Community Health Nursing

New ways of working

Rapid changes have occurred within the NHS since the return of the Labour government to power in 1997. This commenced with The New NHS: Modern, Dependable (DOH 1997) and has  been consolidated in The NHS Plan (DOH 2000a). Health and social policy have provided the driver for change and health care professionals have been required to respond. Clinical governance and quality issues (see DOH 1999d) have impacted on the organisation of the health service and the delivery of services. The aim of this chapter is to consider the effect of these changes. The focus of the discussion will be an analysis of how they have affected community care, and the new ways of working required to accommodate them.


Previously the NHS has been service-led, with an authoritarian, ‘top–down’ approach. The medical model of health care has predominated (Burke 2001). In recent years there has been a paradigm shift in the underpinning philosophy of care delivery, and the focus is now on providing a patient-centred service based on local need (DOH 2000a), which is identified through exercises such as community profiling. There has been a conceptual shift away from illness orientation to health promotion (Naidoo and Wills 2000). There is a greater focus on the social aspects of people’s lives that may affect their health. The individual, whilst being consulted over services, is also being expected to take some responsibility for his/her own health. However, it is recognised that health promotion strategies need to be targeted beyond the individual’s behaviour, as the health of the general public is affected by many factors over which they have no personal control: for example, global warming and air pollution.

The government’s commitment to supporting healthy living initiatives is demonstrated through the introduction of services such as smoking cessation clinics (DOH 1999b). This particular initiative has been placed within the remit of health visitors,district nurses and practice nurses. Their autonomy in this area has been further recognised by their being permitted to prescribe the relevant nicotine replacement therapy for the patients involved. Evidence suggests that this activity is one of the most influential health-promoting activities, and provides a measurable impact on health.The National Institute for Clinical Excellence has published guidelines to endorse this (2002). One example of a simple but effective innovation is described by Roberts (2002), who, in consultations, used three key questions to determine patients’ readiness to give up smoking.The answers given by the patient indicate whether they are definitely resolved, or are considering ‘quitting’ but require more support to do so. This then enables the practitioner to arrange a suitable follow-up appointment to provide that support.

The new agenda is being directed by publications such as The NHS Plan (DOH 2000a) and Shifting the Balance of Power (DOH 2001a), which have evolved from The NHS: Modern, Dependable (1997). It will be influenced further by the forecasted demographic trends over the next 20 years – trends that have been substantiated in the 2001 census. This identified a greater proportion of the population being over the age of 60 than under 16 for the first time. The implications of this fact are enormous, together with the evidence that suggests that a quarter of the health care accessed during a person’s life is accessed during the final years (Wanless 2001).

The infrastructure of the NHS has been radically altered. Primary care trusts (PCTs) have now emerged as the main provider of services. Revenue released from the Department of Health gives PCTs control of 75 per cent of the total health budget (DOH 2002b). Services are being delivered in innovative ways: for example, walk-in centres, NHS Direct. PCTs are now commissioning services at a local level, sensitive to the specific needs of their communities (DOH 2002b). Personal medical services (PMS) demonstrate this concept, and walk-in centres provide quick and effective access for clients, especially those who, because they are working full-time, may have found surgery hours prohibitive.

These initiatives have also led to an expansion of nurse-led services, and the timely extension of nurse prescribing has enhanced nurses’ contributions to this target. Other examples of innovations have been in operation over a longer period of time. ‘Intermediate care’ (DOH 2001b) is well established in many communities and offers a service that reduces pressure on acute beds, whilst meeting the needs of clients more effectively than previous arrangements, which were less flexible. This has provided the opportunity for targeting local problems with the appropriate services, building on previous initiatives evidenced by health action zones (HAZ) and health improvement programmes (HIPs) (DOH 1997). More recent publications (e.g. DOH 2002c) provide guidance on the priorities that local organisations are required to consider when planning future developments in community services. The main theme of this document echoes the underlying philosophy of service delivery in acknowledging the perspectives of all parties involved, including the patient. The public health agenda has also been emphasised, as each PCT is required to have a public health professional on the board. This emphasis is further demonstrated by the development of roles for health care professionals that are concerned with promoting public health.Within some community specialist nursing disciplines this has engendered a new conceptual base to the provision of services, particularly significant within the realms of school nursing and health visiting. Historically the school nursing service has been responsible for duties that have mimicked a medical model of care concerned with the completion of school medicals and health screening and surveillance. This image is swiftly changing, following the publication of School Nursing: A National Framework for Practice (CPHVA 2000),which identifies the school nurse as a dynamic member of the multi-disciplinary team, more involved than previously in issues of health promotion and education. A clear example of such innovation has been provided in Liberating the Talents (DOH 2002a), in which a school nurse describes her development of a profiling tool that identifies health and social issues within the school population so that these can be targeted to improve health.

It is increasingly obvious that the way that health care is delivered has been influenced by a shift in focus and this is common to all community disciplines. The practitioner’s role is increasingly evolving as one with political and ethical dimensions. One clear example of the public’s behaviour being affected by the media and their own interpretation of risk has been demonstrated through the MMR (measles, mumps and rubella) vaccination debate. Clinical staff were in a prime position to offer advice and influence behaviours. The health consequences resulting from the non-uptake of this vaccine were not clearly defined and therefore the public may not have been fully informed as to the implications of their decisions.The outcome has been that now there are unvaccinated infants susceptible to contracting these communicable diseases and the ‘herd’ immunity relied upon to control them is lost (Lewendon and Maconachie 2002). The public health issues underpinning this debate and the public health dimension that has become an expectation within every professional’s remit will be explored further in Chapter 9.

