power in the community for vulnerable and invisible people, including carers, has the potential for abuse or disempowerment. Some professionals retain power to control their work, for example, GPs were able to negotiate with the government not to provide out-of-hours services (Peckham and Exworthy, 2003), even though improving access to primary care is fundamental.
ROLE OF SERVICE USERS IN PROFESSIONAL EDUCATION
The role of professional education in shaping future practitioners is essential.
Changes emphasise the importance of communication and partnership working (HCPC, 2014), recognising that competence alone is not enough to constitute professionalism (Parker et al., 2006). Professionals must balance their technical abilities with those that people value (Leatherman and Sutherland, 2007). These have been codified in the professional standards for education. In this vein, pre- registration nursing has been widely criticised and now an all-graduate qualification has been introduced to redress this imbalance (NMC, 2010). It is an increasing expectation that service users play an active role in all areas of professional education programmes from curriculum design to recruitment of students, teaching and assessment (NMC, 2010).
An evaluation of service user involvement in health and social care education spanning nursing, social work and allied health professions showed that in contrast to the traditional model service users are now part of the specialisation and acculturation process (Skinner, 2011). Service users and carers then hold a new sort of power, manifested in the power of teaching through stories (Fraser and Greenhalgh, 2001). This brings a direct challenge to professional power as well as a rich reality to education whereby
‘knowledge that comes from lived experience be re-valued not necessarily in opposition but alongside more specific professional discourses and bodies of knowledge’. (Brown, in Brechin et al., 2000: 101)
This contrasts with the apprenticeship learning in the traditional model. In the new model of education (and practice) service users participate as experts by experience (Skinner, 2011). Service users in effect now have a quasi-regulatory function locally, by sanctioning aspects of professional education. This could lead to a new form of professional accountability which is shared with or ‘controlled’ by service users, though professionals decide which service users are involved (Skinner, 2011).
Discussion point
Can you identify service user involvement in your course or practice area? If so, what is its nature?
If you were designing a new service from scratch, how would you go about involving service users? How would you ensure this was ‘genuine’ and not tokenistic?
ACTIVITY 3.6
There is no uniform or single set of standards or benchmarks for service user involvement across the health sector. However, PSRB, including the HCPC and NMC, require assurances about it (HCPC, 2014). Universities determine their own service users’ and carers’ involvement (SUCI) policy and practice (Skinner, 2011).
Table 3.1 highlights the dichotomy between the old and new models of professional practice, though in reality elements of both models co-exist and different professional groups are at different stages of transition. It may be the case that professionals are regrouping and professional power is still firmly with the professionals, although service users have more rights, powers and resources at their disposal to challenge practice.
Table 3.1 Professional practice: Old and new models
Then – old Now – new
Patients/individuals Service users; clients; partners; people/groups/community/ population Tradition/knowledge handed down/
scientific discovery/experimental treatment
Evidence-based practice; treatment decisions determined externally by peer-reviewed research or regulatory authorities
Apprenticeship model of learning Service users involved in training and lifelong learning
Expertise rests with professionals Access to specialist knowledge widely available, e.g. Internet service user as expert
Job for life/way of life/once qualified always
qualified Revalidation – proof of ongoing fitness to practice/maintain competence/
lifelong learning
Clinical autonomy Patient autonomy – shared decision making with patients and in multidisciplinary teams
Roles distinct and hierarchical boundaries Role overlap; blurred boundaries; skill mix
Focus on care Focus on care and experience of care
Focus on skills Focus on academe; all-graduate profession Paternalism/professionals define patients’
needs
Client-centred care/autonomy/human rights/patient and public involvement
Medical or social models of health Hybrid holism
Self-regulation; lifelong registration Lay regulation/regulatory bodies; licence to practice must be reviewed to include proof of fitness to practice, continuing competence, peer review, revalidation
High levels of trust Less trust and more accountability required
Vocation Vocation
Best interest; needs determined by professionals
Personal autonomy; rights-based care
Control of resources, e.g. unlimited
prescribing Variable control over resources, direct budgets
Consent Informed consent
Accountability to peers Accountability to public and policy makers; codes of practice, duty of candour
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References
CONCLUSION
This chapter highlights a shift in the balance of power towards service users by challenging and redefining what it means to be a health professional in the twenty- first century. Two models of professional practice, old and new, shape relationships between service users and professionals. These models are in a state of flux regarding the conceptualisation of professionalism, role boundaries, core values and power.
Partnership with service users and carers may now play a significant role in the professionalisation of health and social care practitioners. This process not only meets the expected quality and policy agendas to improve fitness to practice but also empowers service users. This is based on mutual respect, trust and reciprocity, which are fundamental to partnership working (Glendinning et al., 2002). Service users and carers are not just being informed about decisions but are key to decision making (Ovretveit, in Brechin et al., 2000).
