The influence of Florence Nightingale

Florence Nightingale was born in Florence, Italy, in 1820 of wealthy, middle-class parents. After several attempts to receive formalized training in 1850 and 1851, she spent brief periods in Germany at a Protestant institution that trained deaconesses in childcare and nursing. Soon afterwards Florence Nightingale became Superintendent of Nurses at the Institution for the Care of Sick Gentlewomen in Distressed Circumstances in London. For this she received no pay but was able to display her skills in nursing and nursing administration, which included greatly improved standards of nurses and nursing care and also the expectation that care should be based on compassion, observation and knowledge.

In 1854 the Secretary for War appointed Florence Nightingale to travel with a group of 38 women to Crimea to provide nursing services. Later, other nurses joined them so that by the end of the war Florence had 125 nurses under her supervision. Despite resistance from the medical establishment, Florence and her team worked long hours to establish hygienic standards of care. She was obsessed with discipline and through determination and persistence improved ventilation and reduced overcrowding, thereby reducing the mortality rate of wounded soldiers. One of her legacies was the ‘Nightingale ward’, a ward layout where long rooms have beds spaced out on each side, which are still found in some areas today. Florence recognized the soldier’s human dignity and in return they held her in high esteem. She became known as the ‘Lady with the Lamp’ and was glorified by the public and press back home and her reputation grew.

On her return to England, Florence had developed revolutionary ways of collecting statistics known as ‘model forms’ and consequently many now regard her as the first research nurse. Although Florence found she was a heroine, she never enjoyed her fame and disliked the sentimental reference that her name inspired. The only testimonial she would accept was a fund, heavily subscribed by the public and named in her honour, which she used to found training schools for nurses.

The success of the Nightingale reforms led to the rapid expansion of nurse training schools, initially in London voluntary hospitals, then to larger provincial voluntary hospitals and finally to new hospitals being built by local government and poor law authorities (Baly 1995). Despite this there was still a need for nursing at home and Florence worked closely with William Rathbone to establish training for district nurses. District nursing started as a voluntary service, run by voluntary committees, until the value of the service was recognized and local authorities gradually began to accept more responsibility for sick people in the community. It was also recognized that certain occupations carried a particular risk to health and some firms employed a nurse to look after the health of their employees.

As a result of her work, Florence was able to define the nature of nursing clearly and how nursing was distinct from and not subservient to medicine (Box 2.1). This paved the way for the establishment of nursing as a profession with a sound and specific educational base.

Mary Seacole

Mary Seacole was another nurse and healer who contributed to the welfare of allied soldiers in the Crimean War. She was of mixed Scottish and Jamaican descent. Although experienced in the treatment of fevers and wound care, the authorities in England rejected her, so she visited battlefields, dispensing comfort and provisions to the wounded. In 1856, she returned bankrupt to England and published a book about her travels, which was one of the few published writings of any black woman before the 20th century. She was helped financially through funds raised by the soldiers she had nursed and finally received a pension from Queen Victoria. Until the centenary of her death in 1981 Mary had been forgotten but renewed interest in her achievements resulted in a nursing award being named after her. In 2003 a campaign was launched for a permanent memorial of her in London and in February 2004 in an online poll she was voted the greatest black Briton.

Health visiting

The first home health visiting began in the mid-1850s as a public health service which focused on problems of sanitation and epidemics; nurses, sanitary engineers or lay visitors were sent into the homes of families with young children to offer advice about health and hygiene (Kamerman & Kahn 1993). At the same time a ‘Sanitary Association’ was formed to teach the ‘laws of health’, followed 10 years later by the ‘Ladies Sanitary Association’ enabling respectable women, known as ‘Health Missioners’, to teach health to mothers. From the voluntary work of these health missioners, health visitors (HVs) emerged and the importance of lowering the infant mortality rate ensured that their work became recognized and brought under the direction of the Medical Officer of Health. The work of early HVs was mainly educative and persuasive; they visited as counsellors to the whole family rather than either inspectors or nurses. The first training-specific health visiting course was established in 1892, around the same time as the first social work courses in the United States.

Development of nursing specialties

Specialist nursing services such as children’s nursing and mental health nursing have their origins in the 1800s.

The 1930s

During the 1930s the public image of general nursing continued to be that of ‘heroine’ but the media was recognizing that nurses required education, which included development of both skills and knowledge, for practice. Nurses were depicted as brave, rational, decisive, humanistic and autonomous. It was an era of fantasy, romance and adventure where the focus of nursing was loyalty to physicians and patients. Gradually the new values of ‘romanticism’ were taken on board and were likened to hero worship of the leaders and doctors as nurses had a subservient relationship to them. Nursing was dependent on medicine to take the main responsibility for decision-making and nurses became adept at suggesting a course of action to a doctor in a way that allowed the doctor to perceive he had initiated it (Stein 1967). During the 1930s there was a considerable influx of men into mental health nursing, especially from depressed areas.

