provide evidence of the care planned, the decisions made, the care delivered and the information shared; l provide evidence of actions agreed with the patient (including consent to treatment and/or consent to disclose information). And include l medical observations: examinations, tests, diagnoses, prognoses, prescriptions and other treatments

K117 Enhancing your healthcare practice Unit 14 Interpreting and managing information Copyright © 2013 The Open University Contents Unit 14 Interpreting and managing information 2 14.1 Information about service users 2 14.2 Interpreting information 13 14.3 Safeguarding information 16 14.4 The development of users’ records 21 Unit 14 summary 23 References 24 Acknowledgements 25 Unit 14 Interpreting and managing information Copyright © Iurli Sokolov/iStockphoto In your practice setting, you are exposed to a range of data that you need to interpret or understand, in order to have the best possible information available to inform your practice. This, together with evidence (as explored in Unit 13), can then make practice become best possible practice, providing, of course, that a person-centred approach is adopted. While you are in your practice setting, you will come across a range of information that is relevant to your practice. This unit deals with government legislation, service users’ records, organisations’ protocols, and guidelines for employees. The aim is to enable you to understand and effectively manage the data that you have access to from a range of sources. The unit explores the significance of data relating to service users, and addresses security, confidentiality, access to records, record retention and use of multidisciplinary records. There is a range of Acts, national government codes of practice and guidelines, and organisational policy documents and processes available to inform the management of data, which is often very detailed. If you access national documents you are advised to be selective in what you read, focusing on the section that has particular relevance to the aspect of data management you are studying or needing to access to inform your practice. A useful source of information that is more easily understood is information provided to service users about the management of their records. The principles of: l legible and accurate recording of data l maintenance of confidentiality l safe storage l safe disposal apply to all records used by service providers for whatever purpose. 14.1 Information about service users As a practitioner in health and social care, you are required to contribute effectively to the collection and interpretation of data in your practice setting. Activity 14.1 is designed to help you consider what user-related information is handled in your practice setting. Unit 14 Interpreting and managing information 2 of 25 Monday 8 February 2016 Copyright © Denise Hager, Catchlight Visual Services/Alamy, Copyright © Paul Doyle/Alamy Activity 14.1 What types of information do I use? Allow 30 minutes First of all consider what information about service users you handle or need. This is not purely about information as evidence, which you studied in Unit 13, but about all the information that enables practitioners to meet the needs of service users in a person-centred way. This could, for instance involve numerical data, dates, reminders, descriptions or instructions. Note down the different types of information that you think of – you should consider information available from service users, carers, policy documents, charts, department records, and minutes/notes from meetings. Provide your answer… Discussion Your list might have included a lot of different pieces of information, including some of the following: l the personal details of service users l the date when an episode of care or support began l the details of assessments l the result of a specific test, assessment or investigation l plans of care l evaluations of the success of interventions l the date, time and duration of a visit to a person at home l a programme of rehabilitation exercises to be completed by a service user l a list of activities a person with learning disabilities participated in during attendance at a day centre Unit 14 Interpreting and managing information 3 of 25 Monday 8 February 2016 l a list of the dates by which a child achieved pre-determined steps in a selfmanagement teaching programme l a record of attendances at therapy sessions for a person with mental health issues l a record of the visits made by another agency to a specific individual and the assessment reports made at that time l a letter of referral to another service or agency l a letter from one service/agency to another providing an update on their interventions and their outcomes l the date when an episode of care ended l case conference records l notes from team meetings. You probably found that your list contained items that are necessary in order for your service to provide the best possible interventions for service users. You will also be aware of the importance of keeping clear records so that the information can be shared with and interpreted by others. Information recorded by all members of a team is essential to the maintenance of high-quality care. Record keeping The Department of Health published a NHS code of practice for records management (Department of Health, 2006) and included a list of types of information which would be considered to be health records (p.1): l patient health records (electronic or paper-based, including those concerning all specialties, and GP medical records) l records of private patients seen on NHS premises* l Accident & Emergency, birth, and all