Currently practitioners are trying to understand and manage transition. New roles have been created, job descriptions reconfigured and employees are reorientating to their new responsibilities within the emerging structures. These events have taken place against a backdrop of quality enhancement and clinical governance (DOH 1999d). There is a focus on measuring and justifying the delivery of services whilst ensuring that the patient’s perspective is sought and documented (DOH 2002c). For those engaged in delivering services and providing continuity of care whilst all the reorganisation is occurring there is a sense of unease and instability. These behaviours can be clearly related to Tuckman’s (1965) model of group life in which the group of individuals pass through several stages of ‘forming’ and ‘storming’
prior to settling into any type of team formation that is able to perform effectively.

However, it is an environment that can provide opportunities for those who feel enabled. Other practitioners may resist change by raising barriers to prevent any development being successful. These issues will be considered later, and coping strategies discussed.

Other major influences on the delivery of care are the monitoring procedures established to measure performance and the penalties incurred for failing to achieve targets. The National Institute for Clinical Excellence and the Commission for Health Improvement are both involved with ensuring quality in health care delivery underpinned by the implementation of research and evidence-based practice.

One key element of the new approach to the delivery of health care has been the emphasis on widening access. The changing perception therefore relates to both patients and staff as new initiatives are operationalised. The intention is that patients see a health service that is responding more appropriately to individual need and staff are increasingly aware that the provision of care is becoming more patient focused.

The new public health agenda has a strong emphasis on involving, inspiring and supporting local communities to undertake projects in which they, the public, propose and lead the changes (James and Barker 2001). It may be useful to view this concept in relation to the principles of ‘social marketing theory’, first described by Kotler and Zaltman (1971, cited in Lefebvre 1992 ). Lefebvre’s (1992) definition states that social marketing is ‘a method of empowering people to be totally involved and responsible for their wellbeing: a problem-solving process that may suggest new and innovative ways to attack health and social problems. It is not social control.’ The principles are adapted from a business base but have relevance to the introduction of health promoting behaviours from a micro and a macro perspective.


Central to the notion of patient-centred care is the fact that a new approach is necessary. The structure of the whole organisation has been radically altered to facilitate this. Care cannot be delivered in a vacuum so the devolving of decision making and commissioning to localities should assist in the provision of services sensitive to local need (DOH 2002b).

However, these policy initiatives cannot be introduced without a consideration of the staff who will be implementing them. Many of the changes have already caused confusion as new roles have been established and new services developed. Sometimes this has been done without considering the services already in place. Poole (2002) advocates that real working in primary care necessitates an understanding of the complex issues involved. The nature of the work concerns investing in
relationships and dealing with people who do not function in a predictable way like machines. Consequently staff must also adapt to the situations in which they find themselves and be aware of the loss of control that might be experienced. The authoritative or ‘top–down’ model of health care delivery has been succeeded by a more democratic, negotiated model. Poole offers some practical strategies for coping. She suggests that those delivering the services should invest time in developing relationships rather than focusing on roles and functions. Other essential considerations are flexibility in structuring working practice and, underpinning this, a sound communication system.

Community nurses are central to the delivery of the change process. The clinical governance agenda strongly influences working practice, with audit being an important component of practice. The nurses’ contribution to the development of a ‘new NHS’ was documented in Making a Difference (DOH 1999a). This publication outlined the leadership qualities necessary to manage a swiftly changing service and initiated programmes such as the LEO (leading empowered organisations) programme to prepare nurses for their pivotal role (Garland, Smith and Faugier 2002).

A culture shift has also been experienced as budgets were amalgamated between health and social services. This was to promote the provision of a seamless service and to encourage integrated working, necessitating the removal of professional boundaries. One practical example of the Department of Health’s commitment to such initiatives is the ‘Single Assessment Process’ outlined in National Service Framework for the Older Person (DOH 2001b). This has required professionals to co-operate in new ways to deliver appropriate care. Wild (2002) comments that a truly person-centred approach will only be achieved when professional boundaries have been dissolved.

Public service management styles require to be analysed in order to understand the philosophy underpinning the change of emphasis. The evolution of PCTs has ensured that the hierarchical and bureaucratic structures formally associated with health service management are becoming flatter and more democratic, with decisions being taken by those who are closer to the point of delivery and more aware of the outcomes.

The NHS bears little resemblance to the organisation it was even a decade ago. Confusion persists over the new structural components and role definitions. Job titles appear creative and expansive as boundaries and expectations have not been clearly identified. ‘Skill mix’ has become a term encompassing innovative strategies to develop members of the workforce to enable them to offer support in a variety of ways; for example receptionists who are also trained as phlebotomists and ECG (electrocardiogram) technicians. Localities operate in very different ways, and moving from one area to another can provide a culture shock in itself. The sense of change in theorganisational culture is devolved to a very personal level. However, the reorganisation of community care is a constant feature throughout. The drivers
for change are also similar, but the interpretation of how the agenda will be met may vary enormously according to the location in which the care is delivered.


The NHS Plan (DOH 2000a) has outlined a 10-year plan of investment and reform in order to modernise the NHS. The workforce is central to that plan. As previously noted, the NHS must acknowledge that a culture shift is required. Bureaucratic management concentrating on service provision dictated by resource allocation is no longer acceptable. A dynamic and flexible approach is advocated, which places the emphasis on patient participation in decision making. This approach must be transparent, and a variety of options have been developed to facilitate this.

The introduction of local patient forums and the formation of patient advisory liaison services (PALS) indicate that the public are being consulted (Chapman 2002). Collaborative working must be embraced in its widest sense – to include the recipient of care. Further evidence of the government’s commitment is clearly demonstrated by the introduction of the white paper The Expert Patient (DOH 2001c). Whilst acknowledging that many patients with chronic diseases have a more indepth knowledge of the personal management of their particular condition than the professional, it also conveys the message that patients are able to be more independent if encouraged to take control of the management. This relates to the theory described by Rotter (1954) concerning ‘locus of control’. It is also aligned to the concept prevalent in the government documents that the patient should remain in control of the decisions about their health and treatment.

