Community Health Nursing

V. Therapeutic Relationships


           The recognition 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 patient, and she asserts this is the way in which all nursing care is delivered. The importance of this relationship has continued to be widely acknowledged and indeed McMahon and Pearson (1998) suggest that it is central to patient health, well-being and recovery. Since a therapeutic relationship is so important, it is essential to consider what features characterise such a relationship. In reviewing various definitions it becomes apparent that the important factors are:

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

Appropriate boundaries are maintained

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

       Therefore it is important that the nurse, patient and family are clear regarding their relationship and what is reasonably expected of each party. This will protect all those involved in the relationship. A publication from the UK Central Council (1999: p.5) on this subject states that: ‘boundaries define the limits of behaviour which allow a client and practitioner to engage safely in a therapeutic, caring relationship’. The practitioner has the responsibility to maintain appropriate professional boundaries at all times (UKCC 1999). However, the process of finding the boundaries of care is far from automatic (Totka 1996), as will be discussed later in this chapter.

Meets the needs of the patient

       The purpose of the relationship between the nurse and patient is to meet the nursing needs of that patient. It is therefore important that the nursing needs of the patient are discussed at the outset of the relationship in order that mutually identified goals can be set and each person within the relationship can be clear as to their role in the achievement of those goals. This might include the nurse, patient, family members, other professionals and carers. This will require expert communication skills on the part of the nurse in order that a relationship of trust can develop. Whilst the relationship exists to meet the needs of the patient it is likely that the nurse will experience satisfaction in helping the patient to meet those needs. This is entirely appropriate. However, it is important that nurses do not allow their personal needs for positive self-esteem, control and belonging to undermine the professional relationship (Jerome and Ferraro- McDuffie 1992). This requires the nurse to be self- aware and open to seeking support from others when the need arises.

Promotes patient autonomy

          Autonomy is the right to self-determination. Self- determination can be defined as an ability to understand one’s own situation, to make plans and choices and to pursue personal goals (McParland et al. 2000). This further supports the need for excellent communication skills on the part of the nurse in order to assist the patient to understand their own situation. Within a relationship that promotes patient autonomy the patient will contribute to the achievement of personal goals and will move towards independence.

Positive experience for the patient

        The experience of participating in a therapeutic relationship will be positive for the patient as nursing needs will be met, in a way that is most appropriate to the patient and their family. Truly therapeutic relationships can empower the patient, the family and the nurse.

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

             You must at all times, maintain appropriate professional boundaries in the relationships you have with patients and clients. You must ensure that all aspects of the relationship focus exclusively upon the needs of the patient or client. (NMC 2002: Clause 2.3)


          Having considered the features of a professional relationship, some of the challenges of achieving such a relationship in the community setting will be discussed. Professional relationships with the patient are influenced by a number of factors.

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

           In this example the benefits of home visiting are apparent. These opportunities could be lost if health visitors change their mode of practice to give more care in clinic settings, as has been reported by Normandale (2001). However, caring in the home environment can leave the nurse feeling vulnerable. A nurse who has recently left a hospital-based job to work in the community can feel very isolated. 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 the confidence of patients.
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 herself, particularly if the situation has developed over time. The support and guidance of colleagues is essential, as is the willingness of the nurse to be open to that support. Totka (1996) notes that peers often recognise unhealthy situations before the nurse involved, but find it difficult to discuss the situation with their colleague.
Care given by the nurse within the workplace will also be different from the more traditional hospital setting. The occupational health nurse works within a three-way relationship between the employer, employee and the nurse (Atwell 1996).

        Developing therapeutic relationships may also be affected by a clinic or surgery setting, where the patient may gain the impression of busy workloads inhibiting the time they spend with the nurse. Paterson (2001) identified lack of time as a major inhibitor in developing a participatory relationship between professional and patient, and although the nurse is likely to be as busy, if not more so, when undertaking home visits the interaction may be less distracted than in a busy clinic.

           In other cases the relative anonymity the surgery or clinic provides may be of benefit in facilitating the development of a therapeutic relationship. Initial assessments are often the first point of contact between community nurse and patient and the nurse must develop skills to enable a conducive environment in order to establish the start of a therapeutic relationship (Bryans and McIntosh 1996).

        Working in the community, many nurses find that not wearing a uniform removes an unnecessary barrier, which 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 patient’s home, gain the patient’s trust and explain her nursing role, since a symbol, which for many carries some degree of status, has been lost.
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 present 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 consider the appropriateness of the clothing that is worn. Entering a home inappropriately 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 entry into some homes. In order to meet the needs of individual families the nurse must enquire as to family preferences and be willing to adapt behaviours to respect values different from her own, in order to facilitate good 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 wellbeing of patients.

Nature of care

       A key element in the nature of the therapeutic relationship with all patient groups is the duration of the relationship. Morse (1991) describes three appropriate relationships. Firstly, she describes the one-off clinical encounter that, for example, a practice nurse may have with a patient 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–patient relationship there should be a different focus, with the development of what Morse terms as a connected relationship. Morse suggests that the key characteristic of a connected relationship is that the nurse views the patient as a person first rather than a patient.

       Whilst 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 explored later in the chapter.

        In the home environment the patient and his carer could be perceived to have greater control within the relationship. Should the patient decide not to concur with recommended treatment, this may not be immediately evident as the nurse is
spending only a short period of time within the home environment. Parkin (2001) notes that professionals are unable to control the home environment. If, unbeknown to the nurse, the patient has not adhered to the recommended treatment, the therapeutic relationship is threatened, since a relationship based on trust no longer exists. Within a therapeutic relationship the patient should be able to tell the nurse of his intentions. This might allow treatment to be modified such that the patient feels able to follow the regimen, but even if this is not the case at least the nurse is aware of the true situation and can modify her nursing care accordingly.

Patient expectations

         Expectations of the nurse and of the community nursing service may also impact on the relationship between the nurse and adult patient. Over the past 25 years there has been a rapid rise in consumerism (May and Purkis 1997), with a corresponding rise in expectations of the Health Service. In community nursing this can be seen by the use of time bands in allocating home visits and the proliferation of charters and mission statements displayed on clinic and surgery walls.

      Many patients have clear ideas on the service they expect from community nurses with a consequential detrimental effect on the therapeutic relationship when these expectations are either not met or are unrealistic.
However, despite trends in healthy ageing and participation in health care (Lorig et al. 1996), many older adults were bought 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 (Dukes Hess 1996). There is some evidence that not all adult patients wish to be an active partner in the therapeutic relationship (Waterworth and Luker 1990) and there may be a significant number of patients who feel more comfortable with the paternalistic model of care (Roberts 2001). The nurse ‘doing for’ the patient rather than enabling them to self-care contradicts the current trend towards empowerment (Copperman and Morrison 1995), which is a central theme in the National Service Framework for Older People (DOH 2001a). The community nurse may find a challenge in helping some patients in developing the confidence and ability to self care, and again the therapeutic relationship will be focused on trust and the facilitation of realistic independence.

