The impact of changes to the roles and responsibilities of a chosen health care professional.
Introduction
This unit examines the purpose and development of the healthcare professions, and begins by defining and describing the roles and responsibilities of a variety of healthcare professionals.
Technological and scientific advances and social, political, economic, cultural and ethical factors are evaluated, in terms of their influence on health care services and the impact they have had on the skills, competencies and conduct of healthcare professionals.
Throughout the unit, evidence is used to explain why changes occurred and how practitioners have adapted to those changes. Codes of conduct within the healthcare professions are analysed, and the effectiveness of multidisciplinary approaches in healthcare provision is evaluated.
Finally, the influence of selected healthcare professionals and their professional bodies have had on healthcare polices is explored.
Learning Outcomes
The impact of changes to the roles and responsibilities of a chosen health care professional.
Understanding regulation as a chosen healthcare professional.
The multidisciplinary team working in a chosen healthcare
Grade Descriptors
The following grade descriptors will be used throughout this unit.
Understanding of the subject
The student’s work or performance demonstrates very good grasp of the relevant knowledge base, and is generally informed by the major conventions and practices of the area of study.
The student’s work or performance demonstrates excellent grasp of the relevant knowledge base, and is consistently informed by the major conventions and practices of the area of study.
Application of knowledge
What is health care professional
Healthcare professionals working in the UK are qualified practitioners, who belong to particular specialities or disciplines, and who are allowed by their regulatory bodies to provide specific healthcare services to patients.
Healthcare professionals are educated to a specified standard to ensure they have the competencies, skills, knowledge and expertise to engage in their chosen occupation. They are regulated by their own members and required to behave in accordance with agreed guidelines as determined by their professional body.
Some examples of healthcare professionals include:
Medical, surgical, and dental practitioners.
Nurses, midwives, health visitors, district nurses, and social workers.
Professionals Allied to Medicine (PAMs), for example, clinical psychologists, radiographers, physiotherapists, occupational therapists, speech therapists, orthoptists, chiropodists, operating theatre practitioners, and dieticians.
Paramedics, ambulance personnel, and accident and emergency personnel.
Other professionals who have contact with patients such as pharmacists.
Section 1 The role and responsibilities of healthcare professionals
Nurses
Due to the diverse nature of nursing it is difficult to define the role of the nurse. The word `nurse` means to "nourish or nurture ".
The Royal College of Nursing in `Defining Nursing` (2014) state that nursing is the "use of clinical judgement in the provision of care to enable people to improve, maintain or recover their health, to cope with health problems, to achieve the best quality of life whatever their disease or disability, until death" .
District nurses
District nurses play a key role in community care teams. Led by a general practitioner, the nursing care that they provide is determined by population and case management. District nurses facilitate independence, support and care for patients at home who are unwell, recovering, or at the end of life. The Royal College of Nursing describes the role of the district nurse as empowering people to be cared for in their own homes and in the community.st century.
School nurses
School nurses work as part of a team, with teachers and other healthcare workers bridging the gap between education and care. They look after the health and wellbeing of children and young people. School nurses have a vital role in public health, health education and promotion, sexual health, child development, immunisation, screening, and managing medical conditions in school and child protection.
What can history tell us about changes in the healthcare professions?
History tells us that healthcare has always played an essential part in human survival. Historically, we can see that healthcare professions, as we know them today, have been shaped by cultural, political, societal and scientific developments.
Porter (2001), proposed that beliefs about our bodies in sickness and health have always been central to our social value systems. Therefore, all people have a shared responsibility in maintaining their health and changes in healthcare affect everyone.
The professionalisation of medical practice in England
Medicine became a professional occupation long before nursing and other healthcare professions did. For instance, medieval nuns provided medical care, but women healers were excluded as medicine became more scientific and doctors became more powerful.The Royal College of Physicians(opens in a new tab) was formed in 1518 by a Royal Charter from King Henry VIII, in order to formalise medical training and to regulate medical practice.
Medicine became the ‘new science’ in the Age of Enlightenment, when many important scientific discoveries were made that questioned the accepted ideology and religious teachings.
John Hunter, the father of modern surgery (1728-1793), elevated surgery from a craft to a science. He taught surgery, physiology, pathology and midwifery in London, and relied on body snatchers to perform countless dissections. History shows us that doctors have trained in universities and hospitals for centuries. As their knowledge and skills increased, so did the power and authority of physicians and surgeons, along with life expectancy and public expectations.
Modern healthcare professions emerged from the expansion of medical science. The new healthcare professions became disciplines in their own right, using their own research-based knowledge to develop skills and practice and with their own regulatory bodies, which self-determined their roles and responsibilities.
How different medical professions were created:
District nurse
One of the first district nursing training schemes was founded by William Rathbone with the support of Florence Nightingale, at Liverpool Royal Infirmary, in 1862. Trainees shared responsibilities between the hospital and the nursing association set up by William Rathbone in 1861.
In 1875, the Metropolitan and National Association for Providing Trained Nurses for the Sick Poor was established to raise the standard of character and skills of district nurses. This led to the foundation of the Queen Victoria Jubilee Institute for Nursing the Poor in the Own Homes in 1889, with an emphasis on high standards of training.
