified in the Key Stage Skills Framework (2004) as a key skill area for all
nurses to achieve and is reflected in the NMC Code (2015), for example,
within clause 2.2 ‘recognise and respect the contribution that people can make
to their own health and wellbeing’
Consider your own government and local policies, as well as the healthcare
philosophy where you work and the education you have undertaken to date.
Reflect on how they have been influenced by the concept of well-being and the
prevention of ill health from pre-conception of the child until after death.
Influencing Factors 31
INFLUENCING FACTORS
In this section, we explore health inequality, community development and assessing
population needs in more detail.
Health inequality
We already identified that there is a substantial body of evidence which indicates that
individuals further down the social ladder have more disease and die earlier (Donkin
et al., 2002) and this has not changed over time, despite there being an NHS free at
the point of delivery in the United Kingdom. You might like to consider why this is.
Several factors were considered in the Black Report (1980) including genetic factors,
living and working conditions, lack of empowerment or learned behaviour (poor
health literacy). Tackling these persistent health inequalities has traditionally seen
government policy funnel resources towards specific individuals or groups within
society through targeted services. Public health requires services to focus upon the
underlying social and contextual causes of the problems, suggesting that to improve
health for all of us action is needed across the social gradient (Marmot, 2010).
ACTIVITY 2.4 Box 2.2 indicates the National Statistics Socio-Economic Classification
(National Statistics – The National Statistics Socio-Economic Classification,
2010). Consider where you might be on this scale. Now think of life events
that might alter where you sit on the scale and the impact of those on well-
being, for example, divorce or having dependents. Having read about the
determinants of health and well-being; poverty and inequality you may want
to continue this exercise by considering why some people are vulnerable and
others are not in the same circumstances.
• Why can people be vulnerable at different times in their life?
• What makes people vulnerable?
• What are they vulnerable to?
• How is this understanding relevant to you as a nurse?
• How might vulnerability impact health, well-being and the ability to maintain
some control over their lifestyle?
Community development
The National Occupational Standards in Community Development Work (2009)
(available online at: https://www.fcdl.org.uk/learning-qualifications/archive/
community-development-national-occupational-standards-2009/) state that
Potter and Will (2013) identified that community development projects aim to
involve vulnerable and socially excluded people in decision-making processes. In
other words, it aims to promote and foster empowerment at both individual and
community levels, however, projects and goals are often determined by health or
political agendas as well as evidence.
In recent years, there has been an increased fusion between health and social care
services. Generally systematic methods of identifying the health and healthcare
needs of an individual or population and making recommendations for changes to
meet these needs is carried out by both agencies using a tool or model that provides
practitioners with a framework for undertaking this complex and important needs
assessment in a structured way (Public Health England, 2013).
People, through the influence of social determinants, have measurable differences
in their health status. All too often this is compounded by inequitable access to
healthcare. Disadvantaged individuals and groups, despite having the greatest
overall need, are the least likely to access services (Levesque, 2013). However, it is
important that service delivery reaches these groups as it is generally viewed that
a need, if met, will result in an improvement in people’s health (Haughey, 2008);
however, what constitutes need is widely contested. Needs are variable; they can be
objective and measurable, obvious or hidden. Conversely, they too are subjective,
personal and interchangeable according to context (Cowley, 2008a). Taxonomies
of need exist, for example, Bradshaw (1972), as also discussed in Chapter 7, and are
essential to improve and protect health and well-being as a result of meeting the
public health agenda. From your reading and practice experience, you will have a
good understanding of the importance of holistic health needs assessment in your
role as a community practitioner and understand that to attain an accurate health
34 Public health and the promotion of well-being
ACTIVITY 2.5 Take some time to explore definitions of the following key terms:
• Demography
• Epidemiology
• Empowerment
• Social Gradient
• Equity/Equality
Health promotion
Health promotion as a concept came to the fore in the 1980s (Runciman, 2014).
The WHO (1984) succinctly defined health promotion as ‘the process of enabling
people to increase control over and to improve their health’. This definition is
still relevant today and relates to the concept of empowerment and the nurse
as a leader and educator. Ewle and Simnett (2010) note that there is no single
‘right’ approach, activity or way of ‘doing’ health promotion. The definition
underpins current government policy, actively placing the individual at the
center of care and encouraging their involvement in the decision processes in
order to take control of health decisions: ‘No decision about me without me’
(DH, 2010b). Public health clearly encompasses health promotion. It can be
concluded that health promoters (such as community nurses) should aim to
enhance participation, equity and fairness to improve the health of individuals,
families and communities.
Nurses are involved in public health activity through their day-to-day contact
with patients, clients, families and carers; delivering health promotion activity,
planned or unplanned by providing information, education, facilitating motivation
and empowerment. Community nurses are in a strong position to promote health
and well-being. Their knowledge of the local community and access to clients and
their families in their own homes enables community nurses to develop a deep
understanding of the factors that influence the health of individuals, families and
communities. Their ability to influence the care received by individuals and to
influence local health policy development is high.
For community nurses (at every level) health promotion activity is now embedded
in the role – often carried out in a more informal manner on a one-to-one basis. The
challenge is to identify and articulate the community nurse’s contribution to health
promotion through effective leadership and the use of evidence-based, proactive,
contemporary practice (Runciman, 2014).
Promoting Health and Well-Being 35
Health promotion models
There are several models of health promotion, examples of which appear in Box 2.4.
MODEL
Beatie (1991) Beatie (1991, cited in Katz et al., 2000) developed an analytical
model that highlighted the interplay of intervention (authoritative
or negotiated which equates to professional or client led) and the
focus of intervention (individual or society). Beatie (1991, cited in
Katz et al., 2000) developed an analytical model that highlighted
the interplay of intervention (authoritative or negotiated which
equates to professional or client led) and the focus of intervention
(individual or society).
Tannahill (1985) Tannahill identified prevention, health education and health
protection in overlapping spheres to describe the services and
activities that constituted health promotion practice.
Tonnes and Tonnes and Tilford identified educational, preventative,
Tilford (2001) empowerment and radical approaches but viewed empowerment
as central to health promotion.
Ewles and Ewles and Simnett proposed a model that described five
Simnett (2003) approaches to health promotion: medical, behaviour change,
educational, client-centred and societal change. The values which
underpinned the approaches were represented in a corresponding
gradient from professional-led to client-led activity. (See Box 2.5.)
Other theories that contribute towards the understanding of the effect of health
promotion interventions on the client and why people seek help are the psychological
theories of behaviour change which aim to explain why and how people can change
their behaviour. An example is Becker’s Health Belief Model (cited in Wills and
Earle, 2007).
Assets approach
Demographic changes, reductions in public sector spending and the gap between
the life and health outcomes of the best and the worst off have influenced recent
discussion about the need for new approaches to public service delivery.
One specific model which has attracted much attention is the use of asset-based
approaches to improving health.
Taking an asset-based approach involves mobilising the skills and knowledge of
individuals and the connections and resources within communities and organisations,
rather than focusing on problems and deficits. The approach aims to empower
individuals, enabling them to rely less on public services. However, there remains
a limited evidence base linking actions to strengthen individual and community
assets with improved health and well-being. An asset-based approach is, therefore,
one which seeks positively to mobilise the assets, capacities or resources available
36 Public health and the promotion of well-being
APPROACH
Medical • Based on a medical model of health
• Aims to reduce morbidity and premature mortality (freedom
from medically defined disease and disability)
• Targets whole populations or high-risk groups
• Values preventative medical procedures
• Prominent in current health promotion and healthcare, but
could be considered paternalistic (i.e. one person deciding
what is best for another)
• Focuses on the absence of disease rather than on promoting
positive health
• Ignores the social and environmental dimensions of health
• Primary prevention – The goal is to protect healthy people
from developing disease or injury in the first place
• Education – Nutrition, regular exercise, dangers of tobacco,
alcohol and other drugs
• Legislation – Seatbelts, Health and Safety at Work Act 1974,
food hygiene laws
• Examinations and screening tests to monitor risk factors
for illness
• Immunisation against infectious disease
• Controlling potential hazards at home and work
• Secondary prevention – Interventions after an illness or
serious risk factors diagnosed
• Goal is to halt or slow the progress of disease (if possible) in
its earliest stages; in the case of injury, goals include limiting
long-term disability and preventing re-injury
• Tertiary prevention – Interventions after an illness or serious
risk factors are diagnosed
• Goal is to halt or slow the progress of disease (if possible) in
its earliest stages; in the case of injury, goals include limiting
long-term disability and preventing re-injury
Behaviour change • Encourages individuals to change their behaviour and adopt
healthy lifestyles
• Views health as belonging to an individual, and it is the
individual who chooses when he or she is ready and able to
change his or her lifestyle and improve health which involves
a change in attitude followed by a change in behaviour
Educational • Provides individuals with knowledge and understanding to
make well-informed choices about their health behaviour
• Aim of health promoter/health professional to impart
information with minimal personal values
• Individual decides whether to act on the health education and
any decisions reached
• Can also include developing skills required for healthy living
• Does not try to persuade or motivate change in one direction
Promoting Health and Well-Being 37
to individuals and communities which could enable them to gain more control over
their lives and circumstances (Foot and Hopkins, 2010).
A wide range of techniques are used to take an asset-based approach, including
asset mapping, co-production and various community-led, community engagement
and community development methods.
Assests can be grouped into the following:
(NES, 2011).
Strengths-based approach
‘Strength-based working’ is a term that is heard more frequently in health and
social care settings and can be seen as similar to assets approaches to promoting
health behaviour change and public health outcomes. Strength-based working
means viewing and treating people in a positive manner and can be aligned
with the concepts of self-efficacy. Self-efficacy is identified by Borland (2013)
as individuals’ belief that they can facilitate change in themselves within the
context of their circumstances; therefore, some people who have a high level
of self-efficacy may be able to affect change with some success, whereas other
people who have low self-efficacy may choose to not attempt health-improving
activity or give up easily when challenges are presented. Borland (2013) suggests
38 Public health and the promotion of well-being
Nursing skills
Given the complexity of concepts of health, and the interrelationship between the
multiple factors that influence it, you will appreciate that a variety of approaches
and methods can be utilised to promote health.
To help you clarify your own understanding of how health promotion has
developed over the twentieth century, access the Ottawa Charter for Health
Promotion on the WHO site.
Many of the above theories describe or analyse health promotion practice, but the
skill of health promotion practice requires a deep understanding of communication
and partnership working theory to achieve the goal, which is to enable people to
increase control over and to improve their health (empowerment and choice).
Rollnick et al., (1999) proposed a client-centred philosophy of partnership working
(Motivational Interviewing) to complement Prochaska and DeClemente’s (1983)
Trans-theoretical (stages of change) theory. The aim was to facilitate individuals
to move through the stages of precontemplation – contemplation – making
changes – maintaining changes. Rollnick et al., suggested that a practitioner could
reduce resistance to change by relationship building using a therapeutic approach
based on trust and information exchange to negotiate the agenda and to set achievable
goals based on the individual’s vision of importance and their confidence to make
the change. Motivational interviewing is discussed further in Chapters 8 and 13.
Gallant et al., (2002) conducted a very informative concept analysis of partnership
working which identified three phases to the partnership working relationship: the
initiating phase, the working phase and an evaluation phase. To work in partnership
one needs to build a professional therapeutic relationship based on trust. The
professional must be competent and honest and display professional integrity (to
work in the best interests of the client/patient) at all times and the client must be a
willing partner (Potter and Wills, 2013).
Cultural Awareness 39
ACTIVITY 2.6 Consider Box 2.5. What needs to be in place for each of these approaches
to be successful? You can think of policy, legislation, attitude, values, skills,
abilities, and so on. Carry out a mind map. You can use this exercise in relation
to an individual or community you have been involved with clinically.
SCREENING
It is worth considering screening at this point. As a practitioner working in the
community, you may well be involved in a screening programme to meet with the
Public Health Domain of the Quality and Outcomes Framework (HSCIS, 2015).
Screening is considered to be a preventative activity that seeks to identify an
unsuspected disease or pre-disease condition. It aims to find those most at risk for
which an effective intervention is available (Crichton and Mulhall, 2015). Health
screening is now a widely accepted service that is largely accepted by the general
public. Most people at some point in their life have undergone screening of one sort
of another (for example, breast screening, cervical screening, child development
screening, elderly screening; blood tests, hearing test). Although widely accepted,
health screening, because it proactively seeks to detect disease before symptoms
present, is often the subject of continuing ethical debate and concern around
whether the most vulnerable populations are reached (Crichton and Mulhall, 2015).
CULTURAL AWARENESS
In the 1960s, culture and cultural competence were first mentioned in the nursing
literature in relation to the accessibility and equity of service to populations
identified as ‘different’ (Vandenberg, 2010). However, at that point, the focus was
on race and ethnicity. Cultural competence fosters understanding of race relations,
cultural practices both of the client group and importantly the practitioner and the
culture that the healthcare system stems from. Cultural competence and awareness
development is an ongoing process that in the nursing workforce is critical to
reducing health disparities and is important when preparing nurses to deliver high-
quality, person-centered care (Montenery et al., 2013).
Benkert et al., (2005) identified that cultural understanding and knowledge
should further develop and be inclusive of socially constructed factors such as
sexual orientation as well as the traditionally appreciated ones of race and ethnicity.
Continued recognition of the disparities of care provision and access between
differing cultural groups have called for care to be culturally responsive (Diaz et al.,
2015). Garneau and Pepin (2015: 9–15) developed a constructivist definition of
cultural competence that you may find useful:
• Cultural desire
• Cultural awareness
• Cultural knowledge
• Cultural skill
• Cultural encounter
Examples of where cultural dimensions might occur include a person’s’ health
and wellness belief systems; how illness, disease, and their causes are perceived; the
behaviour of individuals seeking healthcare, and their attitudes toward healthcare
providers; and importantly the views and values of those delivering healthcare. As
Szczepura (2005) states, improved openness and understanding of the health beliefs,
practices and cultural needs of individuals is essential to provide equitable and effective
access to healthcare services for all populations over and above service provision.
ACTIVITY 2.7 Reflect on how you deliver sensitive care with an attitude of openness and
tolerance.
This may require you to reflect on your own cultural beliefs
You may find the people whom you care for are the best source of evidence to
access cultural needs and as a professional you must remain cognisant of the
fact that you cannot tar everyone with the same brush. Cultural competence
and safety should not just work at an individual level, but be evident at a wider
level for the provision of care.
CONCLUSION
As services are redesigned to deliver care closer to home it is widely acknowledged
that community environments are where there is an emphasis on health promotion
and prevention of ill health. With population changes and ever-emerging
challenges, for example, antibiotic resistance, it is incumbent on the current nursing
workforce to develop an approach to community nursing that goes beyond the idea
that nursing is no more than assessing, planning and implementing/evaluating the
delivery of care associated with a set of clinical tasks. Effective community nursing
must identify and engage in public health activity, inter-agency working, multi-
agency working and research in order to promote health and well-being in society
and for individuals.
Through the presentation of relevant underpinning theory and policy this chapter
has demonstrated that public health is everyone’s business and that community
nurses are in a key position to enable and empower individuals and communities
across all levels, from some of the hard-to-reach groups in the population, such as
the housebound, to those eagerly involved with promoting their own health and
improving their own sense of well-being.
You may want to conclude this chapter by considering the following:
• What support do we need in the United Kingdom to live healthier lives?
• Thinking about the future of health and social care services, where should our
focus be?
FURTHER READING
Public Health England (2014) A framework for personalised and population
health for nurses, midwives, health visitors and allied health professional. PHE
2014532. HYPERLINK “https://www.gov.uk/government/uploads/system/
uploads/attachment_data/file/377450/Framework_for_personalised_care_
and_population_health_for_nurses.pdf.
Schulte P, Guerin R, Schill AL et al., 2015 Considerations for Incorporating “Well-
Being” in Public Policy for Workers and Workplaces. American Journal of
Public Health 105(8):31–44.
42 Public health and the promotion of well-being
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CHAPTER
3 Professional
approaches to care
Jo Skinner
LEARNING OUTCOMES
• Critically discuss the factors that influence being a professional in the context
of current healthcare practice.
• Analyse and apply ethical principles drawing on codes of practice in relation
to providing care in the community.
• Reflect critically on professionalism in relation to service user and carer
involvement and partnership working.
INTRODUCTION
The relationship between professionals and clients has been the central feature of
professional practice throughout history. Professionalism has never been more
important regarding public trust and care quality. The nature of professional practice
in the community is particularly challenging given the complex care needs, diverse
organisations and professions, as well as the need to demonstrate cost-effective health
outcomes. The relationship between service users and professionals is changing radically.
This chapter explores the transition in professional practice from a traditional,
hierarchical and individualistic model to a more inclusive partnership model.
The partnership model includes extended service user and carer involvement,
interprofessional working and a wider public health approach (see Chapters 2, 8
and 10). Throughout the chapter, issues relating to both models and ethical principles
underpinning practice are highlighted; a case study and examples from different areas
of community practice are used to illustrate the principles. There are three sections:
the first presents an overview of the traditional model of professional practice, followed
by principles informing professional practice and finally factors influencing the
development of a new extended partnership model of professional practice.
CASE STUDY Marjory Davies is 85 years old and lives alone in a three-bedroom house with
four flights of stairs. Miss Davies has had a series of falls; the most recent
fall required several weeks in hospital. Ahmed, her neighbour, had noticed
her curtains were not drawn and he alerted Miss Davies’ general practitioner
(GP). Miss Davies has returned home and the district nurse has assessed Miss
Davies to plan her rehabilitation. Her social worker has advised Miss Davies
about her options for residential care. Miss Davies has consistently refused
any suggestions that she should move out of her home.
46 Professional approaches to care
Control over who may enter these elite professions is strictly governed, usually
through a rigorous selection process. This keeps up demand for such skills by
reinforcing their status, value and power (Finlay, 2000a). Professionals can make
certain demands, including control over the way they practice, in recognition
of their unique skills and status. The process of becoming a professional entails
lengthy and rigorous training validated by peers. Historically, those elite professions
were male dominated and patriarchal in nature. Specialist literature and technical
language reinforce ‘membership of the club’, thus excluding others, particularly
their clients. As Williams (2000: 99) noted, professional autonomy ‘empowers the
strongest at the expense of the weakest’. Professional networks and associations, like
The Traditional Model of Professional Practice 47
membership of Royal Colleges, reinforce entitlement. Professional and statutory
regulatory bodies (PSRB) protect the public, policing entry onto and removal from
professional registers, for example, the Nursing and Midwifery Council (NMC),
the General Medical Council (GMC) and the Health and Care Professions Council
(HCPC). The introduction of revalidation and fitness to practice procedures
provides additional mechanisms for continuing registration.
or doctor to attend a woman in childbirth (Dimond, 2015). Such codification has led
to the creation of hierarchies even within professional groups and characterising
some groups as semi-professions, particularly along gender lines. Boundaries between
professionals have emerged such that they jealously guard them in order to protect
their roles. This can lead to resistance to change, defensive practice or tribalism
(Dalley, 1989; Evetts, 2012). This reflects the traditional view of professions in terms
of historical claims to knowledge and expertise and is ultimately an issue of power.
For many years boundaries between professions were fairly rigid and the
number of professional groups relatively stable. In primary care, the professional
hierarchy was well established (Peckham and Exworthy, 2003), with GPs at the
apex. Using prescribing as an example (Activity 3.2), traditionally doctors and
dentists were legally empowered to prescribe; in 1992 the Medicines Act (1968) was
amended so that all district nurses and health visitors were enabled to prescribe
from a community prescribing formulary with training integrated into specialist
programmes (Dimond, 2015; NMC, 2006). However, nurse prescribing was hard
won; it followed extensive pilots to address the skeptics (Brew, 1997) and was not
fully introduced until 1999. This has paved the way for prescribing rights to be
extended across nursing and midwifery and to other professional groups such as
pharmacists and physiotherapists (Radcliffe, 2008). Interestingly, not all prescribers
were granted the same prescribing rights, so new boundaries emerge, and arguably
maintain hierarchies (Williams, 2000). There is some contention about whether
such developments are extended roles or whether this is really skill substitution. In
the case of nurses they have taken on the work others, namely doctors, no longer
wish to do (Williams, 2000); however, increasing the skill mix among the workforce
has also been an important mechanism for health service managers to reduce costs
(see Chapter 14). In reality, it is a fusion of all these aspects with some degree of
compromise between the various vested interests. Boundaries for professional
practice are shifting and encompass the legal and policy frameworks within which
all practitioners operate (Dimond, 2015; Evetts, 2012).
following the scientific tradition. The standard by which professionals are judged is
in relation to their peers (Dimond, 2015; Greenhalgh, 2006). Steel (2006: 57) makes
the point that, ‘The development of a more open and evidence-based approach
to decision making in healthcare has shown how much personal values influence
professional behaviour’. Referring to public health, he warns that science is far
from being value free but that it is important to make values clear and decisions
explicit (Steel, 2006).
However, the plethora of research published means that professionals need to
be able to access, appraise and use research findings to underpin their practice
(Greenhalgh, 2006). Given the complexity of research findings, particularly weighted
towards quantitative research, this needs to be translated into guidance for practice.
Organisations such as the National Institute for Health and Care Excellence (NICE),
National Health Service (NHS) Evidence, Health and Social Care Information
Centre, King’s Fund, professional bodies and peer-reviewed journals often mediate
and disseminate guidance. The wholesale adoption of the scientific rational model
undermines the ‘art’ of professional practice, which encompasses tacit knowledge,
narrative-based approaches, service user individuality and professional autonomy.
Greenhalgh (2006) points out that professionals may be profoundly influenced by
their own experiences but this may not always be a good basis for making decisions.
It is clearly important to recognise the value of and difficulty in managing both
evidence- and narrative-based approaches. For example, an experienced practice
nurse may intuitively understand that a woman’s reluctance to have cervical
screening is due to past sexual violence. A solely evidence-based practice approach
may lead to task-focused care to obtain consent for a cervical smear and omit the
importance of human interaction and relationships as an integral part of therapeutic
care and may transgress patients’ values (see Chapter 5).
Decision making is influenced by many factors (Box 3.4) including the context
and clinical and ethical aspects (Grundstein-Amado, 1992) sitting within wider
health and social care and fiscal policies. Access to high-quality information is
required from multiple sources, with interplay between them to draw rational
conclusions which can be justified.
Respect for autonomy: Individuals have the right to make their own
decisions. Professionals must respect the decisions that service users make
and ensure their practice is consistent with this (e.g. informed consent).
There are exceptional circumstances where individuals are unable to make
decisions; professionals must understand the circumstances and legislation
that override this self-rule principle.
Justice: Care must be equitable in terms of need and access to resources. In the
community this may be a challenge as there will be unequal circumstances
and resources affecting quality of care, for example, housing, access to
family support or respite. This does not mean that equal time or care has to
be allocated among service users but that there should be equitable provision
relative to the assessed needs (Thompson et al., 2006). For example, Gerrish’s
(1999) research showed that there was unequal access to district nursing
services for ethnic minority patients because of the way district nursing
services were aligned to different GP practices.
52 Professional approaches to care
INFORMED CONSENT
The following conditions need to be present in order for consent to be informed and
thereby valid:
1 Sufficient information is made available in order to make a decision, including
the potential risks and benefits.
2 The information relevant to the decision must be understood.
3 That information must be used or considered as part of the decision-making
process.
4 Consent must be voluntary and without any undue pressure.
In law anyone over 18 years is deemed to be capable of giving consent unless
there is evidence to the contrary (Dimond, 2015). In the case of Miss Davies, staff
may wish to ensure that she is not only capable of making the decision under the
Mental Capacity Act (DH, 2005) but also that there is no undue pressure placed
on her to comply with professional advice. Vulnerable people may be susceptible
to others’ suggestions, feeling they have to comply for fear of losing services or
because they wish to be helpful. It may also be the case that older people are used to
a paternalistic approach where professionals are seen as expert, not to be challenged,
and it is assumed that they always act in the patient’s best interest. In Miss Davies’
case, both the district nurse and social worker will need to work collaboratively to
ensure that she feels supported in whatever decisions she makes and that there are
no mixed messages from them.
Children are also vulnerable: those 16 years and over are deemed as having the
capacity to give their consent. However, the legal position is different for those
Professional Values 53
under 16 years as children do not have a statutory right to give consent to treatment
and Gillick competency must be applied (Dimond, 2015). If the child is mature and is
able to understand the nature, purpose and likely effects of any proposed treatment,
then valid consent could be given without the involvement of the parents (Dimond,
2015). For example, where a school nurse is asked for contraceptive advice by a
young person under the age of 16 years, in making her assessment the nurse would
need to satisfy herself not only that the young person understood the significance
but also that exceptional circumstances applied (see Dimond, 2015). Assumptions
should not be made that informed consent cannot be given purely on the basis of
age or condition such as learning disabilities or dementia (see Chapter 16).
PROFESSIONAL VALUES
Alongside these ethical principles, all professions have their own values and
concepts that guide and shape practice, providing a means to explore with others the
nature of practice and need to be shared (Dominelli, 2009) (Box 3.5). An important
aspect of working in the community is the quality of the service user-practitioner
relationship, which is key to providing care that is personalised and effective.
Community nurses get to know well service users, families and their circumstances
over a period of weeks, months and even years, providing care continuity. Luker’s
(2002) study on community nurses’ construction of quality demonstrates where the
‘centrality of knowing the patient and his/her family was an essential antecedent
to the provision of high quality palliative care’ (Luker, 2002: 775). This value of
knowing the patient is held in high regard in the community and becomes the crux
of person-centred care (The Health Foundation, 2016; NICE, 2015). For example, in
Miss Davies’ case, the district nurse should seek to establish a relationship stemming
from the first assessment and subsequent care planning to adopt a collaborative
approach. This is where patients are fully engaged in managing their own care, but
this is only possible if they feel confident expressing their needs and preferences,
resulting in better outcomes (Coulter et al., 2016).
Values need to be shared; at the abstract level they are less problematic but the
context in which they apply is where conflict may arise (Dominelli, 2009). Williams’
(2000) research showed that despite shared values of caring, compassion and holism
between GPs and community nurses, these values were perceived differently by both
professional groups, which fuelled communication difficulties. Thompson et al.
(2006) state that what appears to be a moral dilemma is more due to inadequate
information or a breakdown in communication. Communication is central to all
aspects of professional practice and is an area that has warranted numerous policy
and practice initiatives to enhance it. For example, the single assessment process
(SAP) was designed to overcome difficulties in sharing information and duplication
for service users (Miller and Cameron, 2011; Worth, 2001). In the case of Miss
Davies, a joint assessment ought to result in a comprehensive plan addressing her
needs and preferences (see Chapter 7). There is variable support for SAP, which may
indicate a failure to understand the values of those who need to use it. Conversely,
the learning disabilities hospital passport identifies the individual’s needs and
preferences in advance and crucially is owned by them; it has proven to be an
essential document that has saved lives (Skinner, 2011).
The traditional model pre-dates formal codes of practice; it reflects the utilitarian
principle of best interest that bypasses the service user undermining the principle of
autonomy. Autonomy is further codified in the Human Rights Act (1998). Conflict
may arise between service users’ rights and the professionals’ duty of care – that is
confidentiality, right to privacy or freedom from discrimination (Thompson et al.,
2006; O’Keefe et al., 1992).
Box 3.6 Excerpts from HCPC, NMC and GMC codes of practice
HCPC (2016)
1.1 You must treat service users and carers as individuals, respecting their
privacy and dignity.
2.2 You must listen to service users and carers and take account of their
needs and wishes.
Professional Codes of Practice 55
While there has been increasing convergence in these codes (Box 3.6), there is
a need for a shared code of practice for health and social care professionals based
on common ethical principles and values, reflecting a human rights approach.
Health and social care professionals are required to keep confidential service users’
information, which is reinforced in the respective professional codes of practice
(NMC, 2015; HCPC, 2016; GMC, 2013) and legislation (Data Protection Act,
1998). However, failure to share vital information with other professions about
service users may not only be inefficient but harmful and in some cases fatal,
most notably in child protection (Laming Lord, 2003) and mental health (Cold,
1994). Paradoxically, professionals may use their codes of practice or legislation
inappropriately, practising defensively and inhibiting partnership working.
Such codes may inadvertently reinforce boundaries and stereotypes between
professional groups and represent a conflict of values. Although confidentiality is
a common value it does not mean that service users’ information can be shared
automatically. The Data Protection Act (1998) governs the way in which information
is collected, stored and shared (Box 3.7).
In the case of Miss Davies, the district nurse and social worker may share
information through the SAP, and in practice formal agreements are made between
organisations with shared service responsibilities. Barriers between organisations
and interprofessional working are increasingly being addressed through integrated
services (Cameron et al., 2012).
In the community professionals hold a great deal of power over service users due
to the invisible nature of the work, staff must be completely trustworthy and uphold
codes of practice, to which they are held to account. Staff too may be vulnerable
to accusations that may be hard to defend, such as elder abuse or stealing from
patients. The expected altruism by professionals working in a service user–centred
approach may be countered by how professional power continues to be exercised
and maintained beyond direct practice (Box 3.9).
• Are self-interested
• Maintain status quo
• Are incapable of self-regulation
• Retain power
• Block change including policy implementation
• Hide behind rules and regulations or may flout them as a defensive practice
Revalidation
• is the process that allows you to maintain your registration with the NMC;
• demonstrates your continued ability to practice safely and effectively, and
• is a continuous process that you will engage with throughout your career.
Revalidation is the responsibility of nurses and midwives themselves. You are
the owner of your own revalidation (NMC, 2017: 6)
58 Professional approaches to care
Service users are generally less reliant on professionals as sole experts or keepers
of professional knowledge. Access to the Internet, promotion of self-care and the
need to involve service users more means that professionals are less able to hide
behind jargon or use terminology that excludes service users. However, for more
vulnerable service users this should not be assumed and all patients have a right to
be consulted (DH, 2015).
New professionalism?
Although a number of changes have taken place following the reappraisal of
professions, professionalism remains a fluid concept and a contested area (Evetts,
2006a, 2012). There is no consensus among researchers about what professionalism
is, but the attributes of professional behaviour have been easier to identify (Parker
et al., 2006). Parker et al. state that ‘the attributes identified as most indicative of
professionalism seem to be the subjective, value-laden types such as integrity, regard
for the patient and interaction with others’ (Parker et al., 2006: 96). The notion that
‘good practitioners’ know what is quality care is a dated view (Katz et al., 2007).
Coulter’s (2005) work identifies that patients want professionals who communicate
well, keep up to date in clinical knowledge and skills, enable participation in decisions
about care and provide emotional support, empathy and respect. Communication
skills are inextricably bound up with the quality of the patient’s experience
(Leatherman and Sutherland, 2007; Freeman and Hughes, 2010).
The balance of power towards service users is changing through a process
of deprofessionalisation and patient empowerment (Finlay, 2000b; APPG,
2014); however, many accept that the ‘traditional’ concept of professionalism is
anachronistic and that there has been a paradigm shift to a new norm which is
just as problematic to articulate (Davies, 2007; Evetts, 2006a, 2012; Coulter et al.,
2016).
Indeed, it is recognised that no single profession is able to meet the health and/
or social care needs on their own. In the last half century, myriad new specialties
and professions have emerged as healthcare becomes more complex. This has led to
greater crossover of traditional roles like prescribing or approved social workers.
In many cases this facilitates better access to health and social care services but
highlights an increased need for partnership working.
This contrasts with the apprenticeship learning in the traditional model. In the new
model of education (and practice) service users participate as experts by experience
(Skinner, 2011). Service users in effect now have a quasi-regulatory function locally,
by sanctioning aspects of professional education. This could lead to a new form of
professional accountability which is shared with or ‘controlled’ by service users,
though professionals decide which service users are involved (Skinner, 2011).
FURTHER RESOURCES
www.cqc.org.uk – Care Quality Commission
www.evidence.nhs.uk – NHS Evidence
www.hscic.gov.uk – Health and Social Care information Centre
www.kingsfund.org.uk – King’s Fund
www.nice.org.uk – NICE (National Institute for Health and Care Evidence)
www.wales.nhs.uk/sitesplus/829/opendoc/167542 – Health and Social Care Working
Together (2010) examples of good practice in Wales
REFERENCES
All Party Parliamentary Group (APPG) (May, 2014) Patient Empowerment: For Better
Quality, More Sustainable Health Services Globally. A Report by the All Party
64 Professional approaches to care
4 Managing risk
Jayne Murphy and Debra Smith
LEARNING OUTCOMES
• Explore issues relating to risk assessment of personal safety for nurses
working in community settings.
• Explain the importance of preparation needed prior to visiting patients and
clients in their homes.
• Critically discuss the implications of risk and use of risk assessment of
patients in a community setting.
• Consider the principles of safeguarding individuals in the community.
INTRODUCTION
Working in the community provides many challenges and opportunities. The
transition to a non-hospital setting as a student nurse or embarking upon a
career as a community staff nurse, requires health professionals to reflect upon
their own and others’ personal safety, as there will be many situations where the
nurse may find themselves working alone. This may include working alone in
patients’ houses, or working out of hours, weekends and evenings where staff
are required to access buildings or other work environments. The importance
of appropriate induction and mentorship is crucial to staff who are new to the
community setting, to prepare and support them in adapting to this new way of
working (Drew, 2011). Working alone enhances the importance of appropriate
risk assessment, identification and management in two respects: risk to self and
risk to others.
This chapter explores risk from both aspects. The first section of this chapter
explores the safety of nurses working in community settings. This includes
preparation for home visiting, car safety and the principles of risk management.
Risk assessment is fundamental to support the health and safety of both patients
and nursing staff (Brennan, 2010), and is part of the clinical governance
structure of the organisation. The second part of this chapter focuses upon risk
to others, primarily patients and the potential risks to them associated with
long-term conditions and living alone. Predictive risk, the use of tools to assess
readmission and admission of patients is discussed as well as exploring the
care of vulnerable groups, including those with mental health problems, older
people, adults and children.
Preparation for Home Visiting 69
RISK ASSESSMENT IN RELATION TO COMMUNITY NURSES
Personal safety
This section includes the considerations for preparation for home visiting, car safety
and organisational support. These issues will be followed by an exploration of the
principles of risk management.
ACTIVITY 4.2 Review your local policy for lone working, and discuss your findings with an
experienced colleague/mentor. Consider whether you will be required to visit
out of hours and the local policy to support staff which may involve visiting in
pairs. It may also be useful to review the local policy for violence, aggression
or harassment.
Before setting out to visit, it is best practice to gather as much information
as possible. A survey by the Royal College of Nursing (2007) highlighted that
risk assessments are not always considered before first visits and this could
potentially put individuals at increased risk. It is important to locate and
become familiar with your own organisation’s Lone Working Policy.
should make sure that any concerns are shared. Things to think about include does
the patient live alone, who else is in the house? Are there any previous issues with
violence or aggression? Are there any pets in the house? Look at the location of the
visit – think about how you will get there.
Always remember that home visits, however welcome by the patient or client, are
an invasion of that individual’s space (Table 4.1). It is important to remember that
the nurse does not have right of entry into the patient’s house. Even when invited,
if the patient asks the nurse to leave, and she does not, then the nurse is actually
trespassing (QNI, 2013).
The community nurse is a visitor in the patient’s home and must wait to be
invited in. It is good practice to discourage patients from leaving notes (for example,
‘please come round to the back – door open’) and hanging keys on strings behind
letter boxes. These strategies, obviously, put patients at risk from unscrupulous
opportunists and should be discouraged. In addition to these measures, the
community nurse should offer personal identification.
Considerations Rationale
Remember that you are the visitor. It is the patient or client’s space that you are invading – it is unknown
what is or has recently been happening within 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 worn)
have come. Show your identity badge. or will be expecting the visit. It is good practice to encourage patients
and clients to ask to see identification. This protects them as well as the
professional.
Wait to be invited into the house and ask Being pushy can make people irritated and angry. It may not be
which room the patient or client would convenient for the patient or client to allow you into a particular room.
like you to use for your visit. This may be for good reason, e.g. if an unpredictable dog is shut in there!
Note the layout of the house – exits, Do this 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 is
which information is given and care carried the patient or client’s home.
out. Do not react to conditions which
may seem unacceptable – dirty, smelly
environments, for example.
Trust instinctive feelings. If you feel that Often assessment of situations takes place on many levels. If
leaving quickly is the thing to do – go. uncomfortable feelings are building up do not wait until there is an
incident.
If prevented from leaving, try not to panic It may be possible for you to de-escalate the situation.
– see the section relating to interpersonal
relationships.
Car Safety 71
The majority of home visits are very welcome to the patient or client. Relationships
between community staff and the people they care for can be very positive and a
rewarding aspect of working in primary care. With thought, observation and self-
awareness many potential problems may be avoided.
CAR SAFETY
Working in a community setting involves being mobile (Griffith and Tengnah,
2007) and for most community staff, this involves the use of a car.
Some practical measures need to be undertaken relating to car safety (Table 4.2)
and areas between car parks and clinic/surgery buildings should be well lit. The
nurse should also be aware of the type of car insurance needed when working in
the community.
In addition, it is helpful to plan the route to the destination with care. As the
geography of the area becomes more familiar, this will become easier. Try not to
give the impression that you are unsure of the way. Some police experts are now
recommending that car doors are kept locked while driving in more dangerous
areas. Good preparation for the journey makes it more likely that the nurse will
arrive at the patient’s home feeling calm. It is better to avoid road rage – especially
if it is your own.
Community nurses should appear purposeful, confident and in control when
walking between car and house. Walk towards the curb side of the pavement and
away from alleyways and hedges. Footwear should be comfortable and allow for
speed, if necessary. It is not a good idea to wear jewellery at work for many reasons.
Chains may catch or be pulled; rings and wristwatches are a hazard to patients and
clients if physical care is needed. In addition to these (well-known) considerations,
jewellery could catch the attention of muggers.
It is important to remember that insurance cover from employers relates to the
duration of the shift.
Consideration Rationale
It makes sense to ensure the Not only is it inconvenient, it may be hazardous to break down in a remote place after
vehicle is well maintained. 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 in remote or
unsavoury places.
Park with thought. Look for safe parking places. In the dark it is helpful to find a street light to park
underneath. Try to park near to the destination.
Take out breakdown cover. At least someone is coming to assist you. Always state that you are alone and make it
clear if you are female.
Keep any nursing bags out Some people may believe that nurses carry drugs in their bags – prevent temptation.
of view – in addition to any
personal valuables.
72 Managing risk
ORGANISATIONAL SUPPORT
Organisations that fail to make sure that their employees drive safely may face
prosecution. Police may investigate whether basic checks have been made by
management (such as whether vehicles have MoT certificates and insurance for
business use). There may also be issues around excessive demands being made on
staff (Griffith and Tengnah, 2007), such as driving when tired.
Under the 1974 Health and Safety at Work Act and the Management of Health
and Safety at Work Regulations (1999), employers have a duty to provide a safe
working environment. Along with the responsibilities for employers there are
requirements that need to be carried out by employees. First, locate any policies and
procedures that exist locally relating to health and safety. Study these carefully and
note the reporting arrangements that are laid down for staff to follow.
Nurses must work within the parameters of their Professional Code (NMC,
2015), and this should be enabled by employers.
It is good practice to ensure that your work colleagues are aware of your
whereabouts during the day. In addition, contact the work base at the end of the
day to let someone know that visits are complete. The team leader or deputy will
delegate visits to each member of the staff and will co-ordinate the team. The order
in which visits are carried out may not be predictable, but someone will know where
each nurse should be visiting on a daily basis.
Most community nurses have the use of a mobile telephone, which can be useful in
difficult situations. You need to ensure that your phone has sufficient charge for the
day. It may not be possible, however, to access the 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. The Suzy Lamplugh
Trust (see Further Resources) offers information about personal safety and car travel.
Assessment of risk is a requirement to minimise potential harm and community
nurses need to consider safety issues from both practical and professional perspectives.
1 Identify the Consider things that may have gone wrong in the past, including near-miss incidents.
hazard(s) – What
can/may go
wrong?
2 Identify who is at Specify who could be harmed by the risk. This could include other members of the nursing
risk – Who might team, other professionals and laypeople.
be harmed and
Remember that employers have their own duty of care for personal health and safety.
how?
3 Evaluate the risk Assess the seriousness of the situation. Identify what can be done to minimise or eliminate
and decide on the risk to protect those who could be harmed. Senior nurses will carry out the assessment
precautions. of the risk with contributing evidence from the team. However, risk assessment is
everyone’s responsibility in order to identify and report potentially hazardous situations.
This may include the use of the organisation’s risk matrix.
4 Record the Decisions taken and workable measures to minimise the risk must be documented.
findings and This provides a working plan for staff and managers outlining all of the above in addition
proposed to steps that may still need to be taken. Be sure to record events accurately (NMC, 2015).
actions. Documentation needs to be comprehensive and accurate, containing a full account of
intervention and assessment of the situation (NMC, 2015). Avoid the use of jargon and
abbreviations. Incident-reporting systems exist to protect the safety of patients and staff
(Armitage, 2005; Evans et al., 2007).
Poor communication of risks can result in misunderstanding and failure to pass on vital
information to other colleagues.
5 Review and Assessment is a dynamic process. It is important to revisit the document, particularly after
revise the incidents are reported. Staff training and communications should also be reviewed.
assessment as Policies and procedures need to be current, available to those who need them and
necessary. comprehensive. In order not to compromise patient care, care plans need to be regularly
reviewed and updated so that staff are clear what has been found on assessment and what
interventions are required.
Patient safety concerns everyone in the National Health Service (NHS), and it is
crucial that every member of the staff is aware of these issues. Recent government
policy focuses on the delivery of safe, effective, high-quality patient-centred care
(DH, 2016a). This can only be achieved if professionals and organisations work
within a culture of open information and take responsibility for their contribution
to the patients they care for.
74 Managing risk
ACTIVITY 4.4 Identify whose responsibility it is to review the health and safety policies in
your area. Find out where these are kept and how often they are updated.
Reflect on your own responsibilities in relation to health and safety. Discuss
with your team leader/mentor any education or training that you may need to
undertake.
A very useful publication by the National Patient Safety Agency is Seven Steps
to Patient Safety for Primary Care (2009), a guide to best practices describing key
areas of activity that primary care organisations and teams can work through
to safeguard their patients (Table 4.4).
for atrial fibrillation and stroke risk (Lewis et al., 2011). Some predictive models
currently in use in England are the Patients at Risk of Readmission (PARR 30)
(Billings et al., 2012) and the Combined Model (Lewis et al., 2011). Scottish Patients
at Risk of Readmission (SPARRA) has also been successfully used, in Wales, Prism
(Predictive Risk Model) has been utilised (Hutchings et al., 2013) and Northern
Ireland have used PARR models (Lupari, 2010). Predictive models identify patients
at the highest risk of hospital admission and allow clinicians to engage with
high-risk patients to instigate behavioural or treatment changes and introduce
preventative measures to reduce risk (Billings et al., 2012). However, few prediction
models have been validated and evidence about their effects on patient care is
limited (Hutchings et al., 2013). Nonetheless, risk stratification is incorporated in
general practitioner (GP) contracts in England (British Medical Association [BMA],
2015) and the importance of admission avoidance remains a significant theme in
commissioning services throughout the United Kingdom.
ADULTS AT RISK
Within the community setting, it is difficult to offer any single definition of the
term ‘vulnerable’ and often the concept of vulnerability is open to interpretation by
health professionals. In fact, the term ‘vulnerable’ is now considered as contentious
because it is deemed to appear as though the cause of abuse is located with the
victim, rather than placing the responsibility on the action or omission on others
(Smith et al., 2010). The preferred term currently is ‘adults at-risk’, although
vulnerable is still used. It generally refers to older adults who may be frail due to
ill health, physical disability or cognitive impairment, have a learning disability,
physical disability or sensory impairment, have a mental health need, a long-term
illness, misuses substances or alcohol, is a carer or is unable to demonstrate the
capacity to make a decision and is therefore in need of support (Social Care Institute
for Excellence, 2015). For the purpose of this chapter, the issues of mental health,
falls and safeguarding will be considered in respect of community nurses and their
involvement in the care of adults and children at risk.
nurse’s role in identifying people who require investigation in order to discover the
causes of cognitive impairment is a crucially important part of improving access to
diagnosis and treatment (Nazarko, 2014).