other registers l theatre registers and minor operations (and other related) registers l administrative records (including, for example, personnel, estates, financial and accounting records; notes associated with complaint-handling) l X-ray and imaging reports, output and images l photographs, slides, and other images l microform (i.e. microfiche/microfilm) l audio and video tapes, cassettes, CD-ROM, etc. l emails l computerised records l scanned records l text messages (both outgoing from the NHS and incoming from service users). *The Department of Health advises that although technically exempt from the Public Records Act it would be appropriate for NHS organisations to treat such records as if they were not exempt. Unit 14 Interpreting and managing information 4 of 25 Monday 8 February 2016 This list recognises that records may be paper-based or electronic. The record may contain information about the current episode of care only, or may be a compilation of every episode of care for that individual. The Department of Health is essentially stating that any information held about service users and any medium used to provide data about the service user is subject to the Public Records Act 1958 sections 3(1)–(2). The Scottish Government (2010) has also published guidance entitled, ‘Records Management NHS Code of Practice’. This guidance is informed by that published by the Department of Health in 2006. The types of records you encounter will depend on the type of services your organisation provides, but it is important to access all relevant information about a person to ensure your interactions and interventions with individual service users are genuinely personcentred. The different sorts of records include: l departmental notes l profession-specific information: supplied by medical, nursing, physiotherapy, occupational therapy, speech therapy staff, and so on l data, for example X-rays and results of other diagnostic tests. Record keeping is a legal requirement and where relevant a professional requirement for all those working in a health or social care setting. It requires a number of skills, including being able to identify what to record and the use of appropriate language. If notes are not kept a number of issues can result: l Regardless of how good your memory is, it is impossible to hold in your head all the information about all the service users you work with. l If you do not record information and you are not available, another practitioner or a carer will be unable to follow the agreed plan of care. l If you do not record or pass on information about a service user, they could be endangered by receiving an inappropriate intervention. l If you do not record or pass on information about a service user, there will be no or limited information to inform the interventions with this person. l Not maintaining a system of recording would cause difficulties in respect of any possible legal proceedings, for instance allegations of negligence. The need for accuracy It is important for service users’ records to be objective and accurate. The fictional case of Tracey in Box 14.1 shows what can happen if misleading labels are given through lack of accuracy and objectivity in record-making practice. Box 14.1 Tracey’s notes Tracey is two years old and has Down’s syndrome. She has attended a child health centre on a number of occasions over the past 12 months due to her failure to gain weight. Her records comprise a great many notes recording her attendances. On the front page of the notes a doctor recorded, ‘This child’s mother is over-anxious, the child is just a little underweight for her age.’ On the second page a social worker wrote, ‘Obvious signs of failure to thrive’. Unit 14 Interpreting and managing information 5 of 25 Monday 8 February 2016 Later in the notes someone (signature and designation not given) said, ‘Signs of malnourishment.’ The rest of the sentence was illegible. Finally, on her most recent visit to the centre Tracey was seen by a different doctor, who wrote, ‘Persistent failure to gain weight refer to paediatric dietician’. The dietician assessed Tracey including a full history from birth. During the discussion about Tracey’s feeding pattern and dietary intake her mother shared Tracey had a voracious appetite although as a baby she had some difficulty swallowing. Her general practitioner had advised her to thicken Tracey’s feeds with ‘Horlicks’ so Tracey’s milk feeds had been thickened with Horlicks from 2 months of age. The dietician recorded in Tracey’s notes, ‘As there is an increased incidence of coeliac disease in children who have Down’s syndrome and Tracey has been exposed to a wheat-based product since aged 2 months I would recommend screening for coeliac disease.’ The following record stated, ‘Screening for coeliac disease positive, commence gluten-free diet and refer back to paediatric dietician to provide information, support and advice to Tracey’s parents.’ Filed inconspicuously at the back of the notes was a letter from a social worker stating that there were no concerns regarding parenting and that Tracey’s condition was not related to over anxiety in her mother. Tracey’s care was compromised by the doctor stating that her mother was over-anxious and that Tracey was only a little underweight. Others noted her failure to thrive, however, according to the records did not take action to establish the cause of the problem. Every time Tracey attended the health centre, practitioners who read the notes fell into the trap of trusting the information on the front page and were biased by it. However, the judgements of the latest doctor and the dietician were made independently of the bias of the previous records. By performing a considered, objective assessment of all the data available, including listening to Tracey’s mother, they were able to establish that Tracey’s presenting signs and symptoms were due to a specific physical cause rather than over anxiety in her mother. If you would like to know more about Down’s syndrome and coeliac disease your may wish to access the sites of the Down’s Syndrome Association and Coeliac UK. The activities in this section are aimed at helping you to keep accurate and appropriate records and to consider how records can be interpreted. The next step is to recognise the features of accurate and appropriate records in relation to policy requirements. Activity 14.2 Accurate and appropriate records Allow 30 minutes Box 14.2 Record keeping best practice Patient records should: Be factual, consistent and accurate Unit 14 Interpreting and managing information 6 of 25 Monday 8 February 2016 l be written as soon as possible after an event has occurred, providing current information on the care and condition of the patient; l be written clearly, legibly and in such a manner that they cannot be erased; l be written in such a manner that any alterations or additions are dated, timed and signed in such a way that the original entry can still be read clearly; l be accurately dated, timed and signed or otherwise identified, with the name of the author being printed alongside the first entry; l be readable on any photocopies; l be written, wherever applicable, with the involvement of the patient or carer; l be clear, unambiguous, (preferably concise) and written in terms that the patient can understand. Abbreviations, if used, should follow common conventions; l be consecutive; l (for electronic records) use standard coding techniques and protocols; l be written so as to be compliant with the Race Relations Act and the Disability Discrimination Act. Be relevant and useful l identify problems that have arisen and the action taken to rectify them; l provide evidence of the care planned, the decisions made, the care delivered and the information shared; l provide evidence of actions agreed with the patient (including consent to treatment and/or consent to disclose information). And include l medical observations: examinations, tests, diagnoses, prognoses, prescriptions and other treatments; l relevant disclosures by the patient – pertinent to understanding cause or effecting cure/treatment; l facts presented to the patient; l correspondence from the patient or other parties. Patient records should not include l unnecessary abbreviations or jargon; l meaningless phrases, irrelevant speculation or offensive subjective statements; l Irrelevant personal opinions regarding the patient. Department of Health, 2003, p. 17 Look at the list in Box 14.2, which is from the NHS Code of Practice on confidentiality, issued in November 2003, and which at the time of writing (October 2011) has not been superseded. Unit 14 Interpreting and managing information 7 of 25 Monday 8 February 2016 Identify which elements of ‘best practice’ were followed or not followed in the case of Tracey. Also make a note of anything on the list that raises questions for you in your own practice setting. Discussion In Tracey’s notes the first entry, by the doctor, might be considered to be an ‘offensive subjective statement’. The later note, relating to the ‘Signs of malnourishment’, is more difficult to tackle, but has a subjective and speculative tone. There is little evidence of dialogue with Tracey or her mother until the last few entries in the notes. There is also an issue of legibility. It possibly struck you that there is a lot in the resource to take into consideration for your own practice, and that it would be easy to miss some of these measures. For example, if notes have to be consecutive it would be good practice to number the pages, but this is something that practitioners might forget to do. You might have concerns about the quality of handwriting in some records, or about the reference in the resource to ‘unnecessary abbreviations’. The resource might also have made you think about whether notes should make more acknowledgement of any dialogue with service users – that is, information given and received, or negotiated. When you are involved in health and social care, it is your responsibility to ensure that the following are recorded: l all attendance and non-attendance for, and any refusal of, treatment l all advice given and interventions completed l any interventions not completed and the reason why l details of any contacts made via telephone or email l identification of all those involved with a particular service user during each intervention. You must ensure that your manager holds a record of your signature, initials and forwarding address to facilitate the interpretation of records in later years if necessary. You must also ensure that you date and sign both the records and a register of service users, if one is held. A method of identifying practitioners who contribute to electronically held records must be in place. Consideration would also need to be given to the requirements of any act, for example the Equality Act (2010) which superseded the Disability Discrimination Act (2005) and the Race Relations Act (2000). You will need to refer to the list above while completing the following activity. Unit 14 Interpreting and managing information 8 of 25 Monday 8 February 2016 Finding out what is in a record Southern Health and Social Care Trust (2010) Patient Centred Care Record, Copyright © Southern Health and Care Trust Activity 14.3 Finding out what is in a record Allow 1 hour Access the records