Patient 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 relationship may have significant physical and emotional needs, such as happens in palliative care. The relationship in such cases may be based on intensive input by the nurse (Goodman et al.1998). In contrast, the practice nurse or occupational health nurse may see a person 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 mental health needs (Brooker and Repper 1998) has resulted in a rapidly developing role for community nurses in supporting this group. With approximately one in six people at any one time suffering from mental illness in the United Kingdom (DOH 1999a) the role is constantly evolving. The National Service Framework for Mental Health (DOH 1999a) is firmly underpinned by a patient focus. However, empowering patients with mental health needs is often challenging, not least because of concerns from society and professionals as to whether some patients have the capability of making decisions over their care and treatment (Feenan 1997).

Table 5.1 Responses to caring role:

Response to caring role – Features of Response

  • Engulfment mode
  1. Cannot articulate needs as a carer
  2. No other occupation
  3. Generally female spouse
  4. Total sense of responsibility and duty
  • The balancing/boundary setting mode
  1. Have a clear picture of themselves as carers (e.g. how they save nation money)
  2. Generally male
  3. Often adopt language of an occupation – treat role as a job
  4. May emotionally detach themselves from recipient
  • Symbiotic mode
  1. Positive gain by caring
  2. Does not want role taken away

            The therapeutic relationship with this group is essential in empowering patients to actively participate in decisions about their care. Peplau’s (1952) developmental model is often used as the framework for developing a therapeutic relationship (Collister 1986) with the assessment (or orientation) phase focusing on the development of mutual trust and regard between nurse and patient, as well as data gathering. Addressing anxiety is the overarching aim of the therapeutic relationship (Aggleton and Chalmers 2000), and the community nurse may take on a number of roles to facilitate this including that of counsellor, resource, teacher, leader or surrogate. All nurses working in the community develop knowledge of local resources and other agencies and facilitating the patient to access these may be the key component within this relationship.

            It should also be acknowledged that the therapeutic relationship in the community setting is not only formed between nurse and patient, but will often encompass an informal carer. In the United Kingdom there are approximately 6 million informal carers who are the primary carers for a range of patients ranging from young people with learning disabilities, to the frail elderly (Bond et al. 1999). The Carers Recognition and Services Act (DOH 1995) and the Carers and Disabled Childrens Act (DOH 2000) enshrined the principle that carers should be assessed and acknowledged as an individual rather than simply an adjunct to the patient. For the community nurse this reinforces that an individual therapeutic relationship must also be developed with the informal carer, but this poses a number of challenges.

            First, a significant number of informal carers are unknown to the community nurse, with Henwood (1998) estimating that only half of all carers receive any support from community nurses. Second, the more an informal carer does for the patient, the less intervention there will be from the community nurse (Pickard et al. 2000). Consequently, the informal carers most likely to benefit from a therapeutic relationship are less likely to be visited by the community nurse. Third, there are often misguided assumptions by many professionals that informal carers should undertake the caring role and that the role is taken on very willingly (Procter et al. 2001).

           Finally, studies have shown that many informal carers have significant health needs of their own which often are unrecognised (Henwood 1998) and undertake very complex and technical tasks (Pickard et al. 2000). All too frequently community nurses first meet an informal carer when there is a crisis and the nursing input is a short-term measure to help the patient and carer over this period. However, the therapeutic relationship with informal carers should ideally be long-term, with the nurse aiming to provide information and acting as a resource (Seddon and Robinson 2001) and responding to the role the carer is happy to undertake.
Twigg and Atkin (1994) describe three different responses by individuals to the informal caring role, given in Table 5.1. It is important for the community nurse to recognise the informal carer’s response to their situation.

          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, and the community nurse must develop a therapeutic relationship in order to enable him to express these. The needs of informal carers are only now being recognised and the community nurse must develop a relationship and provide intervention appropriate to both the patient and informal carer as individuals.


          In reality it is hard to learn about boundaries unless one is involved in setting them, and extending beyond the therapeutic boundary may only be apparent once it has been breached.

          It may be that it is in the interests of the patient and his carer to encourage the professional to develop a relationship of friendship since this has the potential to ‘normalise’ the patient, as it is ‘normal’ to have friends who visit. This is perhaps more likely to occur if nurses do not wear uniforms. Families may be keen that friendships do develop since a friend is likely to respond to requests for help, perhaps more swiftly than a detached professional. Therefore nurses must consider their actions carefully in case actions are misinterpreted, as perhaps was the case when Ann attended John’s party.

        Hylton Rushton et al. (1996) describes over- involvement as a lack of separation between the nurse’s own feelings and that of the patient. Typically the nurse may spend off-duty time with the patient (Barnsteiner and Gillis-Donovan 1990), appear territorial over the care (Morse 1991), or treat certain patients with favouritism (Wilson 2001a). Consequences for the patient are an over- dependence on that particular nurse and a lack of support in reaching therapeutic goals. For the community nurse the implications are often significant stress and deterioration in job satisfaction (Hylton Rushton et al. 1996) and an inevitable detrimental effect on team working.

         Of course, the balance in the therapeutic relationship may be tipped the other way. The detached, cold nurse who seems indifferent to her patient’s emotional needs may be familiar to the reader. The results of under-involvement are a lack of understanding by the nurse of the patient’s perspective, conflict, and standardised rather than contextually dependant care (Hylton Rushton et al. 1996). It has been suggested that the overwhelming feelings that a nurse may have for a patient’s situation can lead to dissociation by the nurse within the therapeutic relationship (Crowe 2000). Within the community setting the feelings of being the last resort in care has also been linked to under- involvement within the therapeutic relationship (Wilson 2001a). The consequences of under- involvement for the patient is that the nurse has a lack of insight into the patient’s perspective and is unable to facilitate the patient in meeting therapeutic goals.

          Maintaining a therapeutic relationship is particularly challenging in the community nursing context because of the commonly intense nature of care, duration of contact and the non-clinical environment. Reflection with colleagues and clinical supervision become invaluable tools to facilitate the nurse in developing the appropriate relationship with patients.


          Long-term interventions within the community setting will continue to increase with an ageing population and rise in chronic illness (Kalache 1996; Wellard 1998; DOH 1999b), and this chapter has already explored the impact of duration of care on the therapeutic relationship. One response by policy makers to the rise in long- term conditions is the facilitation of individuals to self-manage their own conditions. The expert patient programme (DOH 2001b) recognises that individuals often have significant expertise about their chronic illness which has developed over years through experience and the aim of the programme is to further develop this expertise in order to promote symptom control, quality of life and effective use of health resources (Wilson 2001b). Within all spheres of community nursing, nurses are now dealing with far more knowledgeable patients not least because of the readily available access to information via the Internet (Timmons 2001). Therapeutic relationships in the current climate must be based on an acknowledgement that the patient may have considerable expertise in their own condition, exceeding that of the nurse. There has been some debate as to how comfortable community nurses are with this (Wilson 2002), but there can be little doubt that a therapeutic relationship that fails to take into account the knowledge that both nurse and patient bring will fail.

         The expert patient programme is one example of a policy that is based on partnership and responsibility (Wilson 2001b). Another example is the move towards concordance (Royal Pharmaceutical Society of Great Britain 1997), where the patient’s views are considered of equal importance in treatment plans.