Health promotion strategies to prevent the onset of chronic diseases such as coronary heart disease and diabetes are also advocated. Again the government’s commitment to this has been demonstrated by the publication of national service frameworks, for example DOH 2000c and 2001b, which prescribe standards, respectively, for the care of individuals suffering from coronary heart disease, and for the care of older patients, in order to provide equity of care throughout the country. Integral to these frameworks are initiatives concerned with providing both primary and secondary prevention. An example of responding with a team approach is quoted by Fairhead (2003), who describes how a community mental health nurse worked alongside a practice nurse to develop her expertise in managing patients with depression. The general practitioners and patients gave a very positive response, when surveyed, to the resulting improvement in services.

New ways of working are emerging in response to the demographic influences within the workforce. The shortage of nurses is already apparent, and is set to get worse, particularly as the profile of community nurses indicates an ageing population. The problem was identified in 1999 (DOH 1999a) and a response by the government was to provide more training places. However this was not sufficient to resolve the problem. Other solutions have been considered, various of them initiated by the document A Health Service for All Talents (DOH 2000b). Cadet schemes have been reinstated. Further incentives have been provided for those workers (health care assistants) with NVQ qualifications to undertake more in-depth training. These schemes are supported by their employers and delivered in the workplace environment whilst they continue with their employment. This has several advantages in that the workforce is not depleted whilst the care assistants are training and they continue to receive a salary whilst extending their knowledge and skills. Once trained, their employment status will be enhanced to that of ‘assistant practitioners’. They will also qualify academically with a foundation degree (Greater Manchester Workforce Development Confederation 2002). The intention is to initiate a ‘skills escalator’, which practitioners will be able to ‘step on’ and ‘step off’, to provide flexible learning and training, accessible to all individuals at all grades (DOH 2003).

The government has pledged its commitment to initiatives to educate the workforce and support lifelong learning for all sectors of the workforce, and such initiatives as this demonstrate the commitment. Flexible working is further enhanced by ‘familyfriendly policies’ advocated in such documents as Improving Working Lives (DOH 2002d) The emphasis is on recruiting and retaining staff by offering working hours that complement domestic responsibilities.

As previously discussed, the different community disciplines are challenged by a variety of demands according to their roles, although some issues are common to all. This is considered within specialist practitioner degree courses. All community nursing professionals are educated within a core course which includes a specialist element to reflect their specific discipline. This demonstrates the value placed on all these professionals’ contributions to the primary health care team in fulfilling the health improvement agenda.

The NHS Plan (DOH 2000a) placed great emphasis on the development of integrated teams and this was to include practice nurses, who historically have been set apart from their community nursing colleagues due to their employment contracts with GPs. In many instances these arrangements are changing following the formation of PCTs.

New ways of working and managing care are continually being influenced by advances in technology and the health service’s attempt to embrace them. Examples of such influences are the increasing use of telemedicine and the computerisation of patient records. The improvement in communication provided by these systems with their ability to transfer information, particularly between hospitals, laboratories and surgeries has an impact on patient care.


The community environment is changing beyond recognition and there is a requirement for practitioners to change their ways of working to manage it. Practice development can be achieved in many different ways and the success of it depends on the management of change. As previously stated, examples of innovative schemes have been published in the document Liberating the Talents (DOH 2002a). This publication describes creative ways in which health care can be delivered,
acknowledging the fact that 90 per cent of patient journeys involve a contact in primary care (O’Dowd 2002).

Unsworth (2001) contends that within the NHS professionals are expected to plan and implement change in practice, often with very little support. Business organisations meanwhile will import experts to manage the change process. These approaches to managing change refer to ‘external’ or ‘internal’ change agents (Broome 1998).

However, change management is a complex process for which practitioners need adequate preparation. The requirement for preparation was clearly identified in Making a Difference (DOH 1999a) and reinforced in the recommendations of The NHS Plan (DOH 2000a), in which nurses were proposed as the main implementers of the new agenda in practice. A national nursing leadership project, initiated by the Department of Health, is providing training for those considered best placed to move practice forward, advocating an empowering approach.Well established in this area is the LEO (Leading an Empowered Organisation) programme (Garland, Smith and Faugier 2002).

The Department of Health has invested in a variety of measures to ensure that leadership training is devolved to all levels of staff, since leadership qualities do not necessarily only exist within those staff in positions of seniority. Clinical ‘change agents’ do not need to be team leaders but any practitioner who is supported to change practice.

Certain approaches need to be considered if change is going to be effective and smoothly implemented. A primary consideration is that of planning the change and providing a sound rationale for the need to change. If this is clearly articulated and agreed by the team members the chances of success are more likely.

The nature of current change is that it is government-led and -driven, which means that it is difficult for the practitioner to see the need for change or take responsibility for it. This often leads to resistance and hostility. It is vital to consider the perceived benefits of change. SWOT analysis is a useful exercise that will help practitioners do this (Adams 2000). It involves compiling a list of statements that identify the effects of the change under four headings: strengths, weaknesses,
opportunities and threats. It must be remembered that the type of change mainly associated with the new arrangements is ‘imposed change’, often unplanned and swiftly introduced, and with those people who will be most affected are not being consulted over the best means of implementation. Unless SWOT analysis shows obvious benefits to all concerned, practitioners will continue to lack enthusiasm and motivation.

It is clear that change cannot be effectively managed unless certain procedures are followed to identify the need for it: for example, audit, research, reflection, SWOT analysis (Adams 2000). These provide the evidence for change, after which planning the change process must be undertaken. If the ideas of those who will be involved are incorporated, or their comments sought, they are more likely to support rather than resist the change. ‘Planned change’ is generally better received and more likely to succeed than ‘unplanned change’ (Broome 1998).

