Transitions to practice: Essential concepts for health and social care professions

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Preface

Helené Donnelly OBE

I am pleased to write the preface for this important book as I feel that the quality of practice and care in the NHS and social care systems needs to be challenged and improvements made where needed. Human dignity, respect and care for both patients and staff are fundamental to everything we do in the NHS and social care. I believe this book can help all health and social care workers make the transition into this type of healthy working culture.

After the tragic cases of poor care at the Mid Staffordshire Foundation Trust Hospital came to public attention in 2010, it was clear that the NHS needed a drastic culture shift. The suffering of patients at the hospital resulted from a widespread negative culture and a failure on the part of senior staff to listen to the legitimate complaints of staff and patients over a long period of time. I strongly believe that much-needed change hinges on shaping working environments where health care professionals are encouraged to demonstrate openness and transparency.

The Francis Report (2013) revealed that much of what occurred at the Mid Staffordshire Foundation Trust (Mid Staffs) was due to historic and entrenched mismanagement and the unprofessional conduct of some staff. In fact, the legacy of the failings at Mid Staffs should lead to widespread cultural change throughout the NHS, health and social care systems. I have always strongly believed that what occurred at Mid Staffs, was not a unique, isolated incident. Many of the problems at Mid Staffs will have occurred in other wards, units, clinics and hospitals throughout the country at the same time. Sadly, many such incidents predated the Francis Report (2013), and similar tragedies continue to come to light.

Since the Francis inquiry (and the publication of several reports on the events at Mid Staffs), positive steps have been taken towards creating a culture of openness in the NHS. These measures have included the introduction of a statutory Duty of Candour and the appointment of Freedom to Speak Up Guardians, changes to the way unions respond to concerns raised by their members and changes to professional regulations.

Openness on the part of staff is crucial in order to protect patient safety and prevent needless harm; and these values must be embedded across the entire health and care system. Most professionals working in the health and social care services already know that they need to be honest about mistakes they make, and constantly strive to do the best job possible. Health and social care is often delivered in intense environments by hard-pressed staff. By truly listening to the staff who deliver this care when they have concerns, most harm can and should be prevented. When executing their Duty of Candour, staff must be supported and encouraged by the organisations they work for. In order to embed such a culture change, it is imperative that action is taken to address issues as soon as legitimate concerns have been raised, and feedback must be given to all those involved. This will promote the positive impact of raising concerns and, crucially, will improve patient and staff safety.

I can write about this from personal experience, as I became increasingly worried about the welfare of patients and staff whilst working at Mid Staffs hospital. Due to this and the poor experience I had, I am well aware of how difficult and daunting it is to raise such concerns.

As a newly qualified nurse in 2002, I commenced a staff nurse development rotation at Mid Staffordshire hospital. Having trained elsewhere, I went to Mid Staffs with fresh eyes and looked forward to nursing in a hospital close to my home. I had chosen a critical care programme, which rotated every six months between acute units and wards over a two-year period to enhance specialist skills and knowledge. I spent the first year working on an acute respiratory ward and then on the Acute Cardiac Unit. This was a particularly good unit to work on and gave me an opportunity to develop my nursing skills and knowledge whilst delivering excellent care to patients. The staff were knowledgeable, professional, kind and caring.

I later moved to the Medical Assessment Unit. This was an extremely busy unit with a very high turnover of patients during each shift. The unit was not as well staffed as it should have been, but the staff worked well together, often under pressure, and delivered the best possible care and treatment for patients.

At this point, I successfully applied for a permanent post in the neighbouring Accident and Emergency (A&E) department, and in 2004 I started work as a staff nurse. Almost immediately I began to have concerns about the staffing of the department. It was clear that there were not enough nurses or doctors working in A&E for us to deliver safe and effective care. The situation was made worse by a high turnover of staff and high levels of staff sickness. For instance, there was often no triage nurse available to assess patient need and priority upon arrival, which put patient safety at risk.

The use of agency staff was not permitted, as it was deemed too expensive; for similar reasons, bank staff were also seldom used. If bank staff were permitted, they would usually be from the pool of existing A&E staff. This meant that already exhausted staff were returning to complete extra shifts. On the rare occasions when external bank staff were permitted to work in A&E this still did not relieve much of the pressure because they were not familiar with the way the department worked, and needed staff to show them what to do. Unfortunately, their presence neither alleviated the pressure the existing staff were under nor improved the patients’ experiences.

In addition to low staffing levels, staff were not receiving adequate mandatory and statutory training. There was little or no professional development or supervision; and the department lacked vital equipment needed to deliver specific drugs and other treatments. Facilities required to ensure patients’ dignity and privacy were lacking. There were not enough blankets to keep patients warm, nor enough commodes to assist patients to go to the toilet.