             Community nurses are required to demonstrate evidence-based practice (Woodward 2001) and the challenge of today’s therapeutic relationship is to balance this with informed choice by the patient (Wilson 2002). There is a balance to be maintained between the rights of the child (dependant on their age and understanding) and rights of the parents in decision-making, against the risks of significant harm that might result from the treatment. The parents in the above scenario should be advised to ensure the advice regarding the complementary treatment comes from a registered practitioner. Community nurses need to assess their own knowledge base regarding complementary therapy and seek specialist advice if necessary. Within a therapeutic relationship the nurse will be aiming to facilitate an atmosphere where the parents feel able to be honest about the treatments the child is currently receiving, and should be able to direct patients and their families to sources of appropriate information.

            A final feature of the current context of care that may have an effect on the therapeutic relationship is the fragmentation of care. In particular the division of health and social care (DOH 1990) means that patients within the community often have to deal with a vast array of professionals, which can inhibit the development of a therapeutic relationship (Hyde and Cotter 2001).


           In this chapter features of a therapeutic relationship have been identified, leading to an exploration of some of the challenges community nurses face in establishing therapeutic relationships. In future community health care provision, challenges will be shaped by an increasingly multi-cultural, ageing and informed population. The growing provision of health care in the community only serves to reinforce the need to establish appropriate relationships with patients, 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.



Community Health Nursing

IV. Personal Safety in the Community



          Working in the community provides many challenges and opportunities. When placed in non- hospital settings as a student nurse or embarking upon a career as a community staff nurse, it is timely to reflect upon personal safety. This chapter is not intended to deter nurses from choosing to work in a community setting, but to ensure that practical and reasonable steps are taken to ensure their safety.
The first section of this chapter examines safety relating to the prevention and management of violence and aggression.The second part focuses upon manual handling, as the safety of both nurse and patient may be compromised if careful thought is not given to this issue before home visiting. The principles remain the same wherever the nurse is working, but some consideration needs to be made when moving into community settings. Finally, issues of reporting and bringing incidents to a resolution will be explored.


       The 1974 Health and Safety at Work Act and the 1992 Health and Safety at Work Regulations charge employers and employees with responsibilities in risky situations. Assessment of risk is a requirement to minimise potential harm and community nurses need to consider safety issues from both practical and professional perspectives.
Sadly, violence and aggression are an increasing problem in hospitals around the United Kingdom (Health Services Advisory Committee 1997, Royal College of Nursing 1998, Whittington and Wykes 1996). This is also the case for those nurses working in the community who are often working alone (Jackson, Clare and Mannix 2002) despite the Zero Tolerance Campaign launched in 1999 by the government.
This campaign sought to reduce the incidence of violence against nurses by 20 per cent. It has proved difficult to achieve (RCN 2001). It is very important to spend time considering how to prepare for community work and be aware of potential problems.


          This includes developing knowledge of the area of work, developing self-awareness and understanding why and how aggression can escalate.
First, learn the geography of the area, whether that is a town, clinic or surgery. Become familiar with the layout of rooms and buildings and note the position of exits. Find out what is known about the community. Without falling into the trap of stereotyping people, investigate what reputation the area has, find out about crime rates, for example. Talk to your colleagues about safety. It is strongly recommended (Leiba 1997) that visible security measures, involving personnel and technology, should be evident in health centres and clinics.

         There may be areas within the surrounding locality that are considered to be high risk. Sometimes community staff visit these in pairs. Find out if the remit of the post involves visiting after dark. It is good practice to gather as much information as is possible before setting off to a patient or client’s house.


          This section will focus particularly upon home visits, as there are particular features that could, potentially, compromise personal safety. Bearing this in mind, read carefully any records or notes pertaining to the visit. Talk to colleagues, who may know the situation and should make sure that concerns are shared. Look at the location of the visit – think about how you will get there.
Always remember that home visits, however welcome to the patient or client, are an invasion of that individual’s space. Table 4.4 outlines some of the things that should be considered when arriving at someone’s home.
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 letterboxes. These, obviously, put patients at risk from unscrupulous opportunists. In addition to these measures, the community nurse should offer personal identification.

      When visiting in other people’s homes, self-awareness is crucial. The conditions in which some people live can be upsetting. Monitoring facial expressions and choosing words carefully are a must (Leiba 1997). This may not prove to be easy. If so, take the opportunity to discuss your feelings with other members of the team after visits that leave emotions heightened.
The majority of home visits are very welcome to the patient or client. Relationships between community staff and the people that 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.

Table 4.4 :Entering a Patient’s Home

Considerations – Rationale

  • Remember that you are the visitor. – It is the patient’s space that you are invading – it is unknown what is or has recently been happening in that person’s home.
  • State clearly who you are and why you have come. Show your identity badge. – Don’t assume that the person will recognise a uniform (if one is worn) 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 in which room the patient or client would like you to carry out the purpose for your visit. – Being pushy can make people irritated and angry. It may not be convenient for the patient or client to allow you into a particular room. This may be for good reason, e.g. if an unpredictable dog is shut in there!
  • Note the layout of the house – exits, telephones.- In case a speedy exit is required.
  • Be careful with people’s property – protect their belongings. – Spillages, breakages or rough treatment of belongings will irritate – remember the visitor status.
  • Be alert – monitor moods and expressions during the visit. – Changes in the demeanour of the patient or client could indicate potential conflict developing.
  • Be self aware – monitor the manner in which information is given and care carried out. Do not react to conditions, which may seem unacceptable – dirty, smelly environments, for example. – The nurse should not provoke feelings of anger. Remember that this is the patient’s home.
  • Trust instinctive feelings. If it feels that leaving quickly is the thing to do – go. – Often assessment of situations takes place on many levels. If uncomfortable feelings are building up don’t wait until there is an incident.
  • If prevented from leaving – try not to panic – see the section relating to interpersonal relationships. – It may be possible for you to de-escalate the situation.


Working in a community setting involves being mobile. In some localities bicycles may be an entirely appropriate way to get around; in busy cities public transport is often the best option. For most community staff, however, it would be impossible to function effectively without a car.
Some practical measures need to be undertaken relating to car safety (Table 4.2). Areas between car parks and clinic/surgery buildings should be well lit.
In addition to the above, 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 whilst driving in more dangerous areas. Good preparation for the journey makes it more likely that the nurse will arrive feeling calm. It is better to avoid road rage – especially if it is your own.
Walking between  car and house, community nurses should appear purposeful, confident and in control. Walk towards the kerb 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, wearing jewellery could catch the attention of muggers.

Table 4.2 Car Safety

Consideration – Rationale

  • It makes sense to ensure the vehicle is well maintained. – Not only is it inconvenient, it may be hazardous to break down in a remote place after dark. Well worth the expense of servicing and looking after the car.
  • Try not to run out of petrol. – The car will not be happy and again this could leave you stranded in remote or unsavoury places.
  • Park with thought. – Look for safe parking places. In the dark it is helpful to find a streetlight to park under. Try to park near to your destination.
  • Take out breakdown cover. – At least someone is coming to assist you. Always state that you are alone and make it clear if you are female.
  • Keep any nursing bags out of view – in addition to any personal valuables. – Some people may believe that nurses carry drugs in their bags – prevent temptation.