In 1909, the Institute set national standards for training district nurses and in 1978 it became known as the Queen’s Nursing Institute. District nurses now undertake the Specialist Practitioner District Nursing Course at undergraduate and post graduate levels.
School nursing
Nurses have worked in schools since the 1800s when their main job was to quarantine students with communicable diseases. The role evolved due to concerns about the health of children and young people during army recruitment campaigns.
School nurses were appointed under the Education Act 1907, to provide medical inspections for children in elementary schools. The first school nurses worked in Bolton, caring for the poor in their own homes. In the 1960s and 70s, they wore white coats and were nicknamed ‘nit nurses’.
Key changes in modern healthcare professions
Upton and Brooks (2000) claimed that any changes in healthcare, affects the skill profiles of all professionals, inter-agency working and professional standards, achieved through organisational and service developments which are triggered by political, economic, social, and technological or scientific innovations.
Changes which affect healthcare professions include:
Political changes.
Economic changes.
Social changes.
Technological changes.
Organisational changes.
The role of women in society and effects on the healthcare profession
Versluysen (1980) argued that because the history of medicine has been recorded from a male perspective and from a position of power, the role of women, in delivering babies, dispensing remedies and in caring for the sick, infirm and the dying, has been trivialised and largely overlooked. This has delayed the process of professionalisation in female-dominated healthcare, such as nursing and midwifery.
Furthermore, Charlotte Kratz (1980) warned that the role of women as healers in their own right had been so neglected by historians, that for years, society has been denied the improvements that would have come at the hands of women. Kratz (1980), also questioned why physiotherapists, social workers, dietitians and other healthcare workers became professionals long before nurses.
Before the 1920s, women in England were not allowed to graduate from a university. From the 1870s, women were able to attend lectures and participate in examinations, but they were unable to receive a degree. The university statute of 1920 admitted women to full university membership.
The movement for higher education for women began in Britain and the USA in the 1840s.
For example, at the University of Glasgow(opens in a new tab) , a medical school was established in 1890 with facilities for female students to study for their medical licence. Laboratories, a dissecting room, and beds were set aside for clinical instruction in the female ward for female medical students at Glasgow Royal Infirmary.
Elizabeth Garrett Anderson was the first woman to qualify as a physician and surgeon in England, in 1865. In her lifetime, she became the only female member of the British Medical Association and the first female Dean of a medical school.Equal Franchise Act (1928)(opens in a new tab) that women achieved the same voting rights as men, and all women over 21 years were eligible to vote.
Political changes
According to Harrison and McDonald (2008), The NHS Act (1946) promised a comprehensive health service to improve the physical and mental health of the UK population and the prevention of illness, which greatly affected the lives of patients and the roles and responsibilities of healthcare workers at the time.
Since the founding of the NHS in 1948, subsequent government policies have shifted the focus of health service delivery to become more patient-centred to encourage patient autonomy and to actively involve patients in decisions about their care.
In addition, professionals have become increasingly more accountable for their actions. Doctors are now likely to offer counselling, advice, and support rather than prescribing a treatment. The emphasis is on health education and informed decision-making, to promote healthy choices, independence, and independent living.
In England, central government determines levels of accountability and how funding is allocated. Recently, responsibility has been devolved to be as close to the patient as possible. Teasdale (1992) pointed out that when the White Paper, ‘Working for Patients (1989)` was incorporated by Parliament into the 1990 NHS and Community Care Act, it introduced major changes in the way the NHS is funded and managed, which affected healthcare workers and patients alike.
According to Teasdale (1992), the main change was to improve hospital and GP services by introducing the principle of competition in an internal market to encourage improved efficiency and effectiveness in healthcare units.
GP fund holders and district health authorities became main purchasers. NHS hospital and community trusts managed themselves and became responsible for their own decisions. Auditing the quality of clinical services involved professional reviews, pooling data and identifying good practice.
Upton and Brooks (2000) agreed that these policies moved the focus of care delivery from hospital to community-based settings, by reshaping structures and relationships within the NHS. For example, The Patients Charter in the 1990s was designed to make healthcare professionals more accountable for their actions.
In 1997, ‘New Labour’ modernised the NHS in response to social and global economic changes. The White Paper, ‘The New NHS: Modern Dependable’, introduced Primary Care Groups, Health Improvement Programmes and NICE. Foundation Trusts were created in 2002 for better performing hospitals, and the NHS Improvement Plan (2004) outlined major changes to move from a centrally directed system to a patient-led system.
Changes following The Health and Social Care Act (2012)(opens in a new tab) were aimed at meeting increased demand and treatment costs. Clinical Care Commissioning Groups (CCGs) replaced Primary Care Trusts in 2013, putting clinicians in a better position to shape healthcare services, empowering patients, clarifying roles and responsibilities and bringing greater accountability for healthcare professionals.
Harrison and McDonald (2008) suggested that political changes over the last 20 years have challenged the autonomy of practitioners. Healthcare professionals have traditionally kept control of their theoretical knowledge, whereas the production of clinical guidelines tends to routinise and undermine specialist knowledge and skills.