of a person using your service (a service user whose records you normally have access to). If you don’t normally have access to service user records, you will need to seek the support of your supervisor to access a service user’s records under their direct supervision. Identify where in these records you would find the items. Unit 14 Interpreting and managing information 9 of 25 Monday 8 February 2016 Do not record anything that could identify the service user, your colleagues or your organisation. Make a note of anything that makes this task difficult. We have created a Word document containing the table if you wish to fill it in electronically. Item for recording Location of record Notes Record of attendance Record of non-attendance Any refusal of treatment Advice given Interventions completed Details of any contacts made via telephone, email, etc. Identification of all those involved with a particular service user during each intervention Discussion The absence of any particular item of information may mean either that there is nothing to record, or that something has been omitted. In the example of Tracey’s notes, the omissions might have related to the reason for previous attendances: failure to gain weight. If the record is in paper form, the handwriting may be difficult to read, or the record may have suffered some physical loss or damage. It can be dangerous to draw conclusions from just one section of a written record. Tracey’s example shows that you need to read right through the notes to be fully aware of the situation. Her notes also included an unsigned and partly illegible entry. It was not clear who had written ‘signs of malnutrition’, or what the rest of the sentence said – it may well have said ‘possibly due to a malabsorption issue’. If the signature had been clear it would have been possible for others to discuss what had been written with the practitioner concerned. You might also have found that it was not always clear where to look. A number of different people may be delegated to file the notes relating to one individual at different times, resulting in inconsistent and impractical ordering of information. As the responsibility of record keeping is not the responsibility of one person, it is highly likely that unsecured or temporarily filed material may get lost. The loss will not necessarily be noticed by subsequent users. In Tracey’s case notes, there was a report from a social worker stating that her condition was not related to parenting and her mother was not overly anxious. Had this report been seen by those who subsequently read the notes, they might have been more inclined to seek out another cause of Tracey’s problems. When you look at service users’ records, you often distinguish between the different practitioners who have made entries – you may interpret what is written according to the role occupied by the practitioner who wrote it. The doctor who made the original comment about Tracey’s mother being over anxious is likely to have carried a greater level of authority than other practitioners in the multidisciplinary team. Perhaps the Unit 14 Interpreting and managing information 10 of 25 Monday 8 February 2016 social worker who wrote the letter saying that there were no concerns over parenting was not known to the team, or was overruled in some way by others with greater authority, resulting in the letter not being given sufficient acknowledgement. Perhaps the letter was simply filed in a rush, without the information being given the attention it deserved. In another scenario, the social worker’s assessment might have carried more weight and this letter would have been treated as crucial, ‘not-to-be-missed’ information. In the hustle and bustle of practice, or during a crisis, it can be challenging to reserve time for making records. Strong managerial leadership can be key to maintaining standards. In Activity 14.4, you consider Gareth’s position and the potential for mistakes. Unit 14 Interpreting and managing information 11 of 25 Monday 8 February 2016 Records as part of an intervention Southern Health and Social Care Trust (2010) Patient Centred Care Record, Copyright © Southern Health and Care Trust Activity 14.4 Records as part of an intervention Allow 30 minutes Read the scenario below and note the potential for mistakes in service users’ records. Identify where the responsibility lies. Unit 14 Interpreting and managing information 12 of 25 Monday 8 February 2016 Gareth writes up his contact with service users in the multidisciplinary notes. He usually does this each day, but if he forgets or if time is short he writes his notes the next morning instead. Gareth believes that contact with service users is more important than writing notes. His writing is not clear, but then neither is that of other staff. There is no standard system of note writing – each member of staff uses their own method. Discussion By leaving note writing to the next day, the accuracy of the information can be compromised. Information written at a later date may not be an accurate representation of what happened. Moreover, if Gareth goes home without making a record, he is effectively withholding information – as he is not available to share information with colleagues/other agencies and there are no records available to them to inform interventions. Contact with a service user should not be considered complete until the notes are written, thus making note writing an integral part of an intervention. The notes should be completed after each person has been seen. If this is not possible, then they should be written as soon as possible thereafter and at the very latest before ‘going off duty’. Gareth is