The professionalisation of health and social care students is being shaped by service user involvement and this may be considered best practice, increasingly reflected in the regulation of professional education (NMC, 2010; HCPC, 2014), although it is too early to judge the extent and permanence of this influence.
Professionals traditionally have wielded considerable power in relation to
‘non-professionals’ and especially service users. This is viewed as outmoded and undesirable, resulting in a shift in the balance of power towards service users and carers and interprofessional working. This chapter has reviewed the nature of professional practice in relation to two models and the application of ethical principles and values for professional practice within the community. It argues that professional practice has moved from a traditional model of practice towards a more inclusive partnership model involving service users and interprofessional working. The emerging role of service users in the professionalisation process because of their involvement in professional training is explored as part of this new extended partnership model of practice, resulting in a redefinition of what it means to be a health professional in the twenty-first century.
FURTHER RESOURCES
www.cqc.org.uk – Care Quality Commission www.evidence.nhs.uk – NHS Evidence
www.hscic.gov.uk – Health and Social Care information Centre www.kingsfund.org.uk – King’s Fund
www.nice.org.uk – NICE (National Institute for Health and Care Evidence)
www.wales.nhs.uk/sitesplus/829/opendoc/167542 – Health and Social Care Working Together (2010) examples of good practice in Wales
REFERENCES
All Party Parliamentary Group (APPG) (May, 2014) Patient Empowerment: For Better Quality, More Sustainable Health Services Globally. A Report by the All Party
Parliamentary Groups on Global Health, HIV/AIDS. Population, Development and Reproductive Health, Global Tuberculosis, and Patient and Public Involvement in Health and Social Care. www.parliament.uk.
Aw TC, Gardiner K and Harrington JM (2006) Occupational Health Pocket Consultant, 5th edn. Oxford: Wiley-Blackwell.
Beauchamp TL and Childress JF (2013) Principles of Biomedical Ethics, 7th edn. New York, NY: Oxford University Press.
Black C (2008) Working for a Healthier Tomorrow. London: The Stationery Office.
Brechin A, Brown H and Eby MA (2000) Critical Practice in Health and Social Care, 2nd edn. London: Sage OUP.
Brew M (1997) Nurse prescribing. In Burley S, Mitchell EE, Melling K et al. (eds) Contemporary Community Nursing. London: Arnold, pp. 229–43.
Cameron A, Lart L, Bostock L and Coomber C (2012) Factors that promote and hinder joint and integrated working between health and social care services. Social Care Institute for Excellence (SCIE) Research Briefing 41. (Accessed 30 June 2016) http://www.scie.org.uk/publications/briefings/files/briefing41.pdf
Cold J (1994) The Christopher Clunis enquiry. Psychiatric Bulletin 18:449–52.
Coulter A (2005) What do patients and the public want from primary care? British Medical Journal 351:1199–200.
Coulter A, Kramer G, Warren T and Salisbury C (2016) Building the House of Care for people with long-term conditions: The foundation of the House of Care framework. British Journal of General Practice 66:e288–90. doi:10.3399/
bjgp16X684745.
Dalley G (1989) Professional ideology or organisational tribalism? The health service–
social work divide. In Taylor R and Ford J (eds) Social Work and Health Care. Research Highlights in Social Work 19. London: Jessica Kingsley.
Davies C (2007) The promise of 21st century professionalism: Regulatory reform and integrated care. Journal of Interprofessional Care 21:233–9.
DH (2005) Mental Capacity Act. London: HMSO.
DH (2006) A Stronger Local Voice: A Framework for Creating a Stronger Local Voice in the Development of Health and Social Care Services. London: Department of Health.
DH (2007) Trust, Assurance and Safety: The Regulation of Health Professionals in the 21st Century. London: TSO.
DH (2008) Real Involvement Working with People to Improve Health Services Guidance to NHS. London: TSO.
DH (2012) Transforming Care: A National Response to Winterbourne View Hospital Department of Health Review: Final Report TSO.
DH (2015) The NHS Constitution the NHS belongs to us all England. (Accessed 27 June 2016) https://www.gov.uk/government/uploads/system/uploads/attachment_data/
file/480482/NHS_Constitution_WEB.pdf.
Dimond B (2015) Legal Aspects of Nursing, 7th edn. Edinburgh: Pearson Education.
Dominelli L (2009). Part 1 Chapter 1. In Adams R, Dominelli L, and Payne M (eds) Critical Practice in Social Work, 2nd edn. Basingstoke: Palgrave Macmillan.
Evetts J (1999) Professionalisation and professionalism: Issues for interprofessional care.
Journal of Interprofessional Care 13:119–28.
65
References Evetts J (2006a) The sociology of professional groups: New directions. Current Sociology
54:133–43.