In addition, chief executives of NHS services are rarely healthcare professionals, and systems such as clinical governance which made NHS organisations accountable for the quality of clinical services, has been seen as a way of controlling health professionals.
Health and Social Care 2012 fact sheet
Economic changes
Harrison and McDonald (2008) pointed out that the politics of healthcare resources and rationing is based on funding by public contributions, which requires governments responses that manage supply and demand. This is a system that is at risk of inflation of demand over time, demographic shifts, and technological change.
In the UK, public expenditure is controlled to maintain financial balance between increasing demands, higher public expectations, more expensive treatments, the unemployed, retired, and younger generations, and contributions through taxation.
Trade unions also influence pay scales and contracts. The consequences of some government actions have created changes which are not always advantageous to healthcare professionals and patients. For example, the recent junior doctor’s strikes in opposition to new contracts has resulted in the cancellation of planned treatments and senior doctors having to cover the work of junior doctors.
The economic context involves managing spiralling costs, restricting expenditure by prioritising treatments, setting ceilings, and cost improvements. Spending aims at achieving the greatest health gain for most people.
Not all financial changes have benefitted patients. For example, The Telegraph(opens in a new tab) , on September 3rd , 2016, reported that obese people and smokers in a North Yorkshire authority may be denied NHS surgery for non-life-threatening conditions for up to a year, due to hospitals cutting costs.
Some critics have likened this to an abuse of human rights, whilst NHS Providers claimed that there could be more decisions like this due to the deepest financial squeeze in the history of the NHS.
Can you recall any other examples of groups of patients that have been denied treatment on the basis of cost?
Social changes
Upton and Brooks (2000) claimed that social changes in healthcare occur due to increasing pressures on services and funding, as people live longer and the costs of caring for vulnerable and chronically ill people increases. As a result, very different patterns of care, like clinical care pathways, have been introduced.
Reports showing changes in health problems and the increasing connections between poverty and ill health have resulted in changing service provision. For example, higher consumer expectations and individual choice have resulted in measures such as setting maximum waiting times and easy access to complaints.
Salvage (1985) pointed out that healthcare is a social responsibility and healthcare has had to adapt to changing patterns of care that are responsive to the needs of clients. This has been achieved by extending and developing expertise and skills through research and education. User participation in healthcare services has enabled individuals, communities, consumer, and patient pressure groups to represent their interests to government.
Government statistics have revealed that lifestyles are a major cause of many illnesses. Health education aims to achieve a healthier society by changing personal beliefs, attitudes, and behaviour. Health promotion and health education approaches are based on the belief that responsibility for health lies with the individual.
Harrison and McDonald (2008) suggest that clinicians adhering to the systemisation of medical knowledge, such as in clinical guidelines, clinical protocols, and patient pathways, has made medical knowledge more accessible to patients. So, patients are better informed and able to question the decisions of clinicians.
Upton and Brooks (2000) stress that reformation of professional education systems to make them more widely accessible to people who have not obtained traditional academic qualifications, has led to the introduction of competency-based approaches, offering people the chance to be recognised for their skills and abilities. Upton and Brooks also recognise that greater public awareness of health has led to more transparent practice and willingness of healthcare professionals to admit mistakes which has led to increased litigation. Effective risk management and contingency plans are vital. Healthcare professionals have to be prepared to manage outbreaks of new global conditions such as AIDS and the Ebola virus.
Technological changes
With the creation and application of new technology growing at an exponential rate, this has a great effect on how healthcare procedures are conducted. Upton and Brooks (2000), describe the technological context as medical and healthcare discoveries that are reshaping the NHS at an ever-increasing rate. For example, new methods of non-invasive surgery and developments in anaesthetics have resulted in improved patient prognosis and lower costs.
New diagnostic, investigative, screening procedures, and genetic technology have led to earlier interventions and opportunities to improve health, but there is also the need to retrain staff to cope with ethical dilemmas. Upton and Brooks also emphasise the effects of extending local services in the home, clinics, or GP surgeries, which has reduced hospital admissions and shortened hospital stay.
Information technology has led to the availability of wider, more accurate information and higher patient expectations, allowing interventions to be carried out across geographical divides, leading to more sharing and provision of expertise.
Organisational changes
Many reports have triggered the reorganisation of health services, which have led to changes in professional roles and responsibilities. For example, the Francis Report (2013) identified potential patient safety problems in all NHS systems and recommended that staff capability needed to be improved in order to promote safety in complex, changeable healthcare settings.
Ultimately, changes are aimed at improving the quality of patient care and experience of healthcare, which is now more patient-centred and holistic in its approach. Patients are consequently perceived to be partners in care, are more involved in decision-making and have more autonomy over their care outcomes.
SECTION 2 The functions of public bodies, agencies, and regulators in a chosen healthcare profession
The role of regulators in health and social care
Regulatory bodies protect, promote, and maintain public health and safety by ensuring proper standards are in place and by requiring, restraining, and putting conditions on professional healthcare practice that can be enforced.
Healthcare professionals are members of regulatory bodies that ensure proper standards are maintained by health and social care practitioners.
The main duties of professional bodies are to:
Maintain an up-to-date register of healthcare professionals.
Set standards for education, training, and codes of conduct.