responsible for keeping records appropriately. He needs to be sure that his writing is legible. If the notes cannot be read, they will not be helpful to others accessing them. He also needs to seek advice regarding his note-writing skills, and possibly access in-service training. The manager of the department is responsible for ensuring that all staff follow an approved system of record keeping in accordance with professional, organisational and legal guidelines. Service users’ notes are a formal document and must be written as such. When considering service users’ records, it is sensible to think and question beyond what you see. Records can raise questions. What is not recorded? How objective are the comments? How person-centred is the practice reflected in a record? Tracey’s notes did not seem to put her and her family at the centre of her care. The department where Gareth worked did not seem to have any system in place to support good record-keeping practice. How you interpret the information held within records depends on what questions you ask. 14.2 Interpreting information At every level in your organisation, decisions are made about what is important, what needs action, what needs passing on to colleagues, what is not to be taken forward. It is easy to feel as though you are suffering from information overload. It is important, therefore, to be able to make judgements about the meaning and importance of the information you are handling. Interpreting numerical data Numerical data can be presented in a range of ways. For example in tables, line graphs, bar charts, pie charts and scatter diagrams. Using these devices to organise numerical data can help practitioners make sense of statistics to describe the relationships between Unit 14 Interpreting and managing information 13 of 25 Monday 8 February 2016 people or groups and other factors. They can also be used to facilitate the recognition of emergent patterns and to see trends. For instance, you can scan across information in the rows and columns of a table to search for ‘blips’ and trends. In the case of Tracey, practitioners had expressed concern about malnourishment and failure to gain weight, so plotting her weight and height on a percentile chart (as in this example from the World Health Organization) would have clearly demonstrated whether she was underweight for her gender, age and height, and whether there was an emerging trend. Further, if Tracey’s mother had been asked to keep a dietary record of amounts and types of food and fluids Tracey had over a period of time, the team expressing concerns about her wellbeing would have seen that Tracey ate extremely well, and that therefore there was likely to be an underlying cause for her not gaining weight as they felt she should. To understand the significance of data, you also need to understand something about how the information was gathered. If you were aware that there was the potential for mistakes or inaccuracies in the data collection process, you would be more cautious and more questioning of the results. So you need to be sure how the data was gathered. If Tracey is weighed and measured, for example, there are correct ways of going about it in order to obtain the most accurate data possible. The weighing scales need to be correctly calibrated; it needs to be clear whether her weight is to be recorded with or without clothing; the correct technique is required to measure her height accurately, and so on. Activity 14.5 Interpreting numerical data in practice Allow 45 minutes Consider one type of numerical data that is recorded in relation to service users who access your service. This could be a physical measurement (such as height and weight), physiological (such as blood pressure or breathing rate), psychological (such as mood score), the number of times something happens, or any other relevant information. Answer the following questions: l Are there any recognised limitations to accuracy? l What precautions are followed to ensure the data is collected accurately? l How is the data recorded? l What device (if any) is used to help interpret the data? You might need to track changes over time, changes in response to interventions, or compare the data with ‘normal’ values. Discussion Tracey’s situation is used here to illustrate the points, but your results might look very different. Tracey’s height and weight would be measured according to an agreed protocol which means that community-based practitioners, such as the health visitor, who visit Tracey at home, and practitioners in the health centre would all follow the same protocol for removing clothing, being cautious to be culturally sensitive and maintaining Tracey’s privacy and dignity. They would also calibrate the equipment and get her to stand up straight. However, they would be unable to compensate for any variation in the weighing scales in the two settings, as they are likely to be different makes and designs. In each setting, however, it should be noted which scales had been used the first time her weight was recorded so the same scales were used Unit 14 Interpreting and managing information 14 of 25 Monday 8 February 2016 subsequently. Any factors which could affect measurements, for instance Tracey finding it difficult to stand up straight, would also be recorded. By recording factors which influence the accuracy of the data, the practitioner ensures that anyone reading the results at a later date could be mindful of the limits to the accuracy of the data. Tracey’s data would be plotted on two graphs specific to her gender, one of age against height and one of age against weight. Thus changes would be plotted at each appointment. The