Depression and anxiety are common mental health problems; they are thought
to affect about 1 in 10 people in the general population at any time and are the
third most common reason for people visiting the GP (Haddad et al., 2011).
Available data indicate that fewer than one-third of adults with depression obtain
appropriate professional treatment. This is attributed, among other reasons, to
the under-recognition of the problem by health professionals (Lazarou et al.,
2011). Depression can happen suddenly as a result of physical illness, experiences
from childhood, unemployment, bereavement, family problems or other life-
changing events. Symptoms include tiredness, sadness that does not go away, loss
of confidence, not enjoying things that are usually pleasurable, feeling anxious all
the time, sleeping problems, feelings of guilt or worthlessness, appetite changes,
thoughts of suicide (Mental Health Foundation, 2006).
Anxiety is one of the most common mental health problems in the United
Kingdom and it is increasing. Yet, it remains under-reported, under-diagnosed
and under-treated. Experiencing anxiety too much or too often presents the risk
of becoming overwhelmed, unable to find balance in life or the ability to relax
and recover. Estimates of the number of people who experience anxiety vary
because of the different methods for gathering data and the different criteria
used in identifying it (Mental Health Foundation, 2014). In order to improve
recognition of mental health problems, it is imperative for nurses and especially
those working in community settings to appreciate the importance of prompt
diagnosis which presumes both an understanding and knowledge of basic aspects
of the problem and, an understanding of their role in dealing with depression
(Lazarou et al., 2011).
FALLS
Falls leading to injury are the leading cause of accident-related mortality in older
people. Falls among older people are recognised internationally as a risk to older
adults, with the World Health Organization (WHO) producing a global report on
falls prevention (WHO, 2007). Guidance, reports and initiatives on falls prevention
abound, acknowledging the magnitude of the effects of falls on individuals and
society (National Institute for Health and Care Excellence [NICE], 2013, 2015; Age
UK, 2013; NHS England, 2015). Falls and fractures, in people aged 65 and over
account for over 4 million bed days each year in England alone and the healthcare
cost associated with fragility fractures is estimated at £2 billion a year. Falls often
lead to reduced functional ability and thus increased dependency on families,
carers and services (Royal College of Physicians, 2011).
Falls destroy confidence, increase isolation and reduce independence, with around
1 in 10 older people who fall becoming afraid to leave their homes in case they fall
again (Age UK, 2013).
There are many different reasons why people fall and in many cases, it is a
combination of risk factors that leads to a fall, such as different medications or
medical conditions, poorly fitting footwear or just the physiological conditions
associated with ageing, such as natural deterioration in eyesight and muscle
strength. A good assessment is essential when it comes to determining the causes of
and effective treatment for a fall. A multifactorial risk assessment is paramount and
80 Managing risk
Reflect upon an older person you have visited recently. Consider their home
environment and identify any hazards that may impact on their health and
well-being. Discuss with a colleague ways that you can advise this person to
keep himself or herself safe.
With the older population increasing, it is recognised that the consequences
of frail individuals falling will pose a greater challenge to both health and social
care services. Find out about the falls prevention service in your area. Identify
the criteria for referring a client.
for child abuse including living in an environment where domestic violence takes
place, having parents with mental health or substance misuse issues, or living in
poverty (GMC, 2012). It is important to remember however, that these issues do
not necessarily lead to abuse or neglect, as child abuse exists in all areas of society.
In some instances, abuse may result in children being taken into care where a
small number of them remain at risk of abuse, neglect or poor standards of care
from those who are looking after them (Biehal et al., 2014). In the longer term,
when compared with their peers, ‘looked after children’ generally have poorer
outcomes in terms of education and mental health. Many experience poverty,
isolation and housing and employment problems in adult life. A child protection
issue or concerns regarding the possibility of abuse may arise in a variety of
nursing encounters, even when the initial encounter has a completely different
focus. It is possible that nurses who are new to the community environment
may have received little training and preparation for this element of their role.
Furthermore, nurses must recognise the importance of working collaboratively
with other health professionals, so that if a nurse suspects that a child is subject
to harm or neglect, the nurse has a responsibility to refer their concerns to
appropriate personnel (DH, 2015b). This can be a very difficult area of nursing
practice which needs to be addressed in a sensitive manner, and with appropriate
education and training.
All employers have a duty to ensure that the workforce is competent in the area
of adult abuse, child protection and safeguarding. All staff should know what to
do if they suspect abuse, or a possible child protection issue and should be able to
recognise key indicators that suggest that the individual is a risk of harm or neglect
(RCN, 2014; Commissioner for Older people for Northern Ireland, 2014). Often,
inter-agency training is delivered, as it is thought to improve collaborative working
processes between professionals involved in child protection issues (Charles and
Horwath, 2009). The key principles of safeguarding adults include the following:
• Empowerment – Focus on person-led decisions and informed consent
• Prevention – Better to take action before any harm occurs
• Proportionality – The least intrusive response appropriate to the risk presented
• Protection – Support and representation for those in greatest need
• Partnership – Communities working together as they have a role to play in
preventing, detecting and reporting neglect and abuse
• Accountability – Accountability and transparency in delivering safeguarding
(DH, 2013)
Working Together to Safeguard Children (DH, 2015a) suggests that all training
in safeguarding and promoting the welfare of children and young people should
be child centred, promote the participation of children and their families in the
process, value collaborative working, respect diversity and promote equality (DH,
2015b). Effective communication and partnership working are recognised as key
areas in the identification of vulnerable children and protecting them from abuse
(Welsh Government, 2014).
Safeguarding Adults, Children and Young People 83
To understand and identify significant harm to a child, it is necessary for health
professionals to consider
• The nature of harm, in terms of maltreatment or failure to provide adequate care
• The impact on the child’s health and development
• The child’s development within the context of their family and wider environment
• Any special needs, such as a medical condition, communication impairment or
disability, that may affect the child’s development and care within the family
• The capacity of parents to meet adequately the child’s needs
• The wider and environmental family context (DH, 2003)
Furthermore, it is paramount that the child’s needs are put first, and that health
professionals ensure that children are listened to and understand the decisions that
affect them (Scottish Government, 2014).
Please carry out the next activity to supplement your developing knowledge in
this crucial area of practice.
ACTIVITY 4.6 Find out who the lead person is for safeguarding and child protection issues
in your organisation. Identify the local policy and guidelines, read them and
discuss the referral process with a colleague.
ACTIVITY 4.7 Consider the following case studies and discuss any safeguarding issues or
concerns raised with your team leader/mentor:
Jamie is a 3-year-old boy who you meet at the GP practice. He lives with his
20-year-old mother. It is a cold rainy day, but you notice that Jamie only has a
thin shirt under his anorak. He is also wearing sandals. On speaking with his
mother, she tells you that the staff at the nursery where Jamie attends have
spoken to her about his increasingly aggressive behaviour towards some of the
other children. Later, when discussing with your colleagues, you discover that
Jamie has missed many of his regular, routine health checks, and is not up to
date with his vaccinations.
Gladys is 75 years old and lives with her husband George in a bungalow. She
has been visited several times by the nursing team over recent months. Gladys
was diagnosed with dementia several years ago, and depends upon George
for helping with her daily activities. You are visiting Gladys to assess a small
laceration which she has sustained to her shin following a fall. During your
visit and assessment, you notice that Gladys has some bruises on her upper
arms. When talking with Gladys about the bruises she becomes upset and
withdrawn. George also appears agitated and anxious.
The above text and activities are designed to assist you in developing your
professional practice with at-risk groups. You will need to ensure that this aspect
of your work is regularly updated in line with organisational processes and
policies.
84 Managing risk
CONCLUSION
After careful consideration of the issues addressed within this chapter, turn back
to the learning outcomes at the beginning and think about each one in turn. Look
back and reflect upon the notes made for the first activity at the beginning of this
chapter.
If this chapter has raised any concerns for practice, it is important that they are
discussed with an experienced community nurse, either informally or through clinical
supervision channels. Some useful addresses can be found at the end of this section.
Remember that the majority of staff working in community settings enjoy a close
partnership with their patients and clients. The health centre or surgery is at the
heart of the local community and relationships may build over a number of years.
Visiting patients and clients in their homes is a privilege that greatly enhances the
experience of community nursing. Taking practical precautions and taking time to
think about the assessment of risk and preparation are crucial elements of nursing
in the community.
FURTHER READING
Beckett C (2007) Child Protection: An Introduction, 2nd edn. London: Sage.
Corby B (2006) Child Abuse: Towards a Knowledge Base, 3rd edn. Berkshire: Open
University Press.
Powell C (2007) Safeguarding Children and Young People. A Guide for Nurses and
Midwives. Berkshire: Open University Press.
Scottish Government (2008) Getting it Right for Every Child. Edinburgh: Scottish
Government.
FURTHER RESOURCES
www.cqc.org.uk – Care Quality Commission
www.gov.uk – Department of Health
www.hse.gov.uk – Health and Safety Executive
www.suzylamplugh.org – The Suzy Lamplugh Trust
www.nmc-uk.org – Nursing and Midwifery Council
www.npsa.nhs.uk – National Patient Safety Agency
www.rcn.org.uk – The Royal College of Nursing
www.unison.org.uk – Unison
http://www.unitetheunion.org/how-we-help/list-of-sectors/healthsector/
healthsectoryourprofession/cphva/ – CPHVA/Unite
www.mind.org.uk – Mind Organization
www.alzheimers.org.uk – Alzheimer’s Society
www.mentalhealth.org.uk – Mental Health Foundation
www.wales.gov.uk – Welsh Government
www.gov.ie – Irish Government
www.gov.scot – Scottish Government
References 85
REFERENCES
Age UK (2013) Falls Prevention Exercise—Following the Evidence. London: Age UK.
Age UK (2014) Policy Position Paper Loneliness and Isolation (UK). London: Age UK.
Age UK (2015a) Evidence Review: Loneliness in Later Life. London: Age UK.
Age UK (2015b) Safeguarding Older People from Abuse and Neglect. Factsheet 78. London:
Age UK.
Age UK (2016) Later life in the United Kingdom. Age UK. http://www.ageuk.org.uk/
Documents/EN-GB/Factsheets/Later_Life_UK_factsheet.pdf?dtrk=true.
Alzheimer’s Society (2015) Dementia 2015: Aiming higher to transform lives. London:
Alzheimer’s Society.
Armitage C (2005) TRAIL: A model to promote active learning from adverse events.
Quality in Primary Care 13:159–62.
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CHAPTER
5 Therapeutic relationships
Jacqueline Corbett, Patricia Wilson and Sue Miller
LEARNING OUTCOMES
• Identify the features and potential benefits of a therapeutic relationship.
• Discuss some of the challenges for community nurses in establishing a
therapeutic relationship.
• Critically examine the challenges involved and potential consequences of
failing to establish or maintain a therapeutic relationship.
• Analyse the impact of changes in policy on the development of therapeutic
relationships.
INTRODUCTION
This chapter focuses upon the relationship that exists between the nurse, the person
being cared for and their family. It is recognised that such a relationship should be
therapeutic and indeed this is essential to the delivery of effective nursing care.
However, it is unwise to assume a therapeutic relationship will automatically occur,
as there are many challenges in establishing and maintaining such a relationship in
community settings. In this chapter the key features and benefits of a therapeutic
relationship will be identified; in addition, some of the challenges of establishing
and maintaining that relationship in a community setting will be discussed. This
will lead the reader to consider issues of particular relevance to those people receiv-
ing his or her community nursing care, to explore some of the consequences of
failing to establish and maintain relationships and to identify ways to achieve posi-
tive therapeutic relationships. In conclusion, the current and potential changes in
healthcare delivery and policy drivers will be reviewed with particular reference to
the way these changes might impact on the nurse/person/family relationship.
Varying titles exist for people receiving healthcare in the community often
reflecting different community nursing services involved in such care. In this text
‘person’ is generally used as the preferred term and refers to individuals who may
also be identified as patient, client and service user within clinical practice.
embracing the physical, emotional and spiritual needs of the person. The recogni-
tion of the importance of the therapeutic relationship is not a new phenomenon.
Peplau’s (1952) theory of nursing is based upon the importance of the relationship
between the nurse and the individual. She asserts this is pivotal to the way in which
all nursing care is delivered. The importance of this relationship has continued to be
widely acknowledged. It is recognised as central to advancing the best interest and
outcomes for the person and the families (Porr et al., 2012; Canning et al., 2007).
However, discussions regarding the quality of relationships inevitably introduce a
degree of subjectivity. Furthermore, the inter-subjective qualities involved in thera-
peutic relationships such as empathy, respect, trust, positive regard, support, com-
munications skills, person- and family-centred care, acceptance, empowerment
and so on are not easily measureable (Greenhalgh and Heath, 2010). It is suggested,
however, that positive therapeutic relationships can improve communication (Porr
et al., 2015; Pinto et al., 2012; Edwards et al., 2006), achieve concordance (Martin
et al., 2005), service user satisfaction (NCSBN, 2014), help in professional fulfill-
ment, save time, empower and also reduce risk of litigation (Stewart, 2005). Since a
therapeutic relationship is so important, it is essential to consider which key fea-
tures characterise the relationship. In reviewing various definitions it becomes
apparent that important factors include
• Maintaining appropriate boundaries
• Meeting the needs of the person
• Promoting autonomy
• Providing a positive experience for the person and/or family receiving care
Promoting autonomy
Autonomy is derived from the Greek autos-nomos meaning self-determination or
self-rule. While the original meaning of autonomy relates to ‘self-rule’, it can also
refer to liberty of thought, freedom of choice, freedom of action, self-determination
and freedom from coercion (Dworkin, 1988). Therefore, it is about self-governance,
the ability to make choices and decisions about things that will affect oneself (Ellis,
2015). This further supports the need for excellent communication skills on the part
of the nurse in order to assist the person and to understand the person’s perspective
and situation. There is general acknowledgement regarding the therapeutic value of
empathically understanding the person (Clarke, 2010). Empathic understanding is
deemed to facilitate autonomy and so empathy is explored later in this chapter.
Within a relationship that promotes autonomy the person receiving care can con-
tribute to the achievement of personal goals and move towards independence.
Location of care
The delivery of care within the home can provide a feeling of security for the per-
son and his or her carers as they are on familiar territory. This can make it easier
to develop a positive relationship, such that they are able to share their concerns
and worries. It is also probable that individuals and carers will be able to learn
new skills more readily as they are likely to feel more relaxed within their ‘nor-
mal’ environment.
Factors affecting
professional and
patient relationship
However, caring in the home environment can leave the nurse feeling vulnerable.
The Queen’s Nursing Institute (QNI, 2015) highlights some of the challenges facing
community nurses, in particular if they first move from hospital-based jobs to work
in the community. Despite the use of mobile phones and pagers it is more difficult
to seek the advice of a colleague, and help may not be instantly at hand. A nurse who
feels vulnerable and isolated will find it more difficult to inspire confidence.
Working in the relative isolation of the home can provide challenges to nurses in
maintaining standards of care. If the relationship is not ‘therapeutic’ it can be difficult
for the nurse to identify this himself or herself, particularly if the situation has devel-
oped over time. The support and guidance of colleagues is essential, as is the willing-
ness of the nurse to be open to that support. It is important that peers recognise
unhealthy situations that colleagues are involved in (Halter et al., 2007). However, it
can be difficult to express concerns with colleagues and so a shared culture of open
discussion where the person is the priority as directed by Francis (2013) is essential.
Furthermore, the QNI provides a useful online resource, ‘Transition to Commu-
nity Nursing Practice’, which offers practical support and guidance for community
nurses to address personal challenges and identify sources of support which can
reduce feeling of isolation. The resource can be found at www.qni.org.
Care given by the nurse within the person’s workplace will also be different from
the more traditional hospital setting. The occupational health nurse addresses the
health and well-being of the working population in their place of work (Thornbury,
2013). They are often the first point of contact for individuals with health-related
problems. Moreover, the occupational health nurse holds a unique public health
role towards the improvement of health, social well-being and towards improving
the quality of working lives in the workplace (RCN, 2015a).
Example 5.2
Although work-related mental ill health is being increasingly recognised as a legiti-
mate occupational health issue (TUC, 2015) many employees will still consider it
detrimental for their career prospects to report mental health needs to their
occupational health nurse. The challenge for the nurse within this context is to
promote trust with the employees in order to facilitate a therapeutic relationship.
Example 5.3
Consider the scenario of the new mother trying to explain her depression to the
health visitor and how much harder this might be in a busy baby clinic rather than in
the privacy of her own home. In other cases the relative anonymity that the surgery
or clinic provides may be of benefit in facilitating the development of a therapeutic
relationship. Clearly, as a community nurse it is important to recognise the impact
that the working environment has upon relationships with people, carers, family and
colleagues. It is a key element of care influencing communication together with the
quality and safety of healthcare provided (Godsell et al., 2013). Initial assessments are
often the first point of contact between community nurse and the person receiving
care; the nurse must develop skills to enable a conducive environment, in order to
establish the start of a therapeutic relationship (Hagerty and Patusky, 2003).
Working in the community many nurses find not wearing a uniform removes an
unnecessary barrier and makes the development of a therapeutic relationship an
easier task. It does however require skills on the part of the nurse to gain access to the
a person’s home, gain the trust and explain the nursing role since a symbol, which for
many carries some degree of status, has been lost (Shaw and Timmons, 2010).
For those community nurses who do wear a uniform other challenges arise.
Wearing of a uniform can enable almost instant entry to some homes, but may pres-
ent a barrier to acceptance by some people. This may be especially apparent with
children who have perhaps learnt to associate uniforms with pain and discomfort.
In these situations it will take time to address prior conceptions before a therapeutic
relationship can be established.
If nurses do not wear a recognised uniform it is particularly important to con-
sider the appropriateness of the clothing that is worn. Entering a home inappropri-
ately dressed may cause offence and prevent establishment of a relationship. Perhaps
this might require the nurse to cover her arms and legs if visiting Asian families, or
maybe to remove shoes prior to entering some homes. In order to meet the needs of
Challenges of Developing Therapeutic Relationships in Community Settings 95
individual families the nurse must enquire about family preferences and be willing
to adapt behaviours to respect values different from her own in order to facilitate
positive relationships.
A final point about dress code: whether wearing uniform or not it is essential to
carry identification at all times in order to protect the well-being of people living in
the community.
A key element in the nature of the therapeutic relationship is the duration of the
relationship. Morse (1991) describes three appropriate relationships. First, she describes
the one-off clinical encounter that, for example, a practice nurse may have with a per-
son seeking healthcare in a travel clinic. There are also encounters that last longer but
focus on a specific need, such as maintenance of hormone replacement therapy. Both
of these relationships are mutual and appropriate to certain situations, but Morse
argues that within a much longer-term nurse-person relationship, there should be a
different focus, with the development of what she terms a connected relationship.
Morse suggests that the key characteristic of a connected relationship is that the nurse
views a person as a person first rather than a patient, client or service user, and so on.
Example 5.4
A district nurse has been visiting an elderly lady for several years.The visits now may
often include a chat over a cup of tea about how the grandchildren are progressing
or other issues in the person’s life that the nurse has developed a wealth of knowl-
edge on over the years. Although it may be a venous ulcer that initiated the referral
to the district nurse, the connected relationship that has developed with time allows
the nurse to deal with other issues that may be far more important to the person,
such as feelings of loneliness. During the chat, a skilled nurse will be able to assess for
signs of depression or other psychosocial needs that are common for people expe-
riencing long-term conditions. Although for many families and professionals this can
only be positive, there is a potential to step over the professional boundary and it is
essential to maintain the appropriate balance within the therapeutic relationship. The
consequences of not maintaining the balance will be returned to later in the chapter.
In the home environment individuals and carers could be perceived to have g reater
control within the relationship. Should a person decide not to concur with
96 Therapeutic relationships
Example 5.5
Consider the following scenario and your responses.
Rosie is 14 years old and has been diagnosed as having type 1 diabetes for
6 months. She has been asked to record her blood glucose levels once daily, varying
the time of day she takes the readings, but she finds this requirement tiresome and
does not do it. Prior to the community children’s nurse’s visit she wonders what to
do – should she make up some values to keep the nurse happy or should she tell
the truth? Hopefully if Rosie and the community nurse have a good relationship
Rosie can be truthful and they can work together on what can reasonably be
expected. A study by Schaeuble et al. (2010) found teenagers felt it took time to
develop trust in healthcare providers, with respect from the provider being a para-
mount issue. Some of the adolescents in the study stated that they withheld
information out of fear of a provider’s reactions; however, they still wanted to know
the consequences of refusing or delaying treatment. Concordance describes a part-
nership approach to treatments and care; it recognises the importance of individuals
being able to make their own decisions about lifestyle and whether or not to adhere
to advice from health professionals (DH, 2015b).Therefore, concordance returns us
to the theme of person-centred care and decision making. The subject is visited
again in the next and last sections of this chapter.
Expectations
Expectations of the nurse and community nursing service may also impact on the
therapeutic relationship. Over the past 25 years, there has been a rapid rise in consum-
erism resulting in the NHS becoming more business-like with a rise in expectation
and subject to similar consumer drivers identified in other parts of society (Sturgeon,
2014). Recent health policy emphasises person-centred choice and involvement in
care (Foot et al., 2014). Many people have clear ideas on the service they expect from
Challenges of Developing Therapeutic Relationships in Community Settings 97
community nurses, with a consequential detrimental effect on the therapeutic
relationship when these expectations either are not met or are unrealistic. However,
despite trends in healthy ageing and participation in healthcare (Healthcare Com-
mission, 2006), many older adults were brought up in a society where medicine was
seen to have all the answers and the public was expected to be the passive recipient of
care (Coulter, 1999). There is some evidence that some people do not wish to be an
active partner in the therapeutic relationship (Davis et al., 2007), and some may prefer
a more paternalistic model of care (Roberts, 2001).
The community nurse may find a challenge in helping some people to develop the
confidence and ability to self-care, and so the therapeutic relationship will be focused
on trust and the facilitation of realistic independence. Self-care is key policy strategy
for the NHS across all countries in the United Kingdom (Drakeford, 2013; DHSSPS
NI, 2012; DH, 2009; Scottish Government, 2008). Skills for Health (2015) set out
some key principles to support self-care; it involves creating environments in which
people who need care and support are perceived as active and equal partners, rather
than passive recipients. It includes self-management, which means people drawing
on their strengths and abilities to manage or minimise limitations imposed by a
condition, as well as what they can do to feel happy and fulfilled (Skills for Health,
2015). Furthermore, it is suggested by Drakeford (2013) that self-care links closely to
person-centred care, person experience, co-production and improving quality.
Therefore, the nurse ‘doing for’ the individual rather than enabling them to self-care
contradicts current perspectives on best practice (Wilson et al., 2007).
Needs
The main purpose of the nursing or health-visiting intervention may also have a
significant impact on the therapeutic relationship. The patient within the relation-
ship may have significant physical and emotional needs such as in palliative care.
The relationship developed within these cases may be based on intensive input by
the nurse (Dunne et al., 2005). In contrast, the practice nurse or occupational health
nurse may see a patient for health screening with less obvious health needs as the
focus of the intervention.
The substantial shift of care from hospitals to the community for those with men-
tal health needs (Malone et al., 2007) has resulted in a rapidly developing role for
community nurses in supporting this patient group. With approximately one in six
people at any one time experiencing mental illness in the United Kingdom and one
in four of people experiencing problems some time in their life (DH, 2011) the role
for community nurses supporting people living in the community is constantly
evolving. Recent mental health frameworks and guidance (DH, 2012; Scottish Gov-
ernment, 2012; DHSSPH NI, 2011b; WG, 2010) are firmly underpinned with focus
on the patient. However, empowering people with mental health needs and imple-
menting empowerment initiatives is often challenging. The World Health Organi-
zation (WHO, 2010) suggests it requires the person, service and societal levels to be
aligned for this to happen and for stigma, discrimination and marginalisation to be
prevented. Therefore, the therapeutic relationship with this group is essential in
98 Therapeutic relationships
Example 5.6
Imagine the case of Lily, a 75-year-old mother caring for her son Ted, who has
Down’s syndrome. She is devoted to her son and has no other life than caring for
him. The general practitioner has referred Ted for a wound assessment, but when
the nurse arrives it is apparent that Lily is exhausted by her role. The challenge for
the nurse is to establish a relationship which enables Lily to acknowledge her indi-
vidual needs and helps her to accept help without feelings of guilt. This may involve
developing a long-term relationship and not simply the organising of respite, which
many informal carers do not want (Stockwell-Smith et al., 2010).
Another frequently met scenario is that of the husband caring for his wife. He has
every detail organised and is business-like in his approach to the community nurse.
Again, this may hide a number of physical and emotional needs for which the com-
munity nurse must develop a therapeutic relationship in order to enable him to express
these. The needs of family carers should be recognised, and the community nurse must
develop a relationship and provide interventions appropriate to both the person and
the carer as individuals. You can explore carers in greater detail in Chapter 8.
Example 5.7
Consider the case of Ann, who is John’s community children’s nurse. Ann has cared
for John, aged 5, for the last 2 years and supported Gill, his single mother, through
some difficult times while John has received treatment for acute lymphoblastic leu-
kaemia. During Ann’s recent visit to the home, Gill and John invite her to John’s
sixth birthday party the following weekend. Ann considers this briefly and agrees to
come. At the end of the party, Gill asks Ann if she would be willing to babysit for
John, as ‘she’s the only person she feels she can trust to care for John’. What should
Ann do now? It would appear the edges of the professional boundary have become
significantly blurred such that Gill feels it is appropriate to ask Ann to babysit.
CONCLUSION
In this chapter features and benefits of a therapeutic relationship have been identi-
fied, leading to an exploration of some of the challenges community nurses face in
establishing therapeutic relationships. In future community healthcare provision,
challenges will be shaped by an increasingly multicultural, ageing and informed
population. The growing provision of healthcare in the community only serves to
reinforce the need to establish appropriate relationships with people receiving
healthcare in the community, their families and other carers. Current government
policy emphasises partnership in care at all levels; the challenge for the community
nurse is to develop this opportunity in everyday working practice.
104 Therapeutic relationships
FURTHER READING
Norcross JC and Wampold BE (2011) Evidence-based therapy relationships: Research
conclusions and clinical practices Psychotherapy 48(1):98–102
Smith P (1992) The Emotional Labour of Nursing. Basingstoke: Macmillan.
Theodosius C (2008) Emotional Labour in Health Care: The Unmanaged Heart of Nursing.
Abingdon: Routledge.
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106 Therapeutic relationships
LEARNING OUTCOMES
• Compare and contrast the different theories of growth and development.
• Evaluate the issues that influence caring for clients across the lifespan.
• Critically analyse how an understanding of a lifespan approach can enhance
the quality of care provision.
INTRODUCTION
This chapter explores the concept of a lifespan approach to healthcare. It is an
approach that is able to reflect on and adapt to changes in demographics, society and
the expectations of individuals within the community. The health of an individual
is influenced by a complex interaction of a range of factors including physiological,
psychological, social, cultural and environmental issues. A sound understanding of
the factors that influence growth and development across the lifespan can enable
the community nurse to adopt a truly holistic approach in the assessment, planning,
implementation and analysis of healthcare interventions; however, it is recognised
that health professionals may have distinct roles in the community, often focused
on specific stages of the lifespan (e.g. Health Visitor – child health 0–5 years). The
importance of developing a broad viewpoint and an awareness of all aspects of the
lifespan continuum should underpin effective care provision.
will frequently impact on families and carers. The challenge for the community
nurse is to recognise these influences and offer sensitive healthcare that reaches
the client and their family/carers.
BIOMEDICAL INFLUENCES
Historically, the biomedical approach has directed the organisation and provision
of healthcare and remains the dominant model in Western culture (Naidoo and
Wills, 2015; Taylor and Field, 2007). The biomedical approach ignores social
and environmental factors and taken in isolation is essentially a reductionist
method focusing on body mechanics, which assumes that the mind and body
can be treated separately and that they can be repaired (Naidoo and Wills, 2015;
Nettleton, 2013). The emphasis is on what causes illness and how it should be
treated, with responsibility for treatment seen as principally resting with the
medical profession (Ogden, 2012). Nurse education is underpinned by a sound
understanding of human anatomy and physiology, and it is essential that nurses
are able to recognise normal physiology and changes to this in order to provide
safe and effective care (NMC, 2015). This knowledge should include knowing not
only how the different organs and systems of the body work, but also how they
grow and develop. An understanding of growth norms is useful when monitoring
child health and in health surveillance. If we consider Samuel, who is rather small
for his age, knowing there is an adolescent growth spurt which differs between the
sexes, and that the male spurt although greater in intensity is usually on average
2 years behind that of females (Boyd and Bee, 2015) can enable us to determine
whether this is normal variance or not. Tools such as human growth curve charts,
which record the growth of an individual from 0–18 years, allow us to monitor and
interpret recorded results.
A sound understanding of physiological changes and the normal patterns
of ageing may aid us in the diagnosis and treatment of disease. An awareness of
biomedical aspects such as genetic programming, wear and tear theory (cells having
a specified life cycle), cell programming (cells divide until they are no longer able
to), immune theory (immune response diminishing with age) (Aldwin and Gilmer,
2013; Grossman and Lange, 2006) and how the body handles significant changes,
for example, drug administration, bacterial or viral invasion, is fundamental to
effective healthcare. Recognition that homeostasis (the ability of body systems
to maintain equilibrium) may be impaired in the very young or elderly patient is
essential knowledge for effective care provision. For example, individuals with the
influenza virus are more likely to be seriously ill and at increased risk of mortality
if they are at each end of the lifespan. Biologically this correlates with human
development and physiology, lung function continues to increase and develop from
birth until adulthood (around age 20 years) staying stable on average for around
15 years and then it begins to decline (Farley et al., 2011).
Knowledge of the stages of wound healing and the normal progression of wound
healing should underpin nursing care for Margaret and Samuel. Samuel as a young
Margaret Clay Jack Clay (deceased)
78 years 79 years
Lives in 3-bed semi-detached Married for 58 years
house urban area city outskirts Died 6 months ago
Type 2 diabetic diagnosed following myocardial infarction
10 years ago, diet controlled
Rosie Hill Samuel Hill Lauren Hill Jodie Roberts Simon Roberts
16 years 13 years 8 years 22 years 24 years
Schoolgirl Schoolboy Schoolgirl Unemployed Single
Boyfriend William Small child also overweight Asthma, recent hospital 6 months pregnant Lives in shared flat
Spends most evenings with Enjoys computer games admission ×2 Lives with mum following Works shifts in local factory
boyfriend and friends Best friend Gemma split with partner
often in local park On waiting list for re-housing
Joshua Roberts
2 years
Lively toddler
Biomedical Influences
113
healthy child will probably require little more than one or two simple dressing
changes as we would expect his wound to heal within 4–7 days. Advice to Samuel
and Sharon would focus on recognition of possible infection and risk management
(playing football) while the wound heals. However, for Margaret decreased cell
turnover, thinning of the epithelium, loss of collagen within the dermis and
a diminished immune response, factors consistent with ageing, will result in
prolonged healing and this may be further compromised by other physiological
factors such as her diabetes. Advice and management will be more complex;
establishing her understanding of why the wound is not healing and how this is
influenced by her diabetes will be essential. Using a biomedical focus to guide
practice can give the community nurse an indication of what to expect as the body
ages, although patterns of decline will not necessarily follow a predictable sequence
and may vary from individual to individual (Farley et al., 2011; Cameron, 2006).
Although crucial to care provision it is important to recognise that biomedical
factors will be overlaid by psychosocial influences.
PSYCHOSOCIAL INFLUENCES
Sociology can be defined as the study of social relationships; holistic healthcare
recognises that people’s lives and behaviour cannot be divorced from the social
contexts in which they participate (Beckett and Taylor, 2013; Taylor and Field, 2007).
Psychosocial theory attempts to explain human development in terms of individual
changes in cognitive function, behaviour, roles, relationships, coping abilities and
social change, and as such it provides insight into individual personalities and
attitudes across the lifespan. Psychosocial factors impact on health across all stages
of the lifespan in relation to onset of illness, health beliefs, health behaviour, health-
seeking advice and adaptation to, progress of and outcomes of illness (Ogden, 2012).
Life expectations and our understanding of health are not static but develop and
evolve over time and are frequently linked to our socio-economic circumstances.
Health inequalities exist in relation to social class in our society, influenced by
wealth, income and access to resources. Attitudes to health and illness may also
Psychosocial Influences 115
be shaped by generational features related to the era an individual was born into
and the social norms and expectations they have been exposed to (Barry and Yuill,
2012). For example, attitudes to smoking in the last century have impacted on lung
cancer incidence and may influence attitudes to smoking cessation advice.
The way in which we define health will impact on our life choices and subsequent
behaviour. Simon’s definition may reflect strength and fitness, whereas Carol may
focus on the ability to cope with life and the demands of work. Health perception will
vary across the lifespan and genders. Nettleton (2013) suggests that for young men it
may equal strength and physical condition, whereas for young women it may equal
vitality, energy and an ability to cope. As we age, the emphasis shifts from notions
of mental and physical well-being and the ability to do things well in middle age, to
wisdom, contentment, happiness and resilient ageing in late adulthood (Hicks and
Conner, 2014; Alder et al., 2004). Perceptions will be influenced by physiological, social
and environmental factors. For example, a working individual or young mother may
consider that she has no time to be ill and Carol’s perception will be influenced by her
rheumatoid arthritis. It is important to recognise that views on ‘what is health’ are
varied and those of our patients may well be different from our personal perspectives.
Health promotion
The promotion of health is an essential role for every community nurse, and strategies
to support healthy behaviour and lifestyle are at the heart of improving the quality
of life for individuals (Cox and Hill, 2010; Leifer and Hartshorn, 2004). Statistics on
mortality indicate that up to 50 percent of deaths from the 10 leading causes of death
in the United Kingdom can be attributed to health-related behaviour (Ogden, 2012).
116 Care across the lifespan
Sharon’s concern about the increased risk to Lauren of further asthma attacks
through spending time at her friend’s house may be tempered by the needs of
her elderly mother, work commitments and the tearful remonstrations of her
daughter. Lauren’s response is less rational and she is less likely to comprehend
the consequences of continuing with the current arrangement. Understanding of
chronic illness is dependent in some degree on the age of the child. A child aged
4–7 may perceive causality of asthma as related to magic or naughtiness; by ages
of 7–11 they may have developed some understanding of allergies; while the older
child will start to comprehend relationships (Alder, 2013). Lauren is likely to have
an understanding of the cause of her asthma but may not be able to relate this to
cause-and-effect principles and coping mechanisms (Leifer and Hartshorn, 2004).
As a community nurse supporting Sharon and Lauren, a holistic approach to care
encompasses not only the needs of the individual but the family as well. Care
delivery should recognise that the family has complex needs while encouraging
both Lauren and her family to take an active role in healthcare decisions.
Adolescents
Adolescence is a time of significant changes marking the transition between
childhood and adulthood. The characteristic physical changes of puberty are
heightened by corresponding psychosocial development. In Western society factors
such as earlier onset of the menarche and increasing time in formal education have
118 Care across the lifespan
widened the gap between physical maturity and adulthood (Alder, 2013). There is
increased emphasis on social conflicts and personal dilemmas during this time as
the individual endeavours to identify their role within society (Erikson, 1980). This
challenges and changes relationships between parents and peers, and there is often
increased conflict in families as the individual experiments with a variety of roles
and styles. Disputes are frequently related to differences of opinions around rights
and responsibilities (Boyd and Bee, 2015; Alder et al., 2004). In our case history Rosie
is frustrated by the attitude of her parents who consider her old enough to babysit for
her younger siblings but not old enough for a sexual relationship, whereas from Peter
and Sharon’s perspective, Rosie wants sexual freedom without the responsibility of the
potential consequences. The challenge of achieving a sense of self and independence
may impact on healthcare, which may be particularly relevant for adolescents with
a long-term condition. Peer pressure and the need for self-identity may mean that
social logic replaces that of medical logic (Nettleton, 2013).
It is important to take an approach which establishes a level of trust with Rosie.
Rosie may be worried about the community nurse sharing information with her
parents; therefore, an honest approach is important. It is important to take adolescents’
psychosocial and cultural experiences and expectations into account (Briggs, 2010).
Although Rosie’s pregnancy test was negative, she needs advice on sexual health
in the future as adolescents are likely to have a greater sense of invulnerability in
relation to risk taking and are also influenced by peer group norms and pressures
(Beckett and Taylor, 2013; Ogden, 2012). The community nurse needs to adopt a non-
judgmental, approachable and friendly attitude in providing advice and support.
The emphasis should be on helping her to enjoy her teenage years while minimising
the risk of unwanted/unplanned pregnancy, STIs, HIV, cancer of the cervix and
female infertility (NICE, 2014b; DH, 2013; Briggs, 2010). Providing health advice for
adolescents can be challenging and requires an approach in which establishing trust
and offering sound advice and respecting them as individuals are key.
Adulthood
Early adulthood is generally defined as being between the ages of 20 and 40. The
body has reached physical maturity and expectations are to be in good health and
Psychosocial Influences 119
at the peak of physical strength, endurance and energy. The focus at this time is
on forming relationships, finding love and is typically the period in which long-
term relationships are established. Work, career choices, security and satisfaction
are important values. Intellectual growth is a feature and individuals learn how
to evaluate opposing views and assess practicality alongside creative and social
concerns (Leifer and Hartshorn, 2004). For the healthcare professional, this may
be an important time to highlight risk factors and establish preventative goals as
personal concerns for health and well-being may be of low priority.
Simon is probably aware that he has a mental rather than a physical health
problem. His reticence to see the nurse may be influenced by a variety of
psychosocial factors. Gender-related expectations of manliness combined with
Western cultural influence which places an emphasis on self-reliance may cause
him to feel guilty about his lack of ability to cope and therefore to fail to seek
help (Barry and Yuill, 2012; Hammen and Watkins, 2013). The impact of stigma
associated with mental health may also be a factor, although current healthcare
approaches are working hard to change this negative view (TNS BRMB, 2014).
Myths and unhelpful media portrayal, such as characterisation of villains as
having mental imbalance, continue to reinforce negative stereotypical views
(Barry and Yuill, 2012). Simon may well be worried about the impact any diagnosis
of mental ill health such as depression may have on his personal, social and work
relationships. It is important that the nurse recognises how factors such as stigma
and attempts to fit in with social expectations of normality may influence his access
to healthcare, management of his ill health and concordance with prescribed
treatment.
self (stagnation). The consequences of ageing may be an emerging worry. Alder et al.
(2004) highlight the concept of ‘the mid-life crisis’ as a period of uncertainty and
change that may be perceived as a last opportunity to achieve some of life’s goals.
Middle age may also be a time of re-evaluation and self-reflection, a time to focus
on health behaviour and lifestyle choices. Opportunities exist for the community
nurse to effectively manage risky behaviours. Changing demographics along with
increases in the age of retirement indicate that in the future older people will account
for an increased proportion of the working age population (NICE, 2015; ONS, 2013).
Therefore, opportunities to promote health and well-being in the work environment
and to support individuals in changing lifestyle behaviours which aims for healthier
ageing are set to become increasingly important. Occupational health and general
practice nurses are in an ideal position to effectively target these individuals.
It may be appropriate to identify how Sharon and Peter view their health and
their ability to control it. Health promotion and changing behaviour may be easier
if individuals have an internal locus of control where they feel they have some say
in their future health rather than an external locus of control where individuals
feel that their health is governed from the outside and would therefore not take
responsibility for making changes to improve well-being (Naidoo and Wills, 2015).
Decisions to change lifestyle may be based on weighing up any benefit against
disadvantage highlighted in the Health Belief model (Becker, 1974). Concern for
family (generativity) can be a positive influence; Samuel is an overweight teenager
and an increased knowledge that childhood obesity will tend to carry over into
adulthood (Larkin, 2009) may support behaviour changes. Research highlights the
positive association of parental attitude to food, diet and eating behaviour on the
dietary behaviour of their children (Ogden, 2012). Exercise advice can be promoted
not only to prevent declining health but as an opportunity for a family social activity.
The value of implementing a health-promoting social activity with additional social
benefits can act as a useful motivator for ongoing behaviour change (Ogden, 2012).
Activities such as organised bike riding, for example, ‘Big Bike Events’ (Sky Ride,
2016), illustrate this approach. For the community nurse, an understanding of
social, cultural and environmental factors at this point in the family’s lifespan is
essential, and the emphasis should be on shared decision making.
An individual may be challenged by long-term illness at any age, although the
likelihood will increase with age. Long-term illness can confront our sense of self
Psychosocial Influences 121
and reminds us that normal functioning is often central to social relationships and
activities (Nettleton, 2013). The impact of long-term illness on life is twofold: its
consequence, that is, its effects, on the practical aspects of life (work and play), and
its meaning as significant to our sense of self (Bury, 1991).
Ageing
Knowledge and understanding of the ageing process and the meaning of being old
are essential for effective individualised care of clients in the community. Old age is
often considered to begin at 65, but increasing life expectancy means we now have
subgroups of young old, old and the very old (over 85 years) (Erber, 2013). Trends
show there are fewer younger people and more older people in the United Kingdom
with increasing numbers of those living to be very old (Clarke, 2013). By 2051
estimates indicate that 1:4 people will be over the age of 65 and 1:15 will be over 85
(HSCIC, 2014). Our understanding of ageing is influenced by the concept of ageism,
stereotypical ideas, social norms and expectations. We live in an ageist society, where
physical change such as greying hair and loss of skin elasticity is viewed negatively,
particularly in relation to women (Clarke and Korotchenko, 2010; Alder et al., 2004),
whereas in men it may suggest increasing maturity and competence (Alder, 2013).
Ageism may influence the provision of healthcare, while the National Health Service
(NHS) Constitution (NHS, 2013) and Equality Act (DH, 2010c) protect the rights
of the individual against ageist practices and indirect ageism, for example, negative
assumptions that the health of the older person is less significant than the younger
still exist (Narayanasamy and Narayanasamy, 2012). Popular stereotypes of ageing
portray individuals as demented and in poor health and are synonymous with decline,
dependency and vulnerability (Barry and Yuill, 2012). Many elderly individuals may
hold stereotypical ideas of themselves; therefore, respect for individuality is vital
(Taylor et al., 2003). Some individuals may retain a view of the inner self which is
younger than their body as a means of negating ageist expectations and preserving a
sense of dignity (Boyd and Bee, 2015; Alder et al., 2004).
As we age we carry an increasing wealth of health experiences with us, shaped
by the cultural and social norms of the world we live in. Successful ageing may be
marked by an ability to look back on life with a sense of fulfilment and wholeness,
or the extent to which an individual is able to remain socially engaged (Beckett
and Taylor, 2013; Antai-Otong, 2007). Erikson (1980) noted that individuals who
could reflect on life with a sense of satisfaction achieved a sense of integrity rather
than despair. Meaning in life is closely related to health and declining health often
equates to a sense of loss (Grossman and Lange, 2006). Feeling old may relate to
feelings of fear, helplessness, feeling different from peers and losing a sense of
control over one’s life (Nilsson et al., 2000). Physical changes may restrict the
capability for social involvement while factors such as changing role and status
in the community or decline in mental ability will impact on the individual’s
experience of ageing. Economic aspects will also impact on the ageing process
as opportunities for positive approaches to fulfilment in ageing may be linked to
financial standing and deprivation (Barry and Yuill, 2012).
Positive ageing is dependent on a complex interaction of physical and
psychosocial factors. However for individuals who have a long-term condition(s)
and/or declining health ageing may be associated with increasing vulnerability
and frailty. Frailty is not a diagnosis but can be classed as a long-term condition, it
Psychosocial Influences 123
refers to a state related to ageing in which body systems lose their built-in reserves
and fail to integrate adequate responses in response to changes in health or stress,
and as a result the individual becomes increasingly vulnerable (Harrison et al.,
2015; NHS England, 2014; Cornwell, 2012). Frailty presents unique challenges to
healthcare professionals and its management requires knowledge, skill, empathy
and compassion. A positive climate for care can be achieved through advance care
planning and integrated approaches on a multi-disciplinary level (Cornwell, 2012).