Investigate when standards are not met.
The Health and Social Care Act (2015) aims to improve safety and quality of health and social care services by reducing harm suffered by patients and promoting appropriate sharing of information.
REGULATORS
The Health and Safety Executive (HSE)
The Health and Safety Executive(opens in a new tab) is the national independent regulator for maintaining healthy and safe workplaces. The HSE works in partnership with co-regulators in health and social care settings and with local authorities.
The Care Quality Commission (CQC)
The Care Quality Commission is another regulatory body responsible for quality and safety of health and social care provided by the NHS, local authorities, private providers and voluntary organisations in registered settings providing regulated care under the Health and Social Care Act (2008).
There are many professional bodies that regulate the standards and conduct of healthcare practitioners. Two professional bodies that you might like to find out more about are outlined below.
The General Medical Council (GMC)
The GMC is an independent body whose role is to protect patients, set standards for doctors to follow, provide ethical guidance and oversee and improve medical practice and education. The GMC determines which doctors are qualified to work in the UK. The GMC registers all doctors in the UK with a licence to practice.
The main principles underpinning the GMC Code of Conduct are shown below:
Selflessness — doctors must act in the public interest.
Integrity — doctors must not be influenced by people or organisations.
Objectivity — doctors must make decisions impartially.
Accountability — doctors must justify their decisions and actions.
Openness — doctors must act in an open and transparent manner.
Honesty — doctors must be truthful.
Leadership — promote these principles and challenge poor behaviour.
GOOD MEDICAL PRACTICE
Standards published in ‘Good Medical Practice (2013)(opens in a new tab) `, describe what makes a good doctor, covering every aspect of a doctor’s role, work and duties. The four domains of ‘Good Medical Practice’ are summarised below:
Put the patient first. Maintain professional performance, apply knowledge and experience to practise. Record work accurately.
Contribute and comply with systems to protect patients and colleagues, raise concerns, and respond to risks to patient safety.
Communicate effectively, work collaboratively to improve patient care. Teach, train, support, and assess. Ensure continuity and coordination in care. Maintain partnerships with patients.
Respect patients, treat them fairly without discrimination. Act with honesty and integrity. Doctors have a professional duty of candour.
The GMC is obliged by law to investigate cases where patient safety is an issue and can prevent a doctor compromising patient safety or public confidence. If patients have been put at risk through the actions of doctors, the GMC has the power to issue a warning, suspend or impose conditions on their practice or to remove a doctor from the register.
The Nursing and Midwifery Council (NMC)
The Nursing and Midwifery Council regulates for nurses and midwives in England, Wales, Scotland and Northern Ireland. The NMC protects the public and sets professional standards for education, conduct, and performance.
Code of professional standards
The Code of Professional Standards of Practice and Behaviour for Nurses and Midwives (2015)(opens in a new tab) is detailed and divided into sections are summarised as follows:
Treat people as individuals and uphold their dignity.
Listen to people and respond to their preferences and concerns.
Make sure that people’s physical, social, and psychological needs are assessed and responded to.
Act in the best interests of people at all times.
Respect a person’s right to privacy and confidentiality.
Always practise in line with the best available evidence.
Communicate clearly.
Work cooperatively.
Share your skills, knowledge, and experience for the benefit of people receiving care and your colleagues.
Keep clear and accurate records relevant to your practice.
Be accountable for your decisions to delegate tasks and duties to other people.
Have in place an indemnity arrangement which provides appropriate cover for any practice you take on as a nurse, midwife, or nursing associate in the United Kingdom.
Recognise and work within limits of your competence.
Be open and candid with all service users about all aspects of care and treatment, including when any mistakes or harm have taken place.
Always offer help if an emergency arises in your practice setting or anywhere else.
Act without delay if you believe that there is a risk to patient safety or public protection.
Raise concerns immediately if you believe a person is vulnerable or at risk and needs extra support and protection.
Advise on, prescribe, supply, dispense, or administer medicines within the limits of your training and competence, the law, our guidance and other relevant policies, guidance, and regulations.
Be aware of, and reduce as far as possible, any potential for harm associated with your practice.
Uphold the reputation of your profession at all times.
Uphold your position as a registered nurse, midwife, or nursing associate.
Fulfil all registration requirements.
Cooperate with all investigations and audits.
Respond to any complaints made against you professionally.
Provide leadership to make sure people’s wellbeing is protected and to improve their experiences of the health and care system.
To be fit to practise, a nurse or midwife must have the skills, knowledge, good health and character to do their job safely and effectively. The NMC(opens in a new tab) will investigate allegations made against nurses or midwives and can restrict their practice, or remove them from the register permanently or for a set period of time.
Professional organisations and trade unions
Trade unions also advise and support practitioners, helping them plan and deliver the most effective and efficient health services. Professional organisations and trade unions give support and representation to their members in the workplace.
They also provide advice, professional and practical clinical guidance, learning opportunities, and resources for their members. They share the same values as the regulatory bodies. They represent their members when disciplinary action is taken against them by regulatory bodies.
Some examples of professional organisations and trade unions include:
The British Medical Council
The British Medical Council is a trade union and professional body for doctors in the UK. It offers representation and guidance on employment-related issues, such as pay and working conditions, career advice and professional development resources and practical issues surrounding whistleblowing, with case studies.
