The challenges of effectively implementing clinical governance in services 123 based on your knowledge, skills and competence and you are accountable for your actions and omissions’ (UKCC, 1998a, p. 22). The guidelines acknowledge the difficulty in eliminating risk entirely and emphasise the nurse’s responsibility for reducing risks to an agreed acceptable level. It is recom-mended that the reader refers to a recent publication on risk assessment and management that was based on empirical work conducted in the field of men-tal health and learning disability settings (Alaszewski et al., 1997).
The document Guidelines for Mental Health and Learning Disabilities Nursing – A Guide to Working with Vulnerable Clients (UKCC, 1998a) has provided specific reference points for learning disability nurses, in addition to the existing guidelines and standards. Also, students and practitioners should be aware of professional misconduct and that there are a number of other documents providing guidance on nursing’s accountable system, whereby practitioners can be removed from the register because they are a risk to the public. These include:
• Protecting the public – an employers guide to the UKCC registration confirmation service for nurses, midwives and health visitors (UKCC, 1999b)
• Complaints about Professional Conduct (UKCC, 1998b)
• Reporting Misconduct – information for employers and managers (UKCC, 1996b)
• Reporting unfitness to practice – information for employers and managers.
Issues arising from professional conduct complaints (UKCC, 1996c) The continuous maintenance and improvement of standards of knowledge and competence is essential to promote higher standards of care and to ensure that the practitioner is safe to practice in a constantly changing healthcare environment. Therefore, continuing professional development (CPD) seeks to ensure that the practitioner stays up to date and competent to practice.
It encompasses informal private learning and reflection as well as formal courses and supportive mechanisms, such as mentorship, preceptorship and clinical supervision. It is suggested that CPD has the potential to make a significant contribution to clinical governance in that it recognises the importance of maintaining and improving clinical competence and knowledge. The UKCC’s post-registration education and practice (PREP) framework is a CPD standard. In addition, clinical supervision (in Supporting Nurses, Midwives and Health Visitors through Lifelong Learning, UKCC, 2001b) contributes to risk assessment by providing opportunities for reflection on clinical prac-tice (Wolverson, 2000).
The challenges of effectively implementing clinical governance
124 Accountability and Clinical Governance in Learning Disability Nursing The pervasive challenge to implementing clinical governance in services for people with learning disabilities is engendering meaningful changes in the way services are delivered. Changing management and cultural mindsets can be seen to be an overarching challenge to implementing clinical governance.
Many factors contribute to the difficulty of ensuring cultural change in learn-ing disability settlearn-ings, and these factors are listed in Box 10.1.
The potential barriers listed in Box 10.1 are generalised in that they are barriers hindering the implementation of clinical governance in all services and are applicable to all client groups. In relation to implementing clinical governance in services for people with learning disabilities, it is apparent that not only are all the barriers listed in Box 10.1 relevant, but that they are exacerbated by other factors that are more prevalent in learning disability services than perhaps in other services. These specific issues are outlined in Box 10.2 and each is to be discussed below.
Box 10.1 Potential barriers to the changes necessary for the implementation of clinical governance
• professional apathy
• short-term outlook of clinical governance
• poor awareness of clinical governance
• misinterpretation of the concept, e.g. a belief that clinical governance is merely a tool for management to monitor staff
• poor leadership
• a limited research portfolio on which clinical effectiveness should be based
• limited resources in terms of staff, time and support for those implementing clinical governance
• fragmented multidisciplinary working
• poor information systems
• poor communication
• change burnout – staff becoming overloaded by constant and incomplete change(s)
• theory – practice gap – when clinical governance remains a theoretical con-cept and fails to influence practice.