In spite of the preparations suggested above, it may be that tensions rise whilst visiting. Confrontation may occur between patient or carer and nurse. Communication skills are crucially important in all fields of nursing; however, some issues need careful thought when visiting patients and clients in their own homes.
Households vary tremendously and staff new to community working may be surprised or shocked by the conditions in which some people live. An open mind needs to be cultivated in terms of the possible relationships that may be encountered – there are many variations of family life. It is necessary to communicate respect for all patients and clients, whatever thoughts may be experienced. Nabb (2000) found many incidences of family and carers assaulting nurses – remember that the giving and receiving of information should always be carried out courteously and sensitively.

Table 4.3 Interpersonal relationships – Non-Confrontational Behaviour

Considerations – Rationale

  • Be aware of how you are feeling and how you may appear to others. – If you appear worried or defensive you may cause worry or fear.
  • Try to look calm and relaxed. – Never try to domineer or act in an arrogant fashion. Attempts to belittle those who are angry are extremely dangerous.
  • Speak clearly and quietly – speak in a low pitch if possible. –
  • Listen to responses. Use non-verbal communication (such as nodding the head) to convey understanding. – This is a two-way process. Demands and commands should not be issued.
  • Try to accept how the other person is feeling. Ask for further clarification. – Even if the issue is difficult to empathize with, people own their feelings. Don’t argue.
  • Be polite in the face of provocation. – Avoid becoming over-emotional. It is better to be brief and professional if tensions are mounting.
  • Try to ensure that the other person has an escape route. – If people are angry and feel crowded or cornered, aggression can be triggered.
  • Stay seated if the other person is seated. – It can be dangerous to tower over others – the aim is not to provoke.
  • Don’t stand too close. – Leave reasonable personal space to avoid crowding.
  • Watch carefully to plan your exit. – Try to close the conversation if possible.

Table 4.3 suggests guidelines for non- confrontational behaviour to minimise the risk of provoking or encouraging aggression or violence. Some of the suggestions may appear to be ‘common sense’. In situations of potential conflict, however, it is easy to feel anxious and behave inappropriately. Try to think carefully about the considerations and rationales before a difficult visit occurs.
Remember that there may be indicators that a person is potentially aggressive, such as using a raised voice, clenching their fists and threatening assault (Leiba 1997).

Aggression has been defined as:
Any incident in which a health professional experiences abuse, threat, fear or the application of force arising out of the course of their work, whether or not they are on duty. (RCN 1998: p.3)

This definition is useful, as actual abuse does not have to occur in order for aggression to be felt. Fear is a powerful enough experience to warrant action. The Royal College of Nursing’s definition also does not differentiate between on- or off-duty situations. It is important to remember that insurance cover from employers relates to the duration of the shift.


              Under the 1974 Health and Safety at Work Act, employers have a duty to provide a safe working environment. Along with the responsibilities for employers there are also requirements, which need to be carried out by employees. Firstly, locate any policies and procedures, which exist locally relating to health and safety (RCN 1994). Study these carefully and note the reporting arrangements that are laid down for staff to follow.
Many primary care trusts (PCTs) offer training in assertiveness and dealing with aggression and violence. The Health and Safety at Work Regulations (1992) charge employers with provision of training in these fields. Take up the opportunities on offer. If there doesn’t seem to be any training available ask if this could be arranged.
It is good practice to contact the work base at the end of the day to let someone know that visits are complete. The team leader will delegate visits to each member of staff and will co-ordinate the team. The order in which visits are carried out may not be predictable, but someone knows where each nurse should be visiting on a daily basis.
Many community nurses have the use of a mobile telephone, which can be useful in difficult situations. 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 useful addresses) advises holding up the alarm directly to the ear of the attacker and running away as fast as possible.
In addition to all of the above, there is a potential threat (even in a ‘caring profession’), which may not manifest itself in the homes or streets of the community served. Personal safety may be at risk in situations of harassment and bullying. Reported incidents are rising (Jackson, Clare and Mannix 2002; Rippon 2000) and it is important to be aware of ways to deal with bullies.
Bullying has been defined as the misuse of power or position (RCN 2001) and includes aggressive behaviour, ridiculing or humiliation, public criticism and exclusion from opportunities open to others.
Bullying may occur in any NHS setting and is, unfortunately, becoming more prevalent in many societies (Jackson, Clare and Mannix 2002). Many studies have found that aggression between staff is more upsetting and difficult to deal with than assaults from patients (Farrell 1999, 2001).
It is important not to keep bullying quiet – talk to other people (family, friends, trusted colleagues) and document what is happening. Employers are charged with the task of developing a culture of intolerance towards bullying and to deal with incidents effectively (DOH 2002). It is always better to try to address issues informally and directly at first – the person may not realise the effect that they are having. If, however, this does not work, then a formal complaint may be made. It is strongly advised that advice be sought from union representatives if a formal complaint is to be made.
A further requirement of the 1992 Health and Safety at Work Regulations is that of risk assessment in the workplace, which should be followed by planning, organising and monitoring both protective and preventive measures. The Health and Safety Executive (HSE) have issued a five-stage framework for risk assessment. This applies to all situations, which could lead to harm and is used also to evaluate needs relating to manual handling.


          These apply to all situations that have potential for risk. It is the case that many interventions carried out by nurses carry risks of harm to patients, the nurse and the general public. Dale and Woods (2001) state that these risks include clinical issues such as infection control, needlestick injury, inappropriate skill mix and staffing levels. There has been a rise in MRSA (methicillin-resistant Staphylococcus aureus) infections in community settings (Cookson 2000). This is of great concern and should mean that the highest standards are maintained in terms of hygiene.
Measures such as hand cleansing need to be carefully considered, particularly in patient’s homes – not every household will have hot running water and soap, for example. Consult local policies for advice as to how to deal with this problem. There are many solutions for hand cleansing, in addition to traditional soap and water – these should be used as prescribed by the manufacturers. Uniforms and clothes worn for work need to be changed daily and laundered properly (RCN 1999b) to protect nurses and patients alike. Chronic understaffing puts nurses at risk. In addition to personal safety issues, health and safety within clinics and patient’s homes needs consideration.
We shall now look at, each of the five stages of risk assessment and relate them to potentially threatening situations of violence or abuse.

1. Identify the hazards

         This includes reports of threats and abuse, not only of actual physical violence, by patients, carers or others. Remember that this could be whether the nurse is on duty or not. The community staff nurse must report any incidents by following local policies.

2. Identify who is at risk

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

3. Evaluate the risk

            Assess the seriousness of the situation. Identify what can be done to minimise or eliminate the risk to protect those who could be harmed. Senior nurses will carry out the assessment of the risk with contributing evidence from the team. However, it is everyone’s responsibility to identify and report potentially hazardous situations.

4. Record the findings

Decisions taken and workable measures to minimise the risk will be documented.This provides a working plan for staff and managers outlining all of the above in addition to steps, which may still need to be taken. Be sure to record events accurately (NMC 2002).
Poor communication of risk can result in misunderstanding and failure to pass on vital information to other colleagues. Documentation needs to be comprehensive and accurate, containing a full account of intervention and assessment of the situation (NMC 2002, Woods 2002). Avoid the use of jargon and abbreviations.