Clinical governance
Clinical governance is a framework under which NHS organisations are accountable for systematically maintaining and improving the quality of patient care.
The components are summarised below.
Risk management identifies what can and does go wrong in clinical practice. The factors involved, lessons learned and action to be taken to prevent recurrence. Systems are then put in place to reduce risks.
Clinical audit is a way that healthcare professionals measure the quality of care, comparing their performance against a standard to see if it can be improved. Changes can then be measured for success or not. In addition, some trusts participate in national audits, like the National Confidential Enquiry into Patient Outcomes and Death (NCEPOD)
Healthcare professionals should be given opportunities to update their skills and knowledge, to keep up with developments, and learn new skills in order to do a good job. Professional development, nurse and medical education, practice, and clinical skills teams provide in-service training to ensure patients receive best care.
High-quality care is based on good quality evidence from research. The National Institute for Health and Clinical Excellence (NICE) is responsible for publishing national guidance on promoting health, preventing and treating ill health. Clinical Effectiveness Managers monitor compliance with NICE guidance within Trusts.
Patients and carers work in partnership. The views of patients are achieved through patient and carers councils, complaints, and compliments are monitored through Patient Service Departments and Patient Advice and Liaison Services (PALS).
Highly skilled staff working in efficient teams and well-supported clinical environments are essential to the provision of high-quality care.
Codes of conduct
Codes of conduct are sets of rules for healthcare professionals outlining their ethical and legal obligations and responsibilities. Codes of conduct are based on ethical principles that can be traced back to the ancient Greeks. For example, the Hippocratic Oath, taken by all doctors, ensures that they act in the best interests of patients and protecting them from harm.
A guide to the Hippocratic Oath
BBC
Beauchamp and Childress (2013) identified four principles essential to moral reasoning in health professionals. Healthcare professionals are advocates who are ideally placed to promote human rights through their relationships with patients. However, ethical principles can conflict with one another and health professionals often have to decide the best action to take in difficult circumstances.
The four principles outlined by Beauchamp and Childress (2013) are shown below:
Autonomy
Autonomy is enabling patients to make their own choice based on the principle that individuals have the right to make their own decisions according to their values, reasoning, and on the information they are given, but they should not be coerced.
However, in reality, many patients lack competence, capacity, or have different beliefs and need to be supported in asserting their right to autonomy and to participate in informed decision-making.
Nonmaleficance
Nonmaleficance is to avoid doing harm to others. Many medical treatments conflict with this principle. Therefore, healthcare professionals have a duty to ensure that patients understand the advantages and disadvantages of all treatments. Nonmalificance conflicts with autonomy and justice when healthcare professionals are not able to comply with all patient’s wishes, for example, if they are unlawful or not considered to be in their best interests.
Beneficence
Beneficence is to do ‘good’ by safeguarding and protecting vulnerable patients. In some circumstances, the principles of beneficence and autonomy may conflict if the patient and healthcare professional disagree with decisions that are made.
Justice
Justice is ensuring that a person’s human rights are upheld, regardless of their capabilities and competence. This is the principle of equality. People must be treated the same regardless of age, race, gender, etc.
Healthcare professionals are themselves accountable for maintaining high standards of safe care. Failure to do this can result in them being sued or prosecuted if patients have suffered harm as a result of their actions.
Healthcare professionals are accountable for their actions to their profession, their employers, and the public from their duty of care. Healthcare is governed by law to protect the public and prevent harm, therefore professional bodies and regulators provide guidance to practitioners, who require knowledge of relevant legislation.
Chally (1993) pointed out that veracity is fundamental to relationships formed between health professionals and patients. Such relationships are based on effective communication and mutual respect, to enable healthcare professionals to carry out their duties. For partnership in care to work, people must also trust that the information they receive about their health is the true.
The GMC have developed interactive online tools to help doctors with decision making when patients lack capacity. They have also created case studies; the study below is adapted from one of these.
Brenda Jones is 35 years old and has Down’s syndrome. She has been undergoing cancer treatment, which she found very distressing, but now her condition is terminal. Brenda attends a follow-up consultation with her support worker and is seen by an oncology registrar
The registrar explains the diagnosis and offers to continue active treatment to shrink the tumour, which may prolong her life, but will not cure it. There will be further side effects. Alternatively, he offers palliative care in a hospice, where pain and symptoms would be controlled
Brenda becomes upset and her support worker tells the doctor that Brenda is very independent and does not like the thought of having to leave her home. The registrar gives them some leaflets to read at home and arranges for a Macmillan Nurse to visit them there. In the following week, Brenda decides that she does not want any more active treatment.
Whistleblowing
Whistleblowing is when a healthcare worker raises concerns about unethical, unsafe, harmful practice, which is brought to the attention of people who have the power to take corrective action in their work environment.
Whistleblowing promotes patient safety, honesty, and openness in the workplace.