• scepticism – professionals doubt that clinical governance will achieve anything constructive
• maintaining motivation – initial enthusiasm for clinical governance can easily dissipate when seemingly insurmountable barriers exist
• priorities – clinical governance can be perceived to be peripheral when com-pared to more immediate concerns; also management and clinicians may lack agreement about priorities
• lack of consistency – different professionals such as doctors, nurses and researchers may have different interpretations and expectations of clinical governance
• the ‘emperor’s new clothes’ – care staff may perceive clinical governance to be a transient fad and believe they have ‘seen it all before’
The challenges of effectively implementing clinical governance in services 125
Fragmented partnership working
Multi-agency partnership working has long been a laudable goal in the pur-suit of providing quality care for people with learning disabilities. Valuing people (Department of Health, 2001c) has clearly identified strong partner-ship working as a priority, and has stated that there is great variability across the UK in terms of availability, consistency and quality of services. In addition, it is evident that services for people with learning disabilities are increasingly fragmented, with support being provided by a range of agencies such as social services, education and the agencies in the private, independent, not-for-profit and voluntary sectors. Weinstein (1998) has described this fragmentation as a consequence of a plethora of inter-linking issues that included conflict between agencies regarding values, unwilling-ness to accept responsibility, lack of shared aims or goals and lack of under-standing of the roles and function of different professionals and agencies.
Therefore, if clinical governance within learning disability nursing is to be effective then it will need to be implemented in creative and flexible ways to transcend the boundaries between agencies and professions.
User and carer involvement
A key component of the clinical governance framework is a commitment to include the views of service users and carers in the pursuit of quality care.
This element of clinical governance is, in the case of people with learning disabilities, strengthened by the recent advent of person-centred planning (PCP) as outlined in Valuing People (Department of Health, 2001c). The benefits of user involvement are largely self evident and according to Lugon &
Secker-Walker (2001) include:
• providing a mechanism for care staff to demonstrate accountability to the people they serve
• improved communication between users and staff
• a mechanism whereby the experience of users can influence decision making
• a facility for users to express their preferences
• a forum for expressing concerns
• a formal system for processing complaints
Box 10.2 Specific significant barriers to implementing clinical governance in learning disability services
• fragmented partnership working
• difficulties in involving users and carers
• the diverse spectrum of needs associated with learning disability
• quality of life issues
126 Accountability and Clinical Governance in Learning Disability Nursing User involvement in clinical governance is vitally important because it can assist in making the process of care meaningful to people with learning disabilities, and offer ways of improving their lives. However, barriers to effect-ive user involvement must be overcome. Notwithstanding this commitment, opportunities for meaningful consultation are rare, and the methods by which people with learning disabilities are involved in decision-making processes are often seen as ‘tokenism’ (Sang & O’Neill, 2001). Kelson (1997) has identified a number of other barriers that include:
• professional resistance (that is professionals may not value the contribu-tion of users)
• concerns about confidentiality
• concerns regarding whether user and carer spokespeople are truly repres-entative of the client group and the lack of support provided for people with learning disabilities to contribute to clinical governance programmes
• users and their representatives such as advocacy services, may also have agenda that are at odds with mainstream views
The spectrum of need
The term learning disability covers a spectrum of needs, from people with profound and complex healthcare needs, to people with a high functional ability who require limited support. It should be noted that the vast major-ity of people with learning disabilities are not ill, but that they may require social support at different times during their lives. Any system of clinical governance will need to be flexible enough to offer a significant quality of improvement for this diverse group of people.
Quality of life
A key component of the clinical governance framework, is quality improve-ment. The Royal College of Nurses (RCN, 1998a) has stated that: ‘Quality improvement activities encompass standard settings and monitoring, clinical audit and evidence-based practice.’
This drive to continually improve the provision of services is obviously a commendable goal. However, the quality of life of people with learning disabilities can be extremely difficult to ascertain (Cummins, 1997). The improvement activities mentioned by the RCN (1998a), if applied to learn-ing disability services, are often undertaken in subjective, bureaucratic and arbitrary ways that invariably achieve little meaningful improvement for service users. Ellis & Whittington (1993) have discussed how quality is notoriously difficult to define in the context of care delivery. Walshe et al.
(2000) have stated that ‘quality’ can be used as an umbrella term to cover everything without changing anything in particular. Therefore, any clinical governance programme applied to people with learning disabilities needs to
Solutions to the barriers associated with implementing 127 acknowledge the potential barriers to improving the quality of the service-user experience and provide solutions.