High unemployment and a lack of alternative careers made it easy to recruit nurses. However, there was widespread dissatisfaction in the profession over recruitment, pay and conditions, which led the government to set up a committee chaired by Lord Athlone to consider issues of shortages, wastage and training of nurses. This committee made a number of recommendations to improve staff conditions that would encourage nurses to stay in the profession. This included:

However, the report was low key and by 1939 the country was under the shadow of World War 2.

The impact of World War 2 (1939–1945)

The war changed the situation from an apparently adequate supply of nurses to one of acute shortage. Nurses from all fields were recruited for the armed forces, which resulted in too few nurses to care for civilians. The Ministry of Health set up an Emergency Nursing Committee to organize a Civil Nursing Reserve to assist employing authorities to meet additional staffing needs occasioned by the war. This supplied upwards of 1800 nurses and unwittingly through this the Ministry of Health played an important part in the development of nursing by:

The consequence of this was that in 1941 the Ministry of Health recommended that all hospitals paid salaries equivalent to those in the reserve. To assist the Ministry of Health in its new role as employer, a Division of Nursing was created and the first Chief Nursing Officer appointed. In 1943 the pay of nurses was put on a level with that of teachers but this made little difference to the recruitment figures so steps were taken to improve conditions of service (see Box 2.2). The Nurses Act 1943 came into force and State Enrolled Assistant Nurses became subject to the discipline of the GNC.

During World War 2 the recruitment and distribution of nurses was subject to specific controls:

By the end of World War 2 hospital beds had to be closed due to shortages of nursing staff. Through the necessity to attract sufficient recruits, entry qualifications and the age of entry were lowered. Students and auxiliaries were the main recruits and qualified nurses became frustrated. Training began to suffer as there was insufficient support and supervision for students who began to feel that their preparation was inadequate. Many of those who stayed were rapidly promoted to positions of responsibility for which they were ill prepared. During the war years, some nurses took on increased responsibilities, for example on military ships they were expected to conduct physical and psychiatric assessments and initiate treatments, often without any medical support. Their efficiency, confidence and skills demonstrated what could be achieved outwith institutional bureaucracy. However, their experience was by no means comprehensive and they lacked knowledge and skills in managing the chronic conditions prevalent in civilian life (Nolan 2000).

Post war, nurses continued to administer doctors’ orders and to monitor their patients closely. Military nurses maintained their allegiances and the number of male nurses increased as demobbed servicemen with medical experience joined the profession. Many joined the Society of Registered Male Nurses as the RCN remained closed to them until 1960. Through this they sought to improve the status and practice of mental health nursing.

The influence of nursing theory

During the 1960s there was a dramatic change in attitudes acknowledging the shift away from nurses as doctors’ assistants, which was increasingly encouraging nurses to accept direct responsibility and accountability for their actions and their consequences, and for the decision-making processes that led to those actions. An influential quote from Henderson (1961, p. 42) at that time,

stated that:

At the same time other nurse theorists also began to describe what nursing was about and saw the development of the first nursing models, which are descriptions of what nursing is (Pearson et al 1996). Nursing models are based on beliefs about the following factors:

Nursing models are explored in detail in Chapter 14. There are many models, each reflecting the diverse perspectives of nursing roles and care settings (Box 2.3).

Emergence of nursing models saw the beginning of the move away from the medical model (see p. 43 and Ch. 1) and a move towards the holistic approach (see p. 47) which focuses on the value of the person and the quality of their existence and experience. However, as medicine became more technical and more scientific, nurses increasingly took on more skills and procedures that had previously been carried out by doctors. At that time student nurses were part of the workforce and provided most of the nursing care with minimal supervision.

The early influence of nursing research

In the early 1970s the Briggs Report (Department of Health and Social Security 1972) set the expectation that nursing courses would incorporate research methods and that their findings would be used in nursing practice. The first nursing research was undertaken around that time; however, it had little impact on nursing practice. The Briggs Report also recommended the replacement of the existing regulatory body (the GNC) and the Nurses, Midwives and Health Visitors Act was passed in 1979. Consequently, the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC) and four National Boards for nursing were established, one for each UK country, with a specific responsibility for education. The core functions of the UKCC were to maintain a register of UK nurses, midwives and health visitors, provide guidance to registrants and handle professional misconduct complaints (see Chs 6, 7). The main functions of the national boards were to monitor the quality of nursing and midwifery education courses and to maintain the training records of students on these courses.

Code of professional conduct

The UKCC developed the first code of conduct for nurses, midwives and HVs in 1984, which set out for the first time key expectations for professional practice and accountability. Its purpose was to protect the public through providing professional standards, to inform the public of the standard of professional conduct they could expect, to ensure accountability and to make it clear that RNs, midwives and HVs have a duty of care to their patients and clients. This has been refined and is currently published by the Nursing and Midwifery Council (NMC) as The NMC code of professional conduct: standards for conduct, performance and ethics (NMC 2004a) (see Ch. 7).