5. Review and revise the assessment

Assessment is a dynamic process. It is important to revisit the document, particularly after incidents are reported. Staff training and communications should also be reviewed. It has been said that a major source of risk is uncertainty by members of staff about what is expected of them, especially in emergency situations (Dale and Woods 2001). Policies and procedures need to be current, available to those who need them, and 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.
The above stages also apply to other areas of practice – in the interests of patients and nurses it is important to think about manual handling situations arising in non-institutional settings.


The potential for safety to be compromised in manual handling situations in patients’/clients’ homes is very real. The inclusion of this issue within this chapter is in recognition of the fact that over 30 per cent of nurses suffer work-related back pain each year (Institute of Employment Studies 1999).
Although the principles of manual handling remain the same wherever the nurse is working, community visiting gives rise to particular issues. By revisiting the five tenets of manual handling some of these are presented.

The task:

There will be manual handling issues in many nursing procedures undertaken in the home (see Table 4. 4). These include moving patients in bed, helping patients get out of bed and standing up. Toileting and dressing should be approached with thought, as should bathing and washing procedures.

The load:

As in many settings, patients can be heavy and unpredictable. Paralysis, confusion or pain may make the patient a particular challenge.
When handling a load it is important to hold that load as close to the trunk as possible. Think about a patient in the middle of a double bed. This bed is low and not very firm. Immediately problems for safety (both for nurse(s) and patient) are apparent.

The environment:

          Nursing patients in their home environment is very different from doing so in a hospital ward. Hazards could include cluttered rooms with little space for manoeuvre, slippery polished floors, loose rugs and poor lighting. These are a problem for both patients and staff. It is important to address these hazardous conditions with tact and sensitivity. When rapport and trust have been developed between patient and nurse, suggestions for improving home safety will be better received.

The worker:

        Nurses come in all shapes and sizes. The same is true of carers, who tend to be more involved in giving direct care in home settings. Older people who are carers may not be in the best of health themselves. It is important not to make assumptions about the abilities of others.

The organization:

      Policies and procedures relating to manual handling must be studied carefully (Chambers 1998). Mandatory updates in PCTs are necessary to ensure the safety of staff and patients. There may be unfamiliar equipment in patients’ homes. Don’t use unknown manual handling aids until training has been carried out.
Inadequate staffing levels can put nurses at risk. The number of staff at any given time will affect directly the workload of each nurse. Tired staff are more vulnerable to injuries, accidents and mistakes (RCN 1996, 1999a).
In addition to the above, keeping fit and healthy can reduce the possibility of back problems developing. By valuing and safeguarding his/her own health the community nurse can contribute to the risk reduction process.

Table 4.4 Occasions when manual handling procedures must be carefully considered:

1. Moving patients in bed

2. Helping them to sit or stand

3. Toileting and dressing

Note the following:

  • A full assessment will be carried out as required according to the Manual Handling Operations Regulations 1992.
  • The sister or charge nurse will assess patients. Measures to reduce the risk of potential injury will be put in place, e.g. a hospital bed may need to be provided.
  • The assessment will be documented in the care plan. Any changes in circumstances must be reported to the team leader.


Nurses are required to report issues relating to safety under the Health and Safety at work Act (1974). If injury occurs as a result of manual handling procedures, then this must be reported. There is evidence that a large majority of nurses believe that a certain level of aggression is part of the job (Leiba 1997, Unison 1997). This acceptance of abuse seems to be particularly widespread amongst older nurses. In their campaign to ‘stamp out violence’, the Nursing Times received 1000 replies to a questionnaire on the subject (Coombes 1998). In nurses aged over 55 years, 92 per cent felt that violence and aggression was part of the nurse’s lot.

Amongst nurses aged between 26 and 34 this view was held by 76 per cent. Undoubtedly this leads to an underreporting of incidents, which is worrying. It will not be possible to gauge the size of the problem if nurses are reluctant to speak up. It is also unfair to colleagues to keep quiet. Today might have included verbal abuse from a relative, tomorrow (particularly if the situation is poorly handled) may lead to something much worse.
The report should be made as soon as is possible. Events should be clearly and comprehensively stated.


People who have been involved in aggressive or violent incidents need to be supported at work. Reporting the events can be traumatic and it is helpful to have assistance from a colleague when completing the necessary documentation (RCN 1998). It may be helpful to discuss what has happened with other members of staff. A debriefing should take place with the people concerned. The actual events should be explored, including any possible triggering factors and the feelings of those who took part. Ways of preventing recurrence should be considered.

Commonly, following verbal abuse or physical attack feelings of fear, guilt or anger may be experienced. These can manifest themselves in taking the ‘blame’ for provoking aggression, wondering if the experience will be repeated or anger towards the aggressor, the organisation or even oneself.
It may take time for a victim of abuse or violence to regain the confidence to visit alone again. Support may be offered by occupational health, professional organisations or counselling services. Support may also be needed for others involved, including the aggressor.

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 at the notes made for the first exercise at the beginning of this chapter. Is there anything that you would like to add to them?
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 safety can better prepare the community nurse for difficult situations that could arise.




Community Health Nursing

II. New Ways of Working



          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 effectiveinnovationisdescribedbyRoberts(2002), who, in consultations, used three key questions to determinepatients’readinesstogiveupsmoking.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).

         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 the organisational 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 in- depth 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 togetworse,particularlyastheprofileofcommunity 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 ServiceforAllTalents(DOH2000b).Cadetschemes have been reinstated. Further incentives have been provided for those workers (health care assistants) withNVQqualificationstoundertakemorein-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’, whichpractitionerswillbeableto‘stepon’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 life- long learning for all sectors of the workforce, and such initiatives as this demonstrate the commitment.

         Flexible working is further enhanced by ‘family- friendly 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 three- stage 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 organization. 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 (Page 2002) 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 Site news

I. Setting the scene: an introduction


           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 Health Service.

       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 organisations 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 organisation. 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.


          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 co- ordination 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 prioritizing.


          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 fulfill 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.

Community Health Nursing

III: Nursing in a community environment


      Community nurses face many challenges within their evolving roles. The transition from working in an institutional setting to working in the community can be quite demanding at first. As a student on community placement or a newly employed staff nurse, it soon becomes apparent that there is a wide range of factors influencing the planning and delivery of community health care services. Within the home/community context, the issues that impact upon an individual’s health are more apparent.People are encountered in their natural habitats rather than being isolated within the hospital setting. Assessment is so much more complex in the community as the nurse must consider the interconnections between the various elements of a person’s lifestyle.

     Defining health is complex as it involves multiple factors. According to Blaxter (1990), health can be defined from four different perspectives: an absence of disease, fitness, ability to function and general wellbeing. The concept of health has many dimensions: physical, mental, emotional, social, spiritual and societal. All aspects of health are interdependentinanholisticapproach.Itisprudent toviewanindividualwithinthecontextoftheirwider socio-economic situation when considering issues relating to their health. There are acknowledged inequalities in health status between different people within society and major determinants include social class, culture, occupation, income, gender and geographical location. The Acheson report (1998), which informs the present national public health agenda, provides a fairly comprehensive review of the literature/research available on inequalities in health. DOH (1998a) summarises some of the factors influencing health as follows:

• Fixed: genes, sex.

•    Social and economic: poverty, employment and social exclusion.

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

•    Lifestyle: diet, physical activity, smoking, alcohol, sexual behaviour and drugs.