Furthermore, there were too few beds/trolleys in the department to examine patients on and make them comfortable. The flow of patients through the hospital was often disrupted and delayed. This meant patients in A&E could not be transferred to an appropriate ward within the four-hour time limit.

It soon became clear that the pressure of the four-hour wait in A&E (i.e. the need to discharge each patient exactly four hours after admission to the department) took priority over their care and treatment. Pressure from management meant that patients were prioritised in time order (so as not to breach the four-hour time limit), rather than according to their physical or emotional needs. Some staff felt bullied and intimidated by the management. This, in turn, led to some staff members falsifying patient records to make it look as if patients had left the department within four hours, when in reality they had remained in A&E for up to an hour or more in some cases.

The creation of a Clinical Decisions Unit (CDU) was an attempt to manage the flow of patients more effectively and prevent patients remaining in A&E longer than four hours. The CDU was intended to be a specifically designated area for patients to await a clinical decision as to whether they were to be discharged home or admitted. Strict criteria stated that patients who were admitted to this unit must have been seen and assessed by an A&E doctor, they must not require cardiac monitoring and they must not be vulnerable or require observation.

However, these and other directions were not adhered to. The CDU was simply an old, disused A&E operating theatre which was quickly fitted out with four beds. There was no natural light and no appropriate disabled toilet or washing facilities. The unit was situated at the bottom of a long corridor within the A&E department and was very isolated. No extra staff were provided to staff the unit and it was an added responsibility for the existing A&E staff.

Patients could not understand why they were remaining in the A&E department well over the four hours and sometimes for days. Vulnerable, confused older patients were left on their own, without adequate safety precautions. This resulted in some falling out of bed, causing injury and distress.

Patients were often left lying in their own urine or faeces and staff were either too busy to attend to them, or by their own admission, ‘could not be bothered’. The lack of dignity, care and compassion shown by some staff was astounding.

The pressure to discharge patients who had not been adequately medically assessed (either because the patient was going to breach the four-hour time limit or because there wasn’t enough space in the department) became dangerous. Often patients were treated as an inconvenience and a nuisance. Many who had been discharged without proper assessment, examinations and treatment had to return to A&E; some tragically died.

The unprofessional behaviour of some staff created a culture of fear and intimidation. Many staff worked exceptionally hard and cared a great deal. However, some staff in senior positions dismissed concerns that were raised. They would bully subordinates, using menacing, ridiculing, threatening and intimidating behaviour. They would apply pressure to doctors to discharge patients before it was safe to do so, and would threaten staff who did not falsify patient documents pertaining to the four-hour wait. Consequently, patients were harmed, staff were negatively affected and much-needed improvements to the department were never realised.

I persisted in raising concerns internally, which were initially ignored. Eventually an internal investigation was undertaken. This was both corrupt and ineffective and subsequently nothing changed. I therefore began to make my concerns known outside the organisation. I attempted to raise my concerns with the Health Care Commission (now the Care Quality Commission (CQC)) and with my Union, the Royal College of Nursing (RCN). Unfortunately, these efforts came to nothing and I began to feel very discouraged.

In 2008, I left the Mid Staffordshire Foundation Trust to work as a Nurse Practitioner in a neighbouring Trust. Although I had left the organisation, I remained very concerned about the patients and staff who were potentially still suffering. Consequently, I began to raise my concerns with local MPs and campaign groups. This resulted in my giving evidence at the first Francis Independent Inquiry and then at the Francis Public Inquiry. I was later called to give further evidence at a Nursing and Midwifery Council (NMC) Fitness to Practise hearing, which led to two senior nurses being struck off the NMC register.

When I spoke out about the appalling standards of care and low staff morale at Stafford Hospital, I was at first ignored and then threatened. I therefore know how isolating, frustrating and frightening it can be to speak up. Many factors can prevent staff from speaking up. Some fear that their career prospects will suffer; some fear losing their job; some fear being discredited; some are reluctant because it may require them to speak up against friends and colleagues and some are concerned about the potential negative impact on their relationships with friends and family in the local community.

These are all understandable fears and real potential barriers for some. However, raising concerns needs to be normalised so that it is no longer stressful and emotionally draining. Ultimately staff must have faith in the knowledge that they are raising legitimate concerns because it is their professional duty to do so, and that they will be treated fairly. Staff need to feel empowered and enabled to raise concerns before these issues affect patient care.

As a senior nurse with over 19 years of experience working in health and social care, I very much welcome the initiatives put in place since the Francis Report (2013). I am especially proud of the development of Freedom to Speak Up Guardians. I believe that, if these roles are embedded correctly, and fully supported, they will make a real difference to how staff raise concerns. However, there is always more to be done and we must never become complacent. The information and soft intelligence gained from having a Guardian in place will help prevent problems reoccurring in the future. This should help to encourage and support staff to make positive improvements to the services and care they deliver.