It is worthwhile pausing here to consider the components of change management theory discussed by Lewin (1951), as these underpin any strategy that may be devised to manage change in the working environment. Lewin describes a threestage approach: unfreezing, moving (or changing) and refreezing. The unfreezing stage concerns recognising that a change is necessary. This need may be identified through reflective practice or examining research that promotes different ways of
working. The change requires planning in order to achieve the proposed outcomes. Finally, once the change has been implemented refreezing occurs as the new practice is adopted. As with any new initiatives there will be those who are motivated to change and those who are cynical and less keen; enthusiasts ready to accept and implement change; but equally ‘laggards’, who are difficult to convince. Managing these ‘laggards’ is the real challenge, and the leadership style of the person who is facilitating the change is relevant to success. Styles of leadership vary according to the character of the individual and their position in the organisation. The above is an extremely simplified explanation of the change management process. In reality, the successful implementation of a change in practice is a complex task.

Mulhall’s text (1999) examines various theoretical perspectives. Ultimately however, the culture of the practice environment has a strong determining
influence on whether the change is effectively introduced and adopted. Therefore practice development is the remit of all staff, and to achieve success in this area requires an inclusive approach, in which everyone feels they can contribute.


It is necessary and indeed the responsibility of all NHS employees, in order to meet the demands placed upon them, to become involved in providing a service that sets the patient at the centre. It is also important that health professionals are responsive to the feedback offered by the patient (Hollins 2002). If the targets of the NSFs are to be met, practice innovation and new ways of working are required in which individuals are empowered to be self-supporting in taking responsibility for their personal health and wellbeing and that of their community. Models of community health practice (Chalmers and Kristajanson 1989) and practice development can provide a framework for this activity.

The community nurse’s role is multi-faceted and the approach must be adaptable in order to respond to the variety of caring, supportive, or pro-active
roles that she may be required to adopt in this diverse area. The Chief Nursing Officer summed up the diverse roles of primary health care practitioners when briefing PCT lead nurses: It isn’t just what you do that matters, it is also how you work that is important – putting the patient and community first, empowering front line staff and working in partnership across health and social care. (Mullally 2002)

Community Health Nursing

Setting the scene: an introduction

These are exciting and challenging times for community nurses. Liberating the Talents (DOH 2002) provides a framework for the expansion ofclinical roles and calls for greater freedom to encourage creativity. This book has been designed to support staff who may be new to working in acommunity setting and is an essential guide to practice. We envisage it will be useful for community staff nurses and nurses moving from an acute work environment to take up a community post. These ‘front-line’ nurses might be working in any of the following disciplines: occupational health nursing, health visiting, community children’s nursing, community learning disability nursing, community psychiatric nursing, school nursing, district nursing and general practice nursing. Such nurses are not only responsible for personal care of patients and for a range of clinical interventions, but also for the assessment of health needs, planning, delivery and evaluation of direct care for individuals and groups of patients. In addition, they may be responsible for mentoring students, and directing and supervising the work of support workers. The aim of the book is to develop and support a practitioner so she can function safely and effectively in a range of primary care/community settings. The authors take an inclusive approach, working from a health and social needs perspective and demonstrating the involvement of patients, professionals and non-professionals. A range of topics relating to professional issues in community nursing is addressed. The text reflects recent and current government health and social care policy reforms and the effect of these on the roles and responsibilities of community nurses. Community nursing is seen in the context of political, social and environmental influences. Interpersonal and practical skills, as well as the knowledge base required by community nurses, are critically analysed and linked to relevant theory. Examples and exercises relating to the range of community disciplines are included throughout the book to stimulate the reader’s creative thinking. Topics covered include new ways of working, nursing in a community environment, personal safety, therapeutic relationships, working collaboratively, conceptual approaches to care, professional issues in community nursing, public health and health promotion.


The economic crisis of the 1970s led to the first real major reforms in the National Health Service (NHS). The centralisation of administrative power led to dissatisfaction amongst NHS employees. In 1976 the Resource Allocation Working Party reviewed the allocation of funds and began the move away from the focus upon London hospitals. The then government advocated a change of balance in services, emphasizing the need to prioritise older people, people with learning disabilities and the mentally ill (DHSS 1977). The importance of strengthening service provision within the community was clearly stated. In 1979 Margaret Thatcher’s Conservative government was elected to power. The Conservative election manifesto made no statement relating to health policy.

With underpinning values of efficiency savings and cost improvement, the NHS in the early 1980s was bureaucratic and seriously underfunded (Lawton et al. 2000). In 1982, Roy Griffiths, a successful manager but with limited experience of health care management, was charged with the review of the management of the NHS. It was widely thought by the government that poor management was behind the failings of the HealthService.

In the published report (1984) Griffiths proposed the introduction of general managers, who, in his view, would be able to lead services more cost-effectively. It was intended that key members of the disciplines they managed would professionally advise these managers. For the nursing profession this meant that line managers were no longer experienced nurses, which caused concern relating to professional issues and to the representation of community nursing views in policy making and community planning (Thornton 1995).

The introduction of general managers was followed in 1991 by internal market reforms. This step was intended to improve services by introducing competition and a purchaser–provider split. In theory, purchasers would ‘shop around’ for the best deal. General practice (GP) fund-holders were allocated an annual sum of money to buy a defined range of services for patients. The mixed economy of health care was intended to restrain the bureaucracy of the ‘nanny state’ and increase input from voluntary and private organisations (Pierson 1998). The result was an increase in the amount of time and effort spent liaising with a great number of people, but it did also create opportunities for flexibility.