Preventative approaches to care which employ supportive and educative practices
for individuals in managing, recognising and understanding their condition can
aid independent living and reduce levels of risk and episodes of crisis management.
Margaret will be feeling vulnerable as she is aware that her cognitive function is
changing and she is losing a sense of self and control. She is also probably acutely
aware of the changes in how people react to her and this is impacting on her ability
to maintain relationships and socialise. The way in which we present ourselves as
a social being is underpinned by our ability to communicate effectively through
conversation (Barry and Yuill, 2012) and for Margaret this is becoming increasingly
challenging.
The impact of diagnosis is frightening for Margaret and devastating for Carol.
The issue of stigma and negative responses to diagnosis on both personal and social
levels alongside concerns about the likely progress of the disease, are all important
factors to consider in supporting both Carol and Margaret. Raising awareness and
understanding, providing support and enabling the individual to live well with
dementia, supported by competent healthcare professionals are all key elements of
current policy (DH, 2009b, 2015; Scottish Government, 2013b; DH Northern Ireland,
2011; Welsh Government, 2011). Carol will need advice and support on how to cope
with the cognitive and behavioural changes her mother is experiencing. Identifying
strategies to manage cognitive symptoms such as memory books and reminiscence
techniques may be useful. Recognising that behavioural symptoms may be as a result
of attempts to communicate and often reflect unmet needs may also be valuable
(Sandilyan and Dening, 2015). For the nurse an understanding of Margaret’s life
history, personality and her personal reality may be important to maintaining her
safety and maximising her quality of life. A multi-professional approach is essential;
Margaret would be entitled to an assessment of need for social care and support
that places her well-being at its core (DH, 2014). The impact of additional caring
responsibilities may result in stress for Carol, she would be entitled to a carer’s
assessment and would need advice and support on how and where to access both
Psychosocial Influences 125
financial and social help. The challenge for the healthcare professional is to provide
safe patient- and family-centred care that will enable the individual to live well with
dementia and to remain independent for as long as possible.
Communication skills
How well we communicate with patients can influence the quality of the
relationship we develop with them. Person-centred communication which takes
account of patient perspectives, expectations, feelings, needs and wants and has an
understanding of the uniqueness of that individual is essential. Taking a lifespan
approach to communication will enable us to utilise the most effective methods
of communication with each client group. Communication with children requires
concurrent dialogue with the family, and using a partnership approach will enhance
empowerment and the effectiveness of healthcare interventions (Glasper, 2015).
How we explain illness to a young child needs to be thought through in light of their
cognitive abilities; for example, Piaget noted that before the age of 7 years the child
has an inability to distinguish between cause and effect (Beckett and Taylor, 2013).
Communication with adolescents needs an engaging non-judgemental approach
initiated through open dialogue. Good communication strategies will be based on a
sound understanding of their needs and some insight into adolescent culture (Briggs,
2010). The types of resources used will be an important consideration in reaching
certain groups; examples such as the successful YouTube video highlighting
teenage pregnancy demonstrate effective communication with their target group
(NHS Leicester City, 2009). The use of media as a method of communication when
used appropriately can be a powerful tool in shaping the norms, expectations and
patterns of behaviour of individuals, families and communities (Livazovic, 2014).
The ability to communicate effectively is an important aspect of healthy ageing.
Older people may be hampered by age-related changes, such as hearing loss and
decreased vision, which influence how they perceive and control external cues
(Tolson and Wilson, 2012). Barriers to communication with older adults include
ageism, hurried approaches, lack of respect and a lack of appreciation for the
individual’s life experience (Antai-Otong, 2007). Inter-generational communication
may be influenced by nurse assumptions and maintaining a professional, respectful
approach which avoids overly familiar terms such as ‘sweetie’ and ‘love’ is of
paramount importance (Knifton, 2009). Older people may need longer to retrieve
learned material from their memory store and story-telling may be a valuable
means of effective communication (Tolson and Wilson, 2012); therefore, strategies
that allow greater time for assessment may be useful.
The opportunity to utilise effective communication skills with patients at
whatever point in the lifespan is key to effective healthcare delivery. The quality
of face-to-face interaction may become increasingly important as healthcare
interventions become progressively driven by technology (McCabe and Timmins,
2012). Developing a therapeutic relationship can be enhanced by recognising the
psychosocial and age-related factors that influence methods of communication.
126 Care across the lifespan
Gender issues
Gender issues influence health across the lifespan. Life expectancy is greater for
women than men in the United Kingdom by an average of 3.8 years (ONS, 2014).
Biomedical factors indicate that males may be inherently more vulnerable and are
less likely to survive the first year of life (Taylor and Field, 2007). However, it is
the interaction between biological and social factors that is significant in relation
to health. Boys are more likely to die from accidents or have an accidental injury;
gender roles increase the health risk for males as boys are encouraged to be more
active (White, 2013). Female longevity may be linked to more positive health
behaviours; for example, women are more likely to consume a healthy diet, although
conversely more likely to develop an eating disorder (Taylor and Field, 2007).
Male behaviour may be influenced by expectations and pressures of contemporary
society to demonstrate masculinity (Barry and Yuill, 2012). Into adulthood, male
probability of early death is increased by risk-taking behaviour such as dangerous
sports, fast driving, hazardous consumption of alcohol and illicit drug use (White,
2013). However, we should remember that this is not necessarily a static picture.
Evidence shows there is a narrowing of the gap in life expectancy, which may in
part be explained by increasing risk-taking behaviours in females (e.g. smoking
and alcohol consumption) (ONS, 2009, 2016).
The Equality Act (DH, 2010c) supports gender-sensitive healthcare. The
community nurse needs to recognise that men and women may access services
and present symptoms differently, and this may impact on the accessibility of
services. The likelihood of seeing a GP varies with age and gender; females and
older individuals are more likely to access these services. Men are less likely
to attend for screening, preventative health checks and issues such as mental
health and obesity (White, 2013). Women are more likely to recognise symptoms
of illness and seek help earlier (Taylor and Field, 2007). Women are also more
likely to ask questions, be given information and be involved in shared decision
making than men (Antai-Otong, 2007). Although we could argue that female
participation and uptake of services may be related in some part to need, that is,
reproductive years and increased morbidity in later life, this cannot be entirely
explained by these factors, and issues such as masculinity and gender roles may
be relevant (White, 2013). Evidence would indicate that men may delay seeking
help as a result of stoicism, ideals of being strong and being able to endure pain
(Barry and Yuill, 2012). Access to services may also be linked to social factors
such as employment. Peter’s busy schedule means he is less likely to seek advice
if he cannot attend in the evening, whereas Simon’s choice may be guided by the
impact on his salary.
Issues of sexual orientation may also influence access to healthcare. This may
be of particular relevance in adolescence when individuals may be developing
an awareness of their sexual identity as lesbian, gay, bisexual or transgender
References 127
(Boyd and Bee, 2015). Evidence suggests that sexual minorities have a greater
tendency to exhibit health risk factors (e.g. smoking, alcohol consumption),
have an increased incidence of mental health problems and that they may have
reduced access to healthcare (Hsieh and Ruther, 2016; Beckett and Taylor,
2013). The experience of an individual may be influenced by inequalities in
service provision, perceived discrimination and poorly informed healthcare
practitioners (Aleshire, 2016; McCann and Sharek, 2016). It is important that
assumption-free, non-judgmental attitudes are embedded within the provision
of culturally sensitive healthcare.
Understanding how age, gender and gender identity and expression may
influence uptake and accessibility is important in the planning and delivery of
services to effectively meet the needs of the local community.
CONCLUSION
This chapter has explored a lifespan approach to healthcare. Multi-dimensional
views that take account of not only the biological and psychological but increasingly
the social, cultural and environmental aspects of health and illness are essential.
Age, gender and individual perceptions of health will all influence individual
needs, assessment and care provision. It is important to recognise that each person
is part of a family system, and that the healthcare needs of the individual may well
impact on the family. Proactive person-centred approaches and developing positive
health should underpin holistic healthcare provision. Understanding how aspects
of the lifespan relate to the physical, psychological, social, environmental and
spiritual elements of an individual’s life can positively influence care provision and
the quality of life for clients, their families and carers.
FURTHER READING
There is a vast amount of literature relating to the theories of growth and development and
the application of these concepts to healthcare and your interest may well be guided by your
professional role and client group focus. The following texts take a broad view.
Boyd D and Bee H (2015) Lifespan Development, 7th edn. Harlow: Pearson Education.
Beckett C and Taylor H (2013) Human Growth and Development. London: Sage.
Crain W (2014) Theories of Development: Concepts and Applications, 6th edn. Harlow:
Pearson Education Ltd.
REFERENCES
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edn. Hove: Taylor-Francis, pp. 75–93, 143–64.
Alder B, Porter M, Abraham C and van Teijlingen E (2004) Psychology and Sociology
Applied to Medicine, 2nd edn. Edinburgh: Churchill Livingstone, pp. 8–45, 112–13.
Aldwin C and Gilmer D (2013) Health, Illness, and Optimal Aging: Biological and Psychosocial
Perspectives, 2nd edn. New York, NY: Springer Publishing Company, pp. 38–46.
Aleshire M (2016) Sexual orientation, gender identity and gender expression: What are
they? The Journal for Nurse Practitioners 12(7):329–30.
128 Care across the lifespan
NHS Leicester City (2009) Leicester teenage pregnancy and partnership. (Accessed 18 May
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NHS Scotland (2016) Child health surveillance programme pre-school. http://www.
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PS-Clinical-Guidelines-140316.pdf.
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in later life. Nursing Inquiry 7:41–9.
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CHAPTER
7 Community nursing
assessment
Helen Gough
LEARNING OUTCOMES
• Explore the meaning of assessment.
• Explore the concept of need.
• Discuss assessment frameworks.
• Analyse conceptual aspects of assessments.
• Critically reflect on decision making.
INTRODUCTION
The aim of this chapter is to examine community nursing assessment by defining
terminology and identifying what constitutes a holistic assessment. The concept
of need and its relationship to assessment will be explored along with existing
assessment frameworks and models that have been developed to meet the wide
range of assessment perspectives that exists within a community setting. Decision
making and its essential alignment with community nursing assessment will then
be discussed, with opportunities to guide reflection on current practice.
DEFINING ASSESSMENT
It is perhaps somewhat surprising that concise contemporary definitions of nursing
assessment can be challenging to find in current literature. Seminal nursing
theorists Roper et al. (1990) were quite specific in relation to patient assessment,
highlighting that it included collecting information about the patient, identifying
the problems and then determining the priorities. Although this first appears as a
superficial approach, far more detail is then provided and it is clear that assessment
is an ongoing activity that gathers biographical and health data before considering
assessment of the patient’s activities of living (Roper et al., 1990). In contrast, a
patient-centred definition of assessment was provided by Worth in 2001 that
highlighted the ways in which the needs and requirements of the person drove the
subsequent planned care and services. While this approach emphasises patient
need, the need was usually determined by the professional, therefore diminishing
the opportunity for a partnership approach. In a succinct definition, Kenny (2009:
386) explains assessment as, ‘an ongoing process of data collection to determine the
client’s strengths and health concerns’. This definition suggests the person is at the
centre of care and a partnership approach is assumed, making the patient visible.
Making the patient visible is reflected by the Royal College of Nursing (2014)
where assessment guidance includes seeking patient’s views, expectations and
preferences. More recently, the NMC too have articulated patient involvement in
care in the 2015 Code, using a key theme of ‘prioritising people’ to underpin the
guidance and promote a partnership approach to assessment. This places the patient
at the centre of care. Therefore it is perhaps misguided to suggest that historically
nurses have not been involving people in their care when it may simply be due to a
lack of an authentic description in the literature.
PATIENT-CENTRED CARE
The idea of patients being at the centre of their care was established in the Patients’
Charter in 1991, and introduced the concept of the named nurse (King’s Fund, 2009).
Consideration of
• The patient’s needs and beliefs
• The patient as an individual
• The patient’s view in decision making
• The patient’s fears and concerns
• The patient’s family, carers and friends
134 Community nursing assessment
Principles of patient-centred care are detailed in Box 7.1, and it is clear that these
key areas represent an approach to practice, as opposed to a definitive framework.
Furthermore, the principles of patient-centred care link to holistic assessment,
recognising need and shared decision making. Support for this patient-centred
approach is augmented in practice by the growing understanding of the term
concordance and the resulting ‘informed partnership agreement which is
negotiated between the professional and the patient’ (Beckwith and Franklin, 2007).
This partnership agreement was explained in more detail by the Department of
Health (DH) (2007) originally in relation to prescribing, and differentiates between
concordance and compliance in relation to medicines management by stating:
In an alternative stance where the focus is on the practitioner within the assessment
process, Muncey (2002) suggests that the assessment activity undertaken by the
expert nurse is ‘invisible’. Muncey (2002) explains that this is because assessment
is a cognitive process which is then only articulated, and therefore ‘visible’, once
documented in written form. Only then can the visual representation of the
assessment findings and their priority be identified.
Regardless of visibility, this partnership or sharing of power between patient and
professional is a cornerstone of person-centred care, a term promoted in the literature
by McCormack and McCance (2010) that has since been embraced by a range of org-
anisations including The Health Foundation (2014). The Health Foundation (2014: 4)
describes person-centredness as a situation where there is ‘recognition of the active
roles that individuals can play as partners in their health and health care’. Notwith-
standing, person-centred care can introduce complex challenges for community
nurses as sharing evidenced-based information to enable authentic, shared decision
making can be time consuming. At a time where resources are constrained and
community nurses need to justify the time spent in patients’ homes, the concern is
that achieving genuine holistic person-centred care could be compromised.
NURSING MODELS
Nursing models were introduced into the UK nurse education and practice in the
1980s. Designed to inform assessment by collating appropriate data (Aggleton and
Chalmers, 2000), they were developed to guide nurses to deliver practice in a less
chaotic and more organised fashion. Roper et al. (1990) model for nursing is perhaps
the most well known in the United Kingdom, which is no surprise as the authors are
British. Although the five components of the model include the activities of living
and influencing factors, the lifespan, dependence–independence continuum and
individuality in living (Roper et al., 1990), it is almost always the activities of living
136 Community nursing assessment
Normative need is explained as the need that the health/social care professional
identifies. Although professionals are educated to recognise need, it has to
be acknowledged that various professionals may identify different needs from
each other. Furthermore, health needs can change over time.
Felt need is described as a need identified by the patient or carer. Although the
patient or carer will be able to identify some of their own needs, they may not
have a grasp of all that they require.
Expressed need is the articulation of a felt need by the patient or carer.
Comparative need is when in certain areas the patients or carers are not
receiving the same standard of care that is available elsewhere.
W Who is it for?
W What are the symptoms?
Critical Reflection on Decision Making 141
Sometimes it can be difficult to actually unpick what we mean when thinking about
what guides decision making, but what is clear is that for community nurses, nursing
care must be evidence based and not as a result of a whim or, worse, a comment like
‘we always do it like this here’. As accountable practitioners our decisions are rightly
scrutinised and never more so than when a critical incident has taken place. Therefore,
a robust rationale needs to be provided for our actions and decisions (NMC, 2015) and
142 Community nursing assessment
having a guide to support and understand our decision making with an opportunity
to reflect with afterwards, helps us to learn from experience.
CASE STUDY Mrs Grant is aged 84 years and is unknown to you. She has requested that
you visit as she would like some help and advice in relation to a problem with
constipation.
decision and in this case it’s the gender, age and assumed co-morbidity of the
patient.
It is not Mrs Grant who has constipation as you first thought, and it turns
out that Mrs Grant would like some help and advice about her husband as
she is his main carer. Mr Grant has multiple sclerosis and poor mobility,
and he has had several recent falls. As a result he has stopped the osmotic
laxative he had been taking for several months as his bowel movements
are loose and he needs to rush to the toilet fairly frequently. He has been
soiling underwear and sheets, which has been upsetting for them both,
and now his normal bowel pattern has ceased. Mr Grant now feels very
uncomfortable and nauseous. This analytical approach extracts any
irrelevant information (in this case the patient with constipation is not
Mrs Grant), does not focus on the specific context and uses guidelines to
support clinical practice. While repeated specific experiences may convert
analytical decisions into intuitive ones, a raised awareness of the context
of situations, although helping us to make sense of the situation, can also
provide a distraction from the reality and lead us to assumptions that
are not accurate. Earlier work by Croskerry (2002) in relation to pattern
recognition explains a situation whereby a patient presenting with
particular visual aspects of a complaint and their appearance can trigger
a bias in the decision making. Furthermore, any subsequent data gathered
from the patient can be used to confirm the initial diagnosis, even when
it is not accurate. For example, a patient presenting with a painful mouth
with evidence of an ulcer and white plaques on their tongue who confirms
that they have just completed a course of antibiotics may result in a bias
towards oral thrush when the ulcer may actually be the beginnings of oral
cancer. Although this article by Croskerry (2002) is aimed at medics and in
particular those who work in emergency medicine, it can illustrate how a
failed approach to decision making can occur, a fundamental message that
community nurses need to be aware of.
CONCLUSION
So it would seem that in order to deliver effective care to patients in the community,
assessment needs to be placed under scrutiny. Determining existing assessment
strategies and underpinning theory that supports assessment in practice is a starting
point. Holistic assessment in community nursing practice involves a person-centred
partnership approach where information is gathered in relation to the individual’s
physical, psychological, social, environmental, spiritual and cultural well-being
144 Community nursing assessment
using recognised evidence-based frameworks. Family and carers are included in the
assessment where appropriate, and, depending on the needs prioritised, the focus
of the assessment can move along a spectrum from concentrating on a physical
assessment utilising advanced clinical skills with one individual, to focusing
on a broad family assessment. It is this flexible approach practiced by a body of
community nurses that is a real strength. Undertaking robust evidence-based
assessments that have clinical decision making embedded in the process, evidences
accountability and the essential underpinning knowledge and skills in relation to
delivering patient care using shared decision making. This continued approach will
facilitate community nurses to deliver the high-quality care that most patients expect
and deserve. By revisiting theories of assessment, including assessment tools and
decision-making frameworks, current and future community nurses will be able to
provide a clear rationale for their practice and take responsibility for implementing
any improvements within their own clinical area.
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CHAPTER
INTRODUCTION
Community nurses are involved with a range of care provision including support
and care for patients who are unwell, including those with end-of-life care needs, as
well as supporting independence and self-care (Department of Health Public
Health Nursing, 2013). This remit includes increasing the quality of life of people
living with long-term conditions. In order to improve the quality of life for people
living with a long-term condition, and their families, it is important that the district
nurse is able to work collaboratively with other healthcare professionals and across
health and social care (Queen’s Nursing Institute & Queen’s Nursing Institute
Scotland, 2015). In 2008, the Department of Health reported that the number of
people with a long-term condition would increase by 23% by 2033 (Department of
Health, 2008b). Taking into consideration the increase in the number of people, this
chapter examines the relationship between long-term conditions and mental health
and examines the role of the community nurse.
The World Health Organization (WHO) states that
Keyes (2002) identified six feelings that foster psychological well-being, see Box
8.1. It is perhaps unsurprising that living with one or more long-term conditions,
which may impact upon independence and quality of life, can be linked to mental
health challenges.
148 The role of the community nurse in mental health
The evidence regarding the relationship between long-term conditions and men-
tal health identifies that affective disorders such as depression and anxiety are more
prevalent (Naylor et al., 2012). Furthermore, while depression and anxiety are expe-
rienced by people living with a long-term condition it is important to acknowledge
that for some long-term conditions such as diabetes and cardiovascular disease
there is also an increased risk of cognitive impairment including Alzheimer’s and
vascular dementia (Velayudhan et al., 2010).
Cardiovascular • Depression is two to three times more common in a range of CVD including stroke, angina,
disease (CVD) congestive cardiac failure and following a heart attack
• Prevalence estimates vary between 20% and 50%
• Anxiety problems also common in CVD
Diabetes • Two to three times more likely to have depression than the general population
• Also an independent association with anxiety
Chronic obstructive • Mental health problems three times more likely than the general population
pulmonary disease • Anxiety disorders particularly common, for example, panic disorder is 10 times more prevalent
Chronic musculo- • Up to 33% of women and more than 20% of men with arthritis may have a co-morbid depression
skeletal disorders • More than one in five people over the age of 55 with chronic arthritis of the knee have been
reported to have a co-morbid depression
Source: Naylor C, Parsonage M, McDaid D et al., (2012) Long-term Conditions and Mental Health The Cost of Co-morbidities. London: King’s
Fund Centre for Mental Health (p. 4).
premature death from natural causes such as cardiovascular disease is two to four
times more likely for people with mental health problems (Eaton et al., 2008).
ACTIVITY 8.1 Take some time to reflect on two people whom you have worked with who
have a long-term condition. In relation to each of the people you identify
answer the following three questions:
1. Could they have been depressed or anxious?
2. How did you consider the impact of their long-term condition on their
psychological well-being?
3. Did they raise the issue of their mental health with you?
mental health and well-being of people and carers in conjunction with men-
tal health professionals and GPs, identifying needs and mental capacity,
using recognised assessment and referral pathways and best interest decision
making and providing appropriate emotional support.
(Queen’s Nursing Institute & Queen’s Nursing Institute Scotland, 2015: 3)
Primary care can play a key role in supporting people with mental health prob-
lems and is the main source of formal support for mental health problems with only
10% of individuals with a mental health problem being referred to specialist mental
health services (Naylor et al., 2012). Primary care provision with support from
specialist mental healthcare professionals if appropriate can support people’s needs
more appropriately. However, in a King’s Fund report, looking at long-term condi-
tions and mental health, a separation between physical and mental health in the
150 The role of the community nurse in mental health
Community nurses can utilise two focused questions, set out in the National
Institute for Health and Care Excellence (NICE) guidelines (NICE, 2009) when
they suspect that the individual with whom they are working may have depression:
1 During the last month, have you been bothered by feeling down, depressed or
hopeless?
2 During the last month, have you been bothered by having little interest in doing
things?
Box 8.2 Signs and symptoms of depression (adapted from Gurney, 2013)
Key symptoms
• Sadness or constantly low in mood
• Considerably reduced pleasure in activities or hobbies normally enjoyed
• Other common symptoms
• Ability to think, concentrate, remember or make decisions is impaired, with
even simple tasks seeming to be difficult
• Fluctuations in appetite with under- or overeating
• Altered sleep patterns
• Behaviour that is distressed or slowed down
• Lethargy, weariness and reduced energy, aches or pains, headaches, cramps
or digestive problems that do not ease with treatment
• Feelings of worthlessness, hopelessness, helplessness or disproportionate or
inappropriate guilt
• Thoughts of death or suicide (with or without a specific plan) or a suicide attempt
152 The role of the community nurse in mental health
The community nurse may not have specialist mental health skills and knowl-
edge but is likely to know the individual circumstances of the person and their
family and is well placed to undertake an initial assessment and identify the level of
need. An understanding of the NICE guidelines and the DSM-IV definitions for
depression will enable the community nurse to identify co-morbid depression and
gain access for the person living with a long-term condition to specialist mental
health services as appropriate (NICE, 2009).
ACTIVITY 8.2 Having examined the DSM-IV definitions of depression and the helpful list of
signs and symptoms and recommended action take some time to review the
assessment and care of the two people you identified in Activity 8.1. How
could the NICE (2009) guidelines support assessment and decision making in
each case?
ACTIVITY 8.3 Access the Helping You to Assess Cognition toolkit (www.alzheimers.org.uk/
site/scripts/download_info.php?downloadID=1045 accessed 29.10.2015) and
review the cognitive assessment tools for primary care and care homes.
Consider how the use of recognised cognitive assessment tools could enable
the community nurse team to facilitate appropriate and timely referral to
specialist services.
When working with individuals who have dementia and their families it is impor-
tant to ensure that the care is person centred. Nolan et al., (2004) identified the need
to consider both the person with dementia and their carer with services supporting
Introduction 153
key relationships and valuing the contribution of all. Nolan et al., (2004) developed
the Six Senses Framework as a guide for maintaining effective relationships. The Six
Senses Framework, see Figure 8.1, provides a focus on the importance of the indi-
viduals and their families, retaining the focus on relationships and respect. Each of
the six aspects of the framework are considered for older people, family carers and
staff. For example, with regard to a sense of belonging older people need to be able
to maintain and form relationships and be part of the community, for family carers
it is important that they can maintain relationships and are able to feel that they are
not alone in the caring role. For staff, Nolan et al., (2004) identify the importance of
being part of a team where their contribution and value are recognised.
When there is concern about an individual’s ability to make decisions about their
own treatment and healthcare, perhaps as a result of Alzheimer’s or dementia, commu-
nity nurses must consider if the individual has the capacity for decision making. The
Mental Capacity Act 2005 sets out a number of principles to ensure that the interests of
individuals remain the focus of decision making (Callaghan et al., 2009). These princi-
ples include the assumption that an individual has capacity until proved otherwise, all
practicable steps must be taken to support the individual with decision making before
lack of capacity is considered and any decision taken on behalf of someone who lacks
capacity must be in that person’s best interests. The Mental Capacity Act (MCA, 2005)
sets out a framework for assessing decision-making capacity, see Figure 8.2.
Having asked about mental health, community nurses need to engage in the
management of mental health difficulties, for example, depression and anxiety. It is
important that the management of depression and other mental health difficulties
is undertaken by the appropriately skilled healthcare professionals. The National
Security
Significance Continuity
Six Senses
Framework
Achievement Belonging
Purpose
Presume
capacity
No
Record
Is there an
conclusion
impairment or No Diagnostic
no further action
disturbance in the threshold
under the MCA
functioning of the
mind or brain?
Yes
Assess decision-
making capacity Assessment
of capacity.
Does the
impairment to
Does the person the mind or
understand the nature brain affect the
and consequences of person’s ability
accepting or refusing to make the
No
treatment? decision?
Yes
Does the person retain
treatment information
No long enough to make
the decision?
Yes
Does the person use or
weigh the treatment
information as part
No of arriving at a decision?
Yes
Institute for Health and Care Excellence (2009) provide a helpful framework for the
identification of appropriate management, see Table 8.3.
If the individual with whom the community nurse is working in partnership
with to provide patient-centred care requires general advice and monitoring or
more active treatment in primary care there are a number of possible treatment
options available.
Introduction 155
Table 8.3 Appropriate management of depression
functional impairment.
asking open questions and listening reflectively, the third core skill of motivational
interviewing is informing; this may require permission before sharing information
about the situation the patient finds himself or herself in, this needs to be balanced
with asking and listening, if too much information is conveyed the patient may
become resistant to the discussion (Ryrie, 2013a).
Motivational interviewing can also be used effectively to help people with a long-
term condition self-care. In a recently reported study across 16 primary care centres
it was found that motivational interviewing provides a patient-centred approach
that improved older people’s medication adherence (Moral et al., 2015).
Solution-focused therapy is a form of brief therapy that considers the present
time for the individual and focuses on specific goals that can be reached (Ryrie,
2013b). This works by enabling people to identify how they want to be different
and the strengths the individual has that can be utilised to achieve the goal.
While community nurses are unlikely to be trained solution-focused therapists,
the approach taken in solution-focused therapy of considering people as being
unable to manage their problems rather than being unwell can be used to empower
people living with a long-term condition (Webster, 2009). The types of questions
that can lead to considering solutions rather than focusing on the problem are set
out in Table 8.6.
The use of questions to support people to change enables patients to identify
when they have been able to overcome the problem and to utilise the resources,
both social and personal, that are linked to the exceptions when they overcame the
Table 8.6 Solution versus problem discourse
problem. This enables the person to imagine a future without the problem and iden-
tify the small steps required to change the situation (Ryrie, 2013b). This is described as
a forward-looking process that empowers people without becoming trapped within
the problem (De Shazer, 1985). While this section of the chapter has explored two
possible approaches that can be used to work in partnership with patients and
carers, it is important to acknowledge that the community nurse may at times need
to refer to and work collaboratively with specialist mental health services. This
would include occasions when the patient has not responded to treatment for mild
to moderate depression or has severe and complex depression, see Table 8.4.
Collaborative working
The Transforming Community Services programme has resulted in a number of
mental health providers taking responsibilities in some areas for community ser-
vices for people with physical health problems. This in turn provides an opportu-
nity for further developing integrated working between community nurses involved
in working with individuals with long-term conditions and mental health staff. In
order to deliver effective care for people with long-term conditions, effective multi-
disciplinary team working is key. Working in partnership with patients to provide
patient-centred care requires the expertise and competence of a range of healthcare
professionals, for example, chronic obstructive pulmonary disease requires the
identification and management of depression and anxiety, alongside advice regard-
ing relaxation techniques (NICE, 2010). Collaborative case management focusing
on controlling risk factors by a nurse has also been found to improve control of the
long-term condition and depression outcomes in patients with diabetes and CVD
(Katon et al., 2008).
ACTIVITY 8.4 Take some time to review depression in adults with a chronic physical
health problem NICE CG91. You may find it helpful to discuss the role of the
community nurse at a team meeting.
• How does the team view their role in terms of depression in long-term
condition care?
• Is there collaboration with the wider healthcare team, especially the GP?
• What processes support effective working between the primary healthcare
team, mental health professionals and other statutory and nonstatutory
agencies?
Integrating physical and mental healthcare is more effective than adding mental
healthcare and can result in a reduction of service use with the concomitant
improved physical health. Collaborative care is one way in which people with a
long-term condition and depression can benefit from equal consideration of physi-
cal and mental health challenges. Collaborative care requires a multi-professional
approach to patient care with the use of structured patient management plans. This
is further supported by scheduled follow-up and effective interprofessional
Introduction 159
communication (Gunn et al., 2006). Inevitably an understanding of the signs and
symptoms, assessment tools and guidelines for mental health challenges experi-
enced by people living with a long-term condition will enhance interprofessional
communication and access to specialist mental health service. A qualitative evalu-
ation of collaborative care for people with long-term conditions and depression
found that case managers, practice nurses and GPs identified improved co‑
ordination of physical and mental healthcare. This resulted in increased confidence
in managing the care for individuals with complex physical and mental health
needs. Patients reported that the collaborative approach enabled them to access
mental healthcare that they had previously been unable to access as physical health
needs had been prioritised (Knowles et al., 2015).
Reflection point
Scenario
Emily Hobbs is 68 years old and was referred to the district nursing team by her GP
following a home visit. Emily had developed a sacral pressure ulcer. The team have
been for visiting for 4 weeks to dress the Grade 3 pressure ulcer and have referred
Emily for an assessment by the occupational therapist. The initial assessment iden-
tified that Emily has been finding it more and more difficult to manage as a result of
an exacerbation in her chronic obstructive pulmonary disease (COPD). Over the
4 weeks, it has been noted that Emily is increasingly reluctant to make eye contact
and is withdrawn when any of the nurses visit. When asked she is not sleeping well
and it would appear that she may have lost some weight.
Reflection
Take some time to consider what aspects the community nurse should consider and
what steps could be taken for Emily.
There are several factors that you may have identified when considering Emily
and her care. It may be that prior to the exacerbation of her COPD she was able to
get out and manage fairly independently. The deterioration of her COPD and the
consequent reduced mobility may have resulted in a reduction in autonomy, and
feeling of helplessness. These are two of the factors that Keyes (2002) identified as
fostering psychological well-being. Reluctance to make eye contact, being with-
drawn, not sleeping well and weight loss are four of the signs and symptoms of
depression (Gurney, 2013). The community nurse should ask Emily the focused
questions identified by NICE (2009), for example, during the last month, have you
been bothered by feeling down, depressed or hopeless?
It is important that depression is considered and action taken when Emily is
exhibiting subthreshold depressive symptoms to prevent further deterioration. The
NICE (2009) stepped-care model identifies that the community nurse should
undertake an assessment, active monitoring and consider referral for further
assessment and interventions. For Emily solution-focused therapy could be a useful
tool to support Emily to adapt her lifestyle in response to her COPD.
160 The role of the community nurse in mental health
CONCLUSION
It is evident that there is a strong relationship between physical and mental health.
In order to deliver effective quality care to people in their own homes and their care,
community nurses need an awareness of mental health challenges in order to sign-
post services and on occasion facilitate referral and access to mental health services.
This chapter has provided an overview of the role of the community nurse in mental
health assessment and examined some mental health skills that can be used in prac-
tice by community nurses. By developing an awareness of these issues community
nurses are better able to engage in effective interprofessional working, collaborative
care and referral to specialist services to meet the complex needs of people with
complex physical and mental health needs.
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CHAPTER
LEARNING OUTCOMES
• Gain an understanding of carer identity – who is a carer?
• Critically explore the impact of caring on young carers and adult carers.
• Reflect on the financial and practical support needs of carers.
• Recognise areas of community nursing support for carers.
INTRODUCTION
Carers are now acknowledged as an essential component of community care
(McNamara and Rosenwax, 2010), but there still exists some confusion around who
we are referring to when we talk about carers. In this chapter, the definition of
‘carer’ in the United Kingdom will be examined along with the role and contribu-
tion carers make to society.
The exhaustive nature of the caring role will be highlighted along with the finan-
cial and practical impact that the caring role has upon young and adult carers. The
role community nurses have in the identification, assessment and support of carers
will also be made clear.
It has been predicted that by 2021, the number of people aged over 75 years in the
United Kingdom will have increased by 75% and the percentage of young people
will have fallen by 20%. People will be living longer and also living with long-term
conditions for a significant part of their lives (DH, 2008). The need for carers is
projected to increase and the situation now is not unusual where two older people
live together, one caring for the other, but neither with good health.
It is in response to these changes that the UK government wish to increase the
relationship between primary healthcare, social services, charities and the acute
sector. There will be a continuing emphasis on the development of new models of
care in the community with a greater provider role for primary care, health promo-
tion and sustaining people at home (Department of Health, 2014a).
Each country in the United Kingdom has produced its own carer strategies and
policies (see Further Reading). However, the aims and requirements of all UK coun-
tries are broadly the same, as are the needs of carers. Whether a carer fulfils the
criteria to receive benefits or not, the focus for community nursing teams is to
164 Carers: The keystone of communities and families
improve the effective identification of carers, increase the uptake and quality of
carer assessment and provide information and advice. Carers’ health, well-being
and support can be enhanced by assisting them to contact voluntary agencies, pro-
moting short breaks (previously called respite) and providing education with skills
such as moving and handling. Health and social care professionals working closer
together with other appropriate local services can provide and participate in part-
nership training. General practitioners (GPs) are being encouraged to advocate
regular health checks for carers between the ages of 40 and 65 years. This provides
the opportunity for the community nurse to assess how the carer is coping with the
caring role. The ability of the carer to cope and continue to provide care impacts on
the district nurses’ role in terms of time and team capacity.
Carers’ recognition and the rights of carers have increased greatly across Europe
in the last 10 years, and the UK Care Act (Department of Health, 2014a) gives local
authorities a responsibility to assess a carer’s need for support, where the carer
appears to have such need. In Scotland the Carer’s Strategy (Scottish Government,
2010) calls for early intervention and a preventative approach to prevent crises. The
government in England recognises the valuable contribution of carers who support
the independence of other people, and they seek to empower this hidden group by
supporting key national organisations such as Carers UK and Carers Trust (DH,
2010a). However, contemporary government papers emphasise the use of integrated
care with strategic needs assessment and a strong personalisation agenda based on
emerging evidence of effective early intervention in identifying, involving and sup-
porting carers (DH, 2010b, 2012, 2013a,b, 2014b).
The carer’s assessment is carried out by Social Services, or a Single Shared Assess-
ment by Social Services and the National Health Service together (Department of
Health, 2014a; Scottish Government, 2014). These tools are used to assess the carer’s
experience, his or her ability or willingness to cope and the carer’s quality of life.
WHO IS A CARER?
In the United Kingdom a carer is someone who provides a substantial amount of
unpaid care, on a regular basis, to an adult or child who may not be able to manage
daily activities because of frailty, illness or disability (Carer UK, 2014a). A carer can
be an adult or a child. Others who provide care, for example, care workers who work
for local authority or a private agency that provides personal care, are often also
referred to as carers. However, these people are employed to provide care and receive
Who Is a Carer? 165
payment for doing so. To differentiate between paid and unpaid carers the terms
‘formal carer’ and ‘informal carer’ are often used to denote the difference between
paid care and unpaid care. This chapter focusses on the ‘informal carer’.
Anyone might become an informal carer during their lifetime, sometimes caring
for several people at once, or perhaps fulfilling the informal carer role on more than
one occasion, for example, a mother who cares for her own mother, then later is the
carer for her father-in-law. Carers can be family members, who perhaps switch
between several roles at once, who may have learning disabilities or be physically
frail themselves. Carers can be under 16 years of age; they can be migrants or asy-
lum seekers. Carers may also be part of a fixed or travelling community. Young
carers are specifically defined as children and young people under the age of 18 years
who provide regular and ongoing care and emotional support to a family member
who is physically or mentally ill, disabled or misuses substances (Association of
Directors of Adult Social Services [ADASS] and the Association of Directors for
Children’s Services [ADCS] 2009). It is important to make the distinction between
young carers in their juvenile years between 16 and 17 years, and those young adult
carers aged 18–24 years as the former are legally classed as children and the latter
are legally classed as adults. Sprung and Laing (2015) suggest that there are major
implications for policy development and commissioning of services for those carers
who are legally considered children (under 16 years) and those who are legally con-
sidered adults (over 18 years).
use of the term ‘carer’ are important in enabling the identification of both adult
and young carers throughout the country, publicising the support needed for
those carers and directing the appropriate advice and financial provision to them.
The need for carers to take on a caring responsibility will continue to increase as
the population ages and more people live longer with long-term conditions. The
UK-wide Health Service focus on preventative, anticipatory care will only be pos-
sible if carers become equal partners in care delivery. The potential cost to health
and social services if this informal care situation breaks down is highly significant
for the future economic sustainability of society (Jarvis, 2011). District nurses and
community nursing teams often work in partnership with carers and are invaluable
in identifying, supporting and assessing carer needs.
For those in receipt of certain benefits, help with other costs is available such as:
NHS health costs – this includes free prescriptions, free dental treatment, free
NHS eye tests and vouchers to help with the cost of glasses/contact lenses. Fares to
hospital for treatment can be claimed in some instances when travelling as a com-
panion with someone who needs to travel for medical reasons.
Other grants and loans which were previously available from the Social Fund
have been abolished and replaced with local provision from local councils.
Under new arrangements, community care assessments are available for people
who require care from someone else to determine what help is needed and how
social services can help. Community care assessments look at the role of the carer
and the help the carer provides.
Carers’ assessments are available from social services for people who provide
‘regular and substantial’ care for someone else such as a partner, friend or relative.
These assessments are available from April 2015 for anyone who feels that the care
they provide will impact on their life, work and family.
The government is moving towards enabling people to choose and control the
support services they receive through direct payments and personal budgets. Direct
payments and personal budgets are made instead of community social care services
and are designed to give the person needing care more choice and control, allowing
them to purchase their own service providers (Carers UK, 2014a).
The Impact of Caring 169
SUPPORTING CARERS
In community nursing there is generally a good understanding of the importance
of carrying out health needs assessments as discussed in Chapter 1, where the
assessment of need can be carried out for individuals, families, carers and commu-
nities in any situation that the community nurse encounters. Much of the emphasis
on nursing assessment has traditionally been on the patient/individual rather than
the family and the carer, although some assessment tools do include the needs of
family and carer.
Carers are often asked to make proxy decisions on behalf of patients, and their
own interests and perceptions of the situation and the choices available to them can
significantly influence these judgements. It is important therefore for the commu-
nity nurse to be aware of this in order to protect the dependent person and be an
advocate for the dependent person. A specific carer assessment will often help com-
munity nurses and healthcare professionals to understand carers’ experiences and
the support that carers need to fulfil the role (Laing and Sprung, 2013).
Something to note is that the community nurse or healthcare professional carry-
ing out the assessment should not assume that the carer wants to continue in the
caring role. Sometimes carers can think that if they do not care for the dependent
person it will be assumed that they also do not care about the dependent person,
resulting in them taking on a responsibility they are not able or willing to carry out,
to the detriment of all concerned. Any assessment or support tool will require pro-
fessional sensitivity and well-developed communication skills, enabling a relation-
ship of trust and honesty to develop. The development of a trusting relationship and
support building take time, investment and effort.
indicated that the decision for providing family carer support appears to be based
largely on service capacity rather than on carer needs and preferences (Gerrish,
2008; Taggart et al., 2012; Tan et al., 2012).
Education and training related to emotional support and medication manage-
ment were identified as key concerns for carers. Studies that examined health pro-
fessionals’ perspectives also acknowledged deficits in caregiver preparation. District
nurses and community nurses typically viewed carers as ill-prepared both for the
fundamental nursing care aspects and the far-reaching nature of the role (Jack and
O’Brien, 2010; Gerrish, 2008; Greenwood and Mackenzie, 2010). District nurses
and community nurses also emphasised the psychological consequences of inade-
quate caregiver knowledge, which induced carer anxiety and its impact on care-
giver confidence (Whitehead et al., 2012; Walsh et al., 2007).
A number of publications considered the district and community-nursing role in
supporting patients who had been discharged at a much earlier point of the care
pathway. This pressure on carers and district and community nursing teams was
accelerated by an increase of faster throughput of hospital patients mostly with an
emphasis on end-of-life care for patients in their own homes (Jack and O’Brien,
2010; Whitehead et al., 2012). The work by Laing and Sprung (2013) and Sprung and
Laing (2015) also highlights the issue that there has been very little research around
carer support needs. However, they identified specific recommendations in relation
to the characteristics of district nursing support for carers to include enabling, sup-
porting, mediating, care substitution, crisis prevention and crisis intervention.
A number of key themes emerged as helpful for community and district nursing
teams to better support carers’ needs in areas as shown in Table 9.4. These issues
highlight areas for education and training for community and district nursing teams.
It is evident from the literature that a high proportion of carers have significant
health problems themselves, often exacerbated by their caring role. However, the
needs of this group are incredibly under-researched when compared with the paid
workforce or patient groups themselves. Key difficulties experienced by carers are
feelings of being excluded and loss of control, social isolation, financial hardship
and loss of employment as well as their own emotional and health problems. Within
the context of carers’ support requirements a major gap in the literature around the
area of how professionals can best support carers with these needs has been
This could mean a real difference to a carer on the brink of burnout and not being
able to cope towards having a happy healthy life allowing the carer to continue to do
what he or she wants to do, care for his or her loved ones.
Agencies
A voluntary agency, usually a charity or grant-funded body, provides help to people
with a particular need. The Princess Royal Trust for Carers would be an example of
a voluntary agency that provides help for carers. The aim of voluntary and charita-
ble agencies in relation to carers is to make a practical and positive difference
through the provision of useful information, carer relief, a listening ear, support
groups, respite care and everyday support to all carers who need it. These agencies
have the carer and the dependent person at the centre of their philosophy and are
often run by carers themselves or their representatives. This gives a significant and
informed insight into the needs of carers.
Voluntary and charitable organisations are ideally placed to empower carers.
However, as the carer role increases the skills that carers need, such as moving and
handling training, health education, definition of carer role and responsibilities,
will be provided. One of the overall benefits of voluntary agencies is that they are
less bureaucratic and able to respond to need quickly.
A statutory agency (or in Scotland Public Body) is one provided under law and is
usually the responsibility of a Local Authority or Central Government department.
These agencies (voluntary, charitable, statutory and public) work slightly differently
from country to country and between localities. However, it remains important,
especially in the ever-changing face of healthcare provision, that agencies work
together for the common good of the patient. They need to share information, com-
municate effectively and be aware of the others’ roles and responsibilities.
CONCLUSION
The future of caring in the community, with an ageing population and more people
living with long-term conditions, mental health issues or substance misuse, is being
taken seriously by government and service providers throughout Europe.
The important issues of carer identification, assessment, education and collab-
orative partnership have been acknowledged in this chapter, along with an explora-
tion of the definition of ‘carer’. There has been opportunity to gain an understanding
of carer identity and appreciate who may become a carer. There has also been a
chance to consider some aspects of the caring role and consider the financial and
emotional impacts that caring has on young and adult carers.