If we do not respect and look after our staff, how can we expect them to look after patients and service users? Low staff morale leads to increased stress, errors and sickness absence. This will clearly have a negative impact on the delivery of good-quality, safe care of patients.

In an ever-changing NHS and social care system, we must ensure that staff are consulted and their opinions respected when implementing change. Many staff report feeling devalued and disrespected as change happens to them, rather than with them. These staff members can often see that proposed changes will not be sustainable or conducive to ensuring patient or staff safety. Having had personal experience of trying to raise concerns whilst at the Mid Staffordshire Foundation Trust and having been bullied and threatened as a result, I feel compelled to use my experience to highlight these issues and help improve the process of raising such concerns at a national level.

As qualified health or social care professionals and students, you will be aware that you too have a duty to speak up and raise concerns should you have them. In order to do this, you firstly need to be clear and confident about identifying what constitutes professional concern, and secondly be clear and confident about knowing how to actually raise your concern. Being a confident and competent professional means being prepared to act in this way, and know that it is the right thing to do.

In conclusion, we should all be very proud of the NHS and our social care provision and should be working in health and social care precisely because we do care! Unfortunately, though, there may be times when we see poor standards of care, or misconduct or unacceptable behaviour and we all have a duty to speak out about it. Nothing is ever perfect, but I would like to see an NHS that truly encourages and supports its staff in raising concerns, rather than at best paying lip service, or at worst intimidating and ignoring them.

We can create and maintain a culture that expects people to raise concerns when things are not right, and views it as abnormal for them not to do so. As the NHS and social care system is in a constant state of change, practitioners in these fields have to be prepared to deal with a wide range of professional issues. This requires knowledge, resilience, compassion and genuine empathy in order to uphold the values that should be central for all workers in these areas. This is what you must maintain, irrespective of any transitions you move through in your career, whether you progress from student to qualified practitioner, novice to senior practitioner, or practitioner to manager. I hope this book will help you, wherever you are on this journey, as you are the future of service provision and the future must be one of care and respect.

Einführung

Lyn Westcott, Steven W. Whitcombe and Teena J. Clouston

This book emerged from our awareness of the increasing complexity of health and social care systems in the UK and the skills that professionals have to acquire to meet their demands. As editors of this book working in British universities, we particularly wanted to support the transitions of students and early career practitioners in their practice and help them find their way as professionals in health and social care in the four UK nations. These systems have been in a constant state of change throughout our own careers and this is set to continue, so we knew that the text would need to help you, the readers, understand important concepts that would support your development as professionals in a ‘moving landscape’. The book is therefore not a guide to the changing context of health and social care, although inevitably a snapshot of those changes will appear within it. Instead, this book has been compiled to offer personal and professional strategies that will help you develop and flourish in this changing field of work.

Fundamental to achieving this is the ability to pass through key transitional phases confidently and successfully. When we talk about transitions, we mean moving between distinct steps that mark your progression as a health and social care professional. These could be personal steps, linked to your career progression; they may concern the evolution of your profession; or they may be organisational changes, like the major UK-wide agenda of aligning the work of health and social care which is currently steering service developments.

Some of these transitions will be linked to personal aspirations, technological developments, changes to funding systems, new evidence that guides practice or other (sometimes political) drivers to enhance quality and standards of practice. Consider, for example, the critical impact of the Francis Report (2013) which highlighted serious shortcomings in practice, quality of care, personal integrity of NHS staff and how policy could over-ride the importance of human compassion when working with vulnerable people. You may want to read the preface for a first-hand account of the personal impact of the events of Mid Staffordshire and how one professional responded to this. This report, and people’s responses to it, have enforced significant change and highlighted the importance of successful transitions amongst individual practitioners. In addition, organisations that offer health and social care services have had to adapt, driven by a revised political and public mandate that values dignity, care and compassion above unrealistic targets and financial constraints.

In this book, we focus on important areas that influence our practice and affect transitions at a personal, organisational, professional and political level. The contributors are all specialists representing a wide range of professions across the health and social care sectors in the UK. Some are practitioners; others are managers, policy makers, researchers and educators. All are experts in their own field and share a passion to improve services and ease the transitions involved.

To assist the reader, the book has been divided into four main sections, each with an introduction to help you plan your learning.

The first section ‘To begin at the beginning: Scaffolding professional practice’ contains four chapters exploring fundamental aspects of professionalism. These include the implications of registration, expectations of a professional in their practice, and how to sustain professionalism over a long period of time.

The second section ‘Working together and communication’ addresses the importance of communication for effective health and social care practice. This is an area that is subject to continual evolution and change. Through examination of team and partnership working, specific aspects of working life for the health or social care professional in complex organisations are considered. This section finishes with a chapter on communication in the digital age and raises some personal issues to think about as a professional in an instant communication-rich society.