Project 2000

In the 1980s it was recognized that, as a result of changing disease patterns and social contexts and the introduction of reforming modes of care delivery, there would be new healthcare needs that required a different kind of nurse. In order to meet this need the UKCC (1985) put forward a different approach to the education of nurses. The main proposals included:

Moving from rituals to evidence-based practice

The development of education and regulation for nurses and midwives failed to bring nursing the power and prestige that were anticipated by early nursing leaders. Over the last 15–20 years there has been a shift from ‘the practitioner knows best’ to the belief that one can never take one’s own practice for granted. However, nursing had still only developed a limited body of knowledge that could be defined as nursing and which was exclusive of other disciplines. Consequently, the purpose of nursing research is to establish a body of nursing knowledge which in turn increases the professional status of nursing (see Box 2.5 and Ch. 5).

The attributes of a profession include:

The introduction of the nursing process during the 1980s enabled nurses to develop a more systematic approach to care (see Ch. 14). There was the expectation that nurses should carry out best practice that was in the interest of their patients and that they would be accountable for their actions. The systematic nursing process gradually evolved into evidence-based decision-making, a process of turning clinical problems into questions and then systematically locating, appraising and using current research findings as the basis for clinical decisions (see Ch. 5). By using a structured problem-based approach practitioners can logically apply the best available evidence to their care, i.e. evidence-based practice (see Ch. 5). Table 2.1 summarizes the major events influencing the evolution of nursing discussed in this section.

Table 2.1 Major events in the evolution of nursing

Task allocation

Task allocation was the main method of organization when hospitals were established and still persists to some extent in many areas of nursing (Fig. 2.1). Where it continues, this is usually due to autocratic leadership styles (see Ch. 9) and the continuing use of the biomedical model (see p. 43 and Ch. 1). Task allocation is based on a hierarchy of tasks where tasks are carried out according to the status of the caregiver and has much in common with an industrial production line, with each carer carrying out a limited range of care-related tasks for many patients/clients. It also reflects the hierarchical, ecclesiastical and military roots of nursing that value obedience and subservience. For example, in a hierarchy, tasks are allocated by seniority where:

Fig. 2.1 Channels of communication in task allocation or functional nursing

Patient allocation

This was introduced in the 1970s to enable nurses to focus on caring for individual patients/clients rather than on a range of tasks. Nurses were allocated specific patients to care for. The aim was to provide continuity of care; however, both the nursing hierarchy and relationships between charge nurses and other nurses remained the same and essentially task allocation continued but for smaller groups of patients/clients.

Team nursing

In 1956, the RCN developed a theory of team nursing but a number of issues prevented this approach being developed:

However, during the 1980s, team nursing evolved and allowed care to become more individualized. Nurses are allocated to a team who provide care to a specific group of patients/clients (Fig. 2.2). The team leader shares responsibility for patient care, communication and coordination with the ward manager. Ideally, the same team cares for the same group of patients for the duration of their stay. This increased continuity of care provides more meaningful work for nursing teams.

Fig. 2.2 Channels of communication in team nursing

Primary nursing

This involves patients/clients being allocated to an individual RN rather than a team of nurses (Fig. 2.3). The focus is on individual holistic care, where the participation of patients/clients and relatives is encouraged. The primary nurse has 24-hour responsibility for their group of patients, known as a caseload, throughout their stay. Primary nurses have the knowledge and ability to make decisions, and also the authority to carry them out. In the primary nurse’s absence, an associate nurse, another RN or primary nurse carries out the planned care with the involvement of students and HCAs. In settings where primary nursing is practised, the sister/charge nurse acts as consultant, role model (managing a small caseload), ward manager and in-service educator. In common with other care delivery systems, primary nursing has advantages and disadvantages (Box 2.7).

Fig. 2.3 Channels of communication in primary nursing

Care delivery in practice

It has been recognized that when team or primary nursing is used as a method for organizing patient care, less stress is reported by the practitioners involved. Alongside this, there is the belief that patients feel better cared for and their individual needs are met, practice is enhanced, teamwork is more evident and there is greater job satisfaction.

Figure 2.4 summarizes the key characteristics of the four approaches to organizing care. There is growing evidence that nurses do not work in the four ways described above, but that care settings are organized in more complex ways using attributes from more than one of the different approaches to care delivery (Adams et al 1998) (Box 2.8). It is interesting to note that patients’ perceptions of the quality of care are often dependent on individual nurses rather than the system of care delivery (Jupp 1994).

Fig. 2.4 The key characteristics of the four main ways of delivering nursing care (after Adams et al 1998)

Influences on nursing today

The future of nursing holds a myriad of challenges, which include external forces as well as influences from within the profession as the role of the nurse evolves further. External factors that will continue to influence healthcare and nursing include increasing technology, demographic changes, changing patterns of disease, consumerism and increasing recognition of people’s rights, e.g. the Human Rights Act 1998 (see Ch. 6), safety at work, globalization and the impact of increased travel.

