it. This would mean that the health visitor would not seek to make contact with these families, believing that the families themselves would contact the health visitor if they had any concerns. It takes a highly skilled practitioner to be able to make this assessment on the needs of all families on their case load and get it right.
Apart from the need for clear professional judgement, Cowley &
Andrews also state that it is not only the individual practitioner or service commissioner who is responsible for determining an acceptable standard, but also what is determined to be a reasonable standard of practice by the pro-fession. They continue, saying:
There is a need for a credible body of professional opinion against which the actions of individual practitioners or service plans made by trusts can be judged. The source of such a body of professional opinion is, at pre-sent, also unclear. (Cowley & Andrews, 2001, p. 141) This clearly falls within the remit of the clinical governance agenda (see below).
Legal and professional issues in community nursing
Nurses have been attracted to working in the community for a variety of reasons, but high on the list is the feeling that they have greater autonomy and professional responsibility, allowing for more freedom in their decision making and determining the care that they provide. Independent professional practice, valued by community nurses, brings with it a greater responsibil-ity to maintain the highest standards of professional competence. The risk of failure to deliver optimum care can be higher when individuals have a greater degree of autonomy, especially as so much of care in the community is unobserved activity.
A welcome development is clinical supervision, endorsed and encouraged both at Government level and by the profession (Department of Health, 1999c;
Kohner, 1994). A flexible approach to clinical supervision is suggested by Dickerson, who sees it as ‘a means to promote and develop quality patient care and confident accountability’ (Dickerson, 1997, p. 190). Walsh (2001) cites a wealth of evidence indicating positive benefits for nurses in terms of professional development and ensuring quality of care, both of which are integral to an individual practitioner’s accountable practice. The need to engage in effective clinical supervision is one of the professional challenges for com-munity nurses, requiring an investment of skill and time. Sines (2001) argues that it should encompass positive and supportive feedback. Clinical supervision should not, however, be seen as a managerial tool for perform-ance review.
As clinical supervision is not mandatory, practice nurses who are directly employed by GPs may face further challenges in finding regular time for reflection on their practice in this manner. Some may have difficulty in justifying time away from patient contact. However, since the integration of
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general practices into larger primary care organisations such as the LHCCs in Scotland, practice nurses may have an increasing sense of belonging to wider nursing communities, and greater opportunities to access support and ideas (Saunders, 2001).
Clinical governance
The need for evidence to inform understanding of complex nursing skills and assessment has never been greater. The ability to articulate the complexities of practice clearly, and identify the evidence of its effects is at the core of accountability. Historically, health visitors, in particular, have suffered from lack of understanding from other professionals about what they do; so mak-ing their skills and judgement visible and explicit was seen as a way of enhan-cing professional standing and convinenhan-cing people of their worth. Today it is even more imperative for reasons of accountability at a time of great change in the nature and delivery of care. Health visitors may not feel appropriately valued, but as Kendall so succinctly states:
there is an obvious managerial response: if you think that your service is a valuable one that should be retained, prove it – and prove it in cost terms, in clinical effectiveness terms and preferably in public health terms as well.
(Kendall, 1999, p. 35) Unless the case can be made the quality of service and the protection of the public may be diminished. Over their time in office the Labour Government has emphasised the importance of quality in the health service and nurses will play a key role in this process (Department of Health, 1997;
Department of Health, 1998; Scottish Executive, 1998). The concept of clinical governance is at the core of this drive for quality, and accountabil-ity is at the heart of clinical governance. The Department of Health defines clinical governance as:
a framework through which NHS organisations are accountable for con-tinuously improving the quality of their services and safeguarding high stand-ards of care by creating an environment in which excellence in clinical care will flourish. (Department of Health, 1998, p. 33) Allen (2000) sees three strands to clinical governance in primary care: increas-ing the accountability of the professionals involved to local communities, to the NHS hierarchy and to other team members. The variety of activities entailed in clinical governance includes: clinical audit, research and development, risk management, quality initiatives, clinical effectiveness activities, team working and improved communication (Clarridge et al., 2001; Adams &
Forester, 2002).