The role and contribution carers make to society and the personal and financial
issues they experience have been explored. The exhaustive nature of the caring role
has been highlighted along with recognition of the importance of the community
nurse’s role in the identification, assessment and support of carers.
The role of assessment and support by an educated, skilled multiprofessional
health and social care team is valued as fundamental in meeting the needs of carers
and promoting the carer’s ability to cope. Governments are funding and champion-
ing charities and voluntary organisations which are essential providers of services
and support for carers. Although the picture can seem daunting, there are constant
changes taking place in the world of technology with telehealth, social networking
and electronic care applications and packages making care at home more feasible
and the responsibility of caring lighter, enabling carers and patients, although phys-
ically isolated, to access support and maintain communication with the world
around them.
FURTHER READING
Carers’ Strategy for Wales UK – Action Plan. 2007. http://www.asdinfowales.co.uk/
resource/9_0_carers_strategy-e.pdf (Accessed 14/6/17).
Carers UK (2014) Carers Rights Guide 2014/15 Looking After Someone. Carers UK.
Department of Health (1998) ‘They Look After their Own, Don’t They?’ Inspection of
Community Care Services for Black and Ethnic Minority Older People. London: The
Department of Health Publications.
Mutch K (2010) In sickness and in health: Experience of caring for a spouse with MS.
British Journal of Nursing 19:214–9.
Obadina S (2012) Parental mental illness: Effects on young carers. British Journal of School
Nursing 3:135–9.
178 Carers: The keystone of communities and families
Rees J, O’Boyle C and MacDonagh R (2001) Quality of life: Impact of chronic illness on the
partner. Journal of the Royal Society of Medicine 94:563–6.
The Scottish Government (2010) Carers Strategy. http://www.gov.scot/Publications/2010/
07/23153304/0 (Accessed 14/06/17).
FURTHER RESOURCES
http://alzheimers.org.uk/site/index.php
www.ageuk.org.uk
www.barnardos.org.uk/what_we_do/our_projects/young_carers.htm
www.carersuk.org
www.carersinformation.org.uk
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CHAPTER
10 Spirituality: A neglected
aspect of care
Ann Clarridge
LEARNING OUTCOMES
• Critically discuss the concept of ‘spirituality’ and spiritual care within nursing.
• Describe the principles underpinning spiritual assessment and appraise the
associated tools and interventions available.
• Explore the concept of ‘self-awareness’.
• Critically discuss how, as a community nurse, developing self-awareness can
enhance the spiritual assessment of patients/clients.
INTRODUCTION
This chapter is concerned with the concept of spirituality in the care provided by
nursing professionals. Reference is made to some of the relevant research and literary
reviews which offer a useful context for this complex subject area. Some definitions
of spirituality are outlined and the place of spirituality within community nursing is
considered. The consequent implications in terms of spiritual assessment and possi-
ble interventions are discussed. The need for self-awareness and its development in
nurses is explored. Finally, the competence of nurses to deal with the spiritual aspects
of care is considered together with the importance of observational skills and com-
munication, essential tools in the repertoire of all nursing professionals.
spiritual care should not be ‘sequestered’ to specialised texts but integrated into
all textbooks where relevant so that care and nursing practice would indeed be
‘holistic’.
The overall conclusions to be drawn from this extensive review point to the need
for further, systematic and co-ordinated research, particularly in the area of prepa-
ration of nurses in the assessment and provision of spiritual care. The overriding
problems that emerge are how, what, where and when spiritual care should be
taught and who should teach it.
DEFINING SPIRITUALITY
The concept of spiritual care is equivocal. There is a need to define spirituality and
consider how it relates to nursing care.
The terms spiritual and religious are often used to mean the same thing, and
although there is an overlap between the two, not everyone would agree that an
individual needs to be religious in order to be spiritual, or vice versa (Clarke, 2009).
Koenig et al. (2001) mark very distinct differences and define religion as ‘an organ-
ised system of beliefs, practices, rituals and symbols’ and spirituality as the personal
quest for understanding answers to ultimate questions about life, about meaning,
and about relationship to the sacred or transcendent which may or may not lead to
or arise from the development of religious rituals and the formation of community
(Koenig et al., 2001, cited in MacKinlay and Hudson, 2008: 140).
Thus, it could be argued ‘that the practice of religion is a way that humans relate
to the sacred, to otherness’ and that all humans have a spiritual dimension but not
all humans practice religion (MacKinlay and Hudson, 2008: 140).
‘Spiritual but not religious’ is a phrase used by many people to express the belief
that real spirituality is the concern of the individual (Sulmasy, 2009). Those who
hold this view will affirm that their individual experience is one thing and institu-
tionalised religion is another (Jamison, 2006: 142). On one side, classical religion,
including all the main world religions each with its own specific doctrine, rituals
and beliefs, ‘offers us an educative process that helps us to see the whole of life in a
different way’ (Jamison, 2006: 146). On the other side, modern spirituality might
well be defined as ‘psychological well-being combined with the moral golden
rule – do unto others as you would have them do unto you’ (Jamison, 2006: 143).
Chochinov (2006a) suggests that spirituality is to ‘invoke a sense of searching or
yearning for significance or meaning in life’ (Chochinov, 2006b: 88).
Spirituality and Community Nursing 185
Spirituality outside religion often signifies a believer whose faith is personal,
more open to new ideas and numerous influences than the dogmatic faith of mature
religions. Such believers tend to regard spirituality not as a religion but as the active
and vital connection to a force, power or energy, or a sense of the deep self. It can
also signify the personal nature of the relationship or connection with the god(s) or
belief system(s) of a believer as opposed to the general relationship with a deity and
the rites of group worship shared by members of a given faith. Those who claim that
they are spiritual but not religious often believe in the existence of many ‘spiritual
paths’ and would refute that there is an objectively definable best path to follow.
They often emphasise the importance of finding one’s individual path to the divine
and may or may not believe in the supernatural. Where there is such a belief and a
relationship with supernatural beings represents the foundation of happiness then
that will form the basis of spiritual practice. Where there is no such belief, a differ-
ent form of practice provides the way to manage thoughts and emotions which oth-
erwise would prevent happiness (Sulmasy, 2009).
Definitions of spirituality are constantly evolving so it would seem appropriate,
therefore, in the context of this chapter to accept Chochinov’s (2006a) simple defini-
tion without necessarily invoking religion. Thus spirituality may be understood to be
that search for inner peace and the foundation of happiness which requires some
form of spiritual practice but which is essential for the promotion of personal well
being. Chochinov identifies a client who speaks of loss of hope, feelings of being a
burden to others, loss of dignity or loss of the will to live as being one who is experi-
encing spiritual distress. Many techniques and practices have been explored and
developed in religious contexts, such as meditation or contemplative reading, and are
immensely valuable in themselves as skills for managing aspects of the inner life.
Nursing and Midwifery Council (NMC) and the government health departments
to build on existing work and advance the area of spirituality within nursing and
health care’ (RCN, 2010: 28). Health boards and government policies also support
the importance of meeting the spiritual needs of patients. The International
Council of Nurses (ICN) specifies ‘an environment in which the human rights,
values, customs and spiritual beliefs of the individual, family and community are
respected’ (ICN Code of Ethics, 2000: 5). The Department of Health (2002) in its
guidelines for Chaplaincy and Spiritual Care in the NHS in Scotland includes an
aim ‘to develop and implement spiritual care policies’ which are appropriate to
our ‘increasingly multi-cultural society’ (MacLaren, 2004: 457). ‘Spiritual nurs-
ing can be an opportunity for nurses to enquire into that which is fundamental
about the human condition and to give truly whole person care in a multi-faith
society’ (MacLaren, 2004: 461).
Community nurses need a definition of the context for the care they provide. The
term community frequently describes a wide range of patterns of relationships but
generally includes two important characteristics. The first describes those who
share values and a sense of purpose and who encourage and support each other in
the challenges of daily life. ‘The giving and receiving of love is an important element
for this community of people’ and such a community might be the local church,
neighbours or family (Runcorn, 2006: 55). The second describes shared work, spe-
cial circumstances or interests.
It would seem at first glance that community nursing could be defined through
shared work and special circumstances. However, a closer look at what actually
underpins nursing – The Code: Professional Standards of Practice and Behaviour for
Nurses and Midwives (NMC, 2015), for example – suggests that community nursing
may well be identified by the first characteristic – the shared values and sense of
purpose. So, in effect, both descriptions could be said to apply to the work of the
community nurse.
Nurses who work within the context of a community as opposed to an insti-
tution fulfil a specific role. They care for individuals and families with a variety
of conditions in their own homes or in homely settings. They are involved with
people from different ethnic backgrounds, with those who have and with those
who do not have an expressed religious faith. In every case, the nurse needs to
be aware of the spiritual dimension of each individual no matter how it finds
expression. In 1964 Jean Vanier (1989) established a community where people
with various physical and learning difficulties could live as equals with able-
bodied people. He asserted that ‘the fundamental right of each person includes
amongst the right to life and care, the right to a spiritual life’ (L’Arche Charter,
in Runcorn, 2006: 55).
Community nurses find themselves in the role of ‘key players’, able to recog-
nise and meet the spiritual needs of clients and their families (McSherry and
Ross, 2010). The QNI/QNIS voluntary standards for District Nursing Education
and Practice (2015) encompass all aspects of holistic care as provided by the dis-
trict nurse. Community nurses would argue that holistic care of the individual
Spirituality and Community Nursing 187
and not just physical need has always been their concern. Indeed their claim is
justly supported by the plethora of nursing models of care. A holistic approach to
care reflects the underlying principles and philosophy that all nurses draw upon
to shape the way in which they act and carry out their nursing practice. Although
conceptual models of nursing differ quite considerably because nurses have
d ifferent ideas about what nursing means for them, fundamental to most models
is the person or the individual. Each model has something to say about this key
element, especially in the assessment for proposed care. It is here, within this
area of the model, that the spiritual needs of the patient can be addressed (Smith,
2004).
Research undertaken by Perry (2005) identified four areas that were of
importance to nurses: ‘affirming the value of the person, defending dignity,
enabling hope and helping patients find meaning’ (Perry, 2005, in McSherry
and Ross, 2010: 155). Neuman (1995) and Roper et al. (2000) revised their nurs-
ing theories to include spirituality, thus seeking to provide true holistic care
(Smith, 2004).
In times of illness or loss of independence patients will frequently raise funda-
mental questions concerning the meaning or purpose of life wherever they may be
on the spectrum of religious belief. It is the experience of community nurses that at
such times patients turn to those who are caring for them for answers, help and sup-
port. Spiritual care may be said to be ‘that care which recognises and responds to
the needs of the human spirit when faced with trauma, ill health or sadness and can
include the need for meaning, for selfworth, to express oneself, for faith support,
perhaps for rites or prayer or sacrament, or simply for a sensitive listener’ (Depart-
ment of Health, 2009; 6).
Research literature suggests that nurses need to be aware of their own beliefs
and values in order to best meet the spiritual care needs of patients. The RCN
survey (2010) has raised some pertinent issues relating to the personal and profes-
sional boundaries that need to be drawn by nurses when providing spiritual care.
Many nurses expressed the need for help when distinguishing between their own
values and their professional judgments as providers of care. Nurses need to be
clear about how they express their beliefs in their own lives, whether through
doctrine, ritual or membership of a religious community. Such clarity is essential
if they are to remain objective when assessing, planning and delivering holistic
patient care. Those nurses who professed to a personal belief were aware of the
need for objectivity and that while providing support to the patient they should
not allow their own values and beliefs to impinge upon or influence the patient in
any way. Nurses would then be in a position to demonstrate an interest in and a
willingness to discuss issues of a spiritual nature with patients without the neces-
sity of a wide-ranging knowledge of the doctrines, rituals and practices of the
many religions. A review of research established that the level and amount of
spiritual care given by a nurse were related to the amount of time available for
listening and the possession of spiritual awareness, sensitivity and communica-
tion skills of the nurse (Ross, 2006).
188 Spirituality: A neglected aspect of care
However, the nurse must feel comfortable and have already established a relation-
ship of trust with the client before being able to undertake a thorough spiritual assess-
ment and plan appropriate care (see Chapter 5). Tanyi (2006: 289–90) provides a series
of questions and spiritual interventions that can be adapted and used as a guide by
nurses to undertake a spiritual assessment and to plan patient care (Box 10.1).
Spiritual Assessment and Intervention 189
Strengths
• What has helped you in the past to deal with crisis?
• What gives you strength?
• What do you do to rebuild your strength?
Meaning and purpose
• In your daily life, what gives you meaning?
• What gives you peace, joy and satisfaction?
Relationships
• Who is the most important person in your life?
• To whom do you turn when you need help?
Beliefs
• Do you have a relationship with God/deity, universe, or other?
• If yes, how would you describe it and what does it mean to your health?
• Do you practice rituals such as prayer, worship or meditation?
Personal spirituality and preference for spiritual care
• How do you express/describe your spirituality?
• Do you consider anyone as your spiritual leader and if necessary can this
person be contacted?
These questions are provided as a general guide and can be adapted for use
according to the individual and the nurse’s preference.
(Tanyi, 2006; McSherry and Ross, 2010)
The RCN has responded to the findings of the study by producing a ‘pocket-sised’
book which provides guidance for nurses when assessing patients’ spiritual needs:
Preparing to Give Spiritual Care
Just as you would assess your patients’ physical needs, an initial assessment of
their spiritual concerns is important. You may find questions such as these helpful:
• Do you have a way of making sense of the things that happen to you?
• What sources of support/help do you look to when life is difficult?
• Would you like to see someone who can help you?
• Would you like to see someone who can help you talk or think through the
impact of this illness/life event? (You don’t have to be religious to talk to them.)
(RCN, 2010)
(See Further Reading for a full text of the guidelines to spiritual assessment and
interventions for families.)
McSherry (2006: 905) offers a model that includes a number of components
(‘the principal components model’) and suggests that familiarity with it is likely
to give nurses the confidence to tackle some of the difficulties inherent in under-
190 Spirituality: A neglected aspect of care
taking spiritual care. For example, it is recognised that when assessing a client’s
spiritual needs the nurse must develop a relationship of trust which takes time –
the very commodity not always available to busy nurses. If sufficient resources are
to be made available to enable nurses to support clients appropriately, it is neces-
sary for the medical practice or other directing ‘organisation’ to recognise the
value of the relationship and to credit as worthwhile the time spent in listening
(McSherry, 2006).
The patient’s spiritual history is a critical element in the background information
that needs to be taken into account when planning nursing care. It ensures an
understanding and recognition of the patient’s own beliefs and value systems. In
particular, religious beliefs and practices are clarified, so that any intervention by
the professional is appropriate. By identifying individual spiritual needs the patient
is given a clear message of the respect that will be shown in the delivery of the pro-
posed care. Furthermore, significant information may be gathered that sheds light
upon the motivation underpinning the patient’s behaviour. Such information can
provide a useful resource when identifying the patient’s support network, with the
added potential of identifying the patient’s ability to comply with care. Addition-
ally, the information provides a baseline from which the situation can be monitored
(Koenig, 2007).
Koenig (2007) suggests a number of criteria to be considered when choosing an
appropriate model. Perhaps the most important is that questions should be open and
brief, focused upon the beliefs and value systems of the patients and not of the nurses.
Hodge (2001) identified this as an important aspect of assessment recognising the
value of ‘personal and environmental strengths being central to the helping process’
(Hodge, 2001: 204). Based upon this premise, Koenig (2007: 44) offers a single ques-
tion: ‘Do you have any spiritual needs or concerns related to your health?’ This simple
question acknowledges to the patient that this is an area of importance for the profes-
sional. At this point, however, one might take issue with Koenig. An individual who
is in need of care from a nursing professional almost certainly will have spiritual
concerns related to health without necessarily being able to articulate them in such
terms in response to a blunt question. By listening to what is said and by hearing what
is left unsaid, it is for the professional to tease out the spiritual concerns of the patient.
The use of a mnemonic can provide the nurse with a helpful tool when making an
assessment based on a series of questions that explores ‘spiritual and religious
themes’ within an ‘empathic dialogue’ (Hodge, 2001: 205). The following examples
of FICAA (adapted by Koenig (2007: 44) and HOPE (Puchalski, 2002 in McSherry
and Ross, 2010: 87) when suited to the linguistic register of the patient could prove
to be useful as a mental blueprint:
SELF-AWARENESS
Who we are, what we are like and what other people think of us are all questions
that relate to our ‘self’. We are made up of many parts, ‘our bodies, our thoughts,
our feelings, our perceptions of ourselves, our beliefs and our actions’ (Burnard,
1992: 6). The more we come to know our ‘self’ – that is, the greater our self-aware-
ness – the more integrated we become as people and the more able we are to offer
effective spiritual care.
Gardner suggests that ‘practitioners need to be aware of their own spirituality
and the assumptions they may make from their own experience’ and that ‘we are
less likely to be able to hear about other people’s if we are not aware of our own’
(Gardner, 2011: 89). Thus it might be concluded that nurses above all professionals
should have a highly developed sense of self-awareness if they are to function
successfully.
192 Spirituality: A neglected aspect of care
Strengths
• What are my personal beliefs, values, prejudices, assumptions and feelings?
• Am I aware how these might influence the way in which I care for a patient?
Beliefs
• What is the extent of my knowledge and understanding of the rituals and
practices of different religious or non-religious beliefs and is it important
that I know?
Relationship
• Am I enabling a patient to express their spiritual beliefs?
• Am I providing a supportive and trusting relationship within ‘outside’
constraints?
• Do I involve other professionals when appropriate to meet the spiritual
needs of the patient?
Meaning and purpose
• Do I enable a patient to find meaning and purpose in their illness?
• What is my response to a patient who speaks of fear of the unknown,
loneliness or hopelessness?
• These questions are provided as a general guide and can be adapted for use
according to individual preference.
(Adapted from Ellis and Narayanasamy, 2009)
194 Spirituality: A neglected aspect of care
Patients in general required a nurse who could provide good professional skills in
physical care. There was also an expectation that the nurse would ‘be there’ for
patients, would have time for them, be sensitive to their needs and would enable
them to express emotions. It is interesting to note that in relation to conversations
between nurses and patients these frequently started spontaneously and were often
initiated by the patients. Of equal importance to these conversations was whether
or not the patients and the nurses ‘shared the same ideology’ and the same ‘religious
language’. When asked about actions taken in the area of spiritual care, nurses
emphasised how important it was that they did not breach the boundary of an indi-
vidual’s personal limits, their own or the patient’s. Praying with a patient was found
to be acceptable but only at the patient’s request and if the nurse felt able to do so. It
must be emphasised that nurses should not initiate a process that they cannot then
follow through (Van Leeuwen et al., 2006).
Prentis et al. (2014) in considering healthcare lecturers’ perceptions of spiritual-
ity in education found that ‘development of the intellect, emotion and spirit is an
essential component of good teaching’ and that ‘spirituality involves more than
subject knowledge; it implies personal development for students and lecturers’
(Prentis et al., 2014: 49). This conclusion underlines the values and perceptions
already identified in the RCN survey (2010).
It has been established that the goal of spiritual care in nursing is to help patients
find meaning and purpose during times of illness. Unfortunately, spiritual care
cannot be administered like a dose of medicine but depends on the quality and
196 Spirituality: A neglected aspect of care
success of the relationship between the client and the professional. It is for the nurse
a privileged situation to be able to support another in a time of distress (MacKinlay
and Hudson, 2008: 21).
It has already been concluded that if they are to deliver spiritual care in a profes-
sional manner nurses must be competent (Stern and James, 2006). The literature
and research on the provision of competencies through education and practice are
limited (Baldacchino, 2006: 885). The nurse who wishes to deliver professional spir-
itual care is required to exhibit the four nursing competencies identified by
Baldacchino (2006):
CONCLUSION
The place of spirituality in the holistic care of patients, whether in hospital or in the
community, has been an acknowledged fact for a number of years. Information
garnered from recent research has emphasised the pressing need felt by nurses for
relevant training in spiritual care. Further research will inevitably continue to clar-
ify the issues surrounding the content and provision of such training in future edu-
cational programmes.
FURTHER READING
Gardner F (2011) Critical Spirituality. A Holistic Approach to Contemporary Practice. England:
Ashgate Publishing Company.
McSherry W and Ross L (eds) (2010) Spiritual Assessment in Healthcare Practice. Cumbria:
M&K Publishers.
O’Brien ME (2014) Spirituality in Nursing: Standing on Holy Ground, 5th edn. Burlington,
MA: Jones & Bartlett Learning.
Rempel GR, Neufeld A and Kushner KE (2007) Interactive use of genograms and ecomaps
in family caregiving research. Journal of Family Nursing 13:403–19.
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198 Spirituality: A neglected aspect of care
11 Collaborative working:
Benefits and barriers
Sally Sprung and Sue Harness
LEARNING OUTCOMES
• Critically explore the political drivers that influence collaborative working.
• Critically examine the concepts of collaborative working.
• Critically reflect on interprofessional relationships, and consider the chal-
lenges that can affect collaborative working.
INTRODUCTION
This chapter examines the relevance of collaborative working from the nursing per-
spective. Included is a brief outline of the UK political drivers that are influencing
health and social care professionals to work in collaboration with an emphasis on
understanding core concepts. In order to capture the complexity of this phenome-
non, the factors needed for successful collaboration are discussed. To support the
learning from this chapter there is a scenario of a patient named Jenny who has
been diagnosed with breast cancer with widespread metastases and has recently
completed her final chemotherapy treatment. This scenario demonstrates how
important it is to work collaboratively with a wide range of health and social care
professionals including other agencies to provide the best care for Jenny and her
family. The health needs of patients like Jenny are increasing in complexity and the
need to work collaboratively to deliver care is crucial to reduce fragmentation and
improve positive patient outcomes.
POLITICAL DRIVERS
Although successive governments have recognised the importance of collaborative
working and joined-up thinking to improve care, it should be acknowledged that
collaboration and team working across the professions is not a new phenomenon.
However, the current prominence around the integration of health and social care
services signifies the need for collaborative working and consequently the substan-
tial reorientation of professional working practices.
From a historical perspective, since the 1990s, the UK government health and
social policies have focused on developing an integrated approach to improving
health and tackling health inequalities. A leading aim of ‘A Vision for the Future’
Political Drivers 201
(Department of Health, 1995) was targeted towards health professionals and the
need to work collaboratively in achieving common goals. The Primary Care Act
(Department of Health, 1997) underlined seven areas for action; one of these
identified that health and social care professionals including other agencies needed
to form effective working partnerships and encouraged collaborative working.
Another influential UK government policy was The NHS Plan (Department of
Health, 2000), which stimulated the agenda for health and social care professionals
to collaborate to reduce fragmented care and improve patient outcomes. One of the
overriding criticisms that came out of this fundamental policy was that it described
the National Health Service (NHS) as ‘old fashioned in its approach to care delivery
and organisation’. In particular, it identified poor team working as a huge contribu-
tor to past failings within the NHS. Regrettably, and in spite of these government
policies, there were three significant inquiries with the Bristol Royal Infirmary
(Kennedy, 2001), Victoria Climbie (Department of Health, 2003) and Baby P
(Ofsted, 2008), which all found catastrophic failures in the organisational manage-
ment of two different clinical areas related to health and social care. Some core
recommendations emerged from all three inquiries, including the need for health
and social care professionals to have an improved network of communication and
an ethos based on teamwork.
The next decade moved towards a UK government wanting to promote principles
of choice and control for users within a seamless service (Equity and Excellence:
Liberating the NHS, Department of Health, 2010). This policy recognised that
patients’ care needs are increasingly complex and that no one profession could meet
all of these. The government’s aim was to provide a genuinely patient-centred
service that required health and social care professionals to work collaboratively
and as a team. This policy advocated achieving quality and outcomes needed to be
‘the best in the world’ (Department of Health, 2010a: 8). This policy recognised that
when professionals are committed to working collaboratively in a supportive organ-
isation that empowers its staff then this can overcome obstacles to collaborative
working and could lead to less fragmented care and better patient outcomes.
More recently, the agenda for collaborative working is gathering importance. The
UK government has aspired to the improvement of the quality of healthcare through
encouraging inter-professional collaboration within acts of parliament (Health and
Social Care Act, 2012) and policy documents from the four UK nations (Five Year
Forward View, Department of Health, 2014; NHS Wales, 2013; Scottish Govern-
ment, 2014; Department of Health, Social Services and Public Safety, 2012) as inte-
grated care is increasingly being implemented within healthcare services. The focus
will be for health and social care professionals to work in partnership in order that
services can be co-ordinated around the needs of the patient and family. The UK
government is instituting a shift of ambitious changes together with financial
investment to improve collaboration among health and social care professionals.
Within the Five Year Forward View (Department of Health, 2014: 6) the policy
declared that barriers, which can prevent collaboration, need to be broken down
articulating an ambition that
202 Collaborative working: Benefits and barriers
The King’s Fund responded to the poor co-ordination of services and fragmentation
within health and social care with the ‘Place-based systems of care’ paper (King’s Fund,
2015) and argued that providers of services should work together to improve health
and social care for the populations they serve. The need to consider the overbearing
level of financial deficit that the NHS finds itself means that it will be necessary for
organisations to collaborate in order to manage the common resources available to
them. From a strategic perspective, Ham (2014) argued that the transformation of
primary care services will depend on better collaboration between health and social
care professionals to develop integrated care teams which focus on the patient at the
centre of care. Earlier, the World Health Organisation (2010) stated their vision that a
cultural shift is needed in working practices so that health and social care
professionals, voluntary agencies and networks may collaborate to reduce
fragmentation of care and meet the needs of patients and families.
(WHO, 2010: 64)
Oandasan et al. (2006) asserted that each health and social care professional
needed to combine their efforts and work collaboratively. They acknowledged that
resources are scarce and together with an increased workload were crucial to avoid
delivering care that was potentially unsafe and staff could be at risk of burnout.
A common thread running through these concepts is that of collective efficacy –
that is, a shared objective being the necessity for group members to believe that the
combined group efforts are not only necessary to obtain the desired goal but also that
each member is capable of and willing to do their share of the work. H owever, the
term collaborative working can often be misinterpreted. Collaborative working is
often considered synonymous with other modes of interaction such as co-operation,
compromise, teamwork, alliancing, and joint planning, inter-
multidisciplinary,
inter-professional, multi-agency and intersectoral. This ambiguity has resulted in the
term collaborative working sometimes being used inappropriately. For example, it is
often considered on equal terms as co-operation or compromise, which could be
interpreted as having a negative meaning and may actually be counterproductive. If
health and social care professionals do not fully understand the concept, this may
contribute to a lack of collaboration when working with patients and families.
The concept of collaboration is complex which requires time and energy from all
participants. Health and social care professionals need to invest in developing a
relationship with members being confident in their own abilities and competent
and confident in their level of expertise. Members need to consider each of these
themes (Figure 11.1) when beginning to work collaboratively. Crucially, each
member needs to respect and value each contribution from the perspective of each
discipline to enable collaboration to be successful.
Promote
Explain
collaborative
what’s
front-line
important
working
Create
common Hold
Distribute purpose partners to
leadership
account
Appreciate Insist
Share service user’s on whole
Serve power perspective system Resource
others’ approaches new ways
perspectives of working
Spend Build
time on political
relationships backing
FIGURE 11.2 System of classification. (From Gajda, R., American Journal of Evaluation, 25(1),
65–77, 2004.)
FIGURE 11.3 Four categories of collaborative arrangements. (From Gray, B., Collaborating,
Jossey-Bass, San Francisco, CA, 1989.)
PREDICTABILITY
Low
Co-evolution Co-operation
Co-ordination Competition
High
FIGURE 11.4 Model of partnership behaviour. (From Pratt et al., Working Whole Systems,
King’s Fund, London, 1995.)
Co-operation is best, even though organisations are motivated by self-interest,
especially where the landscape is rugged and uncertain. Members try to influence
each other and perhaps achieve win-win outcomes.
Co-ordination is where solutions are knowable but goals are shared and not
individual. Because the strategy is overt and a collective goal must be agreed, vari-
ous co-ordinating structures are set up. The driving force may be to reduce duplica-
tion, pool resources or fit different parts of a service together.
Co-evolution is where the goal is collective but the landscape very rugged which
requires new and innovative solutions. Members need to co-design something for a
shared purpose. It is not about consensus but lifting the game to a new level where
future action is not knowable and the timeframe is convoluted.
Wilson and Charlton (1997: 16) represent five stages within their linear model
that in reality may depict groups travelling back and forth through each stage of the
process (Figure 11.5).
These models and theories are a sample and are not an exhaustive list as there are
many diverse theories to explain collaborative working.
STAGE ACTIVITIES
1 Partners come together through mutual recognition of a common need, or in a joint
effort to obtain public funds.
If they have not worked together before, the partners begin the process of overcoming
differences in backgrounds and approach, building trust and respect.
There may be a need for training, building each partner’s capacity to operate
effectively in this new organisation.
2 Through a process of dialogue and discussion, the partners establish the common
ground and work towards agreeing on a vision and mission statement for the initiative.
The original core group might agree on the need to involve more individuals and
organisations in the initiative.
The partners develop mechanisms for assessing needs and quantifying the size of the
task they propose to undertake.
The initiative combines the information generated by the needs assessment excercise
with the vision and mission statement to produce and agenda for action.
3 The formal framework and organisational structure of the partnership is designed and
put in place.
The partners set specific goals, targets and objectives linked to the agenda for action.
Where appropriate, the executive arm of the partnership selects or appoints a
management team to oversee the work of the initiative.
4 The partnership delivers to its action plan, whether this be service provision or some
other function.
The executive arm seeks to maintain the involvement of all partners, formulates policy
decisions and ensures the continuing accountability of the partnership.
There is an ongoing process of assessing, evaluating and refining the operations of
the partnership.
5 Where appropriate, the partners should plan their exit strategy. This involves
developing a new set of goals for the survival and continuation of the work of the
initiative in some form.
They should seek to create ‘life after death’ by transferring the assets of the partnership
back into the community with which they work.
FIGURE 11.5 Stages in the partnership process. (From Wilson and Charlton, Making
Partnerships Work, JRF, New York, 1997.)
foundation upon which professionals may reflect upon and decide to ‘consciously
and deliberatively develop their collaborative practice’. Successful collaboration
depends on participants sharing power with values placed on knowledge and exper-
tise rather than on status in a role within the organisation or hierarchy. The value of
working in a trusting and honest environment is recognised as facilitating good
collaborative working relationships. It is important that the group recognise the
collective accomplishments rather than individual effort. Effective communication is
essential between participants so that issues can be discussed and debated in order
that the plan and delivery of services are agreed so that patients receive the highest
quality care.
Collaborative working requires each participant to communicate effectively with
each member (Connolly et al., 2010; Rothberg et al., 2011) with trust being an essen-
tial component (Magalhães and Fidalgo, 2010). Successful collaboration allows par-
ticipants to discuss issues, check understanding and share good practice. According
Factors for Successful Collaboration 207
to Andvig et al. (2014), this allows each professional to be able to acknowledge each
other’s roles and responsibilities in order that common goals and decisions are made,
which may improve health outcomes for patients and families. Fortune and Fitzger-
ald (2009) advocate the need for the entire healthcare team to identify and articulate
the benefits of working in partnership so that the needs of the patient can be met.
In Figure 11.6, Mattessich and Monsey (1992: 12) identified a model based upon
types of factors that influenced the success of collaborative working.
Successful collaborative working is dependent on participants feeling supported
within an environment that encourages individuals to share their expertise. A cru-
cial element is that initially each individual needs to be receptive to the idea of
working in collaboration. The success of this may depend on each individual’s past
experience of working closely with other professionals and agencies. From an
individual perspective, their own emotional intelligence, confidence in their exper-
tise and maturity in their role together with how other members within the wider
team recognise and value their professional input can influence the overall success
of collaborative working.
Factors related to the ENVIRONMENT
History of collaboration or co-operation in the community
Collaborative group seen as a leader in the community
Political/social climate favourable
Factors related to MEMBERSHIP CHARACTERISTICS
Mutual respect, understanding and trust
Appropriate cross section of members
Members see collaboration as in their self-interest
Ability to compromise
Factors related to PROCESS/STRUCTURE
Members share a stake in both process and outcome
Multiple layers of decision making
Flexibility
Development of clear roles and policy guidelines
Adaptability
Factors related to COMMUNICATION
Open and frequent communication
Established informal and formal communication links
Factors related to PURPOSE
Concrete, attainable goals and objectives
Shared vision
Unique purpose
Factors related to RESOURCES
Sufficient funds
Skilled convenor
FIGURE 11.6 Factors influencing the success of a collaboration. (Mattessich and Monsey,
Collaboration: What Makes it Work, Amherst H. Wilder Foundation, St. Paul, MN, 1992.)
208 Collaborative working: Benefits and barriers
CASE STUDY Jenny Jacobs, a nurse, is 45 years old with newly diagnosed breast cancer with
widespread metastases. Her husband Chris is her main carer; he works as a
self-employed builder. Jenny and Chris have two children. Luke, aged 14
years, has recently been playing truant from school and complaining of
headaches. Each morning, Chris has struggled to get Luke motivated and
finds that he is reluctant to go to school.
Lucy, aged 8 years, has always enjoyed school and belongs to a small group of
friends. However, her teacher has noticed that Lucy has recently become
withdrawn and weepy in class and in the playground.
Jenny has completed her final chemotherapy treatment and has been told by
her consultant that active treatment is no longer an option available to her.
For the past week, Jenny has complained of severe headaches with some
visual disturbances, which have been quite distressing. Jenny has not had
much appetite recently and her clothes are becoming quite loose. She is also
feeling tired due to not sleeping and is worried for her family.
As the main carer for Jenny, Chris is finding it difficult to cope, both emotion-
ally and financially. He has also found it difficult to support both children, and
has recently discovered Luke has been self-harming. Luke appears angry and
refuses to talk to his Dad. Chris has not spoken to Jenny about this for fear of
upsetting and worrying her further.
The benefits of working collaboratively are well recognised (D’Amour et al., 2005;
Lynne et al. 2009; Reeves et al., 2009 ). This reinforces competence and the value of
their contribution to the planning and delivery of care to the patient and family.
Successful collaboration can facilitate a win-win situation for the health and social
care team and the patient with a sense of accomplishment and job satisfaction that
by working collaboratively enriches respect for each other’s roles.
McDonald and McCallin (2010) recognise that complex scenarios involving the
wider healthcare context, of Jenny and her family for example, are the driving force
for interprofessional collaboration. Team interactions are required here for effective
and efficient patient-centred care to take place as the knowledge and skills of many
services will be required.
Appreciation of roles and respect for colleagues are paramount if healthy
collaboration is to work (Lemetti et al., 2017). For example, Chris has confided that
he is experiencing financial difficulties. He is unable to work because he is the main
carer for Jenny. The social worker may be able to assist him to claim for benefits he
could be entitled to. During your discussions with Chris, he agrees for you to make
a referral. At this point, it would be unwise for you to make any promise or pinpoint
a date and time that the social worker would visit as you are unaware of the social
worker’s priorities and workload. This information can be provided once there has
been some dialogue with the social worker involved.
Integrity places the Jacobs family needs first. The family must be able to trust the
practitioner with their health and wellbeing. This means treating them as individu-
als and respecting their dignity when working with others to promote health (NMC,
2015). Jenny will rely on you to access the knowledge and skills of a variety of
experts for herself and her family. However, McDonald and McCallin (2010) warn
of the risk of the identification of superfluous problems, purely since a collaborative
team is accessible. Ongoing holistic assessment will guide the practitioner to make
appropriate referrals based on need.
While Jenny’s condition is stable, it is useful to examine her wishes for a ‘good
death’. This requires well-developed communication skills. Impending death is a
difficult topic to talk about. This topic can be initiated at an appropriate time when
Jenny is ready, and preferably when the conversation can take place in private with-
out interruption. Jenny’s hopes, fears, requests and expectations must be respected
and documented to inform an advanced care directive. As Jenny’s condition dete-
riorates, it is the role of the practitioner to advocate for Jenny to ensure that her
recorded wishes are met (NMC, 2015). Actions for End of Life Care: 2014–16 (NHS
England, 2014) requires all services to work in partnership to respond positively to
patients’ needs in line with NICE guidelines (NICE, 2015).
Trust involves having a firm belief in the reliability of a person, and in this case
Jenny will develop trust in the interprofessional team as long as they demonstrate
appropriate and sensitive interpersonal skills and a good communication manner.
recognises that partnership working usually occurs within teams. In this scenario,
the team is a wider group of people than the community nursing team. Placing the
patient and family at the centre of a care plan relies on the patient being involved in
the collaborative process at every level.
Veracity and openness form the basis of a good working relationship with
patients, within teams and the wider interprofessional team (Beauchamp and
Childress, 2012). It is essential that Jenny and her family are kept fully informed and
have their questions answered openly and honestly.
Skills Needed to Collaborate Effectively 211
Freedom is the quality of not being controlled. Although it is important to
rovide a firm evidence base to support the care plan designed for Jenny, it is
p
important that she has the freedom to make personal choices (King’s Fund,
2013). C ollaborating with Jenny means working with her to meet her personal
needs, not taking over, and not avoiding sensitive difficult areas of discussion.
Decisions should be s upported and not made on behalf of patients unless the
patient lacks the capacity to make decisions. In this situation, the fourth princi-
ple of the Mental Capacity Act (2005) – ‘best interests’ – will apply, unless an
advanced directive has been drawn up. If an advanced directive exists that
applies to the situation which has arisen, the advanced directive decision will
prevail (Dimond, 2015).
Safety is the key feature for patient care and a shared objective for all involved
(Lemetti, 2015). Risks can be obvious or hidden. They can relate to people or envi-
ronments and can be the result or consequence of acts and omissions. Rigorous
risk assessment is essential to maintain the wellbeing of Jenny and her family. It is
also required to safeguard the visiting services who may be involved in the care of
Jenny and her family. All healthcare providers are bound by policy and guidance
to minimise risk and promote safety (NMC, 2015; HCPC, 2016). For example, if
any risks are identified that may pose harm, this information must accompany the
referral made to other services.
There are known risks associated with chemotherapy. The practitioner can
provide advice and support for Jenny in relation to this. Additionally, vulnerable
visiting staff must be aware of any issues that may pose a hazard or risk, for
example, to a pregnant member of staff. As Jenny’s disease process progresses, it
is vital that the risk assessment is evaluated and updated along with the care plan.
Any changes will need to be disseminated to all those involved in visiting the
Jacobs family.
Knowledge is the theoretical or practical understanding of a subject. In relation
to Jenny and her family, it applies to the utilisation of widely accepted evidence-
based practice performed by a variety of professional and allied healthcarers. All
direct clinical interventions, advice, support and education must be evidence based
and from a valid and reliable source (Ellis, 2016). When working with patients like
Jenny, sometimes they access information online that may not be from a recog-
nised reliable source. In this context, the practitioner must encourage the use of
widely accepted reliable information sources such as NHS direct; however, they are
still obliged to maintain a non-judgemental attitude if the patient chooses to use a
non-evidence-based remedy that claims to be a miracle cure. They are not, how-
ever, obliged to administer any lotion, potion or any other treatment that is not
prescribed by a doctor or nurse prescriber. When patients make such requests, this
should be clearly documented in the care plan along with any advice given. This
will safeguard the patient and guide other staff visiting the family (NMC, 2015;
HCPC, 2016).
212 Collaborative working: Benefits and barriers
• Care
• Compassion
• Competence
• Communication
• Courage
• Commitment
(Department of Health, 2012)
In 2015, the regulator for Nursing and Midwifery published The Code: Profes-
sional Standards of Practice and Behaviour for Nurses and Midwives (NMC, 2015).
The new set of standards puts the interests of patients first under four key headings.
• Prioritise people
• Practice effectively
• Preserve safety
• Promote professionalism and trust
(Nursing and Midwifery Council, 2015)
ACTIVITY 11.2 Considering your role as a community nurse – how do the 6Cs from the
Compassion in Practice document relate to the 4Ps from the NMC Code of
Professional Standards of Practice and Behaviour for Nurses and Midwives?
Sharing information with other services requires that we send and receive infor-
mation; yet, communication is a multifarious concept. The two-way sharing of
Collaborative Attitudes 213
information can be face to face, but as teams and services are generally widely
geographically spread, health professionals liaise in a face-to-face context less
frequently. They increasingly rely on information technology where the interper-
sonal nature of verbal cues and body language are lost. Four dimensions of com-
munication were described by Cox and Hill (2010) as:
• Mechanistic – Transmitted where interpersonal skills are not required. However,
this method is reliant on clear verbal or written information being provided for
accurate interpretation by the recipient.
• Psychological – Emotionally charged dialogue that is written or spoken where
emotive language can make clarity less factual and less objective.
• Social constructivism – Where the same problem can be interpreted in different
ways, depending on the area that the health professional is working. Different
priorities emerge as the health professionals involved interpret the need of the
patient within the commissioning framework of their specific service delivery.
• Systemic – How communication is provided by an organisation, and within an
organisation. Often there are differences in the way in which information is
cascaded and shared both within an organisation and to other organisations and
services.
ACTIVITY 11.3 In considering the care services required by Jenny, Chris, Luke and Lucy in the
last exercise, now think about how those services will communicate with each
other.
Using the four dimensions of communication discussed in the last paragraphs,
examine how these dimensions are used by health professionals providing care
for the Jacobs family.
COLLABORATIVE ATTITUDES
Collaboration is a word used widely in nursing and healthcare. Attitudes of those
involved in team working can influence the collaborative process. Key attitudinal
skills can make or break the sustenance and progression of a successful shared care
episode. Clarridge and Ryder (2004) describe these professional attributes as rela-
tional skills.
Relational skills include readiness, willingness and trust, and these are thought
to be the basic skills required for collaborative work (Pavord and Donnelly, 2015).
However, an expansion on these core skills can include other communication
features such as the following:
214 Collaborative working: Benefits and barriers
ACTIVITY 11.4 In terms of nurse–patient relational skills, what factors do you think contrib-
ute to the issues raised in the following scenario?
Jenny discovers that a lesion on her breast that she thought was a pimple has
developed into a wound that is leaking odorous fluid. She tells the district
nurse. The district nurse assesses the wound and tells Jenny that the wound is
unlikely to heal and it will need to be re-dressed every day. During a subse-
quent outpatient appointment, another nurse tells Jenny that her breast is
fungating and it is likely that the ‘smell’ could become a problem. Jenny
becomes distressed and later in the day she rings the district nurse and
indicates that she has had enough and wants to ‘end it all’.
The district nurse visits Jenny and during their conversation reassures her that
the wound can be managed to maintain her comfort and dignity. Jenny seems
much happier with this information and advice.
You may have considered that the outpatient department nurse has provided too
much information. However, this information may have been given in response to
Jenny asking questions (Leadership Alliance for the Care of Dying People, 2014).
Conversely, while maintaining good relational skills with patients, the nurse could
have contacted the district nurse (as Jenny’s care manager) to alert her to the
sensitive nature of the conversation the nurse had had with Jenny.
Conclusion 215
All of these characteristics are required for the development and maintenance of
professional relationships with patients, carers, healthcare professionals and
organisations allied to health (Riley, 2015).
Although it is wholly appropriate to be open and honest, there is always the need
to be sensitive and empathetic. Also, the use of therapeutic language can cause
alarm to patients and perhaps if the word ‘fungating’ had been replaced with more
suitable language, the distress caused to Jenny may have been minimised (Riley,
2015). However, both nurses work in different settings. Each will have a different job
description, yet both will be working within the same professional code and striving
to meet the same goals in meeting patients’ needs. Therefore, there must be respect
for the roles and responsibilities of others and relational skills apply to professional
relationships, too (NMC, 2015; HCPC, 2016).
CONCLUSION
This chapter has offered an insight into the nature of collaborative working and how the
scenario highlights that the delivery of care to patients can often be complex. It recog-
nises that individual healthcare professionals involved in the scenario will use different
skills but share a common goal of providing a comprehensive service tailored to meet
the needs of the patient and family. The success of collaborative working will require
that individuals must be able to acquire a vision and to develop common goals.
Policy initiatives and the needs of those who use services and resources will
continue to steer the collaborative working agenda. In order for new policies to
operate effectively they need the commitment of healthcare professionals to work
collaboratively together with the ability to critically evaluate practice and work in
partnership with patients and service users.