In May 1997 a large majority elected the Labour government to power under the leadership of Tony Blair – signalling the end of the long Conservative hold on government. Frank Dobson led a well prepared team into the Department of Health. Policies began to be issued almost immediately (Hyde 2001). A key feature of the health policies of this Labour government was that they were ‘joined up’ with those of education and employment. In documents such as Saving Lives: Our Healthier Nation (DOH 1999), links between health and issues such as poverty, housing and employment were acknowledged. Nurses, who daily witness the effects of these links, welcomed this approach. The Labour government continued the work begun by the Conservative administration in shifting the balance of care delivery into the primary care sector, to create a primary care-led NHS.Within 9 months of Labour gaining office, The New NHS: Modern, Dependable (DOH 1997), a 10-year plan for health, had been published. This heralded the introduction of health improvement programmes (HIPs) and the development of primary care groups (PCGs) into primary care trusts (PCTs), which are, in effect, based around clusters of general practice surgeries. A major radical reform of the NHS was in prospect.

PCTs were fully established in England by April 2002. The equivalent bodies in Scotland are also called primary care trusts; in Wales they are known as local health boards; in Northern Ireland as local health and social care groups (Savage 2003).PCTs are responsible for assessing, planning and delivering health services, improving the health of the defined population, and working towards the proposed public health agenda (DOH 1999). They work collaboratively with local partners, such as Social Services, and the local community. Working alongside the PCTs, on a contractual basis, are the NHS trusts. The role of the health authorities has changed significantly: the recently formed strategic health authorities are larger organisations than the previous authorities, and provide overall management for both PCTs and NHS trusts. The equivalent organizations in other parts of the UK are: in Scotland, unified health boards; in Wales, health authorities; and, in Northern Ireland, health and social services boards (Savage 2003).

Alongside these structural changes, government policy focused on the needs of patients and their carers, and advocated patient participation in care (DOH 2001a). A First Class Service: Quality in the New NHS (DOH 1998) considered the quality of services offered, and launched clinical governance as a new framework for ensuring efficient and effective care within the NHS. Nurses were, on the whole, more receptive to the idea than their medical colleagues, who have traditionally monitored themselves. Many community nurses have taken the lead in issues of clinical governance. Quality is high on the agenda, and various structures are in place to ensure the optimum standards, including national service frameworks (NSFs),the National Institute for Clinical Excellence (NICE), and the Commission for Health Care Audit and Inspection (DOH 2000). In July 2000 the government published The NHS Plan, which sets the agenda for health care services centred on the patient and tailored to the patient’s needs. The onus is on PCTs to implement national guidelines to meet the needs of their respective local communities. The PCTs form the hub of the new NHS and are politically and financially powerful. Nurse representatives appointed to PCT boards need to be assertive, astute, have effective leadership skills and a clear vision of the future for community nursing.


The NHS Plan (DOH 2000) committed to the extension of nursing roles in all settings. The development of such initiatives as rapid response, intermediate care, early discharge and nurse-led clinics offer challenges and opportunities for community nurses. In 2001 the Department of Health published a report, Shifting the Balance of Power, which set out a programme of change designed to empower patients and the workforce to deliver this ambitious plan.

Politicians recognise the enormity of the task set before people and acknowledge that a huge cultural shift is necessary together with effective communication at all levels of the NHS organization. Effective implementation of clinical governance is pivotal to the development of innovative community nursing practice and different ways of working.After more than 50 years of domination by the acute, specialist, hospital-based service, these changes are radical. Liberating the Talents (DOH 2002) calls for a transference of power to the front-line staff and – even more radically – to patients. There does seem to be a real attempt to change the status quo. So, it would appear that, after decades of being the Cinderella service, community health care has now gained a pivotal position in the NHS.

Community care and community nursing are by no means new phenomena. Looking back over time, health care has been delivered in various ways and in a wide range of locations. The actual setting in which care occurs is directly influenced by the predominant form of health care at that time. This, in turn, develops as a result of the wider societal influences of the day (Tinson 1995).

Community nurses work in a great variety of settings – clinics, health centres, people’s homes, schools, workplaces and private homes. Additionally, they work with different groups of people. For example, school nurses tend to focus upon children and adolescents and occupational health nurses care for a specified workforce. Some community nurses may care for all age groups, but spend much of their time with a particular subgroup. The majority of district nurse visits tend to be to older people (Audit Commission 1999). Community nurses work together with other team members. Collaboration and team working are essential for effective patient care. These issues are addressed in Chapter 6.


The United Kingdom has been described as an ageing society, in which the number of people over the age of 80 years is set to increase by almost half as many again by 2025 and the number of people over 90 years of age is predicted to double (DOHb 2001). The needs of older people and their carers are often complex, and assessment of these requires a high level of knowledge and skill (Ryder 1997). Effective community care depends on the coordination and integration of health and social care. To ensure that appropriate and effective health and social care is available for those older people who become frail or ill will become one of the community services’ greatest challenges. It is equally important to acknowledge the great potential older people have to contribute towards communities and to encourage their participation in designing and developing services. There are, of course, other groups of people who need to be considered carefully. It is important not to stereotype individuals, but planning to meet the needs of people with common characteristics can produce very effective initiatives. Good examples of these can be found in the government’s ‘Sure Start’ strategy (DOE 1998).

A tool, which may be of great help in assessment of local needs, is a community profile. This can aid the identification of health needs and should involve the general public’s viewpoint. Professional groups and less formal agencies may work together to produce a health needs assessment to assist in prioritising. These important issues are addressed in more detail in Chapters 3 and 10.


Policy directives and patient choice, amongst other factors, have led to the development today of a primary care-focused NHS. According to Clarke (1999), community specialist practitioners work with individuals, families and communities towards the achievement of independence. Community nurses work within a network of complex processes in particular localities – not just in a different context from their colleagues in institutional or acute care settings. Community nursing involves much more than a change of location. From an exploration of the literature, it soon becomes apparent that the term ‘community’ itself is extremely difficult to define, as it can be interpreted in a variety of ways. Three commonly identified elements associated with ‘community’ are locality, solidarity and significance. In beginning to grasp the dynamic nature of a community, we must embrace all three elements and gain insight into the complex social relationships that exist between people, families and the community as they experience health and illness (Clarke 1999).