• Access to services: education, NHS, Social Services, transport and leisure.

      These different categories of influences upon health can be particularly useful in providing prompts when considering the health status of a local population of people. Dahlgren and Whitehead (1991) present a comprehensive model consisting of four levels:

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

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

•    Level 3: Social and community networks.

•    Level 4: Individual lifestyle factors.

      The authors state that all four levels impact upon the health status of the individual, for whom age, sex and hereditary factors are also significant. The increased emphasis lately on the development of a primary care-led NHS has come about in response to demographic, technological, political and financial influences amongst others. An increasing population of older people, shorter hospital stays, improvements in technology and patient preference have all contributed to the movement of resources from the acute to the primary care sector. The development of new competencies to provide services away from hospital settings (Thomas 2000) means that an increasing number of people with both acute and chronic conditions will eventually receive care at home or in a range of other locations within the community. It is envisaged that hospitals will mainly provide diagnostic and specialist services in the future.


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

               Needs assessment requires more than epidemiological data on geographically defined populations. To be responsive to users, it requires the involvement of front-line service providers, particularly those based in the community. These information sources are complementary, and both need to be integrated to plan and deliver appropriate health services. Linking rigorous needs assessment to service definition and the iterative cycle of service assessment and revision requires close collaboration between commissioners and providers. Primary care professionals are closer to service users than most other providers, and have a key role in identifying health care needs.             Primary health care teams (PHCTs) are being required to assess their practice populations’ needs to guide practice and to achieve targets in areas such as health promotion. Systematic approaches to these tasks are required.         Primary care organisations of the future will have to retain their capacity to provide quality personal care and develop a population orientation if they are to move from a demand- led service – however responsive – to needs-led practice, and a better integration of primary health care, secondary care, social services and the voluntary sector. (King’s Fund 1994: p.1) This approach to primary health care is just as relevant today, particularly as we are now providing services to defined populations within primary care trust (PCT) boundaries. It is clearly important that we consider the actual/potential needs of our given population – regardless of our discipline – if we are to provide services that are relevant and efficient.

         Bradshaw’s taxonomy of need (1972), which describes four types of need, provides a useful starting point when addressing this subject: (1) ‘normative’ need is need as defined by professionals; (2) ‘felt’ need is a want as perceived by the population; (3) an ‘expressed’ need is a demand for a felt need to be met; and (4) a comparative need is defined by comparing services provided to individuals/populations with similar characteristics. In order for services to target needs appropriately, they need to respond to felt and expressed needs rather than normative need. Providing ‘needs-led’ services can be somewhat challenging for community nurses as it may well involve a greater empowerment of the client and a willingness on the part of the community nurse to re- examine their own motives/reasons for providing the current service in the way they do. This may lead to a fairly major change in the organisation of the service for the future, which will require regular evaluations. In a review of the district nursing services across England and Wales, the Audit Commission (1999) recognised that at least one in ten referrals to district nurses (DNs) are inappropriate. It is recommended that DNs define more clearly the service they provide. One of the major reasons for inappropriate referrals appears to be a misunderstanding on the part of colleagues within the primary health care team regarding the role andtheresponsibilitiesofDNs.Inresponse,DNscould address this issue in a number of ways.

          Community nurses can identify the needs of their given population by conducting a health needs assessment, which is a process of gathering information from a variety of sources in order to assist the planning and development of services. As society is constantly changing, health needs assessment is not a static exercise. According to the extract from Community- oriented Primary Care (King’s Fund 1994) quoted above, data is required regarding disease patterns (epidemiology) and public health in a particular area (PCT or locality within PCT), as well as information 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.

           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. Any attempt to analyse the series of complex processes that make 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 known as participatory rapid appraisal has been described elsewhere (Chilton and Barnes 1997) and involves community members in the collection of information and in decision making related to this information. Originally used in developing countries to assess need within poor rural populations, it has been employed in deprived urban areas (Cresswell 1992). A wide variety of data collection methods are 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 (DOH 1997, 2000a, 2001) stresses the importance of a localised approach to community health care service provision. Each PCT 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 PCT has its own individualised local targets for public health identified within a HIP and 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 public health department within the health authority, general practice (GP) profiles and caseload analysis data obtained from local health care practitioners. By systematically reviewing local information sources and working within government/professional guidelines, community specialist practitioners have an opportunity to develop practice and more collaborative ways of working.

               DOH (2001) highlights the importance of front- line staff taking responsibility for implementing many of the recent changes in the NHS. This will involve community nurses becoming more actively involved in health needs assessment. It has been recognised that there are populations whose health care needs are unmet (Latimer and Ashburner 1997), which presents community nurses with the challenge of redefining their services to more accurately respond to the needs of their particular patient group. Traditionally, many community nurses have responded to referrals, which are frequently inappropriate and often do not represent the most urgent needs of the population in terms of priority. Responding more appropriately is not any 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,themoreadvantagedpeopleinsocietytend to receive better health care services (Acheson report, 1998). Current NHS policy is attempting to rectify this anomaly and end the so-called ‘postcode lottery’, whichsuggeststhathealthstatuscanbedetermined on the basis of where a person lives. 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 front-line staff to implement them locally and interpret them according to local conditions.

            Ensuring that local NHS organisations work together with local authorities, especially with regard to social care, is fundamental to the new ways of working, and PCTs are in an ideal position to facilitate this collaborative approach. Clearly, there are differences between PCTs in terms of the locations in which community health care services are offered to patients. Provision will vary considerably between a rural and an urban PCT. For example, in a rural location, there might tend to be more community hospitals, providing accessible local services that are not of a specialist nature, whereas walk-in centres, for example, tend to be located in more densely populated locations, such as city centres and airports. In order to provide high-quality care to patients, community nurses need the necessary skills, knowledge and expertise and it is the responsibility of individual practitioners and their employing authority to ensure that the appropriate training is organised. Working alongside their local workforce confederation, PCTs or other employing authorities plan for the future recruitment and training of new staff and the continuing professional development of existing staff. PCTs will also develop and update policies and procedures in relation to the clinical responsibilities of community nurses and these should relate to the latest benchmarking criteria and government/professional guidelines. Under the present government, it is suggested that patients should have an influence on the provision of health care services. Patients’ views should therefore be considered by board members of the PCT, who are charged with the responsibility of ensuring patient participation.


         A new understanding of community care as ‘process’ rather than ‘context’ is proposed by Clarke (1999) to enable us to value community nursing as advanced specialist practice in its own right, rather than as institutional or acute care nursing in another setting. Eng et al. (1992) encourage an ‘understanding that a community is a ‘living’ organism with interactive webs of ties among organisations, neighbourhoods, families and friends’. Community nursing takes place in a wide variety of settings.

     Recent government reforms in terms of the structures and systems that form the NHS (e.g. DOH 1997, 2000a, 2001) have led to an acknowledgement by community specialist practitioners that their roles and responsibilities need to be examined and redefined in preparation for the new challenges ahead. Leadership, practice development and partnership working are key elements within the roles of all community specialist practitioners (DOH 2001). The Nursing and Midwifery Council (NMC) are currently attempting to redefine the role of the specialist practitioner. In the early 1990s, the UKCC conducted the PREP (post-registration education and practice) project to clarify the future training requirements for post-registration nurses. At the time, eight community specialist practice disciplines were identified: occupational health nursing, community paediatric nursing, community learning disability nursing, 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 one year in length. According to the UKCC, 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’. It is perhaps particularly pertinent in the current context of partnership working that we embrace those common aspects of our practice as community specialist practitioners. In espousing the uniqueness of the individual disciplines, there is an acknowledged danger that nurses will miss out on opportunities to influence a primary care-led NHS (Quinney and Pearson 1996).

