A number of quality improvement and accountability procedures can be found currently within learning disability care settings. These include clin-ical audit, research, evidence-based practice, quality assurance, complaint pro-cedures, risk assessment and management, clinical supervision, continuing professional development and lifelong learning (Figure 10.1).
Cost effectiveness
(best value)
Evidence-based practice
Complaints procedure
Quality assurance
User and carer involvement
Clinical audit (processes and
outcomes) CPD, lifelong
learning and supervision
Standards and clinical guidelines Critical
incidents
Risk management
CLINICAL GOVERNANCE
Figure 10.1 Clinical governance.
Clinical governance in learning disability nursing and guidelines for practice 119 One interpretation of clinical governance is that it is a framework of pre-existing agenda that, when implemented, together ensure consistent excel-lence in care delivery. To some extent clinical governance is also concerned with changing elements of the culture of human services by challenging ingrained thinking and entrenched ways of working to improve standards of care. This is particularly relevant to some learning disability settings because of past evidence of long-standing problems in residential services caused by institutionalised ways of working. To paraphrase Mark Twain, by doing things the way you always did, you always get what you always got.
Clinical governance, therefore, is a change-process underpinned by a framework that draws together the various initiatives shown in Figure 10.1 and aims to assist practitioners in the maintenance and improvement of stand-ards of care with the person with learning disabilities as the central focus.
The framework of clinical governance and accountability is supported by professional self-regulation. Nurses are subject to standards set by their professional regulatory body, the Nursing and Midwifery Council (NMC).
Professional self-regulation supports the process of clinical governance by requiring practitioners to monitor themselves and their own good practice.
This is guided by three main principles:
• promoting good practice
• preventing poor practice
• intervening in unacceptable practice
It is thought that the application of the principles of clinical governance will
‘provide an environment in which clinical excellence can flourish and high standards of patient care can be promoted’ (UKCC, 2001a, p. 7).
Clinical governance requires all practitioners to regulate their practice, and fundamental to this concept is the development of appropriate standards and guidance for professional practice. These are encapsulated in a range of regulatory documents and codes produced by the UKCC. Documents such as the Code of Professional Conduct (UKCC, 1992a) Guidelines for Pro-fessional Practice (UKCC, 1996a) and The Scope of ProPro-fessional Practice (UKCC, 1992b) have defined the responsibilities of registered nurses to patients, colleagues, employers, the public and themselves and are pertinent to all practising nurses, health visitors and midwives. At the time of writing this chapter only the Code of Professional Conduct has been updated by the NMC (2002b). However, the particular vulnerability of people with learn-ing disabilities, and the documented history of abuse experienced by this client group (Moore, 2001), make it vital that each registered learning disability nurse safeguards and promotes the interests of people with learning disabilities.
Next, this chapter briefly explores specific guidelines that have been constructed for mental health and learning disability nurses.
The document Guidelines for Mental Health and Learning Disabilities Nursing – A Guide to Working with Vulnerable Clients (UKCC, 1998a) expli-citly recognises that specific guidance was needed for mental health and
120 Accountability and Clinical Governance in Learning Disability Nursing learning disability nurses because of the vulnerability of these client groups and because of the large number of practitioners working in the private or independent sector. The guidelines were designed to enhance awareness and understanding of accountability within an ethical, legal and professional context and cover pertinent issues such as:
• consent
• interdisciplinary working
• evidence-based practice
• advocacy
• autonomy
• relationships
• confidentiality
• risk assessment and management Each of these is now briefly discussed.
Consent
In learning disability practice it is usually more helpful to talk of valid con-sent and this comprises three main elements:
• it is given by a competent person (or their representative)
• it is given voluntarily
• it is informed
Obtaining consent depends on the capacity and competence of the person with learning disabilities to understand the information given to them and to make an informed decision regarding their treatment or care. The capa-city of people with learning disabilities to give consent may be hampered by a range of intellectual, physical, sensory or communication difficulties.
These may significantly impair their ability to consent to treatment or care.
Consequently, the best interests of the client and the duty of care must be assessed on an individual basis to ensure that any decisions made are rea-sonable, ethical and appropriate. Recently, the Department of Health has issued specific guidance entitled Seeking Consent: Working with People with Learning Disabilities (Department of Health, 2001d). It is advised that all students and practitioners familiarise themselves with this document and ensure that its requirements are assimilated into their practice.