As a result of raising concerns, whistleblowers often fear that they could lose their jobs, or will be stigmatised, or bullied. Regulators of healthcare professions, such as the NMC and the GMC and trade unions, like the RCN and BMA offer clear guidelines, support, and advice to whistleblowers. The Public Interest Disclosure Act (1998) is aimed at protecting whistleblowers. However, a report of the Whistleblowing Commission argues that more needs to be done to protect whistleblowers.
The Nursing and Midwifery Council`s ‘Raising concerns: Guidance for nurses, midwives and nursing associates(opens in a new tab) ` distinguished between raising concerns (whistleblowing) and making a complaint. A concern is raised when someone witnesses something that is wrong or is putting patient safety at risk. A complaint is when an employee seeks to resolve a work-related problem.
Health professionals are bound by their codes of conduct to protect the public. Health service employees are advised to raise concerns as early as possible to prevent minor issues becoming serious. Practitioners can go directly to their regulatory body when raising concerns. For example, the NMC (2013) offers step-by-step guidance.
Raising concerns
RCN
Case history of victimised NHS staff
A JUST NHS
NMC
Raising concerns: guidance for nurses and midwives
‘Learning not blaming(opens in a new tab) ’ is a Government UK Policy Paper on whistleblowing, introduced in 2015, following the Francis Report (2013). The aim of this policy is to develop a culture of trust and safety in the NHS using speak-up guardians, sharing good practice and independently reviewing cases involving NHS Trusts who have failed to provide good practice.
The policy promotes openness and honesty and encourages NHS managers to listen to patients, families and staff and to take seriously all complaints within healthcare environments to ensure better care for all.
Employees are required to follow safeguarding policies when raising concerns about abuse. Incidences of abuse are more commonly associated with children, but it occurs in any vulnerable groups.
Sction 3,
How effective the current multidisciplinary team approach is in a chosen healthcare setting
Gold (2005), defined a Multidisciplinary Team as a group of professionals with a common goal that can be achieved by pooling resources, cooperating, problem-solving, and contributing individual activities. The team membership shares collective intentions, within an agreed strategy and organisational format.
Each member of a multidisciplinary healthcare team is influenced by the team leadership style, their own personal attributes and those of others, belief systems and scope of practice, competencies and skills. Multidisciplinary Teams may also include professionals from other statutory services, or from private and voluntary sectors.
Carter et al. (2003) argued that the development of Multidisciplinary Teams was a response to the changing context for the delivery of healthcare, due to increased patient expectations, under-funding and staff shortages, targets and constraints of the European Working Time Directive, which highlighted the need for new ways of organising and purchasing clinical resources.
There are numerous examples of Multidisciplinary Teams in specialist healthcare, for example, in managing the care of people with cancer, diabetes, stroke and many other complex conditions or in cases of suspected abuse. Clinical governance has also prompted the formation of Multidisciplinary Teams replacing smaller consultant-led teams.
A multidisciplinary approach involves several disciplines exploring problems outside their normal boundaries and reaching solutions based on an in-depth understanding of complex situations.
The SCIE (opens in a new tab) highlight that the core goals of all MDTs focus on:
Connecting team members of diverse backgrounds to support one another.
Create clearer forms of communication and trust between groups.
Creating more personalised care plans, which aim to prevent harm and errors from occurring.
Producing a more efficient system for sharing resources.
All participants should be aware of their roles and areas of responsibility according to their professional codes of conduct and scope of practice. Lines of professional accountability must be clarified. A key member of the team is assigned to manage and coordinate care delivery. The care coordinator is fundamental to achieving successful integrated care and positive patient outcomes.
MDT Development
NHS
Working as part of a Multidisciplinary Team
Working within a Multidisciplinary Team involves understanding and respecting the roles of other professionals with specific skills and expertise, collaborating to make treatment recommendations, focusing on holistic needs and facilitating quality patient care. This approach is often used to manage complex health problems, such as cancer and following individual care plans based on best practice.For example, depending on the type of cancer, at any one time, a typical Multidisciplinary Team managing the care of a patient with cancer may consist of:
Medical oncologist.
Clinical radiologist.
Specialist or general surgeon.
Oncology nurse.
District nurse.
Physiotherapist.
Nutritionist.
Occupational therapist.
Macmillan nurse.
General Practitioner (GP).
Social worker.
Cancer Care Strategy
Select the button to access a report on the Cancer Care Strategy implemented in the Northern Territory, Australia.
GOV.AU
Clinical care pathways
Clinical practitioners and NHS Trusts designed clinical care pathways to direct patients with specific medical conditions through their journey of ill health, from discovery, to treatment, to recovery within an identified period of time.
Clinical care pathways enable health care practitioners to provide holistic, systematic, patient-centred approaches to care.
Integrated care pathways were also developed to map multidisciplinary management, monitoring and recording the care of people with more complex illnesses over a specific time period.
There are many types of clinical care pathways which are used for patients with a variety of healthcare problems, for example, in cases of abuse, acutely ill patients in hospital, patients requiring mental health support, or patients with more complex conditions.
The nursing process
Charlotte Kratz (1979) described the nursing process as a systematic approach to care. It has been adapted for use by most health care practitioners today. The nursing process model is a continuous, dynamic, interpersonal cycle of interrelated stages, which is affected by nurse and patient behaviour and environmental factors. As the patient’s needs and problems changes so the cycle of care is ever changing.