Community nursing is a fairly unique area of practice, embracing a philosophy of care that relates to primary, secondary and tertiary prevention, to a wide range of different interventions, and to health education (McMurray 1993). The ‘client’ can be an individual, family or community. Advanced clinical skills are required to fulfil the role of community specialist practitioner, including highly developed interpersonal skills, critical thinking, decision making, creative management and leadership, and a high degree of self-awareness (Clarke 1999). Each member of the community nursing team provides a valuable contribution to the delivery of high-quality effective care.

Nurses are now delivering care in a variety of different ways within the community, and new initiatives within primary care include walk-in centres and nurse-led personal medical services (PMS). Nurses are increasingly becoming the ‘gatekeepers’ of health services in the community. In general practice, the patient’s first point of contact is often a nurse. As their roles develop in response to the current NHS reforms, community nurses are required to expand their repertoire of skills and expertise. Earlier hospital discharges and more sophisticated treatment regimes mean that nurses are engaged in more technical and complex packages of care. ‘Hospital at home’ services, often co-ordinated by community specialist practitioners and their team, provide early hospital discharge for specific groups of patients – for example, those recovering from orthopaedic surgery. Many community hospitals provide respite care in nurse-led beds and ‘rapid response’ teams prevent hospital admissions, for example, for chest infections and stroke (Thomas 2000).

‘Intermediate care’ refers to ‘that range of services designed to facilitate transition from hospital to home, and from medical dependence to functional independence, where the objectives of care are not primarily medical, the patient’s discharge destination is anticipated and a clinical outcome of recovery (or restoration of health) is desired’ (Steiner and Vaughan 1997). Wade and Lees (2002) suggest that now is an ideal time for a review of current health care provision, with appropriate intermediate care services providing an opportunity for practice development which can incorporate interdisciplinary working and build bridges between the acute and community sectors. There is potential for a more needs-led and person-centred approach to care.

Intermediate care can be delivered in a variety of settings, including community hospitals, hospital at home schemes, community assessment and rehabilitation schemes, social rehabilitation schemes, and hospital hotels. An interdisciplinary approach is called for in which nurses, social services personnel, therapists and medical staff work together.Within the framework for nursing in primary care, nurses, midwives and health visitors have been given three core functions: first contact, continuing care and public health.

Community nurses will have a key role in delivering this exciting agenda (DOH 2002). In conclusion, the following chapters further develop the issue raised in this Introduction.

nurses will have a key role in delivering this exciting agenda (DOH 2002). In conclusion, the following chapters further develop the issue raised in this Introduction.

Medical Surgical


Disseminated intravascular coagulation, formerly termed as disseminated intravascular coagulopathy, is not a disease but a sign of an underlying condition. DIC may be triggered by sepsis, trauma, cancer, shock, abruptio placenta, toxins or allergic reactions. The severity of DIC is variable, but it is potentially life-threatening.


 Normal homeostatic mechanism are altered in DIC so that a massive amount of tiny clots forms in the microcirculation. Initially, the coagulation time is normal. However, as the platelets and clotting factors are consumed to form the microthrombi, coagulation fails. Thus, the paradoxical result of excessive clotting is bleeding. The clinical manifestations of DIC are reflected i the organs, which are affected either by excessive clot formation (with resultant ischemia to all or part of the organ) or by bleeding. The excessive clotting triggers the fibrinolytic system to release fibrin degradation products, which are potent anticoagulants, furthering the bleeding. The bleeding is characterized by low platelet  and fibrinogen level; prolonged PT, PTT, and thrombin time; and elevated fibrin degradation products (D-dimers).

Identification of patients who are at risk  for DIC and recognition of the early clinical manifestations of this syndrome can result in earlier medical intervention, which may improve the prognosis. However, the primary prognosis factor is the ability to treat the underlying condition that precipitated DIC.


Patients with frank DIC may bleed from mucous membranes, venipuncture sites, and the GI and urinary tracts. The bleeding can range from minimal occult internal bleeding to profuse hemorrhage from all orifices.  The patient may also develop organ dysfunction, such as renal failure and pulmonary and multifocal central nervous system infarctions, as a result of microthromboses, macrothromboses, or hemorrhages. During the initial process of DIC, the patient may have no new symptoms, the only manifestations being  a progressive decrease in the platelet count. As the thrombosis becomes more extensive, the patients exhibits signs and symptoms of thrombosis in the organs involved. Then, as the clotting factors and platelets are consumed to form these thrombi, bleeding occurs. Initially the bleeding is subtle, but it can develop into frank hemorrhage.


The most important management factor in DIC is treating the underlying cause ; until the cause is controlled, the DIC will persist. Correcting the secondary effects of tissue ischemia by improving oxygenation, replacing fluids, correcting electrolyte imbalances, and administering vasopressor medications is also important.  If serious hemorrhage occurs, the depleted coagulation factors and platelets may be replaced to reestablish  the potential for normal hemostasis and thereby diminish bleeding. Cryoprecipitate is given to replace fibrinogen and factors V and VII; fresh frozen plasma is administered to replace other coagulation factors. A controversial treatment strategy is to interrupt the thrombosis process through the use of heparin infusion. Heparin may inhibit the formation of microthrombi and thus permit perfusion of the organs (skin, kidneys or brain) to resume. Heparin use was traditionally reserved   for patients in whom thrombotic manifestations predominated or in whom extensive blood component replacement failed to halt the hemorrhage or increased fibrinogen and other clotting levels. Heparin is now considered also applicable for use in less acute forms of DIC (Leung, 2004). The effectiveness of heparin can best be determined by observing for normalization of the plasma fibrinogen concentration and diminishing  signs of bleeding. Fibrinolytic inhibitors, such as aminocaproic acid (EACA), Amicar), may be used with heparin. Other therapies include recombinant activated protein C (APC; drotrecogin alfa [Xigris]), which is effective in diminishing inflammatory responses on the surface of the vessels as well as having anticoagulant properties (Aird, 2004).  Bleeding is common, can occur at any site, and can be significant. Antithrombin (AT) infusions can also be used for their anticoagulant and anti-inflammatory properties. Bleeding can be significant, particularly when administered in association with heparin.