Evetts J (2006b) Trust and professionalism: Challenges and occupational changes. Current Sociology 54:515–31.
Evetts, J (2012) Professionalism: Value and Ideology. Siociopedia.isa.
doi:10.1177/205684601231. (Accessed July 12, 2017) http://www.sagepub.net/isa/
resources/pdf/Professionalism.pdf.
Finlay L (2000a) The challenge of professionalism. In Brechin A, Brown H, and Eby MA (eds) Critical Practice in Health and Social Care. London: Sage, pp. 74–95.
Finlay L (2000b) Understanding professional development. In Brechin A, Brown H, and Eby MA (eds) Critical Practice in Health and Social Care. London: Sage, pp. 48–69.
Francis, R. (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry Executive summary. (Accessed 26 June 2016) https://www.gov.uk/government/uploads/
system/uploads/attachment_data/file/279124/0947.pdf.
Fraser SW and Greenhalgh T (2001) Coping with complexity: Education for capability.
British Medical Journal 323:799–803.
Freeman G and Hughes J (2010) Continuity of Care and the Patient Experience An Inquiry into the Quality of General Practice in England Research Report. London:
King’s Fund.
Gatley E (1992) From novice to expert: The use of intuitive knowledge as a basis for district nursing. Nurse Education Today 12:81–7.
Gerrish K (1999) Inequalities in service provision: An examination of institutional influences on the provision of district nursing care to minority ethnic communities.
Journal of Advanced Nursing 30:6.
Glendinning C, Powell M and Rummery K (2002) Partnerships, New Labour and the Governance of Welfare. Bristol: Policy Press.
GMC (2013) Good medical practice (2013). (Accessed 31 July 2015) http://www.gmc-uk.
org/guidance/good_medical_practice.asp.
Great Britain (1998) Data Protection Act. London: Stationery Office.
Greenhalgh T (2006) How to Read a Paper: The Basis of Evidence Medicine, 3rd edn.
Oxford: Blackwell.
Grundstein-Amado R (1992) Differences in ethical decision-making processes among nurses and doctors. Journal of Advanced Nursing 17:129–39.
Guest C, Riccardi W, Kawachi I and Laing I (2013) Oxford Handbook of Public Health Practice, 3rd edn. Oxford: Oxford University Press.
Health and Care Professions Council (HCPC) (2012) Your guide to our standards of continuing professional development. (Accessed 28 June 2016) http://www.hcpc-uk.org/assets/
documents/10003B70Yourguidetoourstandardsofcontinuingprofessionaldevelopment.pdf.
HCPC (2014) Standards of education and training. (Accessed 3 July 2016) http://
www.hcpc-uk.org/assets/documents/1000295EStandardsofeducationandtraining- fromSeptember2009.pdf.
HCPC (2016) Standards of conduct, performance and ethics. (Amended 2014). (Accessed 28 June 2016) http://www.hcpc-uk.org/assets/documents/10003B6EStandardsofconduc t,performanceandethics.pdf.
Hogg C (1999) Patients, Power and Politics: From Patients to Citizens. London: Sage.
Hudson B (2000) Inter-agency collaboration—A sceptical view. In Brechin A, Brown H, and Eby MA (eds) Critical Practice in Health and Social Care. London: Sage, pp. 253–74.
Information Commissioner’s Office (ICO) (n.d.) Health Data Protection––Looking after the Information you hold about patients. (Accessed 3 July 2016) https://ico.org.uk/
for-organisations/health/.
Katz JN, Kessler CL, O’Connell A and Levine SA (2007) Professionalism and evolving concepts of quality. Society of General Internal Medicine 22(1):137–9.
King’s Fund (2007) Professional Regulation. King’s Fund Briefing. London: King’s Fund.
Laming Lord (2003) The Victoria Climbié Inquiry Report. London: Department of Health.
Leatherman S and Sutherland K (2007) Patient and Public Experience of the NHS. London:
The Health Foundation.
Luker KA (2002) Nurse prescribing from the community: Nurse’s perspective. International Journal of Pharmacy Practice 10:273–80.
Marmot M (2010) Fair society, healthy lives: A strategic review of health inequalities in England post-2010. (Accessed 14 December 2010) www.marmotreview.org/english- review-of-hi: www.marmotreview.org/AssetLibrary/pdfs/chapters%20of%20fshi/
FairSocietyHealthyLivesContents.pdf.
Miller E and Cameron K (2011) Challenges and benefits in implementing shared
interagency assessment across the UK: A literature review. Journal of Interprofessional Care 25:39–45.
NICE (23 September 2015) Home care: Delivering personal care and practical support to older people living in their own homes NICE guideline. (Accessed July 12, 2017) nice.
org.uk/guidance/ng21.