graphs also show the normal range of height and weight in the population by age, allowing comparison with children of the same age. There is an example of a BMI percentile chart on page 2 of the World Health Organization’s percentile chart which you looked at earlier in this section. Shaded areas either side of the ‘average’ indicate the normal range. BMI measurement and monitoring is a more accurate measure of the appropriateness and health implications of a person’s weight against gender, height and age. You saw in Activity 14.4 that protocols and guidelines are important to ensure that data is collected in an accurate way. It is also important to be aware of limitations when interpreting such data. Guidelines serve to ensure that the information collected is stored and handled appropriately. Interpreting guidelines Local guidelines, organisation policies and departmental protocols cover a range of activity. Much of what practitioners discover about local practice is passed on by word of mouth or by observing what others do. However, it is best practice to follow up any wordof-mouth information by seeking out the documented standards and guidance in order to confirm your adherence to agreed protocols. Consider record-keeping practice with this in mind. Activity 14.6 Exploring local practice in record keeping Allow 2 hours Explore record-keeping practice in your department or organisation by speaking with senior colleagues and checking policies and guidelines relevant to your practice. It may be helpful here to refer to Resource 14.1: Collecting verbal information. Consider: l the method or model of note keeping you use (one example is problem-orientated health records) l how long records are retained l what reference is made to national and professional guidelines or to other external sources. Discussion The way notes are written can be significant when it comes to interpreting the records, as this can help you to understand the particular perspective presented by a particular Unit 14 Interpreting and managing information 15 of 25 Monday 8 February 2016 discipline. However, notes written from the perspective of one discipline are selflimiting as they do not incorporate all the information from other sources. Statutory/professional bodies set standards for record keeping. Your organisation might draw on guidance from professional/statutory bodies, the Department of Health or national organisations. Records should be disposed of as soon as possible, subject to national and local retention periods. Most service user records are kept for approximately eight years after the last entry, but sometimes the required period is longer. Maternity records are retained for a minimum of 25 years after the birth of the last child; mental health records for 20 years or 10 years after the person’s death if sooner; children’s and young people’s health records until the person’s 25th birthday or 26th birthday if the young person was 17 when the last entry was made (Department of Health, 2009). Local policies and guidelines have been designed to be followed by the local workforce, and as such relate to local structures and responsibilities. However, as pointed out in the last activity, local policy is steered by national and professional agendas. 14.3 Safeguarding information National and devolved governments issue regular information intended to ensure that people receive the best possible care through a framework for good practice. Much of this is contained within legislation. There is a range of government initiatives linked to the management of information, aimed at assuring people’s privacy and rights. All these initiatives have an impact on the records you keep about people accessing your service. Consider data protection and human rights. The Data Protection Act (1998) is about the rights and freedom of living individuals. It lays down conditions for the fair and lawful processing of personal data and particularly sensitive personal data. It is worthy of note that the Act does not protect the deceased. Access to the health records of a deceased person is governed by the Access to Health Records Act (1990). Under the 1990 Act an application for access to a health record of someone who has died can be made by the patient’s personal representative and any person who may have a claim arising out of the patient’s death. The Human Rights Act (1998) embeds fundamental rights as set out in the European Convention on Human Rights, which has been superseded by the Charter of Fundamental Rights of the European Union (2010). Activity 14.7 The Data Protection Act (1998) and the Human Rights Act (1998) Allow 1 hour Explore the information that is provided on Human Rights and Data Protection specific to your nation below. Make notes on the following: l What areas of your own practice do these national interpretations of the Acts impact on? l Consider a person’s rights to private and family life. How might service users be denied this right if the legislation is not followed? Unit 14 Interpreting and managing information 16 of 25 Monday 8 February 2016 For England, Northern Ireland and Wales – Data protection and Human Rights For Scotland – Data protection and Human Rights For States of Jersey – Data protection and Human Rights For Ireland – Data protection and Human Rights Discussion Most information concerning service users, whether held electronically or on paper, falls within the scope of the Data Protection Act. ‘Processing’ of the data covers obtaining, recording, holding, altering, retrieving, destroying or disclosing data. The Act gives people the right to access personal data about themselves which is held in either computerised or