be confined to health visitors and district nurses. The range of ways in which nurses and others will prescribe for patients in their care includes supple-mentary prescribing, independent prescribing, and via patient group direc-tives (Picton & Ganby, 2002). Supplementary prescribing is dependent on another’s diagnosis and managed through an agreed clinical plan with the patient’s permission.
Independent prescribing will occur when the prescriber takes responsibil-ity and is accountable for the clinical assessment of the patient, which may include a diagnosis and any prescriptions issued. Group directives are written instructions designed for specific groups of patients who are not necessarily individually identified before presenting for treatment and who have specified clinical conditions. The evaluation of the introduction of prescribing by health visitors and district nurses found that nurse prescrib-ing was effective, with a service much more appropriate and responsive to patient needs (Luker et al., 1997).
The recent extension of prescribing has led to a refocusing of attention on the prerequisites of such a service by nurses and others such as pharmacists.
As Picton & Ganby suggest, for nurses to exercise their duty of care appro-priately they have to demonstrate their knowledge and competence on an ongoing basis, initially requiring access to an extended curriculum for edu-cation and training. This independence of nurse prescribing is underpinned by legislation. Therefore, nurses have to be aware of the additional legal accountability for practice when writing a prescription (Clarridge et al., 2001;
Picton & Ganby, 2002).
Picton & Ganby have developed a helpful competency framework for pre-scribing, which they suggest ‘has the potential to be employed by individuals, teams or at an organisational level by using existing local infrastructures which may be in place to support continuing professional development’ (Picton &
Ganby, 2002, p. 93). Clarridge et al., discussing district nursing, indicate the need to be mindful of resource implications when prescribing. This demon-strates accountability both to mangers and public resources but has to be balanced against assuring the most effective treatment for that individual client.
This poses a potential conflict of accountability, one which medical colleagues have greater experience in managing. Clarridge et al. suggest that district nurses become involved in the developing collaborative prescribing partnerships within primary care, whether they be at practice, trust or LHCC level, to ensure successful integration of nurse prescribing.
Primary healthcare and public health nursing
There has been a resurgence of interest in the public health agenda in the UK, with policy strategies for public health from central and devolved governments (Department of Health Wales, 1998; Department of Health Scotland, 1998; Department of Health 1999d; Department of Health SSPS, 2000; Scottish Executive 2001b). For a considerable time public health
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objectives have been advocated by the WHO (WHO, 1986). It is evident that public health encompasses a much wider remit than just the medical model of health, and includes social and environmental aspects of health.
Therefore, as Mason (2001) suggests, it is more meaningful to consider what is the contribution of nursing to the public health agenda since there need to be so many other agencies, for example housing, education, environmental health, transport and policing, involved in improving public health.
This challenge was taken up by the Scottish Executive Health Department (2001b) in its review of the contribution of nurses, midwives and health vis-itors to improving the public’s health. Although acknowledging much good practice they indicate that contributions were often uncoordinated and ad hoc. They identified a lack of clear leadership and considered that nurses were not contributing significantly to strategy. The creation of a Public Health Institute has strengthened the opportunity to develop the skills of the work-force involved to contribute to the improvement of health, and also provides a forum for a leadership role for nurses alongside other professionals. Public health practitioners have been appointed to each LHCC. Their role includes clinical leadership, the collation of the wealth of knowledge that com-munity practitioners have built up on the health status and needs of local communities, and mapping all local initiatives for improving public health (Scottish Executive Health Department, 2001b). These initiatives could also contribute to the accountability of nurses to their local communities in so far as the nurses have the position and the skills to articulate in a wider forum the obstacles that impede the choice of healthy options for individuals and families.
The public health agenda can also be seen as giving a welcome impetus to raising the profile of school nurses. As a service they have achieved lower professional status, with poorer educational opportunities, whilst tradition-ally employing a medical model in their work (Bines & Lightfoot, 1999).
Bines & Lightfoot also showed that since school nurses’ activities take place in education settings they can be marginalised and isolated from NHS col-leagues. They highlight that as school nurses work with a captive audience, they are in an ideal position to make a contribution to young people’s health.
They also note, however, that school nurses have no authority, which means that they can not be accountable for carrying out health promotion work, since it is the school who has the formal responsibility for health education. Therefore, nurses must negotiate with schools to undertake health promotional work which may or may not be permitted by the school.