The nursing process is a useful vehicle that enables Multidisciplinary Teams to deliver individualised care, because it directs therapeutic interactions between patients and healthcare professionals to help them to achieve effective interventions and positive patient outcomes.
However, its success depends upon the quality of the relationship between patient and therapist.
Working in partnership with patients
As health service user’s, patients are central to the care they receive, and as health service provider’s healthcare practitioners are required to put the patient first. Working within a Multidisciplinary Team, healthcare practitioners are bound by their codes of professional practice to act within their roles and areas of responsibility and using their skills and expertise to inform, guide, and support the patient.
The relationship between healthcare practitioners and patients is formed during their first contact. The relationships may last for a few minutes, or for several weeks, months, or even years.
The GMC (2013) standards of practice stipulates that doctors must put the patient first. The NMC (2015) states that when working in partnership, a nurse must promote and contribute to the health and wellbeing of the person in their care. This includes protecting their right to privacy and confidentiality even after death.
Clinicians are trained to obtain very personal health and lifestyle-related information and to observe and measure signs and symptoms of illness, in order to assess diagnose, plan, implement, and evaluate the most effective interventions. Those closest to the patient are often relied upon to supplement any given account of changes in behaviour or activities that they have found out of the ordinary, alarming, or distressing.
Person-centred care focuses on the needs of the individual. It was introduced by psychologist Carl Rogers, as a more humanistic approach to therapy and was embraced by the healthcare professions. Rogers believed that client-therapist relationships must be based on mutual respect and unconditional positive regard, consulting, offering choices, and negotiating how needs could be met in order to achieve care outcomes. The aim is to help the client to achieve personal growth and self-respect, as well as physical healing.
Patient-centred coordinated care
Patient-centred coordinated care within a Multidisciplinary Team requires individuals to work together in partnership to understand the holistic needs of patients and their carers. It is achieved through good communication, decision-making, care planning, managing transitions, and evaluating patient outcomes.
The NHS England Handbook `MDT Development: Working toward an effective multidisciplinary/multiagency team(opens in a new tab) `, published in January 2015, recognises the unique position of the patient at the centre of the Multidisciplinary Team, giving the right input at the right time to be in control.
The patient is empowered and encouraged to remain in control, coordinating and developing services with healthcare professionals to achieve the best outcomes of care.
Steve McNeice, patient representative and co-chairman of the NHS England Handbook, described his experience as a patient with a long-term condition, from which he has benefitted from non-specialist and specialist health professionals, who provided different services to keep him mobile, independent, and out-of-hospital as much as possible.
McNeice added that an effective multidisciplinary approach benefits the patient if they are empowered to lead care-giving in their own home. The NHS England Handbook claims that improving patient health and wellbeing outcomes through multidisciplinary care involves enabling patients to make choices and putting people first leads to a reduction in inequality of access to healthcare services.
Communication and compassion in multidisciplinary care
Professional regulatory bodies recognise that care, compassion and effective communication are essential elements of successful healthcare interventions today. Working in Multidisciplinary Teams offers nurses in particular unique opportunities to provide compassionate communication, in order to achieve positive care outcomes.
However, Bloomfield and Pegram warned that nurses work in multicultural environments and the effectiveness of collaborative care depends on the patient’s ethnicity, religion, age, cognitive and physical abilities, their health and social status and preferred level of involvement. The Equality Act (2010) is a framework that enables nurses to promote equality and diversity through their work.
Confidentiality
Confidentiality is central to maintaining trust and establishing partnerships between patients and healthcare professionals. Patients have a right to expect that personal information will be kept private.
Most patients understand that information is usually shared within healthcare teams. However, practitioners are obliged to explain to patients that information may also be disclosed in their own interests or for clinical audit.
As a general rule, the patient must give consent before any information is disclosed. There are exceptional circumstances when information can be shared, for example if it is required by law, or it is justified in the public interest. An exception to this is when a patient is at significant risk. For example, if abuse of a child or a vulnerable adult is suspected, professionals must share information with appropriate agencies.
Protecting children and young people The responsibilities of all doctors
GMC UK
Multidisciplinary case conferences
Case conferences are held to agree a structural approach to plan and coordinate the care of people with complex health or social problems.
Depending on the particular needs of the patient, the case conference team usually includes the general practitioner and other medical practitioners, hospital or community healthcare professionals, personal care providers, and other agencies that have been closely associated with the patient. A minimum of three health or social care providers must be present.
The patient and family members do not have to be present, although in some cases their presence may be required. A case conference can be a face-to-face, phone, or video conference meeting. The aim of a case conference is to understand the problem and agree a safe solution.
The functions of a case conference are to:
Discuss the patient’s history.
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Identify Multidisciplinary Team needs.
Identify outcomes to be achieved by individual members.
Identify and allocate tasks to members of the Multidisciplinary Team.
Evaluate whether previous outcomes have been achieved.
How do we value the effectiveness of Multidisciplinary Teams (MDT)?
According to the SCIE (opens in a new tab), there are eight key factors which increase the effectiveness of MDTs:
Clear purpose — MDTs need a defined role which is supported by team members. Their responsibilities must require interaction across professional and disciplinary boundaries.