Critically evaluating your understanding of collaborative working within your
practice and how this can be incorporated will help you to become an effective
practitioner.
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218 Collaborative working: Benefits and barriers
LEARNING OUTCOMES
• Explore the spectrum of conditions that might be considered acute in
community care.
• Discuss and analyse theory and assessment tools required to support the
community nurse caring for acute conditions.
• Identify and rationalise the skills required to support the community nurse
caring for acute conditions.
• Recognise pharmacology knowledge and interventions to manage acute
conditions.
• Discuss the concept and elements related to discharge planning and avoiding
hospital admission.
INTRODUCTION
The aim of this chapter is to examine approaches to managing acute care in the com-
munity. Current healthcare policy drivers within the four UK countries highlight the
desire to continue to expand the delivery of care within the community (Department
of Health, 2014; Scottish Government, 2013, 2015; Department of Health, Social and
Public Safety, 2011; Welsh Assembly Government, 2010). To achieve this vision, fur-
ther and indeed continued development of community nursing is required to reach
its fullest potential of service delivery, and this includes the use of technology, which
is discussed further in Chapter 18 (Maybin et al., 2016; QNI/QNIS, 2015; Royal Col-
lege of Nursing, 2013; Department of Health England, 2013).
Traditionally ‘acute care’ depicts how and where specialised healthcare is provided
in the case of emergency situations or care as a result of referral for further investiga-
tion, surgical intervention, complex tests or other care, that historically has not been
delivered or available in the community setting. Treatment was continued until the
individual was well enough to be supported and cared for in the community again
(Naylor et al., 2015).The shifting balance of care to the community setting as high-
lighted in policy requires this definition of acute care to be reconsidered and to con-
sider acute care within community-based services, including the home setting. For
the purpose of this chapter acute care in the community refers to a short episode of
care for a new condition or an exacerbation of an existing long-term condition.
220 Approaches to acute care in the community
Complex care at
home
District nursing
infrastructure
Skill mix
Leadership
Public health focus
Clinical expertise
Information technology
Education and training
End-of-life care Acute care at
at home home
Figure 12.1 Three domains for effective care delivery. (From Royal College of Nursing,
District Nursing: Harnessing the Potential, The RCN’s UK Position on District Nursing, London, 2013.)
• Is there an effective skill mix within your team to support the management of
acute care?
• What opportunities are there to promote health and well-being when
managing acute care at home or in other community settings?
• What information technology is available in your area to support your role?
• Do you have access to education and training to support your
development?
Mrs Smith is normally fit and well, she lives at home with her husband whom she
cares for as he has Parkinson’s disease. She attended the health centre and was
diagnosed with a deep vein thrombosis (DVT) and commenced on to anticoagulants.
• What knowledge and skills can you identify that would be required to assess
and manage this patient’s illness?
• What is your knowledge and understanding of anticoagulants?
• What are the risks of such treatment?
• What health education may be required?
• Review local and national treatment guidelines.
• What impact will this diagnosis have in relation to her ability to care for him?
• What psychological support may they need?
• Which members of the multi-disciplinary team can help to support this
couple?
• Who leads the care delivery?
Initially, Mrs Smith is in a lot of pain which you have assessed using a validated
pain assessment tool, and you discover that she is not taking the analgesia
prescribed while in hospital as it makes her very drowsy and unable to help her
husband.
• What tool could you use to ensure holistic pain assessment is completed?
• How does a patient’s pain score help determine the level of analgesia
required?
• Which types of analgesics are required when a patient has severe pain?
Discussion point
Discuss with your pharmacist:
Table 12.1 Conditions that have the potential to become an acute condition in the
community setting
Women’s health Cancer Chronic pain Depression
Chronic o
bstructive Cellulitis Multiple sclerosis Chronic kidney
pulmonary disease disease
(COPD)
Chest pain Pyrexial child Minor injuries Thyrotoxicosis
Non-specific Occluded lines Hepatitis Urinary
abdominal pain incontinent
Respiratory tract Catheters and feeding Hearing loss Alcoholic liver
infections tubes disease
Minor head, neck Eye infections Haemorrhoids Arrhythmias
and back injuries
Pain Skin and mouth Glaucoma Spina bifida
Asthma Nausea and vomiting General ear disease Visual impairment
Cardiac disease Deep vein thrombosis Epilepsy Inflammatory
bowel disease
Arthritis Epilepsy Chronic fatigue Hypertension
syndrome
Mental health Diabetes Blood disease Ulcer
problems
Alzheimer’s/ Chromosomal Allergies Warfarin therapy
dementia disorders including
Down’s syndrome
Cerebrovascular Hypothyroidism Anaemia Malnutrition
Joint disorders Human immunodefi- Bronchiectasis Osteoporosis and
ciency virus (HIV) bone metastases
Endocrine disorders Obesity Prostate hyperplasia Diverticular
disease
Drug and alcohol Osteomyelitis Chronic tonsil
misuse disease
Source: Information Service Division Scotland, http://www.isdscotland.org/index.asp, 2016.
224 Approaches to acute care in the community
National Health Service (NHS) because of increasingly complex patients with multiple
co-morbidities, an aging population and funding limitations, advanced planning of
care has become particularly topical. Approximately 20%–30% of emergency
admissions may have been avoided had there been better management of their care
prior to their admission (Health Foundation, 2013). This statistic highlights the
need for effective anticipatory care planning.
The ethos of anticipatory care planning to look ahead and forward plan care was
referred to in Chapter 13 looking at emerging issues in long-term conditions. Antci-
patory care planning is most commonly completed for patients with long-term con-
ditions or end-of-life care to identify at an early stage, any circumstances which
may have a negative impact on their health or long-term conditions and to help
avoid acute exacerbations (Baker et al., 2012).
The anticipatory care plan evolves through good communication, collaborative
working and shared decision making with the patient to create a dynamic record.
Contained within the plan are preferred responses, interventions and actions to be
carried out in the presence of a clinical deterioration, crisis in care provision or
circumstance. The plan needs to be reviewed on a regular basis to reflect changes in
well-being, wishes or provision of care (Scottish Government, 2011).
CASE STUDY Daniel Manson is 71 years old and has chronic obstructive pulmonary disease
(COPD). He has experienced two episodes of an infective exacerbation of his
COPD in the last 6 months; both episodes resulted in hospital admissions. He
lives at home with his wife, both of whom are normally independent. They have
three children, none of them or their families live local.
CASE STUDY • How familiar are you with the pathogenesis of COPD?
• How is the anticipatory care plan communicated and shared effectively
between varying healthcare professionals?
• How often should they be reviewed and by whom?
• How can the effectiveness of the anticipatory care plan be assessed?
Daniel’s condition deteriorates over time in line with the trajectory of disease
and he enters the terminal phase of his illness.
DETERIORATING PATIENTS
Acute care can also refer to care delivered in cases of sudden and frequently unan-
ticipated deterioration in patients where an illness or injury has occurred creating
an emergency scenario. Without rapid intervention there is high probability of dis-
ability or death (Hirshon et al., 2013). Therefore, an urgent assessment must be
undertaken to determine the full extent of the presentation and the care needs of
the patient (Clarke, 2016). The success rates of rapid intervention to improve health
and well-being are mainly time sensitive and stress the importance of performing a
rapid yet efficient assessment of the patient.
Successes in acute care are achieved when reversible factors are identified dur-
ing assessment and interventions implemented as soon as possible within the
realms of competency and capabilities (Nursing and Midwifery Council, 2015),
treating the most significant threat to life or limb first and continuing in order of
priority.
It is imperative to stress that while managing a patient during an acute presenta-
tion, technology is not always essential initially while stabilising a patient (Hirshon
et al., 2013). This is especially significant in the community setting when a nurse
may be a lone worker or visiting with limited equipment.
P Provocation/palliation
What initiates, starts or causes it?
What helps, improves or makes it better?
What does not help or makes it worse?
Q Quality and quantity
How does it feel, look or sound?
How much is there?
R Radiation
Where is it?
Does it spread?
S Severity
Does it interfere with activities?
Rate the severity on a scale – mild, moderate, severe
T Timing
When does it begin?
How often does this happen?
Is it sudden or gradual?
Airway
Sta
bblele ble
stsata
UUnn
Comprehensive
Breathing
assessment
Stable
Stable
Exposure Circulation
Sta ble
ble Sta
Disability
Unstable
treatment. This approach is most apt allowing for rapid prioritising of treatment to
stabilise patients (Impact, 2010).
AIRWAY
Commencing with an assessment of the patient’s airway, any obstruction of the
airway is an emergency situation and expert help should be sought immediately.
This is a life-threatening scenario as the patient is at high risk of cardiac arrest,
hypoxia, acute kidney injury and death.
Signs of airway obstruction – The airway can be assessed using the look, listen
and feel method:
Look
• Airway obstruction causes paradoxical chest and abdominal movements (‘see-
saw’ respirations) and accessory muscles usage during respiration. A late sign of
airway obstruction is the presence of central cyanosis.
• The mouth should be assessed for any physical obstruction such as foreign body,
blood, vomit, swelling or secretions.
• Reduced level of consciousness often leads to airway obstruction in a critically ill
patent due to depression for the central nervous system.
Listen
• In complete airway obstruction, there are no breath sounds at the mouth or nose.
• In a partial airway obstruction, air oasis:entry is diminished and frequently noisy.
• Although noisy breathing can be frightening to hear and distressing to observe,
remember no sound at all is far more sinister. The airway is completely occluded,
your patient has stopped breathing and has gone into respiratory arrest. When
noisy breathing is evident, such as stridor then air is partially shifting and there-
fore the patient is experiencing a partial occlusion of the airway. This remains an
emergency scenario and expert help is required immediately.
230 Approaches to acute care in the community
Feel
• To establish whether there is any movement of air place your cheek or hand next
to the patient’s nose and mouth.
(Resuscitation Council, 2011)
Any airway obstruction is a medical emergency and therefore expert help should be
summoned immediately. An untreated airway obstruction has serious consequences:
hypoxaemia with the risk of hypoxic injury, cardiac arrest and ultimately death.
Interventions
The majority of airway obstructions can be resolved with simple airway opening
manoeuvres such as head tilt, chin lift. Suctioning should be considered and the
insertion of an oropharyngeal or nasopharyngeal airway. Should these interventions
be unsuccessful then intubation may be required (Resuscitation Council, 2015).
Oxygen therapy should be administered via an oxygen reservoir bag at 15 litres/
minute aiming for oxygen saturations of 94%–98%. Oxygen can then be titrated
down once the patient has stabilised, with a view to maintaining oxygen saturations
between 94% and 98%. Critically ill patients at known risk of hypercapnia, due to
established disease should also aim to be maintained with oxygen saturation of
94%–98% initially (Resuscitation Council, 2015).
Only when the airway is stable can the assessment progress to the next stage.
BREATHING
Breathing can be assessed using the look, listen and feel method:
Look
• Is the patient showing signs of respiratory distress: use of accessory muscles, skin
colour, distress, sweating, central cyanosis, abdominal breathing, patient posi-
tion, nasal flaring, pursed lips, elevated jugular venous pressure (JVP)?
• Does the patient have a reduction in the level of consciousness?
• Check immediate surroundings for any aids or adjuncts: oxygen, inhalers, nebu-
lisers.
Breathing 231
• Does the patient have any chest deformity, scarring, signs of trauma or chest
drains?
Listen
• Is the breathing pattern noisy, laboured, wheezy, rasping?
• Is the patient able to communicate in full sentences?
Feel
• Establish whether there is any movement of air by placing your cheek or hand
next to the patient’s nose and mouth.
• Is the patient hot and sweaty, cool and clammy?
(Resuscitation Council, 2011)
Assessing rate and depth of breathing is one of the easiest observations to record
yet one that is frequently omitted. A patient who suddenly becomes tachypneic is
alarming as breathing is frequently the first clinical observation to become impaired
within a deteriorating patient. Breathing is therefore a good clinical indicator warn-
ing of an adverse event (NPSA, 2007; NICE, 2007).
Breathing must be measured for 1 minute, in addition to determining the num-
ber of breaths the depth and pattern of breathing should also be assessed. Any
added sounds such as wheeze or stridor, presence of cough need to be considered
(Woodrow, 2012). The percentage and rate of any supplementary oxygen in situ
need to be factored into the assessment (SIGN, 2014).
When available a pulse oximeter should be utilised to measure SpO2. Care
should be taken when fitting the probe to ensure the area it is being attached to is
warm and well perfused. Fingers and earlobes are commonly used sites; however,
a deteriorating patient may have peripheral cyanosis which will impact on the
accuracy of the result (Jackson, 2016). Percussion and auscultation of the chest
should be undertaken, if within competencies and capabilities to assess for pres-
ence of fluid, consolidation, reduced or absent air oasis:entry (Resuscitation
Council, 2015).
Interventions
Oxygen therapy should be administered via an oxygen reservoir bag at 15 litres/
minute aiming for oxygen saturations of 94%–98%. The oxygen can be titrated
down once the patient has stabilised with a view to maintaining oxygen saturations
between 94% and 98% (British Thoracic Society, 2016). If the rate of breathing and/
or depth is not stablised with this intervention, then bag-mask ventilation must be
used to support the patient until expert help arrives or the patient stabilises (Resus-
citation Council, 2011).
Patient positioning can also help to enhance oxygenation and whenever safe to
do so patients should be nursed upright to optimise lung expansion. This may not
be possible depending on their level of consciousness or intervention required
(Jackson, 2016).
232 Approaches to acute care in the community
If the patient deteriorates then return to ‘airway’ and recommence the ABCDE
assessment.
CIRCULATION
Circulation can be assessed using the look, listen and feel method:
Look
• Note the colour at the patient’s peripheries: pale, blue; pink.
• Assess their veins: are they collapsed or underfilled?
• Is there a reduction in the level of consciousness?
• If a urinary catheter is in situ look at urinary output.
• Are there signs of haemorrhage?
Listen
• Is the patient alert and orientated?
• Is the patient in pain?
Feel
• Assess the temperature of the patient’s hands and feet; are they hot or cool?
• Assess the peripheral pulse, noting rate, rhythm and volume.
• Measure blood pressure.
• Measure capillary refill time.
Assessment
While measuring the peripheral pulses it is important to assess the rate, rhythm
and volume of the pulse. A bounding pulse could be indicative of sepsis while a faint
pulse could be due to reduced cardiac output (Resuscitation Council, 2015).
The systolic pressure measurement is the most significant while obtaining a
blood pressure reading. It is used during the assessment phase as it is reputed to be
the more reliable marker of well-being. It is important to recognise that blood pres-
sure can appear normal in the presence of shock due to the body’s compensatory
mechanisms and be cognisant of this.
Circulation 233
Interventions
Treatment specifics depend upon the cause of the reduction in cardiac output; how-
ever, initial interventions should be targeted at fluid replacement, control of any
haemorrhage and tissue perfusion repair (Huether and McCance, 2016), interven-
ing urgently with the most significant threats to life and well-being first.
A wide-bore cannulae(s) should be inserted if there is no venous access and rou-
tine blood scan should be drawn prior to the commencement of a fluid challenge(s).
An initial bolus of 500 mL of warmed crystalloid solution (e.g. 0.9% sodium chlo-
ride) should be administered in the presence of hypotension, with an infusion rate
of less than 15 minutes. If the patient is known or suspected to have cardiac failure,
then a reduced volume of 250 mL is recommended. Close monitoring is essential to
observe for fluid overload by auscultating the chest after each bolus.
Regular monitoring of the patient’s pulse and blood pressure is required to deter-
mine whether the intervention(s) are effective. The goal is to restore blood pressure
to normal or a systolic greater than 100 mm Hg. The fluid bolus should be repeated
234 Approaches to acute care in the community
If the patient deteriorates then return to ‘airway’ and recommence the ABCDE
assessment.
DISABILITY
Disability can be assessed using the look, listen and feel method:
Look
• Examine the size of the patient’s pupils, checking for symmetry.
• Is there a reduction in the level of consciousness?
• Check immediate surroundings for any aids: blood glucose monitoring machine,
insulin pens, alcohol, drugs – prescribed and illicit.
• Is there any asymmetry within the body, in particular the face and limbs?
Listen
• Is the patient orientated to time and place and coherent?
Feel
• Is the patient hot and sweaty, cool and clammy?
Assessment
An assessment of a patient’s conscious level can be quickly and efficiently completed
using the AVPU score:
A – Alert
U – Unresponsive
If a patient is able to respond to you fully he or she is scored ‘A’ for alert. When
the patient is able to respond after you verbally give him or her a command, for
example, ‘open your eyes for me’ (always use the patient’s name while doing so to
maximise the chance of him or her responding), this would be a ‘V’ score. If a
patient requires painful stimuli to respond this is scored ‘P’; no response at all
would score ’U’. Any patient achieving a ‘P’ or a ‘U’ score has an altered state of
consciousness (Royal College of Physicians, 2015).
Exposure 235
The Glasgow Coma Scale (GCS) is a more comprehensive system of assessment
which can be utilised once the acute phase of assessment has been completed to
provide further clarity of any deficits (Teasdale, 2014).
Check whether the patient has taken their prescribed drugs correctly – has there
been any illicit drug use? Even when prescribed drugs have been taken correctly
consideration should be given to drug toxicity and whether any are reversible
(Resuscitation Council, 2015).
Intervention
Hypoglycaemia is a common cause of reduced conscious levels and must be dis-
counted or treated during an ABCDE assessment. Local NHS policy should be fol-
lowed to treat hypoglycaemia, initially 50 mL 10% glucose solution administered
intravenously. Patients who are unconscious or have a reduced level of conscious-
ness are unable to maintain their airway independently and therefore should be
nursed in the lateral position. The main concern is the high risk of aspiration due to
the loss of gag reflex (Resuscitation Council, 2015).
If the patient deteriorates then return to ‘airway’ and recommence the ABCDE
assessment.
EXPOSURE
A full top to toe examination of the patient should be undertaken while maintain-
ing dignity to assess for any clues or reversible causes to the patient presentation.
Exposure can be assessed using the look, listen and feel method:
Look
• The patient should be observed for any signs of a rash, discolouration, oedema,
distension, injury, bleeding and abnormalities. Care needs to be taken to mini-
mise heat loss during the assessment (Jevon and Ewens, 2012).
Listen
• Is the patient complaining of any pain, swelling, itch, discomfort, abnormality?
236 Approaches to acute care in the community
Feel
• Does the patient generally feel too hot or cold?
• Is there an area of localised heat, swelling, distension? Were both sides compared
for symmetry?
Assessment
A patient’s temperature needs to be obtained to determine the presence of a pyrexia
or hypothermia. A pyrexia greater than 41°C can lead to convulsions and be fatal,
whereas hypothermic temperatures of less than 32°C can lead to cardiac arrhyth-
mia (Huether and McCance, 2016).
Intervention
Blood cultures should be obtained when pyrexia is present and greater than 38.3°C
(NICE, 2016).
If the patient deteriorates then return to ‘airway’ and recommence the ABCDE
assessment.
If the patient remains stable, then documentation can be completed and a com-
prehensive examination undertaken to establish a differential diagnosis and ongo-
ing management plan.
Red flags
Good knowledge of pathology and clinical presentation allows for recognition of
significant clinical findings more commonly referred to as red flags. The presence of
such findings during history taking and/or clinical examination should trigger
‘alarm bells’ within the practitioner to the potential possibility of significant pathol-
ogy. An urgent referral or escalation of care should be initiated as a matter of prior-
ity (Nuttal and Rutt-Howard, 2016).
Communication Strategies to Manage Acute Episodes of Care 237
Pain assessment
However painful and unwanted a sensory experience pain is, it is essential to our
well-being. The presence of pain indicates the occurrence of an injury or disease.
Without this indicator of something being amiss irreversible and fatal damage
• Situation
• Identify yourself, the site/unit you are calling from
• Identify the patient by name and the reason for your report
S • Describe your concern
• Background
• Give the patient's reason for admission
• Explain significant medical history
B • Inform the consultant of the patient's background
• Assessment
• Vital signs
• Contraction pattern
A • Clinical impressions, concerns
• Recommendation
• Explain what you need – be specific about request and time frame
• Make suggestions
R • Clarify expectations
Figure 12.3 SBAR Communication Tool. (Adapted from NHS Institute for Innovation and
Improvement, SBAR Situation-Background-Assessment-Recommendation. http://www.
institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_
tools/sbar_-_situation_-_background_-_assessment_-_recommendation.html, 2010.)
238 Approaches to acute care in the community
CASE STUDY Miss Parker has had a history of COPD for 5 years; she has requested a visit as she
has not been feeling well since last night. She states that she is struggling to
breathe and feels hot.
Prior to arriving at the house to review Miss Parker what preparatory work could
you complete in preparation for the visit?
• What would you expect to find within each stage of the assessment?
• What interventions could you commence?
• Consider how you would communicate your assessment findings using the
SBAR communication tool.
utcome of this assessment will provide the rationale for analgesic prescribing and
o
can provide clues as to the nature of the ongoing presentation.
Pain control
The desire for patients to receive appropriate analgesics and effective pain control
during an episode of pain is not a new phenomenon. As far back as 1996 the World
Health Organization (WHO) recognised the importance of effective pain relief in
cancer pain. The pain ladder was created in an attempt to guide and standardise
prescribing practice and care received. Although devised within the field of cancer
care, the principles of the pain ladder can be applied to any individual in pain. The
ladder provides a stepwise approach to the level of analgesic required measured
against the pain score (Figure 12.4).
Step 3
Strong opioid
for moderate to
Step 2
severe pain
(e.g. morphine)
Weak opioid
+/– non-opioid
Step 1 for mild to
+/– adjuvant
moderate pain
(e.g. codeine)
Non-opioid +/– non-opioid Pain persisting
(e.g. aspirin, +/– adjuvant or increasing
paracetamol or
NSAID) Pain persisting
+/– adjuvant or increasing
Pain controlled
Supplementary prescribing
Supplementary prescribing enables a voluntary tripartite partnership between the
patient, independent prescriber and supplementary prescriber working cohesively
to agree to a clinical management plan. Within this partnership the independent
prescriber retains accountability and responsibility for diagnosing and prescribing
decisions (Nuttall and Rutt-Howard, 2016).
Gaining a non-medical prescribing qualification helps to facilitate nurses to
extend their role and scope of practice. Furthermore, this can lead to a redesign of
service and innovative ways of working. It is useful for all nurses working in evolv-
ing and developing roles and service to acknowledge and recognise skills and
knowledge they bring. It is essential for all nurses to undertake continued profes-
sional development (CPD) in order to develop and maintain currency of their
knowledge of recommended pharmacological regimes, development, manipulation
and review of management plans and completion of a recognised prescribing course
(NMC, 2015).
CONCLUSION
An acute episode can dramatically alter the whole dynamics of care needs. In sum-
mary, community nursing continues to evolve in responses to policy drivers, s ervice
provision and type and acuity of the patients cared for in the community. Improv-
ing practice is an essential component of practice, and as a practitioner the
242 Approaches to acute care in the community
REFERENCES
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CHAPTER
LEARNING OUTCOMES
• Critically analyse relevant current government policy and how this influences
the management of long-term conditions (LTCs) within the current health
agenda.
• Discuss the ways in which LTCs can be proactively managed using ideas and
techniques to solve problems.
• Appraise the potential impact of LTCs on individuals and their families and
carers.
• Review information to enable you to make judgements about the values of
different models that empower professionals to support people with LTCs
including the principles of case management and the concept self-care/
self-management.
• Reflect on your developing essential skills for successful decision making and
delivering care in complex cases.
INTRODUCTION
The purpose of this chapter is to highlight the key considerations for the commu-
nity nurse when working with people with long-term conditions (LTCs), their
carers and their families. The themes raised in this chapter focus specifically on the
delivery of person-centred and needs-based care, and include performing assess-
ment, handling case management, supporting self-care, promoting behaviour
change, and addressing issues of vulnerability.
Other important topics related to LTCs such as assessing mental health, the use
of telehealth in managing LTCs, the important role of carers and the integration of
health and social care are explored in other chapters in this edition.
LONG-TERM CONDITIONS
An LTC is one that generally lasts a year or longer and impacts on a person’s life
(National Institute for Health and Care Excellence [NICE], 2015). Examples include
arthritis, asthma, cancer, dementia, diabetes, heart disease, mental health condi-
tions, respiratory disorders, gastroenterological conditions and stroke. Long-term
conditions have also traditionally been known as ‘chronic’ conditions.
246 Emerging issues in long-term conditions
In the past there has been a tendency to define LTCs as chronic conditions without
cure, but more recently there has been a different approach, for example, describing
LTCs as
As you can see from this definition, latterly the emphasis is on a more holistic
approach and a more comprehensive understanding of what can be done to alleviate
the impact of having a LTC. This means that care for people with LTCs should be
more about supporting the person to manage rather than trying to treat the condi-
tion. It is generally agreed that this approach calls for a model of care that sits more
easily within a nursing rather than a medical domain (Larsen and Lubkin, 2009)
A longer life expectancy, due to improved technical and medical advances, means
that more people are surviving into old age. It is also known that contemporary
lifestyle choices can lead to more people suffering from long-term illnesses (Nuff-
ield Trust, 2013). So despite living longer, our UK populations are not necessarily
living much healthier and many people reach their later years with multiple or com-
plex LTCs. Additionally, because most people prefer to be cared for in their own
homes, wishing to avoid hospital admissions, there is an increasing need for a range
of community services, particularly community nursing. In order to understand
why and how community nursing services play such a major role in delivery of care,
it is important to consider how key drivers and government policy translate into
strategies for the management of LTCs.
Policy papers
It has been acknowledged for some time that if people with LTCs are supported and
cared for effectively in the community, their health status is likely to remain relatively
stable, with less health crises, avoided hospital visits and an overall improved quality
of life (Ross et al., 2011). So, community-based care is not only better for the health
outcomes of people receiving care, but is also seen to be more effective in terms of
healthcare costs. The most recent health strategy documents and policies associated
with LTCs therefore incorporate a noticeable emphasis on developing models of cost-
effective community-based care, and central to the success of community-based care
is of course the contribution of community nursing services.
Over recent years, there has been a steady increase in UK policies with a focus on
supporting a more effective approach to the management of LTCs. In 2010, the UK
government launched the White Paper, Liberating the NHS – Legislative Frame-
work and Next Steps (DH, 2010a). This set out the NHS Outcomes Framework
which incorporates five domains, one of which is ‘Enhancing Quality of Life for
People with Long Term Conditions’ emphasising the responsibility of health service
providers to develop local strategies to help address the needs of those with LTCs.
In 2012, the coalition government published the first NHS Mandate, and within
this it allocates the responsibility to NHS England for coming up with plans to help
make life better for people with LTCs by
• Helping them to get the skills to manage their own health
• Agreeing with them on a care plan that is based on their personal needs
• Making sure their care is better co-ordinated
The focus on managing LTCs is also reflected in policies and strategies in other
countries of the United Kingdom. For example in Scotland, a ‘National Action Plan’
was developed in 2009, outlining seven high-impact changes that are needed to
improve the care of those with LTCs. These are partnership, mutuality, self-management,
workforce development, integrated care, quality improvement and clinical information
systems (Scottish Government, 2009). In Wales, meeting the needs of people with
LTCs has been a priority for the NHS since 2005 when the Welsh Government outlined
its intention to develop an integrated framework for LTCs. The plan was to change
services from an overreliance on acute hospitals and towards greater use of primary
and community services, and in 2012, the Welsh G overnment reaffirmed its commit-
ment to community-based care with a plan to provide a greater range of services
248 Emerging issues in long-term conditions
available at all times. Their achievements so far with this vision have recently been
evaluated by the Welsh Audit Office and results can be accessed in their report, The
Management of Chronic Conditions in Wales – An Update (Wales Audit Office, 2014).
In Northern Ireland, the Primary Care Development Unit has been developing a policy
framework specifically focused on supporting people with LTCs. The framework is
based on six underpinning principles: working in partnership, supporting self-man-
agement, information to service users and carers, managing medicines, carers as part-
ners and anticipatory care (DHSSPS, 2012).
This focus on LTCs, user involvement, personal choice and self-care for LTC
management is however not new. There are a number of helpful archived docu-
ments developed that are worth a look and include Our Health Our Care Our Say
(DH, 2006a), Supporting People with Long-Term Conditions (DH, 2005b) and Sup-
porting People with Long-Term Conditions to Self Care (DH, 2006b).
The National Institute for Health and Care Excellence (NICE) has recently pub-
lished a guideline which although developed to guide practitioners in specifically
supporting older people with LTCs, provides a useful model for managing LTCs
generally (NICE, 2015). The focus in this new guideline is clearly on pulling together
health and social care services in supporting people with complex care needs and
multiple LTCs. This integration agenda is discussed and explored in more depth in
Chapter 11 of this text.
Level 3:
High
complexity
Case management
Level 2:
High risk
Disease/Care management
Level 1:
70–80% of LTC population
Self-care support/management
a ttitudes and media influence. These can determine whether a person will take a
specific action in relation to their health behaviour. The person’s confidence is also
a factor and is related to their ‘locus of control’ (Morrison and Bennett, 2012). This
means do they believe that the events that govern their lives are initiated from
within or outside themselves? And consequently, do they feel they have the ability
to make desired change? An appropriate level of support from the health profes-
sional, in this case the community nurse, can make all the difference. The commu-
nity nurse will also need to assess the person’s ‘readiness to change’ in relation to
‘The Stages of Change Model’. The four stages of change were originally identified
by Prochasta and Di Clemente (1984, cited by Naidoo and Wills, 2016). The first
stage is pre-contemplation, where the individual is not yet ready to make the change;
second is contemplation, where the person is open to considering altering their
behaviour. The remaining stages involve planning for and maintaining change.
Each stage is led by the individual who may not be able to move readily from one
stage to the next. However, a skilled professional senses the stage which a person
reaches and offers the appropriate support and encouragement to move on when
the person is ready.
Motivational interviewing
Often, when faced with the notion of making lifestyle or health behaviour changes, a
person will feel a degree of conflict about whether to take action. It is in this area of
ambivalence that another tool, motivational interviewing (MI), can help. MI is also
referred to in Chapters 2 and 8. MI was developed in the 1980s by William Miller and
his fellow psychologists working in the area of substance misuse. More recently, it has
been found to be useful in many situations where health behaviour change would be
advisable. A partnership between the individual and health professional is devel-
oped. In this way they together explore this ambivalence to identify a way of moving
forward by appraising the ‘change talk’ expressed by the patient. This includes such
statements as ‘I wish I could…’ ‘It would be better if ….’ Careful listening and clarifi-
cation, combined with a non-judgemental, empathetic and encouraging attitude, will
lead the individual to discover and believe in their own motivation and abilities and
make plans for taking action. Rollnick et al. (2008) set out the four guiding principles
for professionals which are resisting the righting reflex, understanding the person’s
motivation, listening to and empowering the patient. In addition, three fundamental
core skills are crucial if professionals are to achieve this: asking, listening and inform-
ing. This approach is underpinned by the spirit of MI, which has three components:
collaboration, evocation and patient autonomy. Developing skills in these techniques
will enable community nurses to more confidently support those who are grappling
with the challenges of behaviour change associated with taking more self-management
of their illness and their lives. There are a number of resources available, for example,
the website www.motivationalinterviewing.org/ where information on formal and
online training is available.
Case Management in Long-Term Conditions 253
CASE MANAGEMENT IN LONG-TERM CONDITIONS
Owing to global demographics the challenge of managing LTCs is not confined
to the United Kingdom, and health and social care strategists across the globe
have sought ways to address this increasing health need. In the United States, for
example, models of management have been developed by companies such as
Evercare and Kaiser Permanente. It is from their models of care that the UK
models for managing LTCs have been developed. The evidence from the United
States has shown how the concept of case management of patients with LTCs can
have significant potential to deliver both better care for patients and cost sav-
ings. Although there is a marked difference in the configuration of healthcare
provision in the United States, especially in terms of funding, it was felt that
much could be gained by adopting similar approaches in the United Kingdom
(Snodden, 2010).
The case management model is community based and incorporates a targeted,
proactive approach to care. The process involves case-finding, care assessment,
care planning and care co-ordination, and where implemented effectively it has
been shown to improve the experiences of individuals and their carers. This has
meant better health outcomes for both and so reduced the need for hospital-
based care, thus enabling a more cost-effective use of health resources (Ross et al.,
2011). However, any model of case management must be well designed and be
co-ordinated by appropriately trained and prepared professionals. Also, it is
imperative that whichever model of case management is applied, it is soundly
embedded in a wider system based on the integration of health and social care
(Ross et al., 2011). This is an underpinning principle for the model of LTC man-
agement across the United Kingdom (DH, 2005a; Scottish Government, 2009;
DHSSPS, 2012).
Essentially, case management is based on one crucial underpinning principle
of practice which is care co-ordination. This role is usually undertaken by an
individual case manager. In some areas this will be an advanced nursing practi-
tioner, who may have the title of community matron, or it may be an allied health
professional such as an occupational therapist or a physiotherapist. In other local-
ities the responsibility of case management may be allocated to a small team of
health and social care practitioners. However, increasingly case management is
seen as a district nursing role. The responsibilities of the case manager will
include, but are not limited to, a full holistic assessment, medication management
(and prescribing of medicines if a community matron or a health practitioner
with an appropriate non-medical prescribing qualification), self-care support,
advocacy and negotiation, psychosocial support, monitoring of health status and
review of the care planning. The role of the community nurse will be to support
the case manager in the process of case management, collecting information to
inform the assessment and monitoring change and response to care plans, and
reporting back to the case manager.
254 Emerging issues in long-term conditions
ACTIVITY 13.2 This activity is designed for you to consider how the needs of a person with
multiple or complex conditions might be assessed and to consider how the
resources available to provide support in the community might be set in place
to address these needs.
Scenario
Mr A recently registered with the general practitioner (GP) practice. He is 70
years old with chronic obstructive pulmonary disease (COPD) having been
referred to the practice nurse because he is experiencing difficulty in using his
inhaled medication. He has had several hospital admissions and also suffers
from Parkinson’s disease; he has high blood pressure and rheumatoid arthritis.
He has recently moved to the area to live closer to his daughter. What skills
are required to undertake a full assessment? What specific areas would need
an in-depth assessment? What resources will be required to provide ongoing
care, including input from other nurses, health professionals and agencies, and
who will co-ordinate his care? What will be the referral process? Which policy
documents underpin and support relevant standards of care?
Mr A would be in the population located in the top third of the LTC pyramid;
he has highly complex needs. His assessment and ongoing care will require a high
level of expertise and support from various professionals and agencies. In terms
of direct management and care, the case manager’s skills and depth of knowledge
will ensure that Mr A’s condition is closely monitored. For example, the case
manager will have a major role in medicines management. Mr A will potentially
be taking several medicines for each of his conditions, including pain relief. In
accordance with the regulations set down in the NMC Code (Nursing and Mid-
wifery Council [NMC], 2015), the case manager will work closely with Mr A,
developing a concordant relationship to promote adherence to the therapeutic
regime and so effective use of medication. If the case manager is an independent
prescriber he or she can make prescribing decisions according to their specific
area of competence as per the NMC Code (NMC, 2015). An example of this is the
management of COPD where the case manager can help avoid unnecessary hos-
pital admission. People with COPD often suffer from exacerbations of their con-
dition which require hospital admission. The case manager can encourage
self-care not only by teaching and providing information and if a non-medical
prescriber could prescribe a ‘rescue pack’ for Mr A to use when he feels his condi-
tion is deteriorating. The pack will consist of antibiotics and steroids, thus a hos-
pital admission is avoided.
Mr A will also require input from several other professionals. Depending upon
his needs, a mental health professional, allied health professional, social worker or
district nurse may fulfil the role of case manager or may be involved in providing
separate elements of his care. Consider what specialist input each of these may con-
tribute to the care of Mr A.
Case Management in Long-Term Conditions 255
Referral to other health departments and wider agencies may be required and the
skills needed for this include developing effective networking and fostering collab-
orative relationships with others.
An informal evaluation of virtual ward patients in Croydon has shown that their
satisfaction with the service was very high (Commonwealth Fund, 2010).
ACTIVITY 13.3 You might consider how this model could be used in supporting Mr A. What
do you see are the main differences between the usual model of care and the
virtual ward model? What would be the benefits for Mr A and the health and
social care professionals? Who would be the key staff needed in the virtual
ward for Mr A and what would be their role?
ACTIVITY 13.4 The purpose of this exercise is to explore, reflect upon and address potential
risks for the family when a parent is dealing with a LTC.
Scenario
Mrs B (41 years old) has been referred to you for assessment. She has just
been diagnosed with multiple sclerosis, having had distressing neurological
symptoms for some months. She is having problems going out as she tends to
lose her balance and she is very concerned about difficulties she has with
continence. Mrs B is married and lives with her husband in the family home
(for which they pay a mortgage) with their two children aged 13 and 9 years.
Prior to her diagnosis, Mrs B had been the main wage earner in the household,
being employed as an administrator in a local government department.
Consider your assessment of Mrs B and identify potential risks there may be in
terms of her physical and psychosocial well-being. What are the risks for her
husband and children? How can these risks be addressed by community nursing,
the wider health and social care agencies and non-statutory sector? You may
wish to revisit Chapter 9 for further suggestions on how to support carers. It
may help to create a mind map or spider diagram of the various teams who
need to be involved.
In the complex situation in Activity 13.4, there are numerous aspects to consider
and the exercise emphasises the importance of a fully comprehensive and holistic
assessment. The physical aspects alone present profound implications for life
change. They include disability in a young woman, risk of falls; perhaps difficulties
in getting to the toilet and as immobility increases there may be problems with tis-
sue viability. There will be increasing loss of sensation, pain and fatigue.
Psychological considerations are at least as challenging. Will Mrs B be able to
continue working? If not, there may be an economic risk to the family. What about
her status within the family, the local community and the workplace? Will her rela-
tionship with her husband be threatened? Will a sexual relationship still be possi-
ble? What is Mrs B’s understanding of and what are her concerns for her future
health? How will she deal with the unpredictable nature of her condition? What are
Mr B’s needs? Is he prepared for potential caring responsibilities?
There are a number of potential risks in this situation and addressing them will
need sensitive and informed enquiry and support. It is important to consider poten-
tial negative effects such as relationship or family breakdown, substance misuse or
even domestic abuse. The children’s schooling may be disrupted; they may be called
on to provide care for their mother, which will raise enquiry around their well-
being as young carers. Family carers are an integral part of LTC management and
their needs and concerns should be included in all plans of care and in this scenario
the carers’ role(s) may be quite complex. (Here you may like to refer to Chapter 9 for
further information regarding the key role of carers.)
258 Emerging issues in long-term conditions
There may, however, be very positive responses and outcomes, and high levels of
support and care are frequently developed within families who are dealing with the
challenge of LTCs as indicated in the anecdotal evidence gathered by the organisation
Healthtalk.org (see www.healthtalk.org/peoples-experiences/long-term-conditions/
chronic-pain/impact-family). However, even when there is a positive family approach,
the community nurse should be fully aware of the local availability of both statu-
tory and voluntary sources of support and local pathways of care. It is also essential
to be fully confident in implementing safeguarding procedures including those
associated with domestic abuse. Sensitive ongoing monitoring of the situation will
be a key responsibility of the lead health professional.
ACTIVITY 13.5 Owing to medical advances and developments in neonatal and early childhood
health care, more infants and children with life-threatening disorders or
congenital conditions are now surviving into adolescence and adulthood, and
this is of course to be celebrated. It is however important to also consider that
these young people may be growing and developing with the challenge of
ongoing LTCs and associated vulnerabilities. In addition, the conditions that
they have to contend with can follow varying courses of progression. They
might be lifelong (for example, deafness), slowly deteriorating (for example,
muscular dystrophy), potentially curable (for example, cancer) or of a variable
course (for example, cystic fibrosis) (www.healthtalk.org 2016). It is also
essential that health professionals supporting young people with LTCs recog-
nise that the needs of the child or young person will be very different to those
of adults and that their needs and those of their families will change over time
as the young person grows and develops. This can present major challenges for
health service professionals and others involved in providing age-appropriate
treatment, care and support. The following exercise will help you explore the
specific needs of children and young people who are suffering from LTCs and
consider how these might be addressed.
Scenario
Annie, who is 17 years old, was diagnosed 2 years ago with chronic renal
disease. She had not really felt unwell but her legs frequently became swollen
and blood tests suggested some issues with renal function. A renal biopsy
confirmed the diagnosis. Annie was prescribed steroid therapy, and was for a
while very stable, so the dose was gradually reduced.
Two months ago, unexpectedly, further tests showed that Annie’s kidneys
were deteriorating rapidly. She was retaining a lot of extra fluid and was unable
to walk around and was in a great deal of pain. Annie was admitted to hospital
is now having to have dialysis although she had been told at the time of her
diagnosis that it would be a long time before that would be the case.
Supporting Young People with Long-Term Conditions 259
ACTIVITY 13.5 Annie lives at home with her mum and dad and you have been asked to assess
her needs while she is currently recovering from a recent hospital admission.
Consider her physical needs, who should be involved in ensuring Annie has the
optimal physical care, who might be the lead professional in this aspect of her care?
Consider her psychological and emotional needs, what/who might help her
cope with these?
Up to now, Annie’s mum and dad have helped her make decisions about her
care, but Annie is now a young woman. What are the specific considerations
as Annie is on the verge of entering adult services rather than accessing child
and young person services?
What information and support can you offer Annie?
Physical needs
Following your initial assessment advice can be sought from the specialist renal
team, many nephrology teams have outreach services that can dialyse at home and
help individuals manage their own dialysis either at home or in hospital. There may
be a specialist nurse who can offer Annie and her family, and you, support and
information.
Chronic tiredness/fatigue is a common feature of many long-term illnesses, so it
is important to assess how this is affecting Annie in her day-to-day activities and
whether there is any advice you can give her in managing this fatigue. Pain is an
issue to consider for Annie – is it being managed sufficiently for Annie to be pain
free? Pain and tiredness often go together because pain makes it hard to sleep, or
even rest or sit still. Annie may have periods of relapse or remission and so it might
be difficult for her to know exactly how she will feel at any time. It is important to
liaise with the GP and specialist team to ensure that pain relief for Annie is appro-
priate and effective.
Emotional needs
Understandably, it can be particularly difficult for teenagers to be diagnosed with a
chronic condition that requires long-term treatment and medical supervision.
Annie will have found the decision to have dialysis a big shock and may be feeling
upset and let down as she was not expecting this so early in the progression of her
illness. She may feel very vulnerable in respect of her own mortality and the need to
depend on a machine and/or a transplant, and she may be feeling angry and
depressed. Some young people may react to a diagnosis with suicidal thoughts
(www.healthtalk.org – see the list of resources) so it is essential to explore her feel-
ings sensitively but thoroughly so that specialist support for her mental health is
arranged if required.
260 Emerging issues in long-term conditions
Like any other young person, Annie will have plans and goals to achieve, includ-
ing the desire to have a ‘normal’ life. During the teenage years and into young adult-
hood individuals are likely to be going through a number of life changes. Those
with LTCs will have more to contend with and consequently will have specific emo-
tional and social needs. Many will be entering relationships or starting work. They
may be leaving home for the first time, or planning to move away to university
(Mathews, 2012). Annie may be studying and busy preparing for exams and course-
work at college or at school working, or looking for work, or working and studying
at the same time. How will she also cope with the demands and treatment regime of
this illness? How debilitating are the relapses or periods of treatment and how do
they interfere with her mobility and engagement with life generally? The commu-
nity nurse is well placed to recognise and acknowledge Annie’s individual emo-
tional and/or psychological needs, to reassure Annie that they are taken seriously
and signpost Annie to specialist support services or peer support groups. The web-
site ‘Healthtalk’ at http://www.healthtalk.org/young-peoples-experiences/long-
term-health-conditions/topics provides insight and advice for professionals
supporting young people with LTCs.