Occupational Health Nursing (OHN)

            OHN is a relatively new nursing discipline that has developed from its origins in ‘industrial nursing’ in the mid-19th century, when the role was mainly curative rather than preventative (Chorley 2001). Occupational health nurses work within the wider occupational health services and play a preventive role in advising employers, employees and their representatives on health and safety issues in the working environment, and the adaptation of the working environment to the capabilities of the employees (RCN 1991). The role of the OHN is concerned with preventing ill health which affects the ability to work, and ill health caused by employment, and also with promoting good health and developing health promotion strategies in the workplace. OHNs’ responsibilities are as varied as the industries/businesses in which they are employed. Chorley (2001) identifies five elements of the OHNroleasbeingprofessional,managerial,business, environmental and educational responsibilities. Many factors influence the future role of the OHN, including political, economic and public health care strategies. However, Chorley (2001) argues that OHNs can professionally influence key areas of their practice by assessing future health care trends through analysing research, reviewing epidemiological data and conducting needs assessment.

Community Children’s Nursing (CCN)

             According to the Royal College of Nursing (RCN 2002b), the past few decades have seen considerable growth and innovation for CCN services. In 1987, there was a total of 25 services in the UK; currently, there is a total of 150 CCN teams in England alone. There are very few areas (mainly rural) without a service. The development of the CCN services has been supported by a number of pertinent reports (DOH 1991; DOH/NHSE 1996, Audit Commission 1993). The Department of Health and the NHS Executive (1996) agree that ‘CCN services should be led, and predominantly staffed, by nurses who possess both registrations as a children’s nurse and experience of community nursing’. There are three key elements within the delivery of CCN services: (1) first contact/acute assessment, diagnoses, treatment and referral of children; (2) continuing care, chronic disease management and meeting the imperatives of the Children’s NSF; and (3) public health/health protection and promotion programmes – working with children and families to improve health and reduce the impact of illness and disability (DOH 2002).

Community Learning Disability Nursing (CLDN)

        According to Barr (2001), there was a recognition of the need for more community-based services to be provided for people with learning disabilities living at home and their families in the mid-1970s. Around this time, different models of service were developing around the notion of ‘normalisation’, which is the underlying philosophy of many of the services provided for people with learning disabilities. Normalisation may be defined as ‘a complex system which sets out to value positively devalued individuals and groups’ (Race 1999). Service principles for learning disability services should be based on an individual’s assessed needs; flexible and sensitive in service provision; equitable and integrated with an accessible range of services that offer priority to those in the greatest need; prompt, effective and comprehensive and evaluated by the degree to which they provide privacy, dignity, independence, rights and fulfilment for people with learning disabilities (DHSS 1995). CLDNs often work closely with other members of the multidisciplinary team. Bollard and Jukes (1999) stress the importance of CLDNs clarifying their working relationships with other community specialist practitioners and members of the primary health care team in order that people with learning disabilities do not fall between services or receive conflicting advice.

Community Mental Health Nursing (CMHN)

         The CMHN service has been well documented since its inception in the mid-1950s. The expertise of the CMHN lies in assessing the mental health of an individual within a family and social context. CMHNs may be located in health centres, GP practices, voluntary organisations and accident and emergency departments. They represent people with mental health needs and provide high quality therapeutic care (Long 2001). Four elements underpin the professional practice of CMHNs. First is a guiding paradigm, which involves respecting, valuing and facilitating the growth unique to each individual (Rogers 1990). Second, therapeutic presence is needed to restore clients’ dignity and worth as healthy, unique human beings. Third, the therapeutic encounter, which is essential for healing and growth. Finally, the principles of CMHN, which include the search for recognised and unrecognised mental health needs; the prevention of a disequilibrium in mental health; the facilitation of mental health-enhancing activities; therapeutic approaches to mental health care and influences on policies affecting mental health (Long 2001). Although several models are emerging in the organisation, delivery and evaluation of community mental health services, the guiding principles remain the same. Community profiling and collaborative working are considered by Long (2001) to be pivotal in promoting the mental health of the nation.

General Practice Nursing (GPN)

         Nurses have been working in general practice for more than 80 years (Hyde 1995). Since the early 1990s, the number of practice nurses has grown considerably in response to the demands of general practice. The service expanded from 1515 nurses in 1982 to 10198 in 1998 (RCGP 2000). At the same time, the range of services they provide has also developed rapidly. Practice nurses frequently fulfil the role of ‘gatekeeper’ and are relatively easily accessible and acceptable to patients as they are located within GP surgeries. The role of the practice nurse is wide- ranging and covers all age groups within the practice population (Saunders 2001). The types of service provided might include tasks such as ear syringing and venepuncture through to nurse-led chronic disease management programmes operated within agreed protocols. The expansion of nurse prescribing will enhance the provision of care for practice nurses working within clinics such as these (DOH 2000b). Chronic disease management and screening/secondary prevention programmes are areas of expertise for practice nurses, which could be further developed (Eve and Gerrish 2001). More recently, practice nurses have become involved in the implementation of NSF guidelines at a local level and often play a key role in establishing nurse- led clinics to tackle public health targets. For example, clinics for people with coronary heart disease.

School Nursing

          School nurses have been employed within the school health service for more than 100 years but have not been afforded, despite their importance, the same status as their community specialist practice colleagues, according to Thurtle (2001). DeBell and Jackson (2000) state that the assessment of the specific health-care needs of school age children in the community is essential in the development of the school nursing service. They also emphasise that ‘school nursing is committed to the health improvement of children and young people of school age’. In addition to delivering core health surveillance programmes within schools, school nurses consider themselves to have particular responsibility for promoting healthy lifestyles and healthy schools; for child and adolescent mental health; chronic and complex health needs; and for vulnerable children and adolescents (Obeid 2001). DOH (1999a, p.13) emphasises that school nurses are ‘playing a vital role in equipping young people with the knowledge to make healthy lifestyle choices’. 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 multi-disciplinary 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 on and co-ordinating health care to children with medical needs. In addition to this the DOH (1999b) identifies school nurses as public health practitioners with a specific role in the healthy school programme, tackling teenage pregnancy and working with families.

Health Visiting (HV)

       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 role are the search for health needs; stimulation of awareness of health needs; influence on policies affecting health; and facilitation of health-enhancing activities. Although health visitors (HVs) will continue to maintain their public health role, they are also developing a much wider role in primary care. Traditionally, the focus of their work has been on monitoring the development of the under-fives. Several documents (Acheson 1998; DOH 1999a,1999b) have defined a new health agenda for the future, in which health visitors have a key role. A statement from Making a Difference (DOH 1999a, p. 132) reads: ‘we are encouraging [health visitors] to develop a family-centred public health role, working with individuals, families and communities to improve health and tackle health inequality’. Family health maintenance, child protection and community outreach with vulnerable groups are examples of the type of work HVs undertake. Appleby and Sayer (2001) stress the importance of health visitors finding new ways of measuring the effectiveness of their work, which tends to have long-term benefits for society but has always been notoriously difficult to quantify.

