Categories
Community Health Nursing

IV. Personal Safety in the Community

                                                      

INTRODUCTION

          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.

SAFETY AT WORK

       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.

BEING STREETWISE

          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.

PREPARATION FOR HOME VISITING

          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.

CAR SAFETY

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.

INTERPERSONAL RELATIONSHIPS AND NON-CONFRONTATIONAL BEHAVIOUR

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.

ORGANISATIONAL SUPPORT

              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.

HSE’S FIVE STAGES OF RISK ASSESSMENT

          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.

MANUAL HANDLING IN THE COMMUNITY

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.

REPORTING INCIDENTS

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.

SUPPORT AND COUNSELLING

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.

CONCLUSION
After careful consideration of the issues addressed within this chapter, turn back to the learning outcomes at the beginning and think about each one in turn. Look back 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.

 

 

 

Categories
Community Health Nursing

Setting the scene: an introduction

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

SOCIAL AND POLITICAL INFLUENCES UPON COMMUNITY NURSING

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

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

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

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

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

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

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

CHALLENGES AND OPPORTUNITIES FOR COMMUNITY NURSING

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

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

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

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

DEMOGRAPHIC ISSUES

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

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

COMMUNITY SPECIALIST PRACTICE

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

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

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

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

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

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

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