manual form, whenever the record was compiled. The act contains eight ‘Data Protection Principles’. These specify that personal data must be: 1 Processed fairly and lawfully 2 Obtained for specified and lawful purposes 3 Adequate, relevant and not excessive 4 Accurate and up to date 5 Not kept any longer than necessary 6 Processed in accordance with the ‘data subject’s’ (the individual’s) rights 7 Securely kept 8 Not transferred to any other country without adequate protection in place. Part II, Section 7(1)(c) of the Data Protection Act states that a subject is entitled ‘to have communicated to him in an intelligible form … the information constituting any personal data of which that individual is the data subject’. Any records that you keep must be of a suitable quality to be communicated to the parties involved. Some of the rights and freedoms in the Human Rights Act might be impinged upon by health and social care practice. For example, the Act upholds the right to respect for private and family life, the right to life and the right not to be subjected to inhuman and degrading treatment. Under the Human Rights Act, people are able to challenge what they consider to be unlawful interference with those rights by health and social care practice. If Tracey’s mother viewed her daughter’s notes, she could well ask for them to be amended to show that the claim that she was over anxious was unfounded and that investigations had clearly shown her to be a caring parent concerned about her very sick child. In the context of ethical practice, any inaccuracies in the notes should be highlighted and appropriate corrections made. Tracey’s family could well have found that their private and family life was disrupted by the impact of false statements, and thus that there was an infringement of their human rights. You might be able to think of instances where people fear that their private lives will be disrupted if they share sensitive information about themselves. Information security and confidentiality The management of information revolves around considerations of who has access to what, and under what circumstances. Not only must information be closely guarded, but it must also be available to those who are entitled to see it. The Freedom of Information Act Unit 14 Interpreting and managing information 17 of 25 Monday 8 February 2016 (2000) gives a general right of access to all types of recorded information held by public authorities. On occasions, health records may include information about another person, such as a family member or partner. This information is known as third party data. An individual can make a request only for their own information – they do not have right of access to information about other users, so great care needs to be exercised when responding to information requests (Information Commissioner’s Office, 2010). Information about service users is held under legal and ethical obligations of confidentiality, as laid out in guidelines such as the NHS code of practice on confidentiality (Department of Health, 2003). The Scottish Office (1999, p. 24) also stipulates that ‘any personal information given or received in confidence for one purpose may not be used for a different purpose or passed to anyone else without the consent of the provider of the information’. When sharing experiences at workshops or conferences, consent should be obtained from the service user whose case is being quoted. Practitioners citing such cases often use a pseudonym rather than the individual’s real name, but even so circumstantial information may make it possible to identify the individual concerned. Take the example of Dave: Dave gave a presentation based on a case study. He was aware that he had to use a pseudonym in order not to identify the service user concerned. However, Dave shared with the audience the name of the unit where he was working, the individual’s health issue and the person’s age. One of the people listening to the presentation realised that the case study was based on a relative of hers. Inadvertent breaches of confidentiality are a particular risk in small close knit communities where it at least appears that everyone is known to each other. A module team member shared that this was a particular issue in her practice location, one of the Scottish islands. The clinical governance framework in the NHS embraces quality assurance in all aspects of service users’ experience. One element of clinical governance in England, Wales and Northern Ireland is Essence of Care (Department of Health, 2010), designed as a practical toolkit for healthcare practitioners. It focuses on aspects of care such as privacy and dignity, personal hygiene, and nutrition. Within ‘Essence of Care’ there are also benchmarks for record keeping. These are designed to provide information relating to the ‘agreed patient-focused outcome’ – ‘Patients benefit from records that demonstrate effective communications which support and inform high-quality care’. You need to refer to one of these benchmarks in the next activity as you consider the security of records in your own practice setting. Activity 14.8 Finding out about safeguarding user records Allow 1 hour For all students: read Resource 14.2: The Essence of Care: benchmarks for record keeping. Make short notes on some of the obstacles to keeping records secure and confidential which occur to you as you read through the general indicators and four factors. Refer to the specific statements of Factor 4 ‘Security’ and its best practice statement ‘People’s care records are safeguarded’ in relation to secure storage and access. Consider the best practice statements below taken from the above