CONCLUSION
This chapter has provided an introduction to a number of emerging issues associ-
ated with the current LTCs agenda and explored why it is important to consider this
in the context of community nursing. If the challenges posed are to be successfully
tackled, the new generation of community nurses will need to acquire, maintain
and update specific skills and apply new models of intervention. Care and support
for people with LTCs must take account of individual needs and preferences and
people must be given the opportunity to make properly informed decisions about
managing their own care, in partnership with health and social care practitioners
(NICE, 2015). The main contemporary policy drivers have been identified and it is
clear that these will continue to focus on home-based collaborative and co-ordinated
care, where the community nurse role will remain pivotal.
FURTHER READING
Margereson C and Trenoweth S (2010) (eds) Developing Holistic Care for Long-Term
Conditions. Oxford: Routledge.
McVeigh H (2009) Fundamental Aspects of Long-Term Conditions. London: Quay Books.
Nicol J (2011) Nursing Adults with Long Term Conditions. Exeter: Learning Matters.
(Transforming nursing practice series).
Presho M (2008) Managing Long Term Conditions: A Social Model for Community Practice.
Chichester: John Wiley and Sons.
Randall S and Ford H (eds) (2011) Long Term Conditions: A Guide for Nurses and Health
Care Professionals. Chichester: John Wiley and Sons.
Walker R and Rodgers J (2011) Implementing Personalised Care Planning In Long Term
Conditions. Northampton: SD Publications.
FURTHER RESOURCES
There are an infinite number of relevant materials available via textbooks and websites. In
addition to the websites mentioned below, it is worth noting that almost all conditions will
have at least one dedicated website.
264 Emerging issues in long-term conditions
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Update.pdf.
CHAPTER
LEARNING OUTCOMES
• Develop professional and political awareness in relation to national
strategies, guidelines and reports.
• Critically reflect on the importance of identifying end-of-life care and
holistically assessing the patient’s and family’s needs in order to proactively
plan for their future care.
• Explore the requirements for effective co-ordination of high-quality care.
• Identify the key components of providing good quality end-of-life care.
INTRODUCTION
The term ‘end-of-life care’ (EoLC) is still a relatively new phenomenon, and
it encompasses all aspects of care at the end of an individual’s life. Rather than
describing care as palliative, supportive or terminal, EoLC is now the preferred term
when identifying a person who is in the final stages of life, which may last years,
months, weeks or days. The importance of this term is that it helps professionals
acknowledge and more actively plan ahead for the care that may be needed to
optimise quality of life and focus on living rather than dying. The six steps of the
EoL pathway outlined in the End of Life Care Strategy (DH, 2008) have been used to
structure this chapter and each one will be discussed in turn with a cross-reference
to the national Ambitions for Palliative and End of Life Care (2015).
Each year in England around half a million people die, of which two-thirds are
aged over 75 years. This is predicted to increase to 550,000 by 2035 (The Choice in End
of Life Care Programme Board, 2015). Most deaths (58%) occur in National Health
System (NHS) hospitals, with around 18% occurring at home, 17% in care homes, 4%
in hospices and 3% elsewhere (ONS, 2014). Although the number of people dying in
their ‘usual place of residence’, that is, at home or in care homes has risen from under
38% in 2008 to 44.5% (NEoLCIN, 2015). However, the evidence still suggests over 60%
would prefer to die at home (NHS England, 2014), demonstrating a vast difference in
preferences and actual place of death. There are several contributing factors that can
influence this outcome. The older the population, the more likely it is that they have
complex needs and require integrated care packages (Ellershaw and Murphy, 2005).
In addition, the need for hospital admissions increases due to disease progression and
268 Providing quality care at the end of life
carer crises, all of which reduce the patient’s and family’s confidence and ability to
cope with dying at home (Munday et al., 2007). The number of deaths is set to increase
by 17% between 2012 and 2030 in England and Wales, and for those over 85 years from
32% to 44% (DH, 2014), which will have a significant impact on community service
provision (Age UK, 2014) and nurses will need to be equipped with the appropriate
knowledge and skills so they can offer high-quality care (DH, 2009a).
The aim of high-quality EoLC is to support all individuals with advanced,
progressive and incurable illnesses regardless of diagnosis, stage or setting, to live
as well as possible until they die, therefore to be able to live with a quality of life and
have mechanisms in place to enable discussions and make informed decisions about
their preferences and choices so they die where and how they choose (DH, 2008). The
National Council for Palliative Care (NCPC) stresses the importance of identifying
the supportive and palliative needs of both patients and family throughout the last
phase of life and into bereavement, which includes the management of pain and other
symptoms and provision of psychological, social, spiritual and practical support
(NCHSPCS, 2002; National Institute of Clinical Excellence [NICE], 2011; The Choice
in End of Life Care Programme Board, 2015). Although the United Kingdom was
ranked top of the league table (93.4 out of 100) for providing the best in EoLC in the
world which praised the quality and availability of services (BBC News, 2015), there
is still evident need for improvement in providing equity in all care settings.
Over the past century the demographics of dying in relation to age profile, cause and
place of death have changed fundamentally, as previously a greater number of deaths
occurred either in childhood or young adulthood. As a result, the public’s social contact
with dying has been reduced and an experience of someone dying who is close to them
does not tend to occur until later in their own lives (Hanks et al., 2010). The stigma
associated with dying in society today means that we do not tend to discuss death and
dying openly, causing difficulties in communication when end of life approaches either
for the individual concerned or someone close to them (Seymour et al., 2010).
Each individual has their own perspective in terms of what constitutes a ‘good
death’, and the majority agree that it is about being
• Treated as an individual, with dignity and respect
• Without pain and other symptoms
• In familiar surroundings
• In the company of close family and/or friends (DH, 2008)
These elements of high-quality EoLC are important to achieve for the individual
concerned and especially for the family if we respect the words of Dame Cecily
Saunders, the founder of the Hospice movement, when she stated ‘How people die
remains in the memory of those who live on’ (Saunders, 1989).
The Ambitions for Palliative and End of Life Care that was released in 2015 built
on the national EoLC strategy and the associated 12 key principles, highlighting
the need for leadership from commissioning and health and social care provider
organisations, in particular Health and Well-Being Boards. The ambitions include
six goals based on learning from papers such as the Francis Report (2013), More
Care, Less Pathway (Neuberger, 2013), One Chance to Get It Right (Leadership
Alliance for the Care of Dying People [LACDP] 2014) and the Ombudsman Report
(PHSO, 2015). The ambitions are underpinned by ‘building blocks’ that provide
270 Providing quality care at the end of life
foundations for providing high-quality care (Figure 14.1) The six ambitions are as
shown in Figure 14.1.
As the six ambitions are built on the previous goals set by the National EoLC Strat-
egy (2008), in community nursing practice, the six steps of the EoL pathway outlined
in the strategy still provide a useful tool to help apply theory to practice (Figure 14.2).
Step 1: Discussions as EoLC approaches: Identification of people approaching
the end of life and initiating discussions about preferences for EoLC
The key aspect of the EoL pathway is to identify those patients who are approaching
the end of their life. Historically, this has presented a challenge not only in relation
to prognostic tools that can be complex to use, but also in acknowledging the time
when care becomes palliative as opposed to curative. However, unless all members
of the multidisciplinary team (MDT) work together to identify patients regardless
of their diagnosis, discussions around preferences and options will not take place,
families and friends will not be appropriately supported and patients will not achieve
a good death (Hubbard, 2011). Early identification of the EoL stage is one of the most
important processes to take place to allow sufficient time for the individual to discuss
their preferences and wishes (NICE, 2011). The Dying without Dignity investigations
led by the Parliamentary and Health Service Ombudsman into complaints about EoL
care (PHSO, 2015) highlighted several key themes such as the lack of recognition that
people are dying leaving insufficient time for care to be planned and discussed as well
as open and honest conversations with the person and those important to them.
The Gold Standards Framework advocated by the End of Life Care Strategy (DH,
2008) has produced a ‘Prognostic Indicator Guidance’ which outlines the Karnofsky
Performance Status Score, the three main disease trajectories (cancer, neurological
conditions and dementia/frailty) and, most importantly, recommended the adoption
of the ‘surprise question’, Would you be surprised if this patient were to die in the
04 Care is co-ordinated
Figure 14.1 The six ambitions for palliative and end of life
care. (Taken from Ambitions for Palliative and End of Life Care,
2015.)
End-of-Life Care Strategy 271
Step 1 Step 2 Step 3 Step 4 Step 5 Step 6
Delivery of
Discussions
Assessment, high-quality Care in the
as the end Co-ordination Care after
care planning services in last days of
of life of care death
and review different life
approaches
settings
• Open, honest • Agreed care • Strategic co- • High-quality • Identification • Recognition
communication plan and ordination care provisions of the dying that end of
• Identifying regular review • Co-ordination in all settings phase life care does
triggers for of needs and of individual • Acute hospitals, • Review of not stop at the
discussion preferences patient care community, needs and point of death
• Assessing • Rapid response care homes, preferences for • Timely
needs of carers services extra care place of death verification and
housing, • Support for certification
hospices, both patient of death or
community and carer referral to
hospitals, • Recognition coroner
prisons, secure of wishes • Care and support
hospitals and regarding of carer and
hostels resuscitation family, including
• Ambulance and organ emotional
services donation and practical
bereavement
support
Social care
Figure 14.2 The six steps of the EoL Pathway outlined in the EoLC
Strategy. (See Department of Health, End of Life Care Strategy: Promoting
High Quality Care for All Adults at the End of Life, The Stationery Office,
London, 2008. With kind permission from the National End of Life
Care Programme.)
next 6–12 months? (GSF, 2011). This question has been regarded as one of the most
effective instruments in identifying EoLC because of its simplicity and application to
any diagnosis or just old age (Boyd and Murray, 2010). This is now supported with
further questions: Do they have general indicators of decline? followed by: Do they
display specific clinical indicators? (GSF, 2011). The Supportive and Palliative Care
Indicator Tool (SPCIT) produced by NHS Lothian offers a similar model that breaks
down the process into four steps (NHS Lothian, 2016). This also includes the ‘surprise
question’ in its first step titled ‘Ask’, followed by ‘Look for two or more general clinical
indicators’, ‘Now look for two or more disease related indicators’, and finally ‘Assess
patient and family for supportive and palliative care needs. Review treatment/
medication. Plan care. Consider patient for general practice palliative care register’.
Good communication skills are essential not only to initiate conversations and
discussions with patients and their families as EoLC approaches but also to provide
support, help and advice to them along their journey and to help them feel valued
(Munday et al., 2007). It is the professional’s responsibility to recognise that it is a
two-way process and that the individual’s information needs will vary over time and
circumstances (responsive communication) (NICE, 2011). This can be a challenging
prospect for many health professionals as it may provoke professional discomfort
based on many influencing factors, such as the professional’s accountability and
responsibility; knowledge, skills, attitude and expertise; workload pressures; and the
272 Providing quality care at the end of life
fear of getting or creating upset for the patient/family (Watson et al., 2009; Barclay
and Maher, 2010). Four aspects of awareness (closed, suspicion, mutual pretense and
open) were identified by Glaser and Strauss in 1965 (Cope, 1998) which may influence
discussions between professionals and patients. Closed awareness is where professionals
are aware of the patient’s prognosis but refrain from disclosing the information and use
methods to avoid initiating or engaging in a conversation (Seale et al., 1997). The patient
therefore may become ‘suspiciously aware’ and try to use tactics such as cues to find
the truth. If the professional does not recognise it, this can lead to ‘mutual pretense’,
where both parties are aware but do not openly discuss and acknowledge the dying
trajectory (Cope, 1998). Last, ‘open awareness’ is when both parties are able to engage in
conversation in relation to what the patient knows and understands (Seale et al., 1997).
It is everyone’s responsibility to encourage discussions, and the patient’s identified
needs and wishes need to be communicated and co-ordinated within the MDT as
part of the care planning process. If the discussion has not taken place then the MDT
needs to decide who will open the dialogue with the patient (Hanks et al., 2010).
Communication is fundamental to good EoLC (Watson et al., 2009) and Table 14.1
can help facilitate difficult conversations.
their life at risk. However, it cannot be prepared if the individual has lost capacity
and therefore must meet all the requirements of the Mental Capacity Act and will
be legally binding for social and healthcare professionals (NEOLCP, 2008).
ACTIVITY 14.2 Consider who you feel is the most appropriate member of the MDT to initiate
discussions for a patient approaching EoLC and why.
Step 2: Assessment, care planning and review: Assessing needs and preferences,
agreeing on a care plan to reflect these and reviewing these regularly
Organisational and
supporting processes
Engaged,
Health and care
informed
professionals
individuals and
committed to
carers
partnership
working
Person–centred
co-ordinated care
Commissioning
Figure 14.3 The house of care model. (Taken from NHS England, Actions for
End of Life Care: 2014–16, 2014.)
3. Plan
2. Assess
te
nica
u
1. Identify m
om
c
+
Table 14.3
The first step is to identify the last year of life (6–12 months) and list those
identified patients on a GSF Register for the MDT to proactively plan care. Their
disease trajectory is predicted by using the Needs-Based Coding (Figure 14.5) to
estimate their stage to plan their care needs.
Support in line with needs – GSF helps identify people earlier and meet their needs
• Months
• Weeks
• Days
A - Blue ‘All’
B - Green ‘Benefits’ - DS1500 C - Yellow ‘Continuing Care’ D - Red ‘Days’
from diagnosis Navy
Unstable / Advanced disease Deterlorating Final days / Terminal care
Stable Year plus ‘After Care’
Months prognosis Weeks prognosis Days prognosis
prognosis
Figure 14.5 Needs-based coding – using the ‘surprise question’ to predict main areas of need and support required.
(With kind permission from Professor Keri Thomas.)
End-of-Life Care Strategy 277
The second step is to assess through a holistic common assessment including
their benefits – patients may be entitled to claim for non-means-tested benefits, for
example, DS1500 to support a Personal Independence Allowance if aged between
16 and 64 years or if over 65 years, an Attendance allowance. Assess the patient’s
possible needs such as anticipatory care and prescribing including ACP. Most of
all, early assessment of carers’ needs is advocated (formal assessment) along with
provision of written information.
The third step is to plan general care generated from the holistic common and
carers’ assessment, the ACP discussions and any recorded wishes/choices. It is
about thinking proactively and anticipating possible crises, by ordering medication
and equipment and co-ordinating and communicating with the MDT especially
out-of-hours (OOH) services. Identification and allocation of a key worker can
support the patient and family in the EoL Pathway and guide the MDT discussions
(GSF, 2009).
ACTIVITY 14.3 Consider how you would implement and/or evaluate the GSF into your GP and
what resources you would need to achieve this.
Co-ordinating an individual’s care and fair access are one of the key aspects
at the end of life (Ambitions, 2015). Organisations also need to work together
and be effective, providing realistic outcomes for the individual to ensure
care is delivered in the right way and time (NICE, 2011). If their wishes and
preferences are not respected, the individual and their family may feel devalued
and experience unnecessary anxiety. The GSF is one tool that can ensure that
the MDT is communicating and co-ordinating care (Munday and Dale, 2007).
The importance of every health and social care professional being involved in
an integrated personalised care plan that is regularly reviewed is essential to
ensure the patient’s needs are supported (NEOLCP, 2010c). Communication
links with the OOH services such as medical ‘hubs’ and evening and night
community nursing services are paramount as there is more likelihood of a crisis
happening at that time (NICE, 2011). The patient and family feel more vulnerable
and isolated at home when carers’ or professionals’ visits and contact are less
frequent (Munday et al., 2007). By using the tools within the GSF such as the
OOH communication tool or special notes on electronic systems, community
nurses can inform these services that the patient is now end of life and outline
any possible predicament. In some areas of the United Kingdom, the MDT use
an End of Life Locality register alternatively known as an Electronic Palliative
Care Co-ordination System, which is a template comprising a “checklist” that is
communicated to OOH services and other care providers. This lists all the key
information surrounding decisions and actions in the last 6–12 months of life in
a tick-box format (Social Research Institute, 2011).
278 Providing quality care at the end of life
ACTIVITY 14.4 Reflect on how you can assess whether all the services are communicating and
co-ordinating care.
Support for carers, both during a person’s illness and after their death – Many family
members become unpaid carers and there are now around half a million people
who provide care for a terminally ill relative or friend in the United Kingdom
(Payne, 2010). This figure is set to increase due to the rising demographics of the
older population (NHS England, 2014). The role is an intricate one as although they
are still the individual’s relative they are dealing with an unpredictable journey,
providing intimate care that they would never have envisaged and experiencing
the emotional strain that they will eventually be bereaved. Also, they are often
‘thrown’ into this role without any previous knowledge or experience (Payne,
2010). The ongoing pressure of the caring role is one of the key reasons why
patients are admitted to hospital during their pathway and at the end of life (Jack
and O’Brien, 2010). Therefore, many carers need respite, support, guidance and
information to help them cope with their daily lives (NAO, 2008). Although for
some it may be a temporary role, it can still affect the carer’s work and impact on
the rest of their life with regard to their future role in life (for further information
refer to Chapter 9). It is important that the community nurse assesses, co-ordinates
and supports the care in a proactive way to ensure that the carer is involved and
able to cope with the ever-changing circumstances at the end of life (Jack and
O’ Brien, 2010; Milne et al., 2007; NICE, 2011). Additionally, it is important to
explore what community networks are available for the carer and what support
is around locally that might be prepared to help with ongoing tasks (Abel et al.,
2016), and also to recognise that if support is declined initially by the carer that
there is opportunity to change their minds later on, if so desired, with timely
intervention (NICE, 2011).
End-of-Life Care Strategy 279
ACTIVITY 14.5 Joan is 78 years old and has been married to Harold for 60 years. She has had
dementia for 3 years, with a history of arthritis in her hands. Harold is her
main carer and has been finding it increasingly difficult to cope recently as Joan
is unable to communicate her needs and has begun wandering at night. The GP
has referred Joan to an Alzheimer Adviser/Admiral Nurse for further support
and information for Harold. How can you as a community nurse assess Joan
and Harold’s needs in co-ordination with the Alzheimer Adviser/Admiral
Nurse to identify the cause of Joan’s change in condition? What other support
is available to Harold to ensure he feels he is able to manage?
Patients and families may need to use a combination and range of services from across
different organisations and settings, and it is imperative that they should receive
high-quality and equitable care regardless of its origin (NEOLCP, 2010d). The role
of the community nurse is to make certain that all information is documented and
shared with all the professionals involved in the patient’s care. It is an essential part
of the community nurse’s role to recognise their accountability for the delivery of
care and to ensure all documentation is an accurate record of events (LACDP, 2014).
Diversity, equality and language
People approaching the end of life and their families and carers should have access
to the high-quality care (NPELCP, 2015) described in this quality standard on
the basis of need and that takes into account their preferences, regardless of their
individual circumstances, including the following:
• Gender
• Ethnicity
• Disability
• Cognitive impairment
• Age
• Sexual orientation
• Gender reassignment
• Religion and belief
• Culture or lifestyle
• Marriage and civil partnership
• Pregnancy and maternity
• Socio-economic status
• Mental capacity
• Diagnosis
• Choices they make about their care
• Location and setting in which they are receiving care
(Taken from NICE 2011 Quality Standard in EoLC)
The key aim of this chapter is to ensure that the community nurse is aware of EoLC
tools and the EoL Pathway in order to provide a high standard of care. It is, however,
280 Providing quality care at the end of life
2. Sensitive communication takes place between staff and the dying person, and
those identified as important to them.
3. The dying person, and those identified as important to them, are involved in
decisions about treatment and care to the extent that the dying person wants.
4. The needs of families and others identified as important to the dying person are
actively explored, respected and met as far as possible.
5. An individual plan of care, which includes food and drink, symptom control and
psychological, social and spiritual support, is agreed, co-ordinated and delivered
with compassion.
Figure 14.6 The five priorities for Care of the Dying Person. (Taken from
Leadership Alliance for the Care of Dying People, One Chance to Get It Right,
Leadership Alliance for the Care of Dying People, London, 2014.)
The One Chance to Get It Right (LACDP, 2014) Report highlights the key aspects
of communicating with the individual and family/carers throughout their journey
to ensure all their needs are met. The decision to identify ‘recognition of dying’ that
the person is in their last days and hours of life will usually be assessed by the GP,
district nurse and other members of the MDT (DH, 2013) and an identified “lead”
should be nominated. The patient and/or the family should also be involved in these
discussions with sensitive communication and supportive information available
(NICE, 2011; LACDP, 2014). Information that is offered to people approaching the
end of life, and their families and carers, should include the following:
• Treatment and care options, medication
• What to expect at each stage of the journey towards the end of life
• Who they can contact at any time of day or night to obtain advice, support or
services
• Practical advice and details of other relevant services such as benefits support
• Details of relevant local and national self-help and support groups
(NICE, 2011)
Conversations around the diminished need for food and drink should be included
and for professionals to recognise that provision, that may in some cases provide risks,
can often provide comfort to the patient and family/carers (LACDP, 2014). It is essential
that clear and understandable communication regularly occurs to support ongoing
concerns and uncertainties with all those involved in their care (Liddament, 2015).
The main priority is maximising comfort and well-being (NPELCP, 2015). This will
in cases, include discussions around limits of treatment including Do Not Attempt
Cardiopulmonary Resuscitation (DNACPR) – withholding and withdrawing treatment
and preferred place of care and death (LACDP, 2014). It is important to consider that
282 Providing quality care at the end of life
these difficult conversations for the person and their family need to be communicated
with empathy and the recognition of emotional stress and distress that have been
caused (LACDP, 2014). Being fully informed about the process related to decisions
around DNACPR including the Mental Capacity Act (2005) will support individuals
and those important to them in making informed choices about their future care.
The NICE Guidance of the Care of dying adults in the last days of life (2015)
was produced in response to the removal of the Liverpool Care Pathway and the
recommendations set out by the One Chance to Get It Right Report (LACDP, 2014).
It covers the clinical care of adults (18 years and over) identified as dying in the
last 2–3 days of life. It includes all the key points highlighted in the report, such as
clear and sensitive communication with the person and those important to them
and discussions around maintaining hydration. It also provides a repository of
information around comfort and dignity, anticipatory prescribing, the management
of symptoms and the side effects of medications to support care in the last days of
life and maximising comfort and well-being (NPELCP, 2015). For further reading,
see https://www.nice.org.uk/guidance/ng31/chapter/context (Figure 14.7).
The community nurse needs to recognise that when caring for a person in
the last days of life, it includes being prepared to support individual and unique
relationships of the related friends, family, carers and peers in their community.
This will mean also helping those loved ones to be prepared for their loss, grief and
bereavement (NPELCP, 2015).
Process Example
Provide information to the ‘What to do after a death in England or Wales’ and a localised bereavement leaflet
family on what to do next
Verify the death The death can be verified (if certified competent) or refer to the doctor who will
verify and certify the death
Inform the coroner Unexpected death or patient not seen by the GP for 14 days (GP and police to be
informed first)
Request for a post-mortem An unexpected death that the coroner decides needs further investigation
Register the death Within 5 days and then a burial or cremation certificate will be issued by the registrar
ACTIVITY 14.7 Consider what you might need to include in a personalised care plan as part of
your holistic common assessment for an individual’s last days of life.
ACTIVITY 14.8 Reflect on a family that has been bereaved. What emotions were displayed
and how did you feel they coped with them? What strategies did you use to
manage the situation?
CONCLUSION
This chapter has outlined the importance of the provision of good quality EoLC
in the community setting by using the six steps from the EoL Pathway as a
framework for best practice. It has highlighted the need for earlier discussions
in the pathway, even for the public to start thinking about having conversations
before identification of EoLC occurs. It has also identified the essential need for
ongoing communication and ACP throughout the pathway around the patient’s
identified wishes and preferences. Ongoing assessment, care planning and review
of the patient and family, with involvement of the MDT across different services,
References 285
can ensure co-ordinated care. Finally, EoLC tools, policies and NICE guidance that
have been discussed can guide, reinforce and document care but cannot dictate the
delivery as only the community nurse can determine the level of care they provide.
In striving for optimum standards of care, it is important to reflect on the state-
ment made by the National End of Life Care Strategy (2008) which indicates that
‘How we care for the dying is an indicator of how we care for all sick and vulnerable
people’ (National End of Life Care Strategy 2008, Executive Summary: 10).
FURTHER RESOURCES
www.goldstandardsframework.org.uk/
www.terminalillness.co.uk/understanding-grieving-process.html
www.dyingmatters.org
www.nhs.uk/carersdirect
http://www.ageuk.org.uk/
www.hospiceuk.org.uk
endoflifecareambitions.org.uk/
www.macmillan.org.uk
www.ncpc.org.uk/
www.endoflifecare-intelligence.org.uk/home
www.mariecurie.org.uk/help
https://www.gov.uk/government/organisations/office-of-the-public-guardian
www.resus.org.uk/dnacpr/decisions-relating-to-cpr/
http://www.cqc.org.uk/sites/default/files/20160505%20CQC_EOLC_OVERVIEW_
FINAL_3.pdf
www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/
healthcaresystem/datasets/nationalsurveyofbereavedpeoplevoices
www.england.nhs.uk/wp-content/uploads/2016/05/identifying-assessing-carer-hlth-
wellbeing.pdf
www.gov.uk/government/uploads/system/uploads/attachment_data/file/496231/Faith_
at_end_of_life_-_a_resource.pdf
www.fpm.ac.uk/faculty-of-pain-medicine/opioids-aware
www.e-lfh.org.uk/programmes/end-of-life-care/
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CHAPTER
15 Organisation and
management of care
Jill Y. Gould
LEARNING OUTCOMES
• Explore work organisation and care delivery in the community setting.
• Critically reflect on prioritisation, delegation and skill mix.
• Discuss principles of caseload, workload and workforce management.
INTRODUCTION
Community services in the United Kingdom undertake approximately 100 million
contacts each year (Addicott et al., 2015). As these range widely from universal
public health (health visiting and school nursing) to targeted clinical interventions,
it is no wonder that nursing in the community setting is seen as varied, complicated
and challenging (Drennan et al., 2005; Barrett et al., 2007). Community nurses
work in a dynamic and constantly changing care environment with potentially
limitless demands (Bowers and Durrant, 2014). On this ‘ward without walls’ it is
difficult to apply restrictions to the number or complexity of patients with little
control over increased workload or new referrals (RCN, 2010; Ball et al., 2014).
Evidence suggests there is a growing gap between demand and capacity, alongside
the increasingly complex care being delivered (Maybin et al., 2016). Practitioners
need to be responsive to routinely fluctuating workload demands as well as less
predictable wide-scale crises such as flu epidemics. In addition to managing the
risks associated with a continually shifting caseload, community nurses are respon-
sible for safeguarding vulnerable groups, seeking health needs and actively identi-
fying potential patients, employing a patient-centred, proactive, pre-emptive
approach to service provision (Kane, 2008; NMC, 2009; DH, 2013).
Some community nurses such as practice nurses, who work in general practice
(GP) surgeries, or community matrons, who provide ‘advanced nursing and clinical
care, as well as effective case management’ (DH, 2006), have a more clearly defined
patient population or can ‘close’ when their lists are full. This is not normally an
option for those providing universal services or caring for the more vulnerable or
housebound population, so these practitioners need to prioritise and organise care,
as well as make difficult daily decisions about what gets left undone. Professional
accountability encompasses clinical decision making, delegation and raising
290 Organisation and management of care
baby check) and respond to acute situations such as safeguarding. There is little in
the literature to detail how clinical work is prioritised and delegated in these aspects
of care, although numerous attempts have been made to measure and quantify
workload (Kerr, 2004; Hurst, 2005, 2006; Baldwin, 2006; Kane, 2008; Reid et al.,
2008; Kirby and Hurst, 2014; Chapman et al, 2017).
are in a process of change or merger and the fact that services are often commis-
sioned using block contracts. Bridging a vast range of conditions from acute to long
term, district nurses can be seen as ‘the only professionals with no limit to their
workload’ (QNI, 2009a: 22). The varied and ‘invisible’ nature of the work is not
helped by a lack of clearly defined referral criteria (Audit Commission, 1999; RCN,
2003; QNI, 2006, 2009a, 2016a; Jarvis et al., 2006; DH, 2013). Maybin et al., (2016)
suggest a possible response to the demand-capacity gap as the rejection of incom-
plete referrals, but note this poses risks of damaging or delaying patient care. The
development of referral criteria is recommended to reduce the number of
inappropriate referrals, to clarify and add legitimacy to the district nursing role and
294 Organisation and management of care
to help ensure the best use of their skills and judgement (RCN, 2003; Jarvis et al.,
2006). The establishment and implementation of referral processes can thus be seen
as a fundamental step in organising and managing nursing care in the community
setting, particularly for district nurses, who have little control over their workload
(Kane, 2015; Maybin et al., 2016).
Provider organisations should have documented referral criteria as a basis by
which district nurses can monitor and direct the number and types of patients on
their active caseload. Referrals can be received from a range of sources including
general practice (GP), hospitals, residential homes, day centres, social services, fam-
ily, carers and the patients themselves. However, there are variations in the use of
referral criteria for a number of reasons, including
• Detail/specifics – Inconsistency between care organisations/providers; poor qual-
ity information within referrals
• Implementation – A lack of awareness or patchy support for their use
• The commissioning agenda – The need for services to be more ‘marketable’ and
efficient, and thus more flexible. Referral criteria based on ‘block contracts’
comprise only a general outline of the types of care provided by district nursing
services
While there are variations in relation to referral criteria, the Royal College of
Nursing (RCN, 2003: 26) recommends that referrals are categorised in a way that
aids prioritisation:
• Urgent – Contact necessary within 4 hours
• Non-urgent – Contact within 24 hours and visiting date agreed
• Routine – Contact within 48 hours and visiting date agreed
The Audit Commission Report (1999) into district nursing services found great vari-
ations between different geographical areas/community nursing teams of the number
and types of patients on district nurse caseloads. Although there have been no subse-
quent large-scale studies and a recognised absence of data on community health ser-
vices at a national level, indications are that these variations have worsened (QNI, 2009b;
Maybin et al., 2016). Given widespread health service changes, for example, the diversi-
fication of roles (e.g. ‘case managers’, ‘community matrons’ and ‘intervention teams’), it
can be implied there is growing variation between district nursing teams. Further to
considering the appropriateness of new referrals, district nurses need to evaluate each of
the scheduled visits on the basis of their clinical need, identifying those of higher prior-
ity. As suggested in Table 15.2, from that starting point a range of influences on priori-
tisation and delegation is examined before decision making occurs.
Health visitors and school nurses also provide a range of services and show wide
differences in this provision. However, health visitors have worked hard to establish
clear service aims (DH, 2009c) and are broadly viewed as leaders in public health
and within the Darzi stream of ‘children’s services’ (DH, 2009a). There is a recog-
nised decline in the number of specialist qualified district nurses (Cook et al., 2009;
QNI, 2009a, 2010, 2015; HSCIC, 2016; Maybin et al., 2016). Policy in England aimed
Work Organisation and Care Delivery in the Community Setting 295
to redress a shortfall in health visitors by denoting a target number to be educated
and employed, although despite achieving the targets (DH, 2015b), it has been
reported that caseload sizes have not reduced (Turnball, 2015). The policy was likely
in response to concerns over increased workload, with one survey finding that
nearly 70% of health visitors reported they no longer had the capacity to support the
most vulnerable children (Unite/CPHVA Omnibus Survey, 2008). The remit to pro-
vide universal services for the health visitor (Figure 15.1) populations and addition-
ally target those with greater needs may be more clearly delineated than the
equivalent for district nursing services, but remains highly challenging.
This model suggests health visitors work in partnership with other services to
provide universal care for all, as well as support the most vulnerable families, par-
ticularly those where there are safeguarding concerns (DH, 2011c). While there is
potential for flexibility in how outcomes are achieved and services are delivered, the
exigency of safeguarding can be a barrier to practice innovation (Wakefield et al.,
2010). Some public health or population-based health issues have an insubstantial
evidence base potentially leading to variations. As with specialist district nursing
practice, it is difficult to establish an evidence base to make explicit the need to
‘employ health visitors rather than other workers to deliver their traditional role’
(DH, 2009c: 3).
Levels of Service
Your Community
Universal
Universal plus
Universal partnership plus
Care organisation has myriad influences, some of which arise from the key con-
trasts between hospital-based and community care (Box 15.1). While pre-registration
nursing standards (NMC, 2010b, 2014) have since aimed to redress the imbalance
between hospital and community-based education, this analysis helpfully identified
some of the key differences between these settings. Despite the fact that current
pre-registration nurse training is aimed at equipping nurses to work in any care
setting on registration, Health Education England (HEE, 2015: 15) suggest that ‘the
majority of newly qualified nurses need support to develop the skills and competence
required to work in community and/or primary care’.
1 The centrality of the patient perspective: care organisation must take into
account the clients’ interpretation of their needs. This fundamental premise of
the patient being at the centre of their own care has since been reflected in the
‘6 C’s’ and the updated NMC Code (2015a). Community nurses must recognise
that patients at home are much more in control of their decisions (NHS
Employers, 2006) and take into account their personal preferences. For instance,
if a patient is relatively active and requires daily wound packing, he or she may
prefer to be visited at a specified time. However, as with the constraints of insti-
tutional settings, this consideration has to be balanced with other influences on
care organisation such as urgent unplanned visits, staff absence or higher prior-
ity needs. The centrality of the patient perspective can also be seen in a recent
report by Maybin et al., (2016: 16) where ‘good care’ is described in their fi
ndings
as ‘staff caring for the whole person and providing holistic, person-centred care
rather than taking a task-focused approach’.
2 Patients and carers undertake most of the care activities: unlike the hospital
setting, much community-based work involves ongoing identification and
analysis of need, promotion of self-care or co-ordination of services. Integral to
this is ensuring support is available to those providing the bulk of the care. It
Skill Mix, Roles and Responsibilities 297
has been calculated that the economic value of the contribution made by infor-
mal carers is ‘more than the annual cost of all aspects of the NHS’ (Carers UK,
2007: 2). It is recognised that carers have distinct needs with the introduction of
recent strategies, including support for greater personalisation and improved
quality of care (HM Government, 2010), and revisions to the Care Act (2014),
where carers now have the legal right to their own assessment. Maybin et al.
(2016: 16) found that ‘good care’ is seen to include the involvement of informal
carers and family members through offering practical support, including them
in decision making, valuing their contributions and expertise and addressing
carers’ own needs and personal well-being.
3 The multiple systems and infrastructures: care organisation is highly dependent
on the accessibility of services and resources. With a vast array of systems and
structures (such as statutory and voluntary organisations), community nurses
need to have excellent communications skills and sustain an extensive working
knowledge of these resources. The people most likely to be affected by resource
constraints (such as cuts to social care services) are often very vulnerable,
requiring community nurses to advocate for services where gaps are identified.
4 Clinical and professional decision making in isolation: the need to make care
decisions at a physical distance from colleagues can be daunting for practitio-
ners new to nursing or to the community setting. The ranging skills within a
community nursing team demand that more experienced practitioners delegat-
ing tasks need to be assured of the skill level of each team member and must aim
to minimise the risk of less experienced or skilled staff performing visits which
may be, or prove to be, outside their scope of practice. Decisions made by com-
munity nurses, as lone workers, may encompass elements of risk, particularly
when patients are new to the service.
The DH Commissioned Report by Drennan et al. (2005) found that the requisite
knowledge and skills for primary care were often ‘covert’ and needed to be made
explicit in order to create clear guidelines for employers to prepare nurses for com-
munity practice. An outline of the preparation needed for this transition would be
of benefit to any practitioner embarking on a career in community care and it has
been suggested that this should begin with pre-registration nursing programmes
(QNI, 2010; NMC, 2010b; Willis, 2013). A number of tools to assist in knowledge,
skills and competence development are available, including the ‘Transition to com-
munity nursing practice’ resource (Aldridge-Bent et al., 2013) and the Skills for
Health (SFH, 2010) resources website. SFH resources include standards and an edu-
cational framework for ‘unregulated’ staff as well as registered nurses, with tools
and competencies cross-referenced to the Knowledge and Skills Framework (KSF)
(DH, 2004). While there are clear advantages to applying frameworks, it has been
suggested that KSFs could be used more effectively as there is currently variation
and a non-standardised approach (Bentley and Dandy-Hughes, 2010).
NHS Education for Scotland (2011) produced a career and development frame-
work for community nursing and more recently Health Education England (2015)
has published an education and career framework for district nurses and general
practice nurses. Both these frameworks identify core knowledge, skills and educa-
tional attainment at various points in the career trajectory of community nurses,
with an expectation of continued development. With greater accountability and a
need for more stringent methods of professional regulation (NMC, 2015a,b; TSO,
2007), it is beneficial for practitioners to find clear and effective ways to assess, ver-
ify and record their competence and continuing professional development.
300 Organisation and management of care
In line with NMC (2001, 2004) specialist standards and the broader health policy
agenda, community practitioners need to address the immediate prioritisation of
daily work but also look beyond to ensure the right balance of skills and knowledge
to meet the needs of their population. The next section looks at methods of service
evaluation, caseload, workload and workforce management to help this process of
matching skills to service need.
Started in 2007 with the aim of providing a more efficient care delivery model,
it has a non-hierarchical structure with independent teams of a maximum of
12 nurses. These teams provide co-ordinated care for a specific catchment
area, typically consisting of between 40 and 60 patients. The teams organise
and are responsible for the complete process:
• Clients, nurses, planning, education and finance
• Assessment and care of all types of clients: generalists
• 70% registered nurses
• Their own education budget
• Informal networks in the neighbourhood and close collaboration with GPs
(RCN, 2015)
The Buurtzorg model comprises six key services:
1. Conduct holistic assessment of the client’s needs which includes medical,
long-term conditions and personal/social care needs. Care plans are drafted
from this assessment.
2. Map networks of informal care and assess ways to involve these carers in
the client’s treatment plan.
3. Identify any other formal carers and help to co-ordinate care between providers.
4. Provide care delivery.
5. Support the client in his or her social environment.
6. Promote self-care and independence.
(Buurtzorg Nederland, 2011)
Caseload, Workload and Workforce Management 301
Health visiting has traditionally been arranged around a ‘caseload’ of patients,
but there is very little research literature relating to this topic (Cowley and
Bidmead, 2009; DH, 2009c). Brewerton (2015) reports that a simple weighting
tool to suggest ratios of health visits per population was developed by Cowley in
2009 and has since been adapted and used widely throughout the United King-
dom. While this tool helpfully takes deprivation indices into account, Cowley
(Brewerton, 2015a) suggests other factors such as local variations need to be taken
into consideration. When evaluating one health visiting workload tool, Pollock et
al. (2002) concluded that it produced such inaccurate data it would be unsafe to
use unless significant improvements were made. Problems with interpretation
centred on the need for a more rigorous process for weighting elements of ‘health
visiting need’ and scoring more accurately the wide variation in need among
families (Pollock et al., 2002).
This illustrates the inherent difficulties of workload assessment and dependency
scoring, also substantiated by a systematic review of caseload management tools
and models that found there was ‘a poor evidence base’ (Kolehmainen et al., 2010:
47). This extensive review reported that despite ‘considerable literature on caseload
management’ it was not possible to draw conclusions aside from a need to critically
appraise methods and tools. Another literature review (Newland, 2014) found
approaches to be inconsistent or subjective, but suggested computer based tools
were improving this, while Roberson’s (2016) review was unable to achieving its aim
of identifying the most effective validated tool. Maybin et al. (2016: 4) recommends
that ‘robust mechanisms for monitoring resources, activity and workforce must be
developed’ while acknowledging the difficulties in achieving this. Notwithstanding
the inherent challenges, service review is recognised as an important element of
care organisation (Ervin, 2008; Kane, 2008; Bain and Baguley, 2012; Macdonald
et al., 2013; Newland, 2014; Brewerton, 2015a). Research by Bramwell et al. (2014: 6)
concluded that the ‘lack of data about community service activity is a significant
problem… (it) prevents the development of clear guidance about the staffing levels
required to provide services for a given population’. Supporting this conclusion,
Maybin et al. (2016: 73) suggest the absence of ‘robust national data on activity levels
in district nursing services… makes it very difficult to demonstrate, understand
and monitor the demand-capacity gap’.
they are attached to a single GP practice. While the GP practices range in size,
the caseloads of each of the district nursing teams are proportionate, with an
average of 60 patients per whole time equivalent (WTE). The team leader
doesn’t visit every patient on the caseload but as a co-ordinator and provider
of care is familiar with most patients and acts as a mentor/educational resource
for the team, particularly for those who are less experienced. There is a
community matron who is also GP attached who has a caseload of high-
intensity patients with long-term conditions (LTCs).
Organisation B has moved away from the ‘traditional’ model, and the much
larger district nursing teams work with ‘corporate caseloads’. They
communicate with a number of GP surgeries over the geographical patch.
The staff nurses need to be more self-directed as the caseload size is so large
that the team leader wouldn’t necessarily be able to identify individual clients.
The team leader acts as a manager in directing and delegating care, identifying
educational needs and sometimes undertaking patient visits. The community
matrons also work geographically and have a separate caseload of high-
intensity patients with LTCs.
Organisation C has moved away from the job title of ‘district nursing’. The
practitioners who had been district nurses in the past are now ‘case managers’
whose client group are housebound patients with chronic diseases. They
mainly work geographically although some are GP attached. Staff nurses
constitute the ‘intervention teams’ and are geographically based. These teams
are quite large, focus on ‘episodic care’ and are managed by an intervention
team leader who covers what would have previously been three or four
district nursing teams.
Notes: One of the original weighting systems for community nursing care, Frame and O’Donnell (1996) based dependency scores on frequency of patient visits
multiplied by the length of each visit, converting estimated task time into units. This still forms the basis of other workload systems, with recent research finding
benefits and challenges: ‘The Warrington tool can provide an accurate picture of time spent providing direct patient care’, but this is dependent on it being
completed accurately and consistently across teams (Baldwin, 2006). It can be combined with a caseload profiling tool to provide richer data. Originally ‘paper
based’ (but transferrable to spreadsheets).
The West Hertfordshire Patient allocation Daily visits recorded Yes Standardised as per May also include:
Activity and Time Depen- system that Agreed units assigned task; activity is in As above
dency Tool (WHATT) measures actual time per identified care/ 15-minute units
(Thomas et al., 2006) used by the DN task
service, by requiring
verification after care
delivery
The development of this and similar systems is dependent on the creation of well-informed software design and requires significant engagement of district nurses
with the skills, knowledge and experience to articulate and justify the specification (Thomas et al., 2006).
Other: e.g.The Number
Type
Number of Duration; or of Referrals, Admissions
Name of Tool Key Features/Aims (Activity/Task or
Visits Dependency and Discharges; Non-
Diagnosis)
Contact Time
Community Client Need A workload measure- Time per task Seven assessment Based on level of Includes all care groups in the
Classification System ment system criteria; need: dependency community including
(CCNCS) designed to capture 1. Assessment scoring; Need maternity, older persons,
(Byrne et al., 2007; Brady et al., the direct and 2. Physical Care classification via adults and children of all
2007, 2008) indirect elements of 3. Psychosocial scores between 1 ages
community nursing 4. Child and Family and 5 based on The seven assessment criteria
work; enables Support level of need used are nursing assess-
prediction to be 5. Teaching and ment; physical care needs;
made about client Health Promotion psychosocial needs;
need (dependency); 6. Case Management teaching and health
retrospective data 7. Environment promotion needs; case
oasis:entry produces management; carer and
a report outlining family support; environ-
team members’ time mental needs; and travel
over a defined time
period
With a ‘combined’ public health and community nursing role in some areas (such as Ireland), this tool captures the multi-dimensional aspects of the health needs for
all clients of ‘Public Health Nurses’, rather than recording and measuring specific tasks.