In their research, Bines & Lightfoot found that schools often lacked an understanding of the role of the school nurse and they found that there was
‘support for a framework, or “service level agreement” between individual schools and the local NHS trust for school services’ (Bines & Lightfoot, 1999, p. 91) which could improve working relationships, facilitate joint planning for health promotion, and encourage a proactive response to needs (Department of Health, 1994b).
Primary healthcare and public health nursing 155 In the Scottish Executive’s new model for practice:
there is no discernable difference between the role of the health visitor and that of the school nurse, though the need for significant investment in the education of the school nursing force is recognised. In future both groups of nurses will be ‘public health nurses’, holding the same specialist prac-titioner qualification and sharing a joint education programme.
(Scottish Executive Health Department, 2001, p. 29) The potential for nurses in schools to contribute to current policy initiatives is high, but as Bines & Lightfoot (1999, p. 103) conclude: ‘a clear role, based on evidence of need and capable of evaluation must be developed. This would contribute strongly to accountability in its various forms.’ Perhaps one of the most important aspects of the public health agenda is a partner-ship approach to improving the health of communities. It is easy to argue that, although public health activity involves all nurses, health visitors in particular have a particular role to play as the principles of health visiting have their foundations in public health (CETHV, 1977; Twinn & Cowley, 1992).
Appleby & Sayer (2001), in considering the public health role of the health visitor, suggest examples of joint working involving tackling teenage preg-nancy, mental health, Sure Start initiatives, domestic violence, or, for ex-ample, by improving nutritional health with dieticians, community workers, shopkeepers and local councillors. What this highlights is that the practitioner is accountable in various ways, e.g. in relation to external factors such as networking abilities, in the provision of knowledge and resources and main-taining relationships within the team, and in personal day-to-day relation-ships with individuals and families. As partnerrelation-ships become increasingly formalised through, for example, the Joint Futures agenda which aims for greater integration of local services through joint resourcing and joint man-agement of services with a single shared assessment (Scottish Executive Health Department, 2000b), it is imperative that the issues of accountabil-ity are addressed by working committees and steering groups. Multi-agency work requires that agreed roles, functions and lines of accountability are estab-lished, and that, in turn, requires an understanding of others’ skills and exper-tise. Once again shared learning or secondments and attachments would facilitate understanding.
Relationships are at the heart of working in the community. Many com-munity nurses are in the privileged position of being able to develop long-term partnerships with clients and families that can be used to enhance well-being for the whole family. De la Cuesta (1994) emphasises the need for developing trust as a basis for relationship-building, and Vehvilaeinen-Julkunen (1993) found, in research with public health nurses, that clients perceived the nurse as a helpful ‘building block’. The ultimate aim of con-tacts with community nurses is to develop family self-help (Zerwekh, 1992).
By building on trust, nurses work to develop family strength, uncovering
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the capabilities of that particular family. Zerwekh found that reinforcing the positive with mothers enhanced their self-esteem and empowered them to take charge of their lives.
The existence of a relationship does not in itself constitute partnership.
That has to develop through the specific way that the nurse and client work and interact together (Gallant et al., 2002). The nurse constantly has to find ways of sharing power and responsibility with clients. This working in part-nership to foster empowerment, seen as part of developing practice with indi-viduals, families and communities, is not without its pitfalls. Community nurses work within their professional framework, and health visitors, as well as help-ing families through empowerment, have to monitor families for any areas of concern. This is a dilemma for health visitors seeking to balance account-ability to and advocacy for clients, accountaccount-ability to management and the NMC. Zerwekh sees empowerment and enforcement as pulling in opposite directions, requiring community nurses to constantly balance loyalty to families and management.
Conclusion
Working in the community can bring enormous satisfaction for community nurses, and opportunities to foster and develop relationships with families and communities to establish partnerships with other agencies working to promote healthy communities. With the current focus on developing new ways of working in the community there are many opportunities for role devel-opment for community nurses, as well as the concomitant uncertainties. It is easy for individuals living through change to become inward looking and concerned for their own working conditions. Nurses, despite experiencing changes, must keep their focus on their clients. Issues of accountability, in all its guises, remain at the centre of practice.