Nursing and Midwifery Council (NMC) (2006) Standards of Proficiency for Nurse and Midwife Prescribers. London: NMC. (Accessed 27 June 2016) https://www.nmc.org.uk/
globalassets/sitedocuments/standards/nmc-standards-proficiency-nurse-and-midwife- prescribers.pdf.
NMC (2010) Standards for pre-registration nursing education. (Accessed 27 June 2016) https://www.nmc.org.uk/globalassets/sitedocuments/standards/nmc-standards-for- pre-registration-nursing-education.pdf.
NMC (2015) The Code: Professional Standards of Practice and Behaviour for Nurses and Midwives. (Accessed 17 June 2016) http://www.nmc.org.uk/globalassets/
sitedocuments/nmc-publications/revised-new-nmc-code.pdf
NMC (2017) Revalidation how to revalidate with the NMC requirements for renewing your registration. (Accessed July 12, 2017) https://www.nmc.org.uk/globalassets/
sitedocuments/revalidation/how-to-revalidate-booklet.pdf
O’Keefe E, Ottewill R and Wall A (1992) Community Health Issues in Management.
Sunderland: Business Education.
Parker K, Moyo E, Boyd L et al. (2006) What is professionalism in the applied health sciences? Journal of Allied Health 35:2.
Peckham S and Exworthy M (2003) Primary Care in the UK. Basingstoke: Palgrave Macmillan.
Pietroni PC (1991) Stereotypes or archetypes? A study of perceptions amongst health care students. Journal of Social Work Practice 5:61–9.
Radcliffe V (2008) Non-medical prescribing. In Neno R and Price D (eds) The Handbook for Advanced Primary Care Nurses. Maidenhead: Open University Press, pp. 78–88.
67
References Skinner J (2011) VALUE: Valuing Users in Education. An evaluation report. Unpublished.
Steel N (2006) Being explicit about values in public health. In Pencheon D, Guest C, Melzer D, and Muir Gray JA (eds) Oxford Handbook of Public Health Practice. Oxford: Oxford University Press, pp. 56–62.
The Health Foundation (2016) Person centred care resource. (Accessed 17 June 2016) http://
personcentredcare.health.org.uk/area-of-care/what-is-person-centred-care.
Thistlethwaite J (2007) A commentary from the editorial team. Journal of Interprofessional Care 21:2336–9.
Thompson IE, Melia, KM, Boyd KM and Horsbrough D (2006) Nursing Ethics, 5th edn.
Edinburgh: Churchill Livingstone.
Ward D (2009) Groupwork. In Adams R, Dominelli L, and Payne M (eds) Critical Practice in Social Work. Basingstoke: Palgrave Macmillan, pp. 115–24.
Wilkinson R and Pickett K (2010) The Spirit Level: Why Equality Is Better for Everyone.
London: Penguin.
Williams A (2000) Nursing, Medicine and Primary Care. Buckingham: Open University Press.
World Health Organisation (WHO) (December 2015) Health and human rights. Factsheet No. 323. (Accessed 3 July 2016) http://www.who.int/mediacentre/factsheets/fs323/en/.
Worth A (2001) Assessment of the needs of older people by district nurses and social workers: A changing culture? Journal of Interprofessional Care 15:257–66.
Managing risk
Jayne Murphy and Debra Smith
INTRODUCTION
Working in the community provides many challenges and opportunities. The transition to a non-hospital setting as a student nurse or embarking upon a career as a community staff nurse, requires health professionals to reflect upon their own and others’ personal safety, as there will be many situations where the nurse may find themselves working alone. This may include working alone in patients’ houses, or working out of hours, weekends and evenings where staff are required to access buildings or other work environments. The importance of appropriate induction and mentorship is crucial to staff who are new to the community setting, to prepare and support them in adapting to this new way of working (Drew, 2011). Working alone enhances the importance of appropriate risk assessment, identification and management in two respects: risk to self and risk to others.
This chapter explores risk from both aspects. The first section of this chapter explores the safety of nurses working in community settings. This includes preparation for home visiting, car safety and the principles of risk management.
Risk assessment is fundamental to support the health and safety of both patients and nursing staff (Brennan, 2010), and is part of the clinical governance structure of the organisation. The second part of this chapter focuses upon risk to others, primarily patients and the potential risks to them associated with long-term conditions and living alone. Predictive risk, the use of tools to assess readmission and admission of patients is discussed as well as exploring the care of vulnerable groups, including those with mental health problems, older people, adults and children.
4
•
Explore issues relating to risk assessment of personal safety for nurses working in community settings.•
Explain the importance of preparation needed prior to visiting patients and clients in their homes.•
Critically discuss the implications of risk and use of risk assessment of patients in a community setting.•
Consider the principles of safeguarding individuals in the community.LEARNING OUTCOMES
69
Preparation for Home Visiting