Reference: Suzanne C. Smeltzer, Brunner & Suddarth’s Textbook of Medical-Surgical Nursing 11th edition Lippincott Williams & Wilkins pp. 1093-1094

Medical Surgical


Buerger’s disease is characterized by recurring inflammation of the intermediate and small arteries and veins of the lower and (in rare case) upper extremities. It results in thrombus formation and occlusion of the vessels. It is differentiated from other vessel diseases by it microscopic appearance. In contrast to atherosclerosis, Buerger’s disease is believed to be an autoimmune disease that results in occlusion of the distal vessel.

The cause of Buerger’s disease is unknown, but it is believed to be an autoimmune vasculitis. It occurs most often in men between 20 and 35 years of age, and it has been reported in all races and in many areas of the world. There is considerable evidence that heavy smoking or chewing of tobacco is a causative or aggravating factor (Mills, 2003). Generally, the lower extremities or viscera can also be involved. Buerger’s disease is generally bilateral ans symmetric with focal lesions. Superficial thrombophlebitis may be present.


                  Pain is the outstanding symptom of Buerger’s disease. the patient complain of foot cramps, especially the of the arch (in-step claudication), after exercise. The pain is relieved by rest; often, a burning pain is aggravated by emotional disturbances, nicotine, or chilling. Cold sensitivity of Raynaud type is found in half of the patients and is frequently confines to the hands. Digital rest pain is constant, and the characteristics of the pain do not change between activity and rest.

                 Physical signs include intense rubor (reddish-blue discoloration) of the foot and absence pedal pulse, but normal femoral and popliteal pulses. Radial ans ulnar artery pulses are absent or diminished.  Various type of paresthesia develop.

As the disease progresses, definite redness or cyanosis of the part appears when extremity is in dependent position. Involvement is generally bilateral, but color changes may affect only one extremity or only certain digits. Color changes may progress to ulceration, and ulceration with gangrene eventually occurs.


              Segmental limb blood pressures are taken to demonstrate the distal location of the lesions or occlusions. duplex ultrasonography is used to document patency of the proximal vessels and to visualize the extent of distal disease. Contrast angiography is used to identify the diseased portion of the anatomy.

Gerontologic Considerations

              In older patients, Buerger’s disease may be followed by atherosclerosis of the larger vessels after involvement of the smaller vessels. The patients ability to walk may be severely limited. Patients are at higher risk for non healing wounds because of impaired circulation.


              The treatment of Buerger’s disease is essentially the same as that for atherosclerotic peripheral arterial disease. The main objectives are to improve circulation to the extremities, prevent the progression of the disease, and protect the extremities from trauma and infection. Treatment of ulceration and gangrene is directed toward minimizing infection and conservative debridement of necrotic tissue. Tobacco use is highly detrimental, and patients are strongly advised to completely stop using tobacco. symptoms are often relieved by cessation of tobacco use.

             Vasodilators are rarely prescribed because these medications cause dilation of only healthy vessels; vasodilators may divert blood away from the partially occluded vessels, thus exacerbating the manifestations of the disease. A regional sympathetic blocker or ganglionectomy may be useful in some instances to produce vasodilation and increase blood flow.

            If gangrene of a toe develops as a result of arterial occlusive disease in the leg, it is unlikely that toe amputation or even transmetatarsal amputation will be sufficient; often, a below-knee amputation pr occasionally above-knee amputation is necessary. The indications for amputation include gangrene, especially if the infected area is moist; severe rest pain; or fulminating sepsis.


            The patient is assisted in developing and implementing a plan to stop using tobacco and to manage pain. The patient may need to be encouraged to make the lifestyle changes necessary to adequately manage a chronic disease, including modifications in diet, activity, and hygiene (skin care). The nurse determines whether the patient has a network of family and friends to assist with ADLs. The nurse ensures that the patient has the knowledge and ability to assess for any postoperative  complications such as infection and decreased blood flow.

Reference: Suzanne C. Smeltzer,, Brunner & Suddarth’s Textbook of Medical-Surgical Nursing 11th edition

Lippincott Williams & Wilkins pp. 995-996

Medical Surgical

Pulmonary Emphysema

Pulmonary emphysema is defined as a nonuniform pattern of abnormal, permanent distention of the air spaces  with destruction of the alveolar walls and eventually a reduced pulmonary capillary bed. It appears to be the end stage of a process that has progressed slowly for many years. Smoking is the major cause. In a few patients, there is familial predisposition associated with a plasma protein abnormality ( deficiency in alpha-1 antitrypsin), making the person sensitive  to environmental factors ( air pollution, infectious agents, allergens). Emphysema  manifests commonly in the fifth decade of life and is classified as follows:

  • Panlobular (panacinar): characterized by destruction of respiratory bronchiole, alveolar duct, and alveoli; air spaces within the lobule are enlarged  with little inflammatory disease.
  • Centrilobular (centriacinar): cause pathologic changes in the center of the secondary lobule, producing chronic hypoxemia, hypercapnia, polycythemia, and episodes of right-sided heart failure.

Both types of emphysema can occur together.  