Electronic Caseload A knowledge-based tool Number of patients Reason for visit (24 Dependency: A Records information on:
Assessment Tool ‘eCat’ that aims to provide on the working variables to define bespoke measure Demography (e.g. staffing,
(Reid et al., 2008; Kane, 2014, effective caseload caseload (with primary need); developed for the population, GP attached or
2015) management; visits more often reviews tool on two levels: geographical; or mixed)
developed over a than monthly) (8 variables) Activities of daily Caseload size (number of
period of years as a and frequency living (ADL patients)
bespoke electronic dependency) and Visiting patterns (eight
tool that gives access dependency on the variables to describe the
to contemporaneous, nursing team (team visiting frequency)
comparative data at dependency) Caseload throughput (e.g.
each level of district admissions, discharges, etc.)
nursing, from caseload
holders to commis-
Caseload, Workload and Workforce Management
sioners
305
Other: e.g.The Number
306
Type
Number of Duration; or of Referrals, Admissions
Name of Tool Key Features/Aims (Activity/Task or
Visits Dependency and Discharges; Non-
Diagnosis)
Contact Time
Scottish Community Part of a suite of tools Counts face-to-face Not specific tasks but A workload tool as Used in tandem with a
Workload Measurement aiming to ensure a contacts (and four levels of opposed to a professional judgment tool
Tool (SCWMT) consistent approach associated intervention are caseload-profiling and quality data appropri-
(Grafen and MacKenzie, 2015) to measuring nursing workload) defined, ranging tool, so the level of ate to specific areas to
workload across from Level 1: complexity relates triangulate the findings
NHS Scotland and to ‘straightforward’ to to the workload Records: Face-to-face contacts
support evidence- Level 4: ‘complex’ demands of each and non-face-to-face
based decision patient during each contact; visits and associ-
making on staffing contact rather than ated workload (such as
and workforce the overall management, administra-
needs; enables complexity of the tive, meetings and develop-
community nurses to patient; also ment activity); travel and
Organisation and management of care
SystmOne, RIO, CHS, PARIS, Many IT systems currently in use; mainly for patient records; to varying degrees, also provide the ‘The right staff, with the right
ECR, Emis, Lorenzo facility to allocate patients, categorise by task and run reports that reflect caseload and skills, in the right place, at
workload features the right time to deliver
307
high-quality community
nursing care and services’
308 Organisation and management of care
way services are organised, structural systems and staffing resources are an
influence on the everyday practice of work organisation. With scant research
evidence to support specific approaches for assessing and determining nursing staff
requirements and/or skill mix (Fields and Brett, 2015; Jackson et al., 2016), team
leaders are tasked with assuring safe and effective care using the tools adopted by
their organisation and their own clinical judgment. Nurses are accountable for
their own practice and as careers progress to higher levels such as specialist or
advanced practice, this accountability extends beyond the confines of their indi-
vidual competence towards their team, the populations they serve and in the need
to influence services and resources (NMC, 2001, 2004, 2015a).
but the way services are structured, for example, whether services are GP attached or
geographical, may impact on quality and staff engagement. While some benefits have
been described by health visitors changing from GP attachment to corporate casel-
oads (Table 15.4), there has also been a reported need for further evaluation as initial
research demonstrated no improvement in staff stress levels or the quality of client
service or increase in public health nursing activity (Hoskins et al., 2007).
CONCLUSION
The safe, cost-effective and efficient management of care in the community setting
is one of the many challenges nurses face on a regular basis. The practitioner’s
accountability for care delivery extends beyond daily patient prioritisation and
work organisation to influencing the structures and systems within which care is
delivered, measured and recorded. Integral to decision making is the evaluation of
services and the skill mix of the team to ensure the needs of the population are
identified and addressed with high-quality care provision.
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316 Organisation and management of care
LEARNING OUTCOMES
• Explore the concept of person-centredness.
• Critically discuss the role of clinical leadership in the delivery of quality
person-centred care.
• Explain the practice development and consider its contribution to the wider
clinical governance agenda.
• Reflect on enablers and barriers of getting evidence into practice.
• Consider means of achieving sustainable change.
• Examine quality measures and quality improvement processes.
INTRODUCTION
The only certainty within the health service today is that change is inevitable. Change
is constantly occurring in response to new policy and changing demographics and
to meet the needs of service users and their carers. More care is being delivered
at home and in communities and there is an emphasis on avoiding unnecessary
hospital admissions (NHS England [NHSE], 2014; Scottish Government [SG], 2013).
This requires integrated working between health and social care. Community nurses
have a key leadership role in this new health and social care landscape. Effective
leadership is required to shape and develop practice to ensure that service delivery is
based on best evidence, delivered in a manner acceptable to people being cared for,
within a culture that values the participation and involvement of all stakeholders. The
means of achieving this must fit within the framework of clinical governance where
responsibility for providing quality person-centred healthcare lies with every member
of an organisation, as well as the organisation itself. This chapter explores leading
quality person-centred care and is intended to be useful for all community nurses in
the belief we are all clinical leaders. The practice development model, adapted from
seminal work by McCormack and Garbett (2002) is used as a conceptual framework. It
is useful for clinical leaders to evidence and develop their practice, improve patient and
carer experience, while developing teams and transforming the culture and context of
care (Figure 16.1).
Clinical Governance 319
• Developing • Assessment of
shared values practice
• Developing a context
red values and vision
shared vision Sha • Leadership
• Role development
viduals and c
clarification indi on • Developing
• Creative ing tex engagement of
rm t
engagement stakeholders
fo
so
ns
fc
Tra
are
Person-
centred
culture
A
ed en uth
at ga en
cilit ing ge tic
Fa arn m
en
le t
• Reflection • Facilitation
• Action • Action planning
learning • Role modelling
• Workshops • Co-production
• WBL
ACTIVITY 16.1 Take a few moments to consider your own knowledge on leading quality,
person-centred care and questions you would like addressed as you proceed
to read this chapter.
CLINICAL GOVERNANCE
During the mid-1990s, there was recognition of variance in the quality of care
provided for patients/clients throughout the United Kingdom. Until the mid-
1990s, National Health Service (NHS) Trusts were accountable for their financial
expenditure, through corporate governance, but not for the quality of care
provided within their organisations. Twenty years ago, policies such as The New
NHS Modern and Dependable (Department of Health, 1998) and Designed to Care
(Scottish Office, 1997) introduced clinical governance which placed responsibility
and accountability for quality care on the shoulders of chief executives. In order
to carry this obligation, shared responsibility was encouraged through working
in open systems, formal standards, procedures, regular monitoring and reporting
320 Leading quality, person-centred care in the community
were introduced (Wilkinson et al., 2004). The most well-known definition of clinical
governance is that of Scally and Donaldson:
They proposed this would be the main vehicle for continuously improving the
quality of patient care and developing the capacity of the NHS in England.
Since then, the addition of staff governance has led to the concept of healthcare
governance. This includes all three aspects: corporate, clinical and staff governance.
Practice development, key to addressing the clinical governance agenda enables
practitioners to demonstrate accountability, although practice development is
driven ‘bottom-up’, whereas clinical governance is ‘top-down’. Both frameworks
however aim to support safe, effective person-centred care.
ACTIVITY 16.2 You might like to take time to find out the clinical governance structures and
support available in your organisation.
PERSON-CENTREDNESS
You will be very familiar with person-centredness as it underpins current healthcare
policy (SG, 2010, 2014) and is reflected in The Code (Nursing and Midwifery Council
[NMC], 2015). It is linked to the concept of co-production, anticipatory care and
strengths-based approaches which are important in contemporary community
nursing practice. They are equally important in terms of developing practice and the
professional development of community nurses. The emphasis is on commitment
to enable others to take responsibility for their own health and well-being. This
challenges nurses and other practitioners to design and develop their services with
patient and other service-user experience central (Freeth, 2006) and to reflect on
their professional attributes (NMC, 2015).
According to McCormack and McCance person-centredness is
N
MACRO CO TEXT ˆ •
ˆ
EQUISITES •
PRER Prof He
an is ess alt
tive O rg at io nal Sy ion h
• p or stam all &
Sup s•P y
• - CE NT RE D P R O C C
ON om
So
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el
f’ ips PER S S er
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nsh Sh
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pe
io ar
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are
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Working with the
t
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Patient’s Beliefs
ff R
o
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Sta
ip
and Values
ote
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a
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r Inn
E
• ˆ Strategic
•
Providing PERSON-CENTRED Engaging
king Systems
Developed Interp
Care • Good care experience
• Involvement in care
• Feeling of well-being
sion Ma • Existence of a
lues
healthful culture
• ˆ St
i
d Va
e
ec
rs
D
o
Sharing
• Th
s an
Being
nel
d
rate
e
Decision
har
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ix
ica
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PRACTICE DEVELOPMENT
Practice development was initially introduced as a means of developing evidence
from practice to substantiate nursing as a profession in the early 1990s (Redfern and
Stevens, 1996; Pearson, 1997) through the establishment of nursing and practice
development units. Since then, theoretical understanding and the evidence to
support practice development as a means of taking practice forward has grown
considerably. In the early years, the purpose of practice development was advocated
as good quality patient-focussed care achieved through the improvement of
322 Leading quality, person-centred care in the community
technical knowledge and skills (Garbett and McCormack, 2002), and through the
dissemination of research into practice (Kitson, 2009). Although this approach was
direct and effective in working to short-term goals, it was associated with top-down
change and was often an ineffective sustainable approach. McCormack et al. (2007)
and Dewing (2008) among others take a broader, transformational view of practice
development:
ACTIVITY 16.3 Is the culture where you work a person-centred culture? What do you think
would make it a person-centred culture?
I believe the factors that will enable and inhibit a person-centred culture are…
Active learning
Lord Rose’s recent review, Better Leadership for Tomorrow (2015), challenges NHS
staff to become the best versions of themselves at work. Life-long learning is supported
by governmental policy and organisations have the responsibility within the clinical
governance framework, to ensure there are systems in place to support this. Managers
have a responsibility to ensure teams meet all statutory and professional requirements,
although all professionals have a responsibility to ensure they continually grow and
develop. Amy (2008) carried out survey research to identify the contribution of
leaders to learning at individual and organisational levels. She identified the required
behaviours as facilitation, problem solving and decision making, communication,
relating and developing. Although attending courses, study days and conferences, are
useful, there is little evidence to suggest the result is development of practice.
Practice development is achieved through challenging practice learning of
individuals and teams (Manley and McCormack, 2003; Dewing, 2008). The
facilitation of critical reflection, crucial in this type of learning occurs through critical
questioning where enlightenment, empowerment and emancipation occur (Dewing,
2008; McCormack et al., 2009). Emancipation or liberation from old ways of thinking
together with balanced participation is required to recognise areas of practice that
require attention. Active learning is an approach discussed by Dewing (2008).
324 Leading quality, person-centred care in the community
She advocates learning taking place in the workplace rather than being a separate
activity in more didactic training study days. The purpose of active learning is action
which contributes to transformation of workplace cultures. It involves the multiple
use of the senses and intelligences, reflecting and engaging with an internal dialogue
with self and an ongoing dialogue with others (Dewing, 2008). An active learning
relationship is facilitated in practice through relationships that enable high support
and high challenge. The relationship is based on facilitators and co-learners as the
intention is for all of those involved to learn and learn about learning. Relationships
may take the form of clinical supervision (Driscoll, 2007), critical companionship
(Titchen, 2004) and action learning (McGill and Brockbank, 2003). Other relationships
that support personal and professional development are preceptorship, mentorship
and coaching. Preceptorship programmes are now more commonplace for newly
qualified staff and offer support in the consolidation of their educational preparation
programme. Examples of this are NHS Flying Start. The Northern Ireland Practice
and Education Council for Nursing and Midwifery (www.nipecdf.org/) has a similar
programme. Mentorship and coaching relationships however are less commonplace
and appear to be confined to senior managers and leaders.
ACTIVITY 16.4 If you are in one of these relationships, do you consider you are engaging in active
learning and mentorship? What does the facilitation of active learning look like?
MEASURING QUALITY
The Institute of Medicine’s Six Dimensions of Quality Care (2001) (Figure 16.3)
have been adapted in a number of policy documents.
Every practitioner is responsible for ensuring clinical effectiveness, managing risk
and continuous quality improvement. Lord Darzi’s Report High Quality Care for All:
NHS Next Stage Review (Department of Health, 2008) outlined quality improvement
as a core element of any approach to leadership and this has been cemented in current
policy drivers. Healthcare governance and the drive to modernise the NHS has
created a culture where clinical quality indicators, performance indicators and other
targets have become part of the culture of healthcare. In England, the NHS Outcomes
Framework (Department of Health, 2014b), the Public Health Outcomes Framework
(Department of Health, 2015) and the Adult Social Care Outcomes Framework
(Department of Health, 2014a) assure quality by assessing progress in five domains.
These are scrutinised and quality assured by the Care Quality Commission by asking
five key questions of services: Are they safe? Are they effective? Are they caring?
Are they responsive to people’s needs? Are they well-led? (www.cqc.org.uk/content/
five-key-questions-we-ask).
In Scotland, Health Improvement Efficiency Access Treatment (HEAT) targets
are implemented through each NHS Board’s Local Delivery Plan as part of the
national plan, Scotland Performs. While these targets are more acute care focussed,
they now have an emphasis on both health and social care. The Quality Outcomes
Framework, introduced in 2004, as part of the General Medical Services (GMS) contract
Quality Improvement 325
Safe Avoiding injuries to patients from the care that is intended to help
them
Effective Providing services based on scientific knowledge to all who could
benefit and refraining from providing services to those not likely to
benefit (avoiding underuse and overuse); doing the right thing for
the right person at the right time
Family-centred Providing care that is respectful of and responsive to individual
patient preferences, needs and values, and ensuring that patient
values guide all clinical decisions
Timely Reducing waits and sometimes unfavourable delays for both those
who receive and those who give care
Efficient Avoiding waste, in particular waste of equipment, supplies, ideas
and energy
Equitable Providing care that does not vary in quality because of personal
characteristics such as gender, ethnicity, geographic location and
socio-economic status
FIGURE 16.3 Six specific aims for improvement. (From Institute for Medicine,
http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/2001/
Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%
20brief.pdf Accessed 30th June 2017, 2001.)
QUALITY IMPROVEMENT
While examples such as Mid Staffordshire (Francis, 2013) highlight the perils of
targets and performance indicators, practitioners can choose their response to such
measures. Disastrous incidents are most often preceded by an incubation period
where warning signs are ignored or misinterpreted, where false assumptions are made
and misplaced optimism predominates (Macrae, 2014). Leaders can create culture
and processes that ensure such warning signs are understood and addressed early.
They can base their improvement efforts on empirically tested models for person-
centred care that focus on the active engagement of practitioners in transforming the
workplace and practices individuals and teams engage in (McCormack and Garbett,
2003). Rather than measure people and practice, leaders can work collaboratively to
understand their practice contexts and create the conditions that make it possible for
them to enhance their contexts such that practice and people flourish. An example of
how a district nurse (DN) leader can use practice development principles in response
to targets is provided in this case study.
326 Leading quality, person-centred care in the community
CASE STUDY The DN team leader receives communication that there are clinical quality
and financial performance indicators required to be reported every quarter
for their service.
In preparation for the next team meeting, targets that must be achieved are
shared. The team leader asks that the team commit a half hour discussing these.
At the meeting some members of the team express their disgust at imposed
targets. Others express their concerns about being scrutinised while working in
people’s homes. Others debate the relevance and importance of the targets.
Previously, the team have identified and agreed and made explicit shared
values and beliefs underpinning their practice. The team leader refers to these,
‘We believe we should always strive to provide care that is safer, evidence-
based, more effective and more person centred.’ She then encourages dialogue
by asking, ‘How do we currently know we are achieving that?’ The group
discover ‘proving’ care is good is difficult because of the way they work and
that much of what they do is crucial but not reflected in these current targets.
The group agreed it would be useful for them all to be involved in collecting
data about their practice. This would include the specified targets, but also data
on other aspects of practice deemed important by them and their client group.
A member of staff agreed to run a short life working group to use the ‘Good
Enough’ model of evaluation proposed by Wilson and McCance (2015) to identify
appropriate indicators of quality for their service. They also sought to create
a framework that ensured staff were involved in data collection, giving and
receiving feedback and engaged in reflecting on practice in light of their data.
Over the next 6 months, the whole team collected data twice. This included
the clinical quality and financial target data as well as performance data
on wound management and quality of interactions with patients and their
families. They used observation, records reviews and interviews with
patients and families to understand the quality of care provided. Following
their first data collection they commenced an active learning group where
they looked at their collective performance and work on issues in practice.
This led to two projects being commenced, one focusing on improving wound
care and the other at exploring how access to social activities in the local
community can be enhanced.
ACTIVITY 16.5 What evaluation methods have you come across in practice? What types
of data were collected? How were the data used to evidence practice and
evidence key targets set by the organisation?
Contemporary leadership theorists claim old paradigm models are in fact management
rather than leadership (Figure 16.4). In addition, the evidence underpinning the
new paradigm models, they claim is questionable (e.g. Alimo-Metcalfe and Alban-
Metcalfe, 2005). These models are based largely on US studies of ‘distant’ leaders, top-
level managers and chief executives, rather than those close to the realities of practice
directly with their followers. An alternative model of transformational leadership was
proposed by Alimo-Metcalfe and Albans-Metcalfe (2005, 2008) that examined the
leadership interaction with followers. In this model of ‘close’ or ‘nearby’ leadership,
there is a theme or ordinariness, rather than heroism. Follower engagement is placed at
the heart of leadership and leaders are committed to building a shared vision through
participation and inclusion of all stakeholders. They suggest leaders increase followers’
self-efficacy and self-worth by communicating confidence and expectation to a mission
of a better future. Alimo-Metcalfe and Albans-Metcalfe (2008) claim leaders who
achieve high engagement are able to achieve high levels of motivation, job satisfaction
and job commitment among their staff.
Models of leading person-centred practice are more participatory than old and
new paradigm theories suggest. They are also value based, and the leader and follower
have a more dynamic relationship. Participatory leadership is acknowledged by the
King’s Fund (2013). Their model of patient-centred leadership places core values of
care and compassion at the heart of leadership practices. The purpose is focussing on
patients’ needs first and foremost and improving quality care. Stanley (2006, 2008)
developed a model of congruent leadership by studying nurses in one NHS Trust.
He concluded clinical leaders were found at all nursing levels and tended not to be
at the most senior level. They are motivational, inspirational, organised, effective
communicators and relationship builders. Their leadership approach is based upon
328 Leading quality, person-centred care in the community
FIGURE 16.4 Key leadership theories from old and new paradigms.
a foundation of care that is fundamental to their values and beliefs of nursing care.
Stanley identified the attributes of clinical leaders as clinical competence, clinical
knowledge, approachability, motivation, empowerment, decision making, effective
communication being a role model and visibility.
Figure 16.4 provides an overview of some key theories. Please see additional
leadership literature for a more in-depth study of leadership theory.
Lynch (2015) and Cardiff (2014) have developed Hersey and Blanchard’s model
of situational leadership (1993) as a means of leading person-centred cultures in
practice. The model proposed by Lynch (2015) of ‘partnering for performance’
Getting Evidence into Practice 329
suggests that while leaders adapt their leadership style from delegating, supporting,
coaching and directing as advocated by Hersey and Blanchard, the aim of leadership
is to enable followers to assess their practice using McCormack and McCance’s
person-centred practice framework (2016). Partnering will enable followers to
move along a continuum to achieve person-centred practice. It is achieved by
transformational learning (Meizerow, 1981), facilitating critical reflection, engaging
in critical dialogue and using such evaluative tools as the workplace culture critical
analysis tool (McCormack et al., 2009). Cardiff (2014) developed a conceptual
model of person-centred leadership which he suggests enables leaders to base their
leadership practices on person-centred values. This model is relational, involving
leader and associate rather than follower or subordinate, indicating the continually
changing relationship for which he represents in the metaphor of the Argentine
tango. The purpose of leadership for Cardiff (2014) is enabling empowerment and
well-being, allowing associates to ‘come into their own’. This is achieved by sensing
where the other is at, enabling reflexivity, balancing their needs, contextualising or
helping the associate make sense of their social world, presencing and communing
or reaching shared visions or decision making. Leaders respond to individuals
in different situations by stancing. Cardiff (2014) acknowledges the effect culture
and context on leadership and vice versa. He suggests systems of evaluation and
availability of safe, critical and creative spaces and the needs of the associate all have
a significant impact on person-centred leadership.
ACTIVITY 16.6 Is there someone you can think of you consider to be a good leader? They
do not necessarily have to work in healthcare. What is it you admire about
them? In relation to this, what are your strengths and what are your areas for
development? Who and where will you get help in order to develop these skills?
helps the implementation of evidence. This has been developed and tested since the
seminal work by Kitson et al. (1998). She asserts clinical effectiveness is more than
the availability of robust evidence, it is also concerned with effective facilitation and
a receptive context. She identifies these aspects as being on a continuum from high
to low. These are the areas therefore that require attention.
ACTIVITY 16.7 Consider how the core components of the PARIHS framework could be
applied in a community setting to get evidence into practice.
Evidence
The changing context of healthcare delivery means community nurses need
knowledge and the skills to retrieve data, critique the quality of evidence. They must
consider how to use the evidence most effectively to improve patient care and ways of
dissemination of best practice. However, gold standard evidence does not necessarily
take into account person-centredness, evidence from practice or the uniqueness of
the practice context. Patients are people with individual needs and decisions about
care must be based on these needs. Workplace cultures vary in their receptiveness to
change and development. Many areas of nursing practice do not lend themselves to
randomised controlled trials; thus the PARIHS framework considers other types of
evidence. Rycroft-Malone (2013) includes evidence from clinical experience, patients
and local information or data relevant to the context. This should be considered and
critiqued in the same way as research evidence. Figure 16.5 identifies the types of
knowledge required to support clinical effectiveness.
Knowledge
from research
findings
Effective care
Knowledge
Knowledge from clinical
from patients expertise
Term values
Patent/Family stories
Interviews
Surveys
Practice
Observations of care
Policy
Staff stories
Research
Evidence
Best practice
Grey
Literature Surveys
Clinical outcome
Guidelines / indicator reports
Standards
Audits
ACTIVITY 16.8 Figure 16.6 identifies some of the available types of evidence to inform
practice. Can you identify what evidence is being collected in your clinical
area and how it is being used to inform, develop and evaluate practice?
Context
Context is the environment or practice setting, broken down into culture, leadership
and evaluation in the PARIHS framework. Leadership and culture have been
discussed earlier in this chapter. Process and outcome evaluation are of equal
importance in practice development. Practice developers use creative means of
engaging with stakeholders to gain evaluation data. While the data may be numbers
achieved against targets identified through audits, they also emerge through exercises
like values clarification (Manley, 2004), visioning, observations of care and practice
and patient stories. The dimensions of context are outlined in Table 16.1.
ACTIVITY 16.9 Consider the context of practice you are familiar with. Where do you think it
is on the continuum from high to low context?
332 Leading quality, person-centred care in the community
Facilitation
The contemporary leadership advocated in healthcare policies is based on
facilitation (NHS Scotland, 2008) and is ideal for addressing the current changing
context in healthcare. Facilitation, advocated in practice development, is the process
of valuing a nurturing critical questioning environment that allows a team to learn
and develop together (Huber, 2010; Shaw et al., 2008). Heron (2002) identifies
modes of facilitation as planning interventions (setting goals for the group); giving
meaning (helping the group to make sense of experience); confronting (raising the
group’s awareness of the gap between saying and doing and tackling resistances);
structuring (choosing which methods of learning are best suited to the event) and
valuing (creating a climate which gives people recognition).The characteristics
of facilitation in practice development and the attributes of effective leaders and
practice developers are outlined in Table 16.2.
Change models
The literature abounds with change models. While they can be valuable, unlike
practice development, they do not have person-centredness, transforming cultures
and contexts and active learning as explicit intentions. Models of planned change
help to structure the process of change and assist with transition, although are
criticised as being too linear and simplistic. Probably the best known model of
change was developed in 1951 by Kurt Lewin. He said that in order to prepare a team
Tools to Develop Practice 333
Table 16.2 Characteristics of facilitation in practice development
for change, the status quo must be de-stabilised to increase the sense of discontent
with current practice. To assist with this process he recommended carrying out a
force-field analysis where the driving and restraining forces of the intended change
are identified by the team. The ‘unfreezing’ process, he argued would increase the
perceived need for change and involve stakeholders. He then identified the ‘moving’
stage where the change is implemented and established. The ‘re-freezing’ stage was
the change being imbedded into the organisation.
Kotter identified eight steps to successful change in his emergent model of change
(Kotter, 2012: 54). The steps he identified are establishing a sense of increased
urgency, creating a guiding coalition, developing a vision and strategy, communicating
the change vision, empowering broad-based action and generating short-term ‘wins’.
Finally he identified, consolidating gains and producing more change. The DICE
mode, currently being used within the health service, was developed by Sirkin et
al. (2005). They stated duration (of the project), integrity (of the team), commitment
(by both management and employees) and effort (demands made of employees),
determine the outcome of any transformation initiative. If the project is long term,
short milestones and regular evaluation are advocated. The integrity of the team
relates to the ability of the team to deliver the project successfully; commitment, to
the support from senior management as well as ‘buy-in’ from those affected by the
change. Saskin and his colleagues considered employees could not be expected to
make more than 10% increased effort above their current workload. These aspects are
important to be considered when supporting teams through change.
Example: Creating a shared vision. Images were also used to create a shared
vision in the CHOICE project (Figure 16.7). These images represented…
Two groups that then engaged in dialogue and presented the other group with
a vision statement. Together the group turned the two statements into a shared
vision statement:
‘Skilled health and social care staff working together, supporting each other to
build a relationship with the ‘cared-for person’ and family and/or significant
others to provide holistic care where everyone feels valued, has choice and
The National Institute for Health and Care Excellence (NICE) have produced
guidance, How to Change Practice Guide (https://www.nice.org.uk/process/pmg30/
chapter/introduction-and-background). The barriers to change in healthcare
are identified as awareness and knowledge of the required change, motivation of
individuals and teams, skills required to make change happen, acceptance and beliefs
of the quality of current practice and the proposed change and practicalities in terms
of resources and organisational structures.
Other models to guide quality improvement are widely available. Audit is a crucial
component of most processes and helps monitor improvements in the quality of
patient care (Patel, 2010). To be helpful, however, it must be an ongoing dynamic
process that supports the constant reviewing of practice standards (McSherry and
Pearce, 2011). Steps in the audit cycle are outlined in Box 16.1.
Box 16.1
1. Evaluate clinical practice against standards.
2. Identify areas requiring change.
3. Evaluate standards for practice set informed by evidence.
4. Evaluate practice and identify variations.
5. Implement change (development of action plan).
(Adapted from Bryar and Griffiths, 2003)
336 Leading quality, person-centred care in the community
The National Patient Safety Programme in NHS Scotland makes use of the
Improvement Model. The ‘Plan-Do-Study-Act’ or PDSA cycle. A key component
in this model focuses on persistent improvement throughout the process of
change. It also encourages teams to constantly review their practice through
the use of evaluation to shape the ongoing development (Nelson et al., 2007).
Although the emphasis of this quality improvement tool is less on transforming
culture and context and more on testing new ways of working on a small
scale within short time frames, evaluation within it allows effectiveness to be
demonstrated.
• Plan – Plan the change to be implemented and its evaluation criteria.
• Do – Implement the change.
• Study – Evaluate the data from before and after the change.
• Act – Act upon information gained from change and plan further changes
necessary.
ACTIVITY 16.10 Consider an issue in practice where you have identified evidence development
is needed. Using one of the quality improvement tools, develop an outline plan
indicating how it could be addressed.
LEADERSHIP DEVELOPMENT
As developing leadership across organisations is a key priority in the NHS there are lots
of resources available to help you in your leadership development. There is a particular
drive for community nurses to increase their leadership and management capacity as
more people are being cared for in their own homes and communities. The challenging
context of the community, where nurses practice autonomously at all levels means
leadership is essential for safe, effective, person-centred care. Continuous improvement
and development of services requires everyone to play their part across organisations,
at strategic level and at the clinical interface. Attributes of effective nurse leaders have
been highlighted in the literature as stewardship, respect, caring, advocacy, honesty,
confidentiality and initiating a values programme by Jooste (2004). Cook and Leathard
(2004) advocated creativity, highlighting, influencing, respecting and supporting.
The need to develop leadership has been recognised in the emergence of the NHS
Leadership Academy (www.leadershipacademy.nhs.uk/) providing programmes
for different stages of development, discussion boards and interactive activities.
There have also been a range of frameworks developed to guide professional growth,
for example, the Clinical Leadership Competency Framework (NHS Leadership
Academy, 2011 available at www.leadershipacademy.nhs.uk/wp-content/uploads/
2012/11/NHSLeadership-Leadership-Framework-Clinical-Leadership-Competency-
Framework-CLCF.pdf). This is centred on five pillars, demonstrating personal
References 337
qualities, working with others, managing services, improving services and setting
direction. In Scotland, NHS Education for Scotland has established a National
Leadership Unit and provides resources for developing leaders (www.nes.scot.
nhs.uk/education-and-training/by-theme-initiative/leadership-and-management.
aspx). In Scotland, Leading Better Care (LBC) (SG, 2008) is a role framework which
provides senior charge nurses and community team leaders with support to meet
Knowledge and Skills Framework profile (www.evidenceintopractice.scot.nhs.uk/
leading-better-care.aspx). The aim of LBC is to help in the achievement of high-
quality, person-centred safe and efficient care for every patient the first time and
every time. This is achieved by ensuring there are better processes, effective ways
of working, efficient and person-centred care that result in more effective use of all
resources.
ACTIVITY 16.11 Access one of the leadership frameworks above. Take a look at the resources
available to support leadership development. Identify the qualities you would
like to develop. Design your own personal development plan indicating how
you will develop, who will help you and the resources you need.
SUMMARY
The practice development conceptual framework (Garbett and McCormack, 2002) and
the Person-Centred Practice Framework (McCormack and McCance, 2016) provide
useful frameworks to consider leading quality, person-centred care in community
nursing practice. Practice development is everybody’s concern and therefore an
understanding of the purpose and processes involved is essential for all practitioners.
The essential elements of leadership, person-centredness, quality and evidence-based
practice together with process to achieving change have been discussed within the
context of the clinical governance agenda. After reading the chapter and undertaking
the activities, it is hoped you will develop an understanding of, not only the context
of their practice, but of yourselves as leaders of quality, person-centred community
nursing practice.
FURTHER RESOURCES
www.fons.org – Foundation of Nursing Studies
www.leadershipfoundation.no – Leadership Foundation
www.realworld-group.com – Real World Group: Engaging Leadership
McCormack B, Dewar B, Wright J et al. (2006) A Realist Synthesis of Evidence Relating to
Practice Development: Final Report to NHS Education for Scotland and NHS Quality
Improvement. Scotland: Quality Improvement Scotland.
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CHAPTER
17 eHealth
Heather Bain
LEARNING OUTCOMES
• Explore the meaning of eHealth including the associated terminology of
telehealth and telecare.
• Appraise the suitability of eHealth for use within community nursing practice.
• Explore the professional and ethical issues in the use of technology within
community nursing.
• Discuss the educational needs of the future eHealth community nurse.
INTRODUCTION
One of the most significant developments in health and social care in recent
years has resulted from the increased use of information technology (IT), in
particular the Internet and the World Wide Web. Accelerating the uptake of digital
technologies and providing support for its implementation was identified as one
of the recommendations to address the nine characteristics of good quality care
in district nursing (Maybin et al., 2016). Considering the changing demographics
of society and the fact that advances in technology can save time and money,
national strategies have identified eHealth as an approach to improve healthcare
(Cruickshank et al., 2010; Department of Health, 2014; Scottish Government, 2015;
Welsh Government, 2015; Health and Social Care Board, 2016).
All four UK countries have identified national IT programmes which support the
diverging health policies in the UK countries. Northern Ireland, Scotland and Wales
all have identified specific strategies to address eHealth development, whereas England
have introduced it in the ‘Five Year Forward View’ (Department of Health, 2014) and
have developed supporting work-stream road maps (National Information Board, 2015)
and a resource for commissioners (NHS England, 2015). eHealth is about improving
health outcomes, the safety of care and providing efficient care; it is not just about
technology (NHS England, 2015; Scottish Government, 2017; Welsh Government,
2015; Health and Social Care Board, 2016). However, it is also important to note the
strategic direction in the four countries towards the provision of integrated health
and social care and this will be reflected in future developments where organisational
boundaries are not a barrier to care in the community (Scottish Government, 2015;
Welsh Government, 2015; Gilbert, 2016). It is therefore clear that eHealth needs to be
an integral part of nursing practice, and it is important that community nurses have
The Terminology 343
the underpinning knowledge relating to this technology and can use it effectively to
meet the healthcare needs of individuals, families and communities.
This chapter therefore aims to explore eHealth within community nursing. First,
the associated terminology will be examined, then the evidence base to support its
use will be explored. Finally, some professional, ethical and contemporary issues
will be considered specific to nursing in the community.
THE TERMINOLOGY
eHealth
The term eHealth first appeared in the literature in the 1990s (Booth, 2006) but has
since been increasingly and inconsistently used. The widespread use of the term
suggests it is a significant concept that is commonly understood despite the lack of a
precise definition. Oh et al. (2005) undertook a systematic review of definitions and
identified 51 unique definitions with no clear consensus. However, they did identify
two universal themes, health and technology, and six less mentioned themes of
commerce, activities, stakeholders, outcomes, place and perspectives. Therefore, it
can be concluded that the various definitions reflect different perspectives, settings
and contexts where technology is used to support healthcare needs. The World
Health Organisation (2016), which was not included within this systematic review,
encompasses the two universal themes and defines eHealth as ‘the use of informa-
tion and communication technologies for health to, for example, treat patients, pursue
research, educate students, track diseases and monitor public health.’ The Scottish
Government (2015) suggests eHealth is an umbrella term with wide parameters
and is defined as ‘the use of information, computers and telecommunications to
meet the needs of individuals and improve the health of citizens’.
Within this definition of eHealth it is recognised that there are many evolving
terms encompassed, such as health informatics, nursing informatics, information
communication technology, assistive technology, telemedicine, telenursing, tele-
care, telehealth, electronic patient record, and they are often used interchangeably
(Cowie and Bain, 2011). It is not possible to cover them all in depth here; however, it
is important that there is an understanding of the broad principles of the key terms,
in order that technology can be used appropriately within the community.
CASE STUDY Mrs A is an 83 year old who lives alone in her own home. She has rheumatoid
arthritis, chronic obstructive pulmonary disease and type 2 diabetes. Mrs A
has been assessed on numerous occasions by various health and social care
professionals including the occupational therapist, social workers, the district
nurse, the diabetes specialist nurse, and is also under the care of a hospital
consultant for her rheumatoid arthritis, and her general practitioner. Until
recently, Mrs A has had to repeat her story every time she was assessed
by a new professional. Now, using a shared electronic care record all the
professionals involved in her care have access to share information and
co-ordinate care, and if she has an exacerbation of any of her co-morbidities
out of hours there is adequate information to manage her care in a timely
manner and ideally avoid hospital admission.
Telehealth
Telehealth is the provision of health services at a distance using a range of digital
technologies and mobile technologies (Scottish Government, 2012; Telecare
Services Association, 2016). This can be to promote self-care, for example, to
enable a patient to monitor their own vital signs such as blood pressure, or from
a monitoring perspective, physiological data could be transferred to a remote
monitoring centre to allow for health professionals to intervene if measurements
fall outside of expected parameters. The RCN (2012c) suggests telehealth is not a
new technology or branch of health care, but should be integrated within existing
The Terminology 345
healthcare infrastructures. The services could involve consultation, patient
monitoring, diagnosis, prescriptions or treatment and can be done in real time or
delayed through media such as teleconferencing, videoconferencing or the Internet.
It should be a targeted approach to enhance service delivery focused around
the service user, enabling a more efficient and effective use of clinical resources
(Cruickshank et al., 2010; RCN, 2012a, c; Telecare Services Association, 2016).
CASE STUDY Mrs B is a 31 year old who has recently been diagnosed with type 1 diabetes.
She has been commenced on twice-daily insulin and has received education
from the diabetic clinic at her local hospital, and has been followed up by her
practice nurse. Her blood glucose levels remain unstable.
She is therefore identified as suitable for the telehealth programme until her
blood glucose stabilises. A telehealth monitor is installed in her home and she
is shown how to connect her glucometer to the telehealth monitor.
Mrs B then carries out a monitoring session using the telehealth monitor
daily. The monitor gathers her blood pressure, heart rate, oxygen levels and
weight, and some data from prescribed questions. Finally, she connects
her glucometer to the monitor and the readings from the past 24 hours are
transmitted.
Her data are then analysed by a triage nurse at the local community hospital.
The triage nurse then contacts her to discuss the readings that are outside
of normal limits and provides the relevant education and support. A weekly
report is then sent to the diabetic clinic.
Following 8 weeks of this high intervention, Mrs B’s blood sugars stabilise and
she is confident to self-care for her condition.
While the ‘generation terms’ are still used by some in the literature, they are
becoming increasingly redundant as technology continues to evolve. Recent strategy
documents and organisations such as Telecare Services Association and Joint
Improvement Team no longer make reference to these categories within telecare.
CASE STUDY Mrs B is an elderly lady living in sheltered accommodation. She has a medical
history of rheumatoid arthritis, angina, deafness and a history of falls.
Following discharge from hospital after a fall, she was assessed by a district
nurse who arranged for care workers to attend four times a day to meet her
personal needs. However, Mrs B became increasingly confused and was
getting out of bed and wandering through the sheltered housing complex at
night.
Mrs B was then referred for a telecare assessment to identify the risks and
to see if there were any interventions that could manage these risks. This
resulted in the property being fitted with an activity monitor which is used
to monitor movements within the home, flood detectors, a gas sensor and a
bed sensor, which will detect if Mrs B has failed to return to bed in the time
set. This ensures that if she gets out of bed and falls the warden can intervene
accordingly.
Telehealthcare
Considering all the definitions above, it is evident that there are interrelationships
between all the terms. Doughty et al. (2007) have reviewed the terminology used and
348 eHealth
Telecare
Health Telehealthcare
Informatics
Telehealth
eHealth
Taking into account all the various concepts within eHealth, it is clear that there
are many overlaps and all have a potential use within community nursing. The oppor-
tunities and challenges are summarised in Table 17.1. There are also many ways that
eHealth can be used by a variety of methods, some of which are identified in Table 17.2.
There have been several projects across the United Kingdom to ensure that
eHealth becomes an integral part of community care provision. However, one of
the challenges has been to accurately quantify the benefits, due to the small scale
of the projects and the differing methods of evaluation. To further confirm the
contribution of eHealth to healthcare, evaluation needs to integrate monitoring,
outcomes and personalised feedback (Flodgren et al., 2015; Verhoeven et al., 2007;
Fatehi et al., 2016).
The Terminology 349
Table 17.1 Summary of opportunities and challenges of eHealth
Strengths Challenges
Reinforces existing advice May be expensive to develop
Overcomes challenges of distance Lack of access to software and hardware
Addresses needs of remote and rural areas Lack of consistency across services and interoperability
Reduces unnecessary outpatient appointments Technical problems and compatibility
Out-of-hours access Relies on technical competence of staff and service users
Quicker access to specialist advice Potential health and safety risk with equipment
Improved safety because of up-to-date recording of Maintaining confidentiality
information
Usability for people requiring reasonable adjustments
Reliability of evidence within apps
Improved continuity of care
Portable information
Improved health outcomes
Early diagnostic capability
Evidence-based healthcare accessible to all 24 hourly
Surveys
Case reports
Qualitative studies
Expert opinion
Anecdotal opinion
From undertaking Activities 17.3 and 17.4, you will have recognised that integrating
telehealthcare within your nursing practice requires different clinical skills and
approaches to care. The following practice recommendations can be made:
• Practitioners must assess the suitability of telehealthcare to manage healthcare
needs on an individual basis.
• The use of telecommunications is feasible for the motivation and management of
patients with long-term conditions, and can be cost-effective and reliable.
• Telehealthcare is feasible and acceptable for educating patients, monitoring and
assessing clinical outcomes.
• Telehealthcare is more meaningful to service users if delivered by specialised
nurses and prescribers.
• More complex systems such as web-based medical records and permanent
healthcare professional support can achieve significant benefits in improving
clinical outcomes.
• Effective management and improved clinical outcomes in the management of
long-term conditions involves medicines management.
Professional and ethical issues of eHealth can all be directly mapped to the
Nursing and Midwifery Council’s (NMC, 2015a) Code: Professional Standards of
Practice and Behaviour for Nurses and Midwives, and in particular to the following
clauses:
2.2 Recognise and respect the contribution that people can make to their
own health and well-being
3.3 Act in partnership with those receiving care, helping them to access
relevant health and social care, information and support when they need it
5.2 Make sure that people are informed about how and why information is
used and shared by those who will be providing care
5.5 Share with people, their families and their carers, as far as the law allows,
the information they want or need to know about their health, care and
ongoing treatment sensitively and in a way they can understand
10.1 Complete all records at the time or as soon as possible after an event,
recording if the notes are written some time after the event
10.4 Attribute any entries you make in any paper or electronic records to
yourself, making sure they are clearly written, dated and timed, and do not
include unnecessary abbreviations, jargon or speculation
13.5 Complete the necessary training before carrying out a new role.
21.6 Co-operate with the media only when it is appropriate to do so, and then
always protecting the confidentiality and dignity of people receiving treatment
or care
In reality, many of the professional and ethical issues are not different from other
areas of nursing practice, but because of the evolving nature of eHealth the issues
are perceived to be more challenging to address.
While undertaking Activity 17.5, many professional and ethical issues will have
been identified. You may also have considered the following issues.
Professional and Ethical Issues 353
Access to information
Assessment of individuals, families, carers and communities as identified in
Chapters 1, 7, 8 and 9 is a core skill in community nursing to address healthcare
needs. However, often the first assessment of a change in health status is not
undertaken by a health professional, but by the individual. In 2006, the Picker
Institute estimated that a third of the 80% of people actively accessing information
about their health first do it through the Internet. Ten years later in 2016, 89% of
households have Internet access; 82% of adults access the Internet on a daily basis;
and 70% of adults access the Internet on a mobile phone (Office for National Statistics,
2016). While the use of technology is perceived by many to be a generational issue
for both healthcare professionals and service users, one must be careful not to
make assumptions on this. Institute for the Future (2016) in their international poll
identified that 79% of people 55 years and over regarded technology as important to
improve healthcare, compared to 69% of those aged 18–34.
Information is most often accessed via a search engine on the Internet. Although
there are many benefits to this, such as quicker access to information, there is the
danger that service users can access incorrect information or it can be of variable
quality (Aveyard et al., 2016). However, the NHS in the United Kingdom provides
much credible information to the public via the Internet promoted through media
campaigns. For example, NHS Inform online allows users to check their symptoms
online and provides advice accordingly, and similarly there are many mobile apps
which provide access to health information. This technology is changing the balance of
power between health professional and the public. However, it provides nurses with the
opportunity to empower and enable people (National Information Board, 2014), which
has always been a key concept within nursing practice (NMC, 2001, 2004, 2015a).
Decision making
When an individual chooses to consult with a community nurse or is referred to
a community nurse, eHealth can play a supportive role in the decision-making
process of the assessment. Clinical decision support systems can be utilised for
this purpose (Stacey et al., 2017). Increasingly, these clinical decision systems are
being integrated with electronic patient records or are applications that can be
354 eHealth
downloaded onto tablets, mobile phones and potentially smart watches and are
therefore a useful tool for the community nurse, who is often working in people’s
homes. However, as with all expert systems, they should be seen as tools and not as
a replacement to clinical judgement.
Social media
The use of social media is another development within ehealth. Social media
tools include social networking platforms such as Twitter and Facebook,
blogs, microblogs, wikis, virtual reality and gaming environments. There are
many different uses of social media tools from the patient’s, the carer’s and the
professional’s perspective. Social media can be used in the promotion of health,
and support of those with long-term conditions and their carers, as well as
practitioners using them to keep up to date and share the latest evidence (Moorley
and Chinn, 2014).
As a professional, it is essential that you are aware of professional and personal
boundaries within online practices. The NMC (2015b) has produced additional
guidance which underpins The Code (NMC, 2015a) that it is essential you are aware
of. A term that has been emerging in recent years is digital professionalism that
supports the professional/personal boundaries when engaging online. Ellaway
(2010: 706) identified seven principles of digital professionalism:
Professional and Ethical Issues 355
Establish and sustain an online professional presence that befits your
responsibilities while representing your interests. Be selective in which
channels and places you establish a profile.