There remains the tension of trying to satisfy equally the issues of ac-countability for each of the three strands as identified by Allen, that of local communities, management and other team members and also the profession,
Clinical governance 149 since there can be conflicts of interest between these groups. Allen sees the need to prioritise some aspects and feels accountability to team members is the ‘bedrock’ of clinical effectiveness in primary care, so good team working with leadership that can address the various agenda for change is essential (Adams & Forester, 2002). Allen thinks that the NHS hierarchy will be satisfied through attention being given to a mixture of centrally estab-lished clinical issues and locally identified issues in the health improvement plans, so attention to accountability to local communities may be reduced in the short term.
Although there is some lay representation at various levels of primary care organisation, the NHS faces challenges in trying to involve users in service planning. Community nurses work very much at the interface between the public and lay carers, on one hand, and management and other profes-sionals on the other, and this creates particular dilemmas with regard to accountability. Health visitors, in particular, have striven for many years to clarify their remit as a profession that seeks to bridge the gap between professionals and recipients of care, consistently claiming an advocacy role and aiming to use health visiting expertise to represent and empower clients;
not a straightforward task. The developing public health agenda, and the inclusion of health visitors and other community nurses on primary care management groups such as local health community councils, may afford opportunities to channel communication more effectively to local decision makers. This may ensure that the professions’ perception of the causes of health problems, gained through their local knowledge, and their accessibility and acceptability to local communities, will be understood and considered in the planning of service provision.
Clinical effectiveness and evidence-based practice
Clinical effectiveness entails nurses (and others) utilising the best available evidence in their practice, the outcome of which is then evaluated, as part of an audit process. An integral aspect of the commitment to lifelong learn-ing is another part of clinical governance. This involves not just attendlearn-ing study days; it is more a way of continually reflecting on practice and seek-ing ways to find examples of initiatives that have been effective for others.
Therefore, ways of disseminating and sharing the knowledge of achieved effect-iveness is also part of clinical effecteffect-iveness. What is equally apparent is that the evidence has to be used in a sophisticated manner so that the context of care is incorporated into the decision-making process (Closs & Cheater, 1999).
Consultation with the client and carers is essential to reach a decision that is the most suitable for the client’s needs (Clarridge et al., 2001). Kendall (1999) addresses the specific evidence base for health visitors’ work with a well argued assessment of utilisation of research. She notes that there is still some way to go before the authorities are convinced of the worth of para-digms of research that reflect the qualitative characteristics of health visiting,
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and gives the examples of reassurance to an exhausted first time mother and confidence building in a group of single teenage parents.
Many authors (Bergman, 1981; McClymont et al., 1986; Glover, 1999) indicate that responsibility can only be a reality if the professional has the authority to act. Clearly the authority is invested in community nurses for much of their practice through education and knowledge but as McClymont et al. (1986, p. 88) point out: ‘responsibility without authority undermines professional autonomy and creates frustration’. There can be problems if a community nurse assesses that an individual needs a variety of services but the authority to provide them is outside their jurisdiction. It is perhaps sur-prising then that the Code of Professional Conduct only defines accountability as ‘responsible for something or to someone’ (NMC, 2002b, p. 10).
Health visitors, Kendall states, are often in a position of responsibility with-out the authority. Kendall argues that this may mean that research cannot be put into practice to improve health. She argues further that health vis-itors must be empowered to discover the best possible evidence for practice and that this implies investment by management in training in critical think-ing, evaluating research, and other research skills, as well as being given time away from clinical work (Kendall, 1999). It is an argument that would apply to all community nurses.
In relation to the practice nurse, Saunders (2001) states that access to infor-mation technology must be available, along with the skills to locate and iden-tify evidence-based material in the many databases currently available.
Currently the Community Practitioners and Health Visitors Association (CPHVA) is pursuing a high profile campaign to ‘make IT happen’ follow-ing a survey of members to find out what access they have to the internet and email. The aim of the campaign is that every community nurse will have desktop access to a computer and access to the internet and NHS directory services. They highlight that provision is still patchy and that some NHS employers remain slow in empowering staff to benefit from the health infor-mation revolution (CPHVA, 2001).