The third section ‘Quality in practice’ has three chapters focusing on drivers that steer the changes in health and social care services and how these are implemented. With chapters on political systems and mechanisms in the four UK nations, achieving quality with limited resources and the role of research in health and social care, the authors of this section help readers to consider how their practice is influenced at a national level to achieve high standards within budgetary constraints.

The final section ‘Understanding values and the duty of care’ returns to a more personal agenda for practitioners concerning our interaction with the people we work with. Chapters on safeguarding adults and children provide some thought-provoking content on our duties to some of the most vulnerable people in society. Other authors raise issues about caring values, revisiting how essential these are, and what happens if things go wrong. A chapter on spirituality in health and social care practice explores a dimension of your practice that you may not have considered but is always there within health and social care work. Finally, there is a chapter that looks at protecting yourself as a practitioner in an emotionally demanding area of work. These self-preservation strategies are essential to ensure that you remain healthy, strong and resilient throughout your career.

The book finishes with an Epilogue, in which we as editors draw together its key messages. We link these to the concept of transitions and highlight the importance of the interconnectedness of the themes described throughout the book in terms of health and social care practice. This final contribution suggests how you might wish to take these messages forward in your own career journey.

As you would expect, many of the chapters in this book share common themes and, where appropriate, there are cross-references to other parts of the book. Each contributor has outlined a number of specific learning outcomes for their chapter. It is recommended that you read these outcomes carefully before each full chapter in order to maximise your own learning. The chapters also contain reflective questions to help you apply the discussion to your own experiences and practice. They have been designed to challenge you and help you embed the content into your own professional journey and the important transitions you may undergo within it.

Whilst some of these reflective questions may seem very general, the depth of inquiry they prompt will develop over time – because you will undergo transitions in your career and, in addition, the systems you work in (like the NHS or social care services), will be in a constant state of change. Bearing this in mind, it may be helpful to keep a note of your responses to the questions and revisit them later in your study or career to see how things have developed and altered in your own thinking. It will be interesting to track your appreciation of the meaning of the concepts involved and how they impact on your practice. Reflections of this type have the added value of helping you monitor your own professional development and giving you feedback on your own personal transitions in the career journey.

Please note: The contributions in this book reflect the personal opinions of each of the authors. They do not represent the views of the organisations that employ them. The terms ‘patient’, ‘client’ and ‘service user’ are used interchangeably in the book and represent the personal choice of the author. In all cases, these terms are used to describe the people accessing health and social care services.

For Percy Whitcombe – thanks for your love and support

Section 1

To begin at the beginning: Scaffolding professional practice

Einführung

by Lyn Westcott

This initial section of the book examines some fundamental concepts that underpin the more personal elements of professionalism for effective, high-quality health and social care practice.

All professionals working in health and social care systems in the UK have accepted the need for their practice to be subject to wider quality systems and frameworks. These frameworks ensure that every practitioner operates within baselines of safety and competence in order to protect the public and the scope of their practice. This has not developed by chance, but out of a need for effective regulation and scrutiny following a series of shocking failures by professionals, such as that at the Mid Staffordshire Hospital described in the Preface. Alongside this, each new professional develops their skills and thinking to meet society’s expectations of their professional role, as well as their own expectations of themselves as a professional practitioner.

This section takes a dual approach to these fundamental issues concerning the concept of professionalism. One approach is to look at the systems that monitor professional practice; the other considers the more personal journey that guides, develops and sustains people when they become newly qualified professionals. This section therefore explores aspects of the key transition from layperson to professional practitioner. Some of the chapters describe systems and expectations that all practitioners need to understand and abide by. Others consider how individuals can embrace the challenges of becoming a professional practitioner. They look at each person entering the professional world and gaining an understanding of their role and obligations within that world. This section thus provides an underlying structure or scaffolding for the later sections of the book. It is a useful section for students, new practitioners or those mentoring or educating students within practice settings.

Chapter 1 sets the scene by outlining the importance of professional ethics, registration systems and fitness to practice procedures in health and social care. Drawing on the lessons of critical incidents from the recent past, the author outlines how systems such as registration and maintenance of ethical standards by professionals ensure the safety of the general public, including the importance of raising concerns about services when working within them. The chapter finishes by posing some reflective questions on how all this works on the ground and challenges the reader to reflect on their role in maintaining ethical standards.

Chapter 2 is authored by two NHS service managers and discusses professionalism in terms of expectations concerning specific professional behaviours within practice settings, especially for students. The chapter challenges the reader by raising specific examples where professionalism might be questioned through behaviours seen in the workplace. It also highlights situations where expectations might differ between academic settings and placement settings. The chapter concludes by asking readers to reflect on a framework of issues that contribute towards professional behaviours.

Chapter 3 takes a very personal approach to considering the journey towards professionalism, making the transition from novice student