Demography

In mid-2004 the UK population was 59.8 million people (National Statistics Office 2004) with an average age of 38.4 years; one in five people in the UK was under 16 and one in six was aged 65 or over. As a result of declining fertility rates and increasing life expectancy, the UK has an ageing population. International migration into the UK from abroad has been an increasingly important factor in the population change. In response to this, healthcare has to develop new ways of working; for example, to increase the expertise and partnership working with frail older adults and to promote understanding of other cultures and changing disease patterns. With the breakdown of the extended family and the increased need to demonstrate status through the acquisition of material possessions, people are becoming more isolated and stressed.

Changing disease patterns

Modern healthcare and medical technology have begun to transform the health of the nation and life expectancy for many has increased but not to the same degree in all social groups (see Ch. 1) and geographical areas. The development of vaccines has dramatically improved health by reducing mortality and morbidity from infectious diseases. People are less physically active and are eating more sugar and fat and insufficient fresh fruit and vegetables, which has led to increasing obesity. This is also contributing to the increased incidence of chronic conditions such as diabetes, cardiovascular disease and cancers. Chapter 1 discusses the UK Government health targets that have been devised as a focus for health promotion and aim to reduce the incidence of these common and largely preventable conditions.

Smoking is the greatest preventable cause of illness and premature death and despite an overall fall in prevalence (DH 1998b) there is an increase among younger people (DH 1998c). Adolescent pregnancy is a major cause for concern, as is the increased incidence of drug and alcohol misuse and other mental health problems (The Scottish Office 1999).

Diversity and equity

Diversity is about recognizing and valuing human differences for the benefit of patients/clients, carers, staff and the public at large. Diversity goes hand in hand with equity and equality, which is about creating a fairer society in which everyone can participate and has the same opportunity to fulfil their potential. In reality, there is no equity or equality of opportunity if differences cannot be recognized and valued (Scottish Executive Health Department 2005).

Human rights

People’s rights have become more widely acknowledged, particularly since the passing of the Human Rights Act in 1998 (see Ch. 6) and the European Union Social Charter. These have wide-ranging implications for the profession as they impact on nursing practice and nursing research. Examples include conscientious objection, age and disability, right to life, patient advocacy, role expansion, healthcare resource allocation, emergency contraception, do-not-resuscitate orders, rights to privacy and dignity, confidentiality and anonymity, ethics, genetics and informed consent, advance directives (called advance decision to refuse treatment in the Mental Capacity Act 2005) and patients’/clients’ right to choice (see Chs 6, 7).

The healthcare system must challenge discrimination, promote diversity and respect human rights. It is not uncommon for certain groups of people to be discriminated against, including older adults, drug users, homeless and unemployed people, minority ethnic groups and those with mental health problems. In practice, diversity should mean that all people are treated as equal and can access free healthcare at the point of need.

Roles in the community

The National Health Service and Community Care Act (1990) has led to significant changes in the place of care delivery, heralding a move from largely hospital-based provision to care within community settings (see Ch. 3). The emphasis on community services will further increase with the implementation of the English White paper Our Health, Our Care, Our Say: a New Direction for Community Services, which provides for a shift of resources from hospital- to community-based services (DH 2006). Nurses are increasingly the first point of contact for patients/clients, whether in NHS walk-in clinics or via NHS direct (England and Wales) or NHS 24 (Scotland). In addition, nurses are increasingly taking a lead in providing services for some people with mental health problems and chronic physical health conditions. These services tend to focus on the health of the patient/client, rather than their illness, and are largely community based. Nursing roles in the community include those of specialist community public health nurses (school nurses with specialist practice qualifications, HVs and occupational health nurses) and community practitioners such as district nurses, community mental health nurses (see Ch. 3) and community learning disability nurses. Some of these roles are discussed below.

Hospital nursing

In hospitals many nurses are expanding their roles to meet demands for increasingly complex care needs based on innovative technologies and to compensate for a shortage of medical staff. Many RNs, along with midwives and therapists, undertake a wide range of clinical activities including the right to make and receive referrals, admit and discharge patients, order investigations and diagnostic tests, run clinics and prescribe drugs.

Effective teamwork within the MDT

Teamwork is about working together and requires cooperation and understanding (see Ch. 9). The readiness to develop a collaborative approach is recognized by a group’s capacity to experience and manage competition, conflict, risk and stress, and their willingness to communicate (Rowe 1996). Team members must be aware that their behaviour not only affects others but also the overall performance of the team. The aim should be to adopt the helpful roles outlined in Table 2.2. Moving towards the helpful behaviours involves self-awareness and a team with members who are ready to change and learn from others (see Ch. 9).