Clinical Manifestations

  • Dyspnea with insidious onset progressing to severe dyspnea with slight exertion (major symptom)
  • Chronic cough, hyperinflated “barrel chest” due to air trapping, muscle wasting, and pursed-lip breathing
  • On ausculatation, diminished breath sounds with crackles, wheezes, rhonchi, and prolonged expiration.
  • Hyperresonance with percussion and a decrease in fremitus .
  • Anorexia, weight loss, weakness, and inactivity.
  • Hypoxemia and hypercapnia, morning headaches in advanced stages.
  • Inflammatory reactions and infections from pooled secretions.

Assessment and Diagnostic Method Evaluation entails primarily chest x-rays,  chest computed tomography CT) scans, pulmonary function tests, pulse oximetry, blood gases, and complete blood count.

Complications Right-sided heart failure  (cor pulmonale) leading to central cyanosis and respiratory failure

Medical ManagementThe major goals of medical management are to improve quality of life, slow progression of the disease, and treat obstructed airways to relieve hypoxia. Treatment is directed at improving ventilation, decreasing work of breathing and preventing infection.

  • Smoke cessation
  • Physical therapy to conserve and increase pulmonary ventilation
  • Maintenance of proper environmental conditions to facilitate breathing
  • Psychological support
  • Ongoing program of patient education ans rehabilitation
  • Bronchodilators and metered-dose inhalers (aerosol therapy, dispensing particles in fine mist)
  • Treatment of infection (antimicrobial therapy at the first sign of respiratory infection).
  • Oxygenation in low concentrations for severe hypoxemia

Reference: Joyce Young Johnson, Brunner & Suddarth’s Textbook for Medical-Surgical Nursing 11th edition Lippincott Williams & Wilkins pp. 331-333

Medical Surgical

Anemia, Megaloblastic (Vitamin B12 and Folic Acid Deficiency)

The anemias caused by deficiencies of the vitamins B12 and folic acid show identical bone marrow and peripheral blood changes. Both vitamins are essential for DNA synthesis.


The two main vitamin deficiencies may coexist. In each case, hyperplasia of the bone marrow occurs, and the precursor erythroid and myeloid cells are large and bizarre in appearance. The RBC’s produced are abnormally large (megaloblastic). A pancytopenia (a decrease in all myeloid-derived cells) develops.

Vitamin B12 deficiency can occur from inadequate intake in strict vegetarians; faulty absorption from gastrointestinal tract; absence of intrinsic factor (pernicious anemia); disease involving the ileum or pancreas, which impairs B12 absorption; and gastrectomy. People with pernicious anemia have a higher incidence of gastric ulcer than the general public.

Folic acid deficiency occurs when intake of folate is deficicnet or the requirement is increased. People at risk include those who rarely eat uncooked vegetables or frutis, primarily elderly people living alone or people with alcoholism. Alcohol use, hemolytic anemia, and pregnancy increase folic acid requirements. Patients  with malabsoptive or small bowel disease may not absorb folic acid normally.

Clinical Manifestations

Symptoms are progressive and may be marked by spontaneous partial remissions and exacerbations.

  • Gradual development of signs of anemia (weakness, listlessness, and pallor)
  • Possible development of a smooth, sore, red, tongue and mild diarrhea (pernicious anemia)
  • Possible development of confusion, more often, paresthesias in the extremities ad difficulty keeping balance, loss of position sense
  • Lack of neurologic manifestations with folic acid deficiency alone
  • Vitiligo (patchy loss of skin pigmentation) and prematurely graying hair (often seen in pernicious anemia)
  • Without treatment, patients die, usually as a result of congestive heart failure from anemia

Assessment and Diagnostic Findings

  • Schilling test (primary diagnostic tool)
  • Complete blood count (Hgb value as low as 4 to 5 g/dl, WBC count 2,000 to 3,000/mm3, platelet count less than 50,000/mm3, MCV is very high, usually exceeding 110)
  • Serum levels of folate and vitamin B12 (folic acid deficiency and deficient vitamin B12)

Medical Management: Vitamin B12 Deficiency

  • Oral supplementation with vitamins or fortified soy milk (strict vegetarians)
  • Intramuscular injections of vitamin B12 for defective absorption or absence of intrinsic factor
  • Prevention of recurrence with lifetime vitamin B12 therapy for patient who has had pernicious anemia or non correctable malabsorption

Medical Management: Folic Acid Deficiency

  • Intake of nutritious die and 1 mg folic acid daily
  • Intramuscular folic acid for malabsorption syndromes
  • Folic acid taken orally as a separate tablet (except prenatal vitamins)
  • Folic acid replacement stopped when hemoglobin level returns to normal, with the exception of alcoholics, who continue replacement as along as alcohol intake continues

Nursing Management

  • Assess patients at risk for megaloblastic anemia for clinical manifestations (eg, inspect the skin, sclera, and mucous membranes for jaundice, note vitiligo or premature graying or smooth, red, sore tongue).
  • Perform careful neurologic assessment (eg, note gait and stability; test position and vibration sense).
  • Assess need for assistive devices (eg, cane, walkers) ans need for support and guidance in managing activities of daily living and home environment.
  • Ensure safety when position sense, coordination, and gait are affected.
  • Refer for physical or occupational therapy as needed.
  • When sensation is altered, instruct patient to avoid excessive heat and cold.
  • Advise patient to prepare bland, soft foods and to eat small amounts frequently.
  • Explain that other nutritional deficiencies, such as alcohol-induced anemia, can induce neurologic problems.
  • Instruct patient in complete urine collections for the Schilling test. Also explain the importance of the test and of complying with the collection.
  • Teach the patient about chronicity of disorder and  need for monthly vitamin B12 injections when patient has no symptoms. Instruct patient how to self-administer injections, when appropriate.
  • Stress importance of ongoing medical follow-up and screening, because gastric atrophy associated with pernicious anemia increases the risk of gastric carcinoma.

Reference: Joyce Young Johnson, Brunner & Sudddarth’s Textbook of Medical-Surgical Nursing 11th edition Lippincott Williams & Wilkins pp. 45-48