Think carefully and critically about how what you say or do will be perceived
by others and act with appropriate restraint in online communications.
Think carefully and critically about how what you say or do reflects on
others, both individuals and organisations, and act accordingly.
Think carefully and critically about how what you say or do will be perceived
in years to come; consider every action online as permanent.
www.nhsemployers.org/case-studies-and-resources/2012/02/case-
studies-five-high-impact-actionswww.skillsforhealth.org.uk/services/
item/16-realtime-rostering
Please access a selected case study or reflect on a case example from your
own area. What are the challenges of implementing electronic packages to
support rostering, caseload management and workforce planning? What are
the advantages?
It is clear from considering the above that the professional and ethical issues
in the use of eHealth are similar to other areas of nursing practice and many
of the skills are transferable. However, the focus can be different and there is
a need to develop new approaches and additional knowledge to use eHealth
efficiently and effectively to address healthcare needs in the community.
Outcome: 1 2 3 Evidence
1. Demonstrate understanding of how and why
information technology is able to support clinical
practice and ways of working.
2. Demonstrate understanding of how electronic health
records are used in your practice.
3. Demonstrate understanding of assessment tools used
to assess the use of telecare as a nursing intervention.
4. Demonstrate understanding of the key NHS national
initiatives to support eRostering.
5. Describe the principles of digital professionalism.
CONCLUSION
This chapter has provided an overview of eHealth considering some of the key
terminology. The suitability of its use has been briefly explored within community
nursing and some of the associated professional and ethical issues have been
highlighted. It is recognised that eHealth is not just about technology, it is about using
technology more effectively to address healthcare needs. Although eHealth is becoming
an integral part of government policy, applying the principles in practice can be a
challenge, and it is therefore essential that healthcare professionals are provided with
appropriate education and training to prepare them for the development of eHealth.
FURTHER RESOURCES
www.ehealthnurses.org.uk – Health Nurses Network
http://sctt.org.uk – Scottish Centre for Telehealth and Telecare
https://digital.nhs.uk – NHS Digital
http://www.ehealth.nhs.scot/ – eHealth
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358 eHealth
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360 eHealth
18 Development of community
nursing in the context
of changing times
Anne Smith and Debbie Brown
LEARNING OUTCOMES
• Identify the key policy drivers that impact on delivering effective healthcare.
• Examine the new roles and ways of working that are emerging in response.
• Analyse personal skills development that may enable practitioners to
contribute more effectively.
• Explore the impact of enhanced skills such as non-medical prescribing on the
delivery of services.
INTRODUCTION
It is important to have a working understanding of health policy in order to
contextualise the changes that are occurring in commissioning, managing and
delivering community services. The four nations of the United Kingdom are
responsible for managing their own National Health Service (NHS) services
(The Health Foundation and Nuffield Trust, 2014). This is achieved in different
ways according to the priorities set by each one, but the principles are common
to all. There is a commitment across the four nations to integrate primary and
secondary care provision, aiming for a smoother transition for patients between
the two, but more importantly trying to reduce hospitalisation by anticipating
potential problems and providing support services to prevent admission. There
is an increasing emphasis on public health, health promotion and self-care. It
is recognised that with the changing demographics in the population, with life
expectancy now extended, services must be reconfigured to respond. A higher
percentage of the population is now living with long-term conditions or terminal
illnesses, increasing the challenges on health and social care services. The nations
face similar issues trying to devise a workable framework on which to base their
service delivery. These will be explored further within this chapter.
Since its inception, the NHS has been a service free to all, but there has been a
conceptual shift away from illness orientation and paternalism to a more egalitarian
approach, with the user taking interest and responsibility for making decisions
362 Development of community nursing in the context of changing times
about their care. The language has changed from that of ‘patient’, suggesting
dependency, to that of ‘client’, ‘consumer’ or ‘service user’, all of which suggest
a partnership approach (Hinchliff et al., 2008). The ‘Expert Patient’ programmes
(DH, 2001) were a catalyst for this shift of emphasis. These programmes were
designed to enable people to become more confident in making educated decisions
about their condition and their care. This approach continues to be a central
tenet of the government’s ideal (DH, 2012a) reflected in publications such as ‘No
Decision about Me without Me’ (DH, 2012b).
This chapter first briefly examines the ways in which healthcare is managed
by the devolved governments of the United Kingdom. The Conservative
Government returned to power in 2015 and are keen to progress with reforms
initiated prior to the General Election. Practitioners will be required to respond
in real time to changing needs employing scarce resources more productively.
The whole infrastructure of primary care will change dramatically according
to the latest projections (NHS England, 2014a, 2016a). While there is a dearth
of general practitioners (GPs) to deliver care, new roles are being designed and
training put in place. There is a radical change required to manage the changing
demography and changing health needs of the population as we move forwards
to 2020 and beyond. Community nursing services are central to the management
of the health needs of an ageing population within primary care. One of the
considerations within this chapter is to examine how the four countries have
equipped themselves to undertake this task.
Scotland
In Scotland, there has also been progress in responding to the primary care
agenda in relation to managing the demands placed upon it from the increasing
number of older people in the population. Projections made in 2013, indicated
that over the next 20 years demography alone could increase expenditure on
366 Development of community nursing in the context of changing times
health and social care by over 70% (Scottish Government, 2013). Social care
has been free in Scotland since 2002. This has huge implications as the elderly
population increases, because the financial burden of such a policy could well
become unsustainable. The emphasis continues to be focused on integration of
services, which became a reality in April 2016, and on anticipatory care rather
than reactive treatment options. Scotland has the same issues to contend with
as the other countries in devolving budgets from acute care to community. The
publication of a national clinical strategy in 2016 (Scottish Government, 2016)
has provided a strategic paradigm that builds on the 2020 vision outlined in 2013.
The Route Map 2020 (Scottish Government, 2013) was a visionary document that
focused on proactive care aimed at keeping people healthy. It also acknowledged
that invariably primary care professionals are pivotal to enabling individuals with
health challenges and long-term conditions to maintain their health. Its principles
include enabling people to live at home in a fully supported environment. Scotland
has a particular issue associated with delivering care because of the remote and
rural distribution of their client group.
Major strategies have also been developed, for example, to assist with caring for
patients with dementia, as estimates suggest that the number of people with dementia
is set to rise from 71,000 to 127,000 within the next 20 years (Scottish Government,
2013). This is set against the background of the modernisation programme which
commenced with the introduction of the Modernisation Community Nursing Board
in December 2009 (RCN, 2010). The board’s main aim was to provide a more cohesive
approach to the delivery of community services across Scotland. The ‘Remote and
Rural Healthcare Action Plan’ (Scottish Government, 2008) identified that 79% of
the Scottish population live in remote or rural locations and life expectancy in these
areas is the third worst in Scotland. The Scottish Government commissioned the
development of a toolkit to support the work of the Modernisation Board. They
have continued with the vertical integration of services first conceived 15 years
ago and which culminated in implementation in April 2016 (Scottish Government,
2016). The CNO for Nursing and Midwifery has undertaken an educational review
and set out six strategic aims with an implementation programme and action plan
for nursing (Scottish Government, 2014b). This provided an educational bridging
between the career framework (NES, 2012) and the route map to a 2020 vision
(Scottish Government, 2013). The latter provides a futuristic perspective of how
nursing can contribute to the strategic vision for health and social care. More
recently a career framework has been published that determines developmental
paths for all specialisms (NHS Education for Scotland, 2016).
Initiatives that have already been developed working towards this vision
include the Intermediate Care framework (Scottish Government, 2012) which
contributes to the idea that care is geared towards offering solutions other than
hospital admission. The Reshaping Care for Older People Programme 2011–21
provides a jointly compiled framework (Scottish Government, 2011) whose
central aim is to focus their approach around personalised outcomes for older
people rather than to fit them into the service. It also seeks to be more creative
Key Policy Drivers That Impact on Delivering Effective Healthcare 367
when examining the support network available to older people. The Change
Fund has been established to make this possible and to support preventative and
anticipatory care.
In order to initiate the changes the eHealth strategy is a critical element and
the investment in this will be the catalyst for the other changes to be effective.
The eHealth Strategy 2011–17 (NHS Scotland, 2011) is progressing well with
development of the patient identifier, more sharing of patient information between
professionals and better organisation and access to NHS 24 and OOH facilities. It
has since been refreshed and updated which according to the Scottish Government
aims to develop ‘an interoperable and clinically rich eHealth ecosystem’ (Scottish
Government, 2014a: 5). The Integrated Resource Framework (IFR) (NHS Scotland,
2012) is responsible for monitoring the costs and activities associated with this. In
2014 the Health and Social Care information sharing strategy framework (Scottish
Government, 2014a) was published projecting activity until 2020. This acknowledges
and seeks to overcome perceived barriers to the integration of care that may arise
from the lack of a cohesive IT strategy to aid communication.
All the themes discussed above related to providing a streamlined and cost-
effective service have been examined further within the National Clinical Strategy
(Scottish Government, 2016). It sets strategic aims rather than describing the detail
of how services will be adapted to achieve the outcomes. These aims encompass all
the considerations with regard to providing care that is proportionate and relevant
for the individual. Integrated care became a reality in April 2016. A fundamental
aspect of such a strategy is more timely discharge linked to providing a more
responsive approach in primary care.
Wales
The Welsh Government has taken a radical approach by removing the ‘internal
market’ and implementing an integrated organisational structure. The detail
concerning this was set out in Setting the Direction (WAG, 2010: 6). The reorgani
sation took place in 2009, creating seven single health organisations responsible for
all aspects of healthcare in their area. The purpose of this strategy was to improve
the delivery of community-based services in Wales by adopting a more integrated
approach between the sectors that offer support. Interestingly, a primary principle
of this strategy is to encourage ‘citizens’ to ‘develop confidence in their ability to
manage their own health’. ‘Together for Health’ (WAG, 2011) outlined the challenges
to be overcome in Wales in order to provide a world-class service and set a 5-year
action plan in place. ‘Prudent Health care’ (WAG, 2015) is a more recent initiative
adopted by Welsh Government to endeavour to prevent over diagnosis and medical
management of people. It is based on similar principles to the 2010 strategy. It is
a term harnessed by Welsh Government defining an approach to healthcare that
highlights the importance of demand management and involving the public in healthy
behaviours and self-management of their health, rather than over management by
health professionals. It advocates using a ‘nudge’ principle to motivate individuals
368 Development of community nursing in the context of changing times
Northern Ireland
Health and social care in Northern Ireland are more integrated than in the
other countries of the United Kingdom. Responsibility for healthcare has been
devolved from central government at Westminster to the Northern Ireland
Assembly. However it is difficult to draw analogies or seek to replicate their
approach as the situation in Northern Ireland is unlike the other UK countries,
in its demography and geography. It is also unique in that since 2009 there has
been only one commissioning body for the whole province (Ham et al., 2013).
The basic principles associated with NHS care delivery remain the same, but
across Northern Ireland it is suggested that there is inconsistency around how it
is interpreted. Another fundamental issue that has to be addressed is the fact that
Social Services consider themselves the poor relation with regard to providing
an integrated approach to care. Their perspective is that it is not a marriage of
equal partners. Coupled with the view that financial investment continues to be
poured into the acute sector there is still some way to go in providing integrated
community care (Sprinks, 2015).
Community nursing services came under the spotlight in June 2011 with the
publication of a consultation document reviewing the District Nursing Service
(Department of Health Social Services and Public Safety) (DHSSPSNI, 2011a).
Key Policy Drivers That Impact on Delivering Effective Healthcare 369
Key messages that emerged from this related to the pivotal role of the district nurse
in providing person-centred care in the community. The document advised that
care management must include a proactive and anticipatory approach rather than
a reactive one. The need to move funding across to community services from the
hospital sector was highlighted and a model of ‘outreach’ and ‘in reach’ suggested
(p. 55). This was further supported by the intention for district nurses to facilitate
discharge planning and thus enable a more seamless approach to patient care. It
also identified that patients with long-term conditions would benefit from a care
management approach (p. 52).
The number of DNs in the workforce has dropped from 7% to 6% since 2010. In
line with the national picture, there has been much disillusionment across the DN
service with the current staff shortages but there is also optimism as the DHSSPS have
increased the numbers of DN training places, and DNs are becoming more involved
in the strategic development of the service. Currently, work is being undertaken to
review the DN services in Northern Ireland.
During the past 5 years, other documents have been influential in shaping services
with a common theme of moving care away from hospitals and also with the intention
to move budgets. Transforming Your Care (TYC) (DHSSPSNI, 2011b) otherwise
known as the Compton Review identified key changes in the arrangements for care
provision including the establishment of Integrated Care Partnerships (ICPs) but the
Health and Social Care Trusts have not demonstrated consistency in their approach
towards implementation. Age UK NI published a report in 2014 which argued that
people were being assessed differently according to where they lived and which
Health and Social Care Trust they resided within. In 2015 the departments of Health
and Justice published a joint document regarding the safeguarding of adults at risk
which will also have implications for community teams and the population they
serve (DHSSPS and Department of Justice [DOJ], 2015).
The TYC document focused on providing care for an ageing population but NI
has not been able to transfer services from hospital to community. A first contact
single assessment tool (NISAT) has been developed to enable any member of the
integrated care team to undertake a first assessment and share that information
with other members of the team (Regulation and Quality Improvement Authority,
2012). While the tool has many benefits, it is however unwieldy in practice and
not always available electronically. In some areas further nursing assessments
have been developed by community nurses, therefore inconsistency in practices is
evident. DNs are working with commissioners and colleagues from across primary
care to implement the vision of TYC. This is evident from the use of an electronic
caseload analysis tool (eCAT) which examines individual caseloads and allows for
comparison of these (Yarra Software, 2010). This tool has since been piloted by a
community team in England with a view to implementation (Bhardwa, 2015).
The Northern Ireland Practice and Education Council (NIPEC, 2015) has
published its Annual Business Plan for 2015/16. Their mission is to provide a
‘beacon’ of good practice to aid nurse and midwife development in order that safe
and effective care can be delivered across the Province. Key priority 2D in this report
370 Development of community nursing in the context of changing times
demonstrates their commitment to work with the NMC and QNI in developing
educational standards for Specialist District Nursing programmes that truly reflect
the complexity of the DN role. This is a comprehensive and timely document.
Digital solutions such as telehealth are becoming more widely available although,
not surprisingly, these have not been embraced and used to their full potential by DNs.
The development of the caseload and workload analysis tools and the single assessment
document are reliant on communication technology which was a theme highlighted
in the Donaldson Report (DHSSPS and DOJ, 2015). The report took an overview of
the whole of NHS delivery in Northern Ireland and concluded that there needed to be
a culture change across the whole organisation. It focused on serious case reviews but
the recommendations were concerned with standardisation of best practice across all
areas, citing examples from other regions where this approach has had a favourable
impact. The report also highlighted the need for the implementation of robust and
joined up IT systems which had been found lacking to date. This is a recurring theme
across the United Kingdom in respect of community nursing where further investment
is needed to provide nurses with the technology to support their role.
All four countries recognise the benefits of shifting the balance of care from
the acute sector to the community. While there are differing opinions on how
to develop health services, all the nations are challenged with the same issues
associated with the changing demographics of the population. People are living
longer, but associated with this is the potential for ill health and compromised
quality of life. It is clear that one approach to coping with the increased demand
on services is to proactively seek out and support the highest users of services.
However, in tandem with this there is the need to actively promote a healthy
lifestyle for individuals, families and communities.
Example 18.1
In south London, health and social services are providing a co-ordinated approach
to enable older people to remain in their homes with extra assessment and support.
Southwark and Lambeth Integrated Care is a partnership that spans the Foundation
hospitals, GP practices and social care agencies. They make use of technology to
enhance communication both with the clients and colleagues within the team. They
are able to rapidly access specialist advice and they also have support from voluntary
agencies such as Age UK (Benison, 2015).
Audit and community (or practice) profiling are useful tools with which to examine
the uptake and the success of services, as previously discussed in Chapters 1 and 7.
In order to provide cost-effective, appropriate care, audit and evaluation are essential
(Jack and Holt, 2008). Without such data it is difficult to justify changing services.
Historically, the community nursing workforce have not been actively promoting
their expertise or publishing good practice which makes it difficult to appraise the
evidence. Front-line practitioners should be proactively involved in this process, and
should be contributing to the decision on changes. The QNI (2010) has cautioned that
nurses may well end up as merely the ‘passengers’ as the governmental reforms take
place. However, there are opportunities for staff to contribute to the agenda. Burke
and Sheldon (2010) describe the benefits of using such information-gathering models
as the ‘World Café’ model. This is an exercise organised at local or national level in
which groups of practitioners meet in a relaxed café-style environment in order to
network and share ideas about new ways of working and innovative approaches.
This model was utilised to explore the ‘Transforming Community Services’ (TCS)
initiative in England (DH, 2011), a programme with a variety of work streams
examining the Quality Innovation, Productivity and Prevention agenda (QUIPP). This
calls for practitioners to be personally equipped with the skills to engage with the
vision which aims to transform services in the community in several key areas.
The whole idea of nurses being at the forefront of service redesign can seem
daunting but with enthusiasm and tenacity it can be achieved.
Example 18.2
An excellent example is provided by two nurses who worked in general practice.
When both GPs left their surgery simultaneously and they were unable to recruit
to the vacancies, the nurses decided to tender to run the surgery. Nine years later,
they have just moved into new premises as their enterprise has been so successful,
372 Development of community nursing in the context of changing times
demonstrated by the fact that they received an outstanding result in their CQC visit
(Bhardwa, 2014). The concept of new business approaches such as creating a social
enterprise is alien to many nurses. Rather than being viewed as passengers (QNI,
2010), the community nursing workforce remains central to the implementation of
these far-reaching reforms.
It is pertinent to explore other factors that will determine the efficiency of the
community workforce. The chief executive of the NHS has pointed out (NHS
England, 2014a) that we are being confronted with an ‘information revolution’ that
will affect our lives just as significantly as the agricultural and industrial revolutions
did in their time. The use of technology to support nurses to work more effectively
has been promoted for a long time, but organisations have been slow to engage with
the concept or the opportunities. There are fundamental barriers to be overcome
such as poor Internet connections. However, in the future practitioners will be
reliant on mobile devices to access notes and communicate when the majority of
their work is done in isolation.
‘Agile working’ is a term adopted by various organisations to describe the use
of a flexible approach to working (enei, 2013: 3) They define it as ‘based on the
concept that work is an activity we do, rather than a place we go’. Increasingly
the community workforce has abandoned the regular morning meetings for work
allocation and has taken to working remotely. In this way, caseload and workload
management have moved from the traditional allocation style. District nursing
historically has been managed in a fragmented way and there has been a dearth of
research to inform practice. However, the QNI have recently provided a report for
the Department of Health (NHSE/QNI, 2014) that explores how a more robust
system may be implemented that will ultimately assist commissioners of services to
definitively measure the workload pressures associated with delivering services and
to allocate resources appropriately.
Another emerging model is provided by the private sector. Since the Labour
Government initiated the idea of competitive tendering for some primary care
services in 2004, organisations such as Virgin Care have been entering the
marketplace. The delivery of care by these alternative providers of medical services
is centred on a business model driven by profit margins. Greaves et al. (2015)
examined the impact of these organisations and found they performed poorly in
comparison with the traditional GP service. This was partly due to the fact that
they mostly served a non-traditional population. While they were able to provide
a more flexible service with extended opening hours, for example, they were more
likely to refer clients on to secondary care services. Greaves et al. (2015) suggest
that when profit is a driver then the contact is important but the outcome is often
influenced by moving the patient on rather than seeking a treatment option. They
caution against the competitive market being introduced. This business model does
not always sit comfortably alongside the values instilled in nurses associated with
the 6Cs (DH/NHS, 2012) such as compassion, which are not possible to measure.
The more aesthetic values encompassed by the 6Cs provide a benchmark for good
nursing care, but the time needed to give quality care is not always appreciated by
providers driven by targets of numbers treated. In 2016, a national framework with
10 ‘commitments’ was published as a guide for all nursing, midwifery and care staff
374 Development of community nursing in the context of changing times
(NHS England, 2016b). It discussed the ‘triple aim measures’ highlighted in the
Five Years Forward View (2014a) and incorporated these themes with the 6Cs to
provide a framework that encouraged all levels of staff to work towards providing
the best experiences for patients while within the constraints of finite resources.
It also reinforced the need for a whole population approach to enabling people to
enhance their health and well-being.
Example 18.3
It is interesting to examine an international perspective such as the model provided
by Buurtzorg Nederland (2011) which is a unique district nursing system and
entirely nurse-led and cost effective. Buurtzorg is Dutch for ‘Neighbourhood Care’.
The King’s Fund in its analysis of Buurtzorg (2013) has reached a similar conclusion.
While extolling the model’s virtues, it recognises that Buurtzorg’s approach ‘may
not be right for all health systems but it highlights the potential benefits of taking a
fresh look at professional roles.’ The RCN in 2016 has also observed and critiqued
the approach. It has candidly discussed the merits but is cautious about the
transference of such a system to a country with a different healthcare economy
and other significant issues. However, Buurtzorg is being piloted in several centres
in the United Kingdom (RCN, 2016).
It is described as patient centred with highly skilled staff who offer a compassionate,
innovative and synergistic approach to care. Jos de Blok and three other
entrepreneurial nurses first created this concept in the Netherlands in 2006. They
developed their own enterprise centred on a mission to provide holistic patient-
centred care for their clients within their own homes. The Buurtzorg nurse acts as
‘a navigator’ for the patient and family, advising on innovative solutions to receiving
the best care at home. This model has the potential to be replicated into primary
care, enabling teams of healthcare workers to offer support for patients within
a locality by navigating the patients’ journey with other professionals. They are
empowered and autonomous and their approach has been replicated and adopted
across other countries such as Sweden, Japan and the United States.While the costs
per hour are greater, fewer hours have been needed for care in total. Buurtzorg has
accomplished a 50% reduction in hours of care, improved quality of care and raised
work satisfaction for their employees.
ACTIVITY 18.4 Before you consider the next section on personal skills that you bring to
the workforce, reflect on your personal strengths by doing a short exercise
that assesses your personality type. Find the Myers Briggs Inventory at
www.16personalities.com/free-personality-test and see what type of personal
attributes you have.
CONCLUSION
The NHS and primary care continue to undergo radical change. The Francis
Report (DH, 2013) has influenced policy and practice as all the countries of the
United Kingdom have responded by tightening their governance arrangements and
providing transparency regarding their systems. The use of IT has the capacity to
transform processes and care management although as yet this has not achieved
its full potential. Professional nursing organisations are campaigning throughout
the UK nations to ensure that standards of care are not compromised by the new
agenda. All the countries of the United Kingdom are examining and promoting the
district nurse and general practice nurse roles; these specialist generalists are seen
as the lynchpin of the integrated team. Community nurses must ensure that they
are involved in the decisions about how services will be developed at the strategic
level. The future is going to involve working across community and acute care to
offer a more seamless service. Integrated teams will be a critical factor in managing
the complex needs of the ageing population. It is imperative that practitioners
prepare to assert themselves as key members of the team, demonstrating the range
of skills that they bring to contribute to the emerging landscape.
FURTHER READING
It is important to be familiar with any new government document that impacts on service
delivery. The reference list contains many references to recent publications concerned
with shaping services in primary care.
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INDEX
Abbreviated Mental Test Score (AMTS), 152 need, concept of, 137 CCN, see Community children’s nursing
ABCDE approach, 226–229 new roles, 138–141 CCNCS, see Community Client Need
Access, information technology, 353 nursing models, 135–136 Classification System
Accountability patient-centred, 133–134 CEPN, see Community Educational
collaborative working, 209 in public health, 32–34 Provider Network
and leadership, 298 and review: end-of-life care (EoLC), CETHV, see Council for the Education and
ACP, see Advance care planning 274–277 Training of Health Visitors
Active learning, in workplace, 323–324 shared/single, 144 Change
Acute care, 219 workload, 301, 302 behavioural, 36–37, 251–252
ABCDE approach, 226–229 Asset-based approach, 35, 37 and development, 361–362
airway, 229–230 Audit, 371 key policy drivers, 362–370
breathing, 230–232 Audit Commission, 294, 302, 345–346 new agenda, 376–378
case study, 222 Autonomy new ways of working, 370–372
circulation, 232–234 Human Rights Act (1998), 54 skills, 374–376
communication strategies to manage, professional, 46 social enterprise, 372–374
237–240 respect for, 51 and leadership, 375
conceptual framework, 221 Children
deteriorating patients, 225 Behaviour change, 36–37, 251–252 consent, 52–53
disability, 234–235 Beneficence, 51 families and, 116–117
exacerbation of chronic conditions, Bereavement care and process, 282–284 risk management, 81–83
223–225 Biomedical influences over lifespan, CHOICE, see Connecting Health and Social
exposure, 235–236 112–114 Care to Offer Individualised Care at
‘hospital at home’ services, 220 Bio-psychosocial-spiritual concept, 135 End of Life
minor injuries and minor illness, 220 BNF, see British National Formulary Chronic obstructive pulmonary disease
nursing assessment in, 226 Boundaries (COPD), 111, 159, 224
pharmacological knowledge and between professions, 48 CIDS, see Community Information Data
interventions, 239–241 therapeutic relationship, 90, 100 Sets
red flags, 236 Breathing, acute care, 230–232 Clinical commissioning groups (CCGs),
Adolescents/young people, 81–83, 117–118 British National Formulary (BNF), 377 363, 364
Adult carers, 169–172 Buurtzorg model, 300 CMHN, see Community mental health
Adulthood, psychosocial impacts of, 97 nursing
Advance care planning (ACP), 273 Caldicott Principles, 56 CNLDs, see Community nurses for people
Ageing Capillary refill time (CRT), 233 with learning disabilities
population, 165 Care Act, 81 Cognitive behavioural therapy (CBT),
psychosocial impacts of, 122–125 Care Quality Commission (CQC), 261, 155
Age issues (carers), 163–164 324, 363 Collaborative working, 200, See also End-
Agencies (voluntary, charitable, statutory Carers of-life care
and public), 176–177 definition, 163 attitudes, 213–215
Airway, acute care, 229–230 family, 98–100 case study, 208
AMTS, see Abbreviated Mental Test Score impact of caring, 166–172 concept and definition, 203
Assessment adult and young carers, 169–172 factors, 205–208
community needs, 4, 7–9 financial and emotional impact, interface, 208–211
conceptual aspects, 138 167–169 long-term conditions, 255
decision-making support, 172–177, 278 models and theories of, 203–206
case study, 142–143 agencies, 176–177 political drivers, 200–203
context, 142–143 areas of community nursing, 172–176 skills, 212–213
critical reflection on, 141–142 Carers Allowance, 167 virtual ward concept, 255
frameworks, 144 Carers UK, 98, 163, 165 Communication
definition, 133 Caseload management, 300–311 collaborative working, 53, 212, 213
frameworks, 136–137 Case management, in long-term conditions, with patients, end-of-life care (EoLC),
holistic, 135 253 271–273
assessment tools, 139 Cassandra Matrix workload activity tool, skills, lifespan approach, 125–126
and intervention: spirituality, 188–191 307 Community
meaning of, 132–133 CBT, see Cognitive behavioural therapy definitions, 1–4
mental health, 149–155 CCGs, see Clinical commissioning groups development, 32
Index 385
healthcare eHealth, 342, 344 identification, 270–274
complex nature of, 10–12 end-of-life care (EoLC), 269, 271 last days of life, 280–282
future vision, 18–19 Expert Patient Programme, 102 service delivery, 279–280
matrons, 370–371 long-term conditions, 246, 253, 260 England, key policy drivers, 362–365
needs, identification and assessment, 7–9 organization and management of care, 296 England Safety Thermometer, 80
profiling, 8, 371 professional issues, 60 Entrepreneurs, 372, 373
Community children’s nursing (CCN), 13–14 public health, 28 EoLC, see End-of-life care
Community Client Need Classification risk management, 75 EPP, see Expert Patient Programme
System (CCNCS), 305, 308 spirituality, 186 Equality Act, 122, 126
Community Educational Provider Network Department of Health Social Services and Ethical issues, 51–52
(CEPN), 377 Public Safety (DHSSPSNI), 368 eHealth, 351–356
Community Information Data Sets (CIDS), Depression, 78, 150 Evidence base, 350–351
310 definitions, 151 Evidence-based practice, 49, 102
Community Links, 4 management of, 155 Expert Patient Programme (EPP), 102
Community mental health nursing signs and symptoms of, 151 Extended roles, 49
(CMHN), 14–15 DH, see Department of Health
Community nurses for people with learning DHSSPSNI, see Department of Health Falls, 79–81
disabilities (CNLDs), 14 Social Services and Public Safety Families, and children, 116–117
Co-morbid mental health problems, Diagnostic and Statistical Manual of Mental Family carers, 98–100
148–150 Disorders, 4th edition (DSM–IV) Family Health System (FHS), 135
Competence diagnostic system, 150 Family Planning Association campaign, 116
long-term conditions (LTCs), 262–263 District nurses (DNs), 16–18, 290, 294 FHS, see Family Health System
and spirituality, 194–197 District Nursing Education and Practice, Financial impact (carers), 167–169
Connecting Health and Social Care to Offer 186 Five Years Forward View (FYFV), 201–202,
Individualised Care at End of Life DNACPR, see Do Not Attempt 362, 364
(CHOICE), 334 Cardiopulmonary Resuscitation ‘Followership’, 375
Consent DNs, see District nurses FYFV, see Five Years Forward View
children, 52–53 Domiciliary Scheduling in the Community
end-of-life care (EoLC), 273 (DominiC), 306, 309 GCS, see Glasgow Coma Scale
informed, 52–53 DominiC, see Domiciliary Scheduling in the Gender issues, 126–127
Continued professional development Community General Medical Council (GMC) code of
(CPD), 241 Do Not Attempt Cardiopulmonary practice, 55
COPD, see Chronic obstructive pulmonary Resuscitation (DNACPR), 281 General practice (GP)
disease Dress code/uniform, 95 electronic records, 344
Council for the Education and Training of Dying without Dignity investigations, 270 nursing, 15
Health Visitors (CETHV), 16 General Practitioners (GPs), 2, 362
CPD, see Continued professional eCat, see Electronic Caseload Assessment acute care, 220
development Tool attachment vs geographical/corporate
CQC, see Care Quality Commission Education/learning caseloads, 311
CRT, see Capillary refill time information technology (eHealth), Genograms, 191
Cultural competence, 39–40 356–357 Gillick competency, 53
professional, 47 Glasgow Coma Scale (GCS), 235
Data Protection Act (1998), 55 service user role, 61–62 GMC code of practice, see General Medical
Decision-making eHealth, 343, 348, 349, See also information Council code of practice
clinical and professional, 297 technology (IT) Gold Standards Framework (GSF), 270–271,
information technology (IT), 353–354 Electronic Caseload Assessment Tool 275–277
professional, 49 (eCat), 305, 308–309 ‘Good death’, definition, 268
shared, 144 Electronic Palliative Care Co-ordination Grieving process, 284
Delegation/prioritization, 292, 293 System, 277 Growth and development theories,
Dementia, 79, 123 Electronic patient records, 344 110–112
Department for Children, Schools and Emotional impact (carers), 167–169 GSF, see Gold Standards Framework
Families, 81 End-of-life care (EoLC), 267–268
Department of Health (DH), 2, 147, aims, 268 HCAs, see Healthcare assistants
See also National Service ‘good death’, definition, 268 Health and nursing informatics, 343–344
Frameworks government strategy, 269–270 Health and social care, 200–202
acute care, 220, 240 pathway, 270–284 model, 250
assessment, 132, 134 assessment and review, 274–277 Health Belief Model, 117, 120, 251
carers, 171 bereavement, 282–284 Healthcare assistants (HCAs), 364
change and development, 364, 365, 372, co-ordination, 277–279 Health, definitions and concepts, 5, 25–26,
373, 375 Gold Standards Framework (GSF), 115
collaborative working, 201, 202, 209 275–277 Health Education England (HEE), 296, 299
386 Index
Health Foundation, The, 134 LCP, see Liverpool Care Pathway Mental health services
Health Improvement Efficiency Access Leadership assessment, 149–155
Treatment (HEAT), 324 and accountability, 298 collaborative working, 158–159
Health inequalities, 6, 31–32 and change, 375 interventions, 155–158
Health map, 5 development, 336–337 physical health vs., 148–149
Health promotion, 34–38, 115–116 Leading Better Care (LBC), 337 psychological wellbeing, 148
Health visiting (HV), 16, 294, 295, 301 Leading quality person-centred care reflection, 159
HEAT, see Health Improvement Efficiency change models, 332–333 mHealth, 346–347
Access Treatment clinical governance, 319–320 Middle age and work life, 119–121
HEE, see Health Education England conceptual model of, 329 Motivational interviewing (MI), 155–
Home visits, 69–71 contextual factors, 331–332 157, 252
House of care model, 274, 275 evidence, 329–331 Multi-Specialty Provider Model (MCP), 363
Human Rights Act (1998), 54 facilitation, 332, 333
HV, see Health visiting leadership development, 336–337 National Association of Primary Care
measuring quality, 324–325 (NAPC), 363
ICN code of ethics, see International paradigm leadership models, 326–328 National Council for Palliative Care
Council of Nurses code of ethics practice development, 318, 319, 321–322, (NCPC), 268
Identification 333–336 National Dementia Strategy, 152
community needs, 7–9 quality improvement, 325–326 National Health Service (NHS), 28, 201,
end-of-life care (EoLC), 270–274 workplace cultures, 322–324 224, 319, 361
risk management, 72–73 Lifelong Learning UK, 3 Board’s Local Delivery Plan, 324
IFR, see Integrated Resource Framework Lifespan approach Education for Scotland, 337
Independent prescribing, 241 biomedical influences, 112–114 Scotland Improvement Priorities, 325
Information technology (IT) growth and development theories, National Health Service (NHS)
access to information, 353 110–112 Constitution, 122
access to services, 354 psychosocial influences, 114–127 National Institute for Health and Care
care organization records, 308 utilizing, 111–113 Excellence (NICE), 79, 80, 91, 151,
decision making, 353–354 Liverpool Care Pathway (LCP), 280, 282 153–154, 248, 261, 268, 282, 335
education, 356–357 Local area, knowledge of, 69 National Nursing Research Unit (NNRU),
eRostering and workforce planning, Local information sources, 9 11
355–356 Long-term conditions (LTCs) National Occupational Standards in
evidence base, 350–351 behaviour change, 251–252 Community Development Work,
mHealth and mCare, 346–347 case management, 253 3, 32
opportunities and challenges, 349 collaborative working, 255 National Patient Safety Agency, 73, 74
professional and ethical issues, definition, 245 National Service Frameworks (NSFs), 10, 15
351–356 developing competence in, 262–263 National Statistics Socio-Economic
social media, 354–355 exacerbation of, 223 Classification (NS-SEC), 31–32
uses, 349 family unit, 257–258 NCPC, see National Council for Palliative
Informed consent, 52–53 impact of, 120–121 Care
Integrated Resource Framework (IFR), 367 motivational interviewing, 252 NHS, see National Health Service
Integrity, collaborative working, 210 new roles, 263 NHS Constitution, see National Health
Inter-generational communication, 125 person-centred perspective and Service Constitution
Intermediate Care framework, 366 responses, 248–249 NHS Direct/NHS, 376
International Council of Nurses (ICN) code policy drivers and government strategy, NHS Education for Scotland, 299
of ethics, 186 246–248 NHS Employers, 296, 297
self-care and self-management, NHS health costs, 168
Johari window, 194, 195 249–251 NHS Positive Practice Guide, 248
Justice principle, 51 supporting young people with, NICE, see National Institute for Health and
258–261 Care Excellence
King’s Fund, 17, 50, 57, 77, 133, 149, 202 younger people and, 256 NIPEC, see Northern Ireland Practice and
‘Knowing the patient’, 53, 292 LTCs, see Long-term conditions Education Council
Knowledge NMC, see Nursing and Midwifery Council
collaborative working, 211 Macmillan nurses, 209 NNRU, see National Nursing Research Unit
local area, 69 Marmot Review, 6 Non-maleficence, 51
pharmacological, 239–241 MCA, see Mental Capacity Act Northern Ireland, key policy drivers,
Knowledge and Skills Framework (KSF), mCare, 346–347 368–370
299 MCP, see Multi-Specialty Provider Model Northern Ireland Practice and Education
KSF, see Knowledge and Skills Framework Medical model of health, 47 Council (NIPEC), 369–370
Mental Capacity Act (2005), 52, NS-SEC, see National Statistics Socio-
Laming, Lord, 55, 212, 291 153, 211, 274 Economic Classification
LBC, see Leading Better Care Mental health issues, 76–78 Nurse entrepreneurs, 373
Index 387
Nursing and Midwifery Council (NMC), PHSO, see Parliamentary and Health Service Remote and Rural Healthcare Action Plan,
55, 62, 298 Ombudsman 366
accountability, 298 Physical health vs mental health, 148–149 Risk management
acute care, 225, 227 Plan-Do-Study-Act (PDSA), 336 adults, 76
assessment, 133, 141 Policy drivers/government strategies, car safety, 71
code of practice, 55, 186, 352, 354 See also Department of Health children and young people, 81–83
collaborative working, 209 change and development, 362–370 home visits, 69–71
long-term conditions, 254 end-of-life care (EoLC), 269–270 knowledge of local area, 69
prescribing, 377 long-term conditions, 246–248 mental health issues, 76–78
register, 13, 16 Political drivers/government strategies, older people, 78–79
risk management, 74 200–203 organizational support, 72
therapeutic relationship, 90, 92, 100 PQRST, see Palliative/provoking, quality, patient
Nursing assessment, in acute care, 226 radiation, severity, timing identification, 75–76
Practice-based commissioning (PBC), 363 raising concerns, 74–75
Occupational health nurses (OHNs), 13 Practice development, 319, 321–322 safety, 74, 211
OHNs, see Occupational health nurses Prescribing, 240–241, 254, 377 personal safety, 69
Older people Primary Care Act, 201 principles, 72
dementia, 76 Primary Care Development Unit, 248 principles of, 72
risk management, 78–79 Primary care navigator (PCN), 363 vulnerable groups, 71, 76
Organizational support, 72 Prioritization/delegation, 292, 293 Roles/skills, 10, 291–293
Organization and management of care, Professional approaches substitution vs extended, 49
289–291 case study, 45 Royal College of Nursing (RCN), 13, 75,
delivery, 291–297 codes of practice, 54–58 133, 135, 183, 185–187, 189, 220–
new roles, 291 critique, 56 221, 294, 344–345, 356, 364, 373
prioritization/delegation, 292, 293 decision-making, 49–51, 297
referral criteria, 292–294 eHealth, 351–356 Safety thermometer (ST), 80
service provision, influence of primary hallmarks of practice, 58 SBAR, see Situation, background,
care nurses, 309–311 informed consent, 52–53 assessment, recommendation
service review, principles and methods, partnership model, 58–60, 134, 139 School nursing, 16, 290, 291
302 practice principles, 49–52 Scotland, key policy drivers, 365–367
skills mix, roles and responsibilities, service user involvement and role, Scottish Community Workload
297–300 60–62 Measurement Tool (SCWMT), 306
Organization for Economic Co-operation traditional model, 46–49, 63 Scottish Executive (SE)/Government (SG),
and Development (OECD), 27 trust, 56–58 1, 132, 342, 343
values, 53–54 Scottish Patients at Risk of Readmission
Palliative/provoking, quality, radiation, Professions, characteristics of, 46 (SPARRA), 76
severity, timing (PQRST), 226, 227 Profiling, 8, 302, 303, 371 SCWMT, see Scottish Community
PARIHS, see Promoting Action on Research Promoting Action on Research Workload Measurement Tool
Implementation in Health Services Implementation in Health Services SDRN, see Sustainable Development
Parliamentary and Health Service (PARIHS), 329–330 Research Network
Ombudsman (PHSO), 270 Psychological responses to diagnosis, Self-awareness, 191–194
Participatory Rapid Appraisal, 9 248–249 Self-care and self-management, 249–251
Partnership working, 59–60, 134, 139 Psychosocial influences over lifespan, Self Care Forum, 249
Patient-centredness, 133–134 114–127 Service delivery
Patient-focused approach, 173 Public health end-of-life care (EoLC), 279–280
Patient perspective, 296 applying theory to nursing practice, factors influencing, 4–7
PBC, see Practice-based commissioning 40–41 Service users, involvement and role, 60–61
PDSA, see Plan-Do-Study-Act assessment, 32–34 Sexual health, 118
Person- and family-centred healthcare, cultural awareness, 39–40 Sexually transmitted infection (STI), 116
90–91 definition and concepts, 28–30 Shared decision-making framework, 144
Person-centred care health promotion, 34–38, 115–116 Sheffield Community Caseload
focus on, 12–18 screening, 39 Classification System, 307
leading quality, see Leading quality Situation, background, assessment,
person-centred care QNI, see Queen’s Nursing Institute recommendation (SBAR), 237
Person-centred communication, 125 QNI/QNIS voluntary standards, 186 Six Senses Framework, 153
Person-centredness, 320–321 Quality Outcomes Framework, 324–325 Skills for Health (SFH), 28, 299
Person-centred perspective, 248–251 Queen’s Nursing Institute (QNI), 17, 93, Social determinants of health, 27–28
PESTELI model of change management, 294, 364, 365, 370, 371 Social enterprise, 32–374
375–376 Social model of health, 48
Pharmacological knowledge and RCN, see Royal College of Nursing Social workers, 210
interventions, 239–241 Referral criteria, 292–294 SOCRATES, 238
388 Index
Solution-focused therapy, 157 Telehealth, 344–346 West Hertfordshire Activity and Time
SPARRA, see Scottish Patients at Risk of Telehealthcare, 347–349 Dependency Tool (WHATT), 304
Readmission Therapeutic relationships WHATT, see West Hertfordshire Activity
SPCIT, see Supportive and Palliative Care boundaries, maintenance and failure to and Time Dependency Tool
Indicator Tool maintain, 90, 99–102 WHO, see World Health Organization
Spirituality challenges of developing, 92–99 ‘5 whys’ model of change management,
assessment and intervention, 188–191 current and future context, 102–103 375
community context, 185–187 features, 89–92 Workforce management, 300–311
definition, 184–185 location of care, 92–96 Work life, middle age and, 119–121
literature review and research, 182–184 nature of care, 95 Workload
nursing competence and, 194–197 patient issues, 96–99 assessment, 301, 302
self-awareness, 191–194 Transforming Community Services (TCS), management
Spirituality and Spiritual Care Rating Scale 158, 291, 371 Buurtzorg model, 300
(SSCRS), 183 Transforming Your Care (TYC), 369 overview of, 304–307
SSCRS, see Spirituality and Spiritual Care Trust, 56–58, 210 Workplace cultures, 322–324
Rating Scale TYC, see Transforming Your Care ‘World Café’ model of information
ST, see Safety thermometer gathering, 371
Stages of Change model, 252 UKCC, see United Kingdom Central World Health Organization (WHO), 97
Stepped-care model, 156 Council collaborative working, 202, 208
STPs, see Sustainability and Transformation UK-wide Health Service, 166 definitions
Plans Uniform/dress code, 95 falls, 79
Strengths-based approach, 37–38 United Kingdom Central Council health, 25
Supplementary prescribing, 241 (UKCC), 12 health promotion, 34
Supportive and Palliative Care Indicator eHealth, 343
Tool (SPCIT), 271 Values, professional, 53–54 health, 115
Support, organizational, 72 Virtual ward concept, 255–256 mental health, 147
Sustainability and Transformation plans Voluntary Standards for District Nurse pain relief ladder, 239, 240
(STPs), 2 Education and Practice, 149
Sustainable Development Research Network Young carers, 169–172
(SDRN), 26 Wales Audit Commission, 368 Young people/adolescents, 81–83, 117–118
Wales, key policy drivers, 367–368 Young people, with long-term conditions
TCS, see Transforming Community Warrington Workload tool, 304 emotional needs, 259–260
Services Well-being, concept of, 26–27, information and support, 260–261
Telecare, 345–346 34–38 physical needs, 259
Telecare Services Association, 345 Welsh Assembly, 1 transition to adult services, 261