Table 2.2 Helpful and hindering roles in team working

Adapted from Hersey & Blanchard (1988).

However, effectiveness is not down to individuals alone. An effective team requires skilful coordination which West and Field (1995) argue involves:

Carrying out the activities in Box 2.10 will help you to understand the characteristics of effective teamwork.

Pre-registration nursing programmes

The new direction for the nursing profession, established in the wake of Project 2000, brought a profound shift in ethos and culture. Following a review of nursing education, the UKCC (1999) recommended measures that would enable fitness for practice through better preparation of student nurses which was to be based on healthcare need. There was also a move to ensure that placement experience and mentors prepared competent practitioners who were able to provide safe care. This resulted in the development of proficiencies for pre-registration nursing programmes. Two major changes were:

Nursing programmes now include a common foundation programme, which is followed by one of four branch programmes:

The NMC has a responsibility to ensure that registered nurses, midwives and specialist community public health nurses provide high standards of care to their patients and clients. To this end, the NMC (2004c) has set out CFP outcomes necessary for entry into a branch programme and the standard of proficiency that must be achieved prior to registration (Table 2.3). They are described under four domains:

Table 2.3 Standard 7 – First level nurses – nursing standards of education to achieve the NMC standards of proficiency

Reproduced with kind permission of the Nursing and Midwifery Council (2004).

Adult nursing

Adult nurses are primarily responsible for health promotion and providing holistic care for physically ill or injured adults with wide-ranging levels of dependency in both hospital and community settings. The focus is on the individual patient, rather than the condition from which they may be suffering; and the needs and anxieties that their condition may generate, including the pressures on their family and friends.

Adult nursing placements include care homes, hospital wards and specialist clinics, and community placements that may involve visiting people at home or attachments to health centres. Nurses play an increasingly prominent role in the provision of health-focused care in the community. Many hospital-based nurses are found in specialist areas such as intensive care, cancer care and care of older adults (Table 2.4). Adult nurses work with people over 18 years of ages who have acute (short-term) and chronic (long-term) conditions.

Table 2.4 Some adult nursing specialties

Despite the wide range of specialties, there are a number of features common to most adult nursing roles (Box 2.11). While this often includes physical care, it extends well beyond that, including counselling, advice and education that draws upon interpersonal and communication skills to address psychological, social and spiritual aspects of holistic care.

Most patients have specific problems but can eventually look forward to an independent future. The nurse’s role is to offer support while it is needed and give people the skills, strength or knowledge that will help them to regain independence. Box 2.12 provides the opportunity to consider the types of health-related problems that people may experience as a result of sudden illness and change in independence.

Learning disability nursing

Health policy in the UK is explicitly directed at social inclusion and social justice for all citizens. This policy is clearly outlined in Valuing People (DH 2001) and The Same as You? (Scottish Executive Health Department 2000a). These documents state that people with learning disabilities should be respected and valued and afforded the same opportunities as others, as well as receiving additional support and services to meet their individual needs.

In Scotland the policy around promoting health and supporting inclusion for people with learning disabilities has developed considerably over recent years. As there are, as yet, no similar developments elsewhere in the UK, it is useful to examine how policy and practice in Scotland has been developing. Caring for Scotland is the strategy for nursing and midwifery in Scotland (Scottish Executive Health Department 2000b). This strategy outlined the intention of the Scottish Executive to undertake a review of the contribution of all nurses and midwives to the care and support of people with learning disabilities. Promoting Health, Supporting Inclusion was published by the Scottish Executive in 2002 and details the actions required from all nurses and midwives to improve the health and well-being of children, adults and older people with learning disabilities in Scotland. Recommendation 1 of Promoting Health, Supporting Inclusion invited NHS Health Scotland, Scotland’s national health improvement organization, to undertake a strategic needs assessment of the health needs of children, adults and older people with learning disabilities. This comprehensive health needs assessment was published in 2004 and details the inequalities that require to be addressed strategically and locally in order to promote social justice for this group of Scottish citizens (NHS Health Scotland 2004). Thus it is evident that these health inequalities need to be redressed so that people with learning disabilities can indeed be included in our society in an equitable, respectful and dignified fashion.

There is some confusion regarding the use of the term learning disability, which can vary from country to country. The term learning disability has been adopted in the UK and is the one that users of services prefer. However, the terms intellectual disability and developmental disability are commonly used in other parts of the developed world. In the UK the term usually refers to a variety of disorders that adversely affects the acquisition, retention and understanding of new or complex information and often also the use of verbal or non-verbal communication. It has a lasting effect on development and results in a varying degree of support from others being required to cope with daily living (Gates & Wilberforce 2002).