Interdisciplinary working
‘Providing care is an inter-professional and inter-agency activity and it should be based on co-operation, shared understanding and respect’ (UKCC, 1998a, p. 10). Effective team working with clear lines of accountability is essential to ensure the health and well-being of people with learning disabilities.
Client care and needs should always take priority over the resolution of
Clinical governance in learning disability nursing and guidelines for practice 121 interprofessional differences and conflicts. Interprofessional working is par-ticularly important in view of the multi-agency context of care for people with learning disabilities. Increasingly, the lead agency in providing care will be social services and not health services (Department of Health, 2001c).
Clearly there are significant challenges here for the practice of learning dis-ability nursing and, whereas this speciality has a long history of interdis-ciplinary work, it will now have to face the challenge of inter-agency work.
Evidence-based practice (EBP)
EBP is a requirement that should be used to inform and develop all nursing practice in learning disability contexts. Nurses are responsible for continu-ally updating their practice (as described in the Code of Professional Conduct (NMC, 2002) ) and ensuring that the best possible evidence is taken into account when making clinical decisions. Muir Gray (1997) suggests that EBP ‘is an approach to decision making in which the clinician uses the best evidence available, in consultation with the patient, to decide upon the option that suits the patient best’ (p. 9). As with clinical governance, patient or client choices are central. EBP is also supported by the Research Govern-ance Implementation Plan (Department of Health, 2001e) which aims to give guidance on good practice in health and social care and promote and enhance the research culture.
Advocacy
Clinical governance and accountability place safeguarding the interests of clients at the centre of practice and nursing care. However, within learning disability contexts it must not be assumed that the nurse necessarily knows what is best for the client as: ‘advocacy is about promoting the clients’ right to choose and empowering them to decide for themselves’ (UKCC, 1998a, p. 14).
The literature on advocacy in learning disability remains divided as to whether advocacy is a legitimate and integral part of their nursing role (Cabell, 1992; Carpenter, 1992). Some authors have suggested that a conflict of interest militates against assuming such a role (Gates, 1994, 2001). The guidelines acknowledge this potential area of conflict and suggest that in most circumstances an independent advocate can provide more objective support to clients.
Autonomy
The guidelines for learning disability nurses support those of the Code of Pro-fessional Conduct (NMC, 2002b) and emphasise the importance of fostering client independence and autonomy. In practice, this means that decisions made by the multidisciplinary team should not only be in the client’s best interests,
122 Accountability and Clinical Governance in Learning Disability Nursing but should also, where possible, involve the client. Central to the issues of pro-moting autonomy is the question of who holds the power to make decisions?
Valuing People (Department of Health, 2001c, p. 26) has identified a gov-ernmental objective (no. 3) as being: ‘To enable people with leaning disabilities to have as much choice and control as possible over their lives through advoc-acy and a person-centred approach to planning the services they need.’
Relationships
The guidelines again refer practitioners back to the Code of Professional Conduct (NMC, 2002b). This document states that: ‘in the exercise of your professional accountability, [you] must avoid any abuse of your privileged relationship with patients and clients and of the privileged access allowed to their person, property, residence or workplace’.
All nurses are required to be aware of the power imbalance that exists between client and carer. Also, people with learning disabilities are particu-larly vulnerable to the misuse of power by their carers and registered nurses.
In addition, Practitioner-Client relationships and the prevention of abuse (UKCC, 1999a) makes explicit the expectations of practitioners in therapeutic relationships and provides guidance on the prevention, detection and man-agement of abuse that may occur.
Confidentiality
The UKCC Guidelines for Professional Practice (UKCC, 1996a) have pro-vided advice on confidentiality and its importance within the therapeutic relationship. The Guidelines for Mental Health and Learning Disabilities Nursing (UKCC, 1998a) stated that a clear standard of confidentiality should always be explained to clients and documented, and that confiden-tiality should only be violated in exceptional circumstances with clear justification. These circumstances included when:
• the client consented
• it is required by law
• it is required by the order of a court
• it is in the public interest
The duty of confidentiality often poses specific problems for learning disability nurses when working with clients with a history of offending behaviour when they also and sometimes simultaneously have to liaise with colleagues in the criminal justice system.
Risk assessment and management
Risk management involves assessing the extent of risk relating to client care, care systems and the environment of care: ‘The calculation of risk must be
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).