District Nursing (DN)

          District nurses can trace their roots back to the mid- 1800s at least and the historical development of the service is well recorded. District nurses used to work in relative isolation but are more likely nowadays to work within a team (Thomas 2000). The role of the district nurse has evolved over time in response to political influences 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 (Audit Commission 1999). The three major elements of the role are that of clinical expert, manager and teacher (Clarridge et al. 2001). District nurses care for people with acute and chronic illnesses as well as those requiring palliative care. The majority of people on the district nurse’s caseload tend to be from the older generation. According to the RCN (2002a), the value of the district nursing service comes from its holistic approach to patient need and its ability to implement a package (often complex) of treatment that transcends health and social care. District nursing work is complex and wide ranging. Intermediate care, rehabilitation, rapid response and prevention of admission teams are current initiatives within the modernisation programme. District nurses are playing key roles in developing many of these innovative services.

Integrated Nursing Teams

        Integrated nursing teams are ‘teams of community- based nurses from different disciplines, working together within a primary care setting pooling their skills, knowledge and ability in order to provide the most effective care for their patients within a practice and the community it covers’ (HVA 1996). According to the Department of Health (1999a), integrated nursing teams are beneficial as they promote greater understanding of each other’s roles, help to reduce duplication and allow for more targeted use of specialist skills. Considering the acknowledged importance of tailoring services to patient need, an approach that responds to and addresses nursing/health issues identified as part of an individual or population- based health needs assessment exercise is preferable.

       Beech (2002) explores the potential for integrated nursing teams in primary care settings and recognises that, at present, very little research-based evidence exists in relation to integrated nursing teams, particularly in terms of patient outcomes. She believes that all those people with a vested interest need to be consulted prior to the establishment of integrated teams and a structured approach is required for successful practice development.


        With the launch of their new manifesto for health in 1997, the Labour government stressed the importance of delivering quality standards within the NHS: Professional and statutory bodies have a vital role in setting and promoting standards but shifting the focus towards quality will also require practitioners to accept responsibility for developing and maintaining standards within their local NHS organisations. For this reason, the Government will require every NHS Trust to embrace the concept of ‘clinical governance’ so that quality is at the core, both of their responsibilities as organisations and of each of their staff as individual professionals. (DOH1997) The DOH (1998b) reinforces the importance of ensuring that the services provided by health care professionals are of a high quality. The present government have established a number of organisations and initiatives designed to support a culture of excellence in health care: the National Institute for Clinical Excellence (NICE), national service frameworks (NSFs), the Commission for Healthcare Audit and Inspection (CHAI), the National Performance Framework, a National Survey of Patient and User Experience, and clinical governance (CG). NICE provides advice on best practice with regard to existing treatments and evaluates new health interventions. In so doing, it encourages the use of the most appropriate treatments in terms of clinical and cost effectiveness. NSFs are evidence-based national guidelines issued in relation to the treatment of specific client groups or disease categories. They act to ensure that people receive integrated, safe and clinically effective care (RCN 2002c). Collaborative practice is a prerequisite for the successful implementation of the NSFs. NSFs include strategies to support their implementation and establish performance milestones against which progress, within an agreed timescale, can be measured. NSFs form one of a number of initiatives designed to raise quality and decrease variations in service. There are plans to publish only one new framework annually. An external reference group (ERG) consisting of health professionals, service users and carers, health service managers, partner agencies and other advocates assists in the development of the NSFs with the support and supervision of the DOH. Since its launch in April 1998, the NSF programme has embraced established frameworks on cancer and paediatric intensive care and developed the mental health NSF (September 1999), the coronary heart disease NSF (March 2000), the national cancer plan (September 2000), the older person NSF (March 2001), the diabetes NSF (2001) and the children’s NSF (2003). NSFs are being prepared for renal services and long-term neurological conditions. The Commission for Healthcare Audit and Inspection (CHAI) is due to replace the Commission for Health Improvement (CHI), the national body that supports and monitors the quality of clinical governance and of clinical services. CHAI will be a more powerful health inspectorate, responsible for both public and private sectors. CHAI’s other responsibilities will include conducting ‘value for money’ audits; determining star ratings for all NHS bodies and recommending special measures where necessary; validating performance assessment data, including waiting list information; reporting on NHS organisations’ performance; providing independent scrutiny of patient complaints and reporting annually to parliament on health care progress and the resources that have been used. There are plans to create a single Commission for Social Care Inspection at the same time as CHAI, with a legal obligation on the two bodies to co-operate. The National Performance Framework is designed to give a rounded picture of NHS performance and will address six areas: health improvement; fair access to services; effective delivery of appropriate healthcare; efficiency; patient/carer experience and health outcomes of NHS care. The National Survey of Patient and User Experience is conducted annually to elicit the opinions of people in relation to care provided by the NHS. The current government has proposed a 10-year modernisation programme for the NHS, which incorporates clear national standards, local delivery, statutory duty, life-long learning and professional self-regulation, monitoring of services through CHAI and the NHS Performance Framework and User survey. Clinical governance (CG) is the central concept that embraces all of these elements. It is a framework through which NHS organisations are accountable for continuously improving the quality of their services. According to Bennett and Robinson (2002), clinical governance is the vehicle for identifying not only excellence in care but also those aspects of practice that require further development. The RCN (2002c) describes three main elements within clinical governance: quality improvement, risk management and management of performance and systems for accountability and responsibility. Quality improvement includes standard setting, clinical audit and evidence-based practice. Standards are devised in line with national/local clinical guidelines and evidence-based best practice and then implemented. Clinical audit is conducted to evaluate whether care meets the required standards and, where necessary, improvements are made, implemented and re-audited. Risk management involves all of those activities designed to promote best practice and avoid detrimental events happening. Individual practitioners are encouraged to view critical incidents and patient complaints positively and to learn from experiences, supported by a ‘no blame’ culture. In the clinical area, this involves clinical supervision, continuing professional development and effective clinical leadership. Within the wider NHS organisation, risk management systems might include incident reporting procedures and strategies/protocols to prevent adverse events. Systems for accountability and responsibility place a statutory responsibility for care within all NHS organisations. PCTs, and more specifically the chief executive, are responsible for the quality of care provided within their organisations. A clinician is appointed within each NHS organisation with responsibility for the implementation and evaluation of the CG framework. A spirit of teamworking and commitment to high standards of care is essential if CG is to be effective.

        According to Zeh (2002), CG needs to be considered alongside professional self-regulation and continuing professional development. Increasingly, community specialist practitioners are being encouraged to develop their practice by discussing and sharing experiences with colleagues and regularly updating their skills, knowledge and expertise. In addition, there is a requirement to voice any concerns regarding compromised care and actively link into the wider organisational CG framework. Community nurses are accountable to the Nursing and Midwifery Council (NMC) and the public for the duties they perform. With CG, there are increased opportunities for patient involvement in decisions about care and more explicit mechanisms in place to make complaints and put forward their views.