The role of the nurse is to help people with a learning disability and their families to maintain and improve their lifestyles by promoting health, and to participate fully as equal members of society. The Quality Assurance Agency (QAA) for Higher Education (2002, p. 9) identifies that learning disability nurses:

It can be seen then that the primary role of the learning disability nurse is in meeting the health needs of people with a learning disability. However, the role is wide-ranging and could also include helping people to develop their manual and recognition skills so that they can use kitchen equipment to make a pot of tea. In other instances, nurses may, with the rest of the MDT, be involved in underpinning people’s efforts to find a job and bring up a family. It requires considerable sensitivity and skill to offer the best care to people with learning disabilities and their families without being intrusive.

The ultimate aim is to empower the individual to maximize their full potential. O’Brien (1981) describes this process as ‘normalization’ which includes five accomplishments:

The distinctive contribution of learning disability nurses is their influence on behaviours and lifestyles that promote health and maximize well-being and independence for people with learning disabilities, their families and carers. Care takes place in a wide variety of settings: people’s own homes, their family homes, community houses, residential care, schools, workplaces, leisure centres and healthcare facilities. Some nurses maintain this broad spread of activity, whereas others choose a specialist area such as supporting people with interactional challenges and complex needs education, or management of learning disability services.

The main challenge is meeting health needs since it is apparent that the health needs of people with learning disabilities are greater and more complex and often present differently from those of the general population. Some conditions occur more frequently than in the rest of the population. These include:

Other health needs are associated with particular groups, e.g. people with Down’s syndrome are more prone to depression, thyroid function disorders, hearing impairment and dementia. It is obviously important that learning disability nurses have the ability to recognize these differing health needs but it is also apparent that all nurses require an awareness of these specific health needs in order to reduce intentional discrimination and enhance access to healthcare services (NHS Health Scotland 2004).

Learning disability nurses coordinate care and work with the whole family and other carers to befriend, teach, support, counsel and carry out therapeutic activities. They also make regular assessments of healthcare needs and ensure the availability of resources to meet them. In this field it is not only important for nurses to know how to care for the well-being of their clients but also to teach their families, friends and carers who provide regular care to do the same. Often this entails caring for a person who has seizures or epilepsy, incontinence (see Chs 20, 21) or a physical disability that has led to immobility (see Ch. 18) or sensory impairment.

The Scottish Human Services Trust works in partnership with organizations to help them become more responsive to the people they serve (Box 2.13). Their values of inclusion mirror those of ‘person-centredness’ (p. 47) and are considered appropriate for use in the health and social care of people with a learning disability. Box 2.14 provides the opportunity to consider the impact of this in relation to people with learning disabilities.

Using the information in Box 2.14, consider the realities of caring for John. It is frequently physically and psychologically demanding, particularly on parents and other carers. Breaks from physical caring will be few and liable to interruption at any time. Furthermore, there is the need to ensure that John does not become frustrated or depressed by the constraints and demands placed on his life. Since it is difficult for John to travel, the family will hardly ever go away from home together, even to enjoy a meal out. Finally, John’s parents may constantly worry about what will happen to John when they grow older and die; most parents of people with a learning disability live in fear of their children going into institutional care when they are no longer there to look after them. The learning disability nurse could help John’s parents in a variety of ways, for example:

In conclusion, the role of the learning disability nurse is built on developing equal partnerships with the people they work with so that the health needs of people with learning disabilities, their families and carers can be met in an effective, efficient and resourceful manner. Learning disability nurses treat people as unique, whole individuals with specific needs and desires. They practise in a sensitive and non-discriminatory manner to enable people to fulfil their needs and aspirations so that people with learning disabilities can truly be include within our society.

Mental health nursing

Mental health nurses care for people with mental health problems, also known as mental distress, in diverse settings in both the hospital and community. They play key roles in the promotion of good mental health and the prevention of mental health problems, provide care and interventions to people experiencing mental health problems and support people to develop strategies to enable them to work towards recovery. A major focus of the role of mental health nursing is promoting social inclusion and challenging stigma. To facilitate this, mental health nurses must practise in a way that is underpinned by a clear values base that is focused on delivering rights-based care. At the time of writing the publication of reviews of the role of mental health nursing in Scotland and England are set to influence further development of the profession (Box 2.15).

Everyone can experience distress at some time in their life, e.g. episodes of stress, anxiety or depression (see Ch. 11). At any given time, one adult in six suffers from some form of mental health problem (National Statistics Office 2004); in other words, mental health problems are as common as asthma.

Mental health nurses are at the forefront in providing the support required for people with mental health problems who need to access health services, working as part of multidisciplinary teams with other professionals such as GPs, psychiatrists, social workers and allied health professionals to coordinate and provide care. A wide range of other services, e.g. voluntary organizations, local government and housing agencies, may also be involved. In recent years, there has been a significant shift from hospitals to the community as the main setting for mental health care. Nurses work with people in their homes, in small residential units and in local health centres with considerable autonomy in how they plan and deliver care. Community psychiatric nurses (CPNs) (increasingly known as community mental health nurses) are key members of the MDT in mental health service provision. The one-to-one therapeutic relationships that mental health nurses form with their clients are at the heart of mental health nursing. Nursing interventions include providing social and physical care, and psychological and psychosocial interventions such as counselling and cognitive behavioural therapy, as well as working with other professional groups and the voluntary organizations involved in supporting people with mental health problems. Mental health nurses also have a role in assessing and managing individual risk, which requires sophisticated assessment skills.