Institutional support — MDTs benefit from public endorsement from local leaders of their place and neighbourhoods to provide legitimacy and wider recognition within the system. Practical support with digital infrastructure, shared records, and integrated performance systems are also important enablers.
Team leadership — leaders should generally be facilitative in their approach to encourage different contributions within the team but be ready to be more directional when necessary. An awareness of inter-professional dynamics and a willingness to challenge poor collaborative practice are important competences for team leaders.
Collaborative spaces — MDTs need supportive physical and/or virtual environments and dedicated time for their members to reflect on how the team is operating. These improve communication and strengthen constructive discussion between team members.
Person-centred — there is a danger that teams become too inwardly focused on their own functioning. This can lead to people and their families feeling more, not less excluded, from discussions about their care. MDTs, therefore, need to ensure good communication with individuals about what is being discussed and genuine opportunities for them to contribute to decision-making.
Role diversity — the blend of professions and practitioners must reflect the needs of the population concerned. Processes to engage other specialist practitioners in MDT discussions when relevant will support more holistic working.
Outward-looking — MDTs need to engage with other teams and services in their local neighbourhood and place. This will enable more coordinated care and help the wider system to better understand the role and skills of the MDTs.
Evidence focused — teams require timely and accurate evidence of their shared impact. Structured opportunities for teams to reflect on this evidence will strengthen their effectiveness.
Fleissig et al (2006), evaluated the effectiveness of Multidisciplinary Teams in cancer care in the UK, and concluded that there are huge advantages for patients undergoing complex treatments for life-threatening diseases.
The advantages and disadvantages of multidisciplinary healthcare
Advantages
Disadvantages
Treatment decisions based on many and not just one opinion.
Traditional power bases are weakened, particularly in relation to acquiring resources.
It is easier to achieve continuity of care, which increases patient confidence and improves patient care.
Shared goals overshadow individual professional goals.
Clinical management protocols (agreed clinical practice guidelines) become embedded in practice.
There is insufficient time for reflective clinical management, team building and development (for example, in some busy clinical areas, team meetings are seen as a ‘waste of resources’).
It enables continuous audit of care interventions and outcomes.
Difficulties associated with balancing and listening to individual contributions.
Communication opportunities to interact with other clinicians and professionals are increased.
Underdeveloped team leadership and a high turnover of membership can affect patient outcomes.
Cross-fertilisation of ideas are facilitated
Defining the boundaries of the team can be problematic, as too many individuals may hinder progress and waste valuable time.
Professional knowledge and expertise is shared.
Mature Multidisciplinary Teams can get frustrated with the hierarchical structure of the NHS.
Resource management is more efficient and effective.
A sense of partnership between all involved, especially in the management of clinical errors or complaints is enhanced.
Some healthcare professionals are calling for more autonomy in order to overcome some of these disadvantages. For example, forming independent specialist services that would be purchased by the NHS from cooperatives of clinicians.
The NHS Charter of Patient Rights
Multidisciplinary Team approaches can be confusing for many patients. The Patients Charter of Rights (1992) identified the standard of services patients have the right to receive.
To summarise, patients have a right to:
Receive health care on the basis of clinical need.
Register with a general practitioner.
Access emergency medical treatment at any time.
Be referred to a consultant if a GP thinks it is necessary.
Full explanations about treatments in order to give informed consent.
Access your health records.
Have complaints investigated and to receive full written reply.
Receive detailed information about local health services.
Patients were also informed that they could expect that the NHS would make it easy for them to access specialist services, and that the NHS would respect their privacy, dignity, religious and cultural beliefs.
Patient rights and responsibilities charter "Patient rights and responsibilities charter" report from the Scottish Government.
GOV.SCOT
The consequences of ineffective multi-agency failure
The consequences of multi-agency failure can be devastating, as revealed in a serious case review in 2010, following the tragic death of baby Peter, aged 17 months, who was killed by his mother and her boyfriend in 2007. Prior to his death, there had been 60 visits from social workers, doctors, and police over an eight-month period. The review found that Peter’s death could and should have been prevented.
The case review catalogued a series of blunders, including a GP, who failed to report suspicious bruising, police who failed to investigate injuries, and lawyers and social workers who delayed decisions for seven weeks. The case review announced that Peter deserved better services, which were there to protect him.
Example
Victoria Climbie was killed by her aunt and her boyfriend in 2000. She was eight years old. Lord Laming’s Report (2003) found that every agency had failed her, including police, doctors, nurses, and social workers; 12 occasions were identified when they could have saved her life. Two social workers were subsequently sacked for gross misconduct
Lord Laming blamed senior managers and those in charge of staffing and funding for many of the failures. The report recommended that senior positions in the public sector must be held accountable for failing to protect vulnerable children. Another key recommendation was that agencies must be rigorously monitored. A major reform was to set up a national children’s commissioner.
Unit summary
In this unit, we have covered:
The impact of changes to the roles and responsibilities of a chosen health care professional.
The regulation as a chosen health care professional.
The multidisciplinary team working in a chosen healthcare.
You can review any of the learning in this unit by selecting the links in the menu to the left of the screen.
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