Mental health nurses work with people of all ages and from a wide range of backgrounds, and mental health nursing provides opportunities to practise in diverse areas including older people’s mental health, child and adolescent mental health services (CAMHS), forensic mental health services and acute inpatient care.

Children’s nursing

Children’s nurses are responsible for teaching families, providing support and helping families to make decisions in the best interest of their child. To do this, nurses need to develop partnerships with families and acknowledge that family members provide nursing care. Chevannes (1997) identified three stages of interaction when working in partnership with families:

Some difficulties may be encountered, for example:

Children have different physical, psychological and social needs at different ages and developmental stages (see Ch. 8). Children’s need for intervention by health professionals starts before conception and continues through adolescence and transitional care to adult services. The type of intervention required depends upon the particular health needs of the child and family at any given time. Children’s nurses learn skills in caring for whole fam-ilies, including grandparents, siblings, carers and friends. Skills in family-centred care also involve teaching (see Ch. 4) so that the nurse can teach families and empower them with knowledge and skills so that they can carry out almost any of nursing care the child requires.

Children’s nurses in hospitals provide care and skilled observation and treatment. They involve parents at all times, helping them to cope with their fears and the trauma of sudden hospital admissions. Parents may be unsure that they have done everything they should have and whether they have called the doctor early enough. The children’s nurse listens to these worries, explores issues with parents and provides information and health promotion advice as appropriate. Involving parents helps them to feel included in the nursing care and maintains their relationship with their child.

Children’s nurses work in homes, schools and other community and hospital settings. They work in special schools for children with learning disabilities or may support children who have long-term health problems such as asthma, cystic fibrosis, diabetes or eczema and those with life-limiting conditions. This can be at home and in community, day care, hospice or hospital settings.

Nurses working with children in any setting must become vigilant, observant and attentive in order to identify vulnerable children, i.e. those at risk or potential risk from physical or emotional injury, abuse or neglect. Although children are generally best looked after by their families, the welfare of children is absolutely paramount and their needs are uppermost if there is conflict between those and carers/parental needs. Nurses have a responsibility to respect and promote the rights of the child and play an important role in child protection by reporting any suspicion of non-accidental injury, abuse or neglect and following local protocols for safeguarding children (see Chs 3, 6).

National vocational qualifications

National vocational qualifications (NVQs) and Scottish vocational qualifications (SVQs) are methods of gaining academic credit through a combination of theory, work-based learning and assessment. Some NHS organizations and other employers have developed work-based training for clinical support workers that lead to the acquisition of NVQs/SVQs levels 2 and 3, which can provide entry into pre-registration nurse education. The main purpose of this development was to improve the skill mix in practice, to ensure clinical support workers are competent in the skills they are expected to carry out and to offer improved career opportunities. NVQs and SVQs are also available in many fields outside the healthcare sector.

Mentoring

It is expected that RNs will take on the role of mentoring student nurses about a year following registration (Box 2.16). They should receive support from nurse educators in carrying out this role. The NMC (2004d) outlined standards for mentors and mentorship that include:

This approach is based on a partnership between the student, mentor and university lecturer. Promoting this partnership approach encourages student nurses to do the same for the patients/clients for whom they are caring.

Teaching

Nurses need to provide environments that are conducive to learning and be able to respond to the individual learning needs of colleagues, members of the public, patients/clients or carers. Different roles have evolved to support learning in practice settings; these include mentorship (see above), clinical teacher, practice educator, link lecturer and lecturer practitioner. These roles aim to bridge the theory–practice gap by closely linking theory and practice, and involve teaching students and staff, supporting ward managers, assessing competence in practice and contributing to education programmes. These teaching roles provide an opportunity for student nurses to be supported by experienced mentors and teachers, enabling them to reflect, learn and develop their practice and improve their level of confidence when interacting with patients/clients.

Lecturers who teach nursing in universities are normally RNs who have undertaken a teaching qualification recognized by the NMC. In addition to classroom teaching, they facilitate student-centred learning including reflective groups, provide support to personal students and act as link lecturers in practice placements. Many also undertake nursing research.

Clinical leadership

Clinical leaders are from any discipline within an organization; they are often team leaders but not necessarily line managers. While managers promote organizational structures, leaders promote the achievement of excellence in others (RCN 2006). However, in clinical nursing it is expected that a leader coordinates a team of healthcare professionals whose focus is ensuring that effective patient-centred care is delivered. The qualities required that are central to patient-centred leadership are:

Leadership is about setting direction, opening up possibilities, helping people achieve their potential, communicating and delivering; what people do as leaders is even more important than what they say (see Ch. 9). The Department of Health (2005) suggests that clinical leadership is about not knowing everything, reflecting on practice, harnessing the energy of the clinical team, stopping ‘doing’ and starting to be creative, making improvement part of everyday work and encouraging others to lead and improve. Leaders of improvement need to:

Department of Health (2005)

Clinical nurse specialists

The clinical nurse specialist (CNS) has acquired extensive specialist knowledge about a specific area of nursing. CNSs work closely with doctors who specialize in the same area of healthcare and are involved in patient care, family and staff education and support. Many CNSs run clinics where they have a caseload of patients and often have full responsibility for making decisions about care. Some also prescribe and monitor the effects of medication (see Ch. 22). They often work across the hospital and community interface, following the patient pathway.

CNSs share their specialist knowledge with other nurses, help to ensure that national standards are put into practice locally and may contribute to developing care policies, e.g. management of breast cancer, learning disabilities, palliative care and aspects of children’s nursing, pain management and mental health. National standards provide a consistent approach to the education of specialist nurses (UKCC 2001). These standards indicate that specialist practice involves exercising judgement, discretion and decision-making in clinical care in any area of healthcare delivery.

The CNS role has developed in some areas to provide outreach services where the CNS acts as a link between different areas on the patient pathway. For example, in critical care their role may be to enable early identification of patients whose conditions are deteriorating and require more specialist input, provide advice to ward nurses or to transfer seriously ill patients, e.g. to coronary care or intensive care units. Another example is outreach nurses who bridge the gap between community and hospital, providing support for children and/or adults with complex needs and their families/carers.

Nurse practitioners

A nurse practitioner is a registered nurse who has undertaken a specific course of study and who takes full clinical responsibility for clinical decisions based on systematic physical assessment, accurate diagnosis and the delivery of a wide range of treatment options. Doctors previously undertook most of these roles. The roles are diverse and can include pre-assessment to post-discharge follow-up in areas such as dermatology, stoma and breast care, accident and emergency, general practice and walk-in centres.

Nurse consultants

The nurse consultant is an expert practitioner who works with a specific group of patients or clients, influencing the quality of care through:

Expert practice includes both direct and indirect nursing practice, which must make up 50% of the nurse consultant role.

Professional leadership involves a variety of skills and processes that involve facilitating a culture of practice development that allows staff to become leaders themselves. The consultancy role encompasses not only giving advice and guidance but also developing the clinical skills and problem-solving abilities of nurses. Enhancing outcomes for patient care involves influencing clinical practice in any healthcare setting. This encompasses consultancy across traditional boundaries or care settings, interagency working, and partnership or community development in addition to the specialist area.

The education, training and development role aims to develop a culture for learning in practice and to maintain links with higher education.

The role of practice and service development, research and evaluation involves establishing a research culture (see Ch. 5). Nurse consultants are required to make a significant contribution to the strategic development of clinical governance (see Ch. 3) and in the promotion of clinical effectiveness in their area of practice.

The role is complex and its success is through the promotion of patient-centredness, development of teamwork and meeting service needs while demonstrating effective transformational leadership (Manley 2000).

The modern matron

The modern matron, sometimes known as the clinical nurse manager, was introduced to provide support to ward managers and to refocus attention on patient care. It was considered that ‘the basics’ had been lost in areas of nursing such as infection control, adequate food and drink for patients/clients, pressure area management, communication, dignity and compassion as ward managers and clinical leaders were spending more time dealing with management and paperwork. The role of the modern matron has three main functions:

The role of the ‘traditional’ matron disappeared in the 1960s when formal management was introduced into the NHS. However, the security, stability and ‘care focus’ that the role had provided to both staff and patients was overlooked. The old-style matron was often considered to be a formidable character who held considerable authority and respect for both their knowledge and expertise from both patients and staff.

Modern matrons must have credibility and expertise and present themselves as figures of authority without imposing fear. The role is intermediary; patients can ask to speak to the matron if they have a complaint about their care or the standards of the ward. The matron is in a prime position to resolve complaints at a local level by providing feedback to ward staff.

Modern matrons need skills that include effective communication, mediation, influence, negotiation, under-standing and experience of working on wards. In addition, the role requires sound clinical experience, the ability to monitor and measure the effectiveness of care, change management and an understanding of the dynamics between a distressed patient group and ward staff. As a result, the ward staff are supported in their role of caring for patients.

Nurses as researchers

At the heart of the drive to modernize the NHS is a commitment to the development of high quality, person-centred services that are evidence based. The vision for nursing in the 21st century is for all nurses to be able to both seek out evidence and apply it in their everyday practice, with an increasing number actively participating in research and practice development. All RNs are expected to have the ability to understand and implement research findings (see Ch. 5) but only a small number will become full-time researchers who will contribute to the development of nursing knowledge.