document, and explore the measures taken in your own practice setting to support best practice. You can enter your findings in the table provided below. Unit 14 Interpreting and managing information 18 of 25 Monday 8 February 2016 We have created a Word document containing the table if you wish to fill it in electronically. For students in Scotland the relevant resource is ‘Information Governance in NHS Scotland: A Competency Framework’ (NHS Education Scotland, 2011). The relevant competency statements from this resource have been mapped against the following Essence of Care benchmarks for record keeping (Department of Health, 2010) so on completion of this activity you have evidence of which Scottish competencies have been considered. Unit 14 Interpreting and managing information 19 of 25 Monday 8 February 2016 Factor 4: Security: people’s care records are safeguarded NHS Scotland Competency Indicator of best practice My practice setting’s practices H.1.1 people’s confidentiality is respected O.1.1 U.1.2 S.1.1 people are aware that there are circumstances in which confidential information about them may be used or disclosed, for example, reporting infectious diseases, births of children or where there is a court order O.1.2 people are aware of the choice they have to decide whether their information can be disclosed or used in particular ways H.1.1 people’s confidentiality is respected according to Caldicott principles H.1.3 arrangements are in place to send and receive confidential information in a secure setting, such as when sending faxes of information concerning care H.2.1 paper and electronic records can only be accessed by specified individuals using a secure system H.1.2 people’s care records on removable media (such as tapes, disks, laptop and handheld computers, optical discs (DVD and CD-ROM), solid state memory cards, memory sticks and pen drives) is encrypted to the appropriate standards H.1.2 care records and information concerning people are not left accessible or in public places, for example, there is a ‘clear desk’ policy in place that is adhered to and staff ‘log out’ of electronic record systems when not in use H.1.3 care records are stored and transported securely and there is a record tracking system in place there is a system to dispose of care records appropriately that includes their destruction Discussion There should be local policies in place to deal with safety and security. In terms of basic security, notes should not be removed from an organisation. However, the Access to Health Records Act (1990) gives service users the right to access records (thus stressing the importance of correct records), although not to remove them. If they are happy to do so, some records may be kept by the service user themselves – emphasising the focus on person-centred records and all that it implies. There is an issue about computer-based records, but the same principles apply. Records should be closed after each entry is completed, and backed up to prevent loss. Passwords and PIN numbers should be changed regularly and known only to the Unit 14 Interpreting and managing information 20 of 25 Monday 8 February 2016 individual practitioner, not shared with others. Giving passwords to other practitioners would be considered misconduct, and so subject to possible disciplinary action. The Chartered Society of Physiotherapy lays down guidelines stating that notes must not be left unattended in a car, even in a locked boot, and never left in a car overnight. You may have found that reviews of records security include reference to documentation audits or complaints audits. Issues of security might also crop up in critical incident reviews or user satisfaction surveys, for example. There are significant issues to be considered regarding the security and confidentiality of user records. Records must be kept securely – when a room containing records is left unattended, it should be locked. In the case of electronic records there is increased potential for reproduction and dissemination, so access has to be carefully passwordcontrolled. 14.4 The development of users’ records National and devolved government initiatives from as early as 2000 have focused on improving the quality of health and social care through a collaborative approach between disciplines and agencies (Department of Health, 2000). This collaboration often extends to multidisciplinary user records, as described by Simpson (2003), who found the process brings benefits such as improved communication, clarity and continuity of the person’s healthcare journey in a palliative care setting. Simpson has also identified evidence of reduced workload, because there was less duplication of effort, and greater satisfaction from service users who did not have to keep repeating details of their history. The development of electronic user records continues to create challenges and opportunities. The Department of Health’s key aim in introducing these was to achieve a service designed around the individual service user. In 2009 the Department of Health, the Royal College of General Practitioners and the British Medical Association jointly published guiding principles for general practitioner electronic patient records. Included in this publication was the expectation that record keeping and service user information would be shared between agencies and across service providers as appropriate and with the full knowledge of service users (Department of Health et al., 2009). Changes in the way records are made and stored raise issues for staff training and culture change. Combining records requires professional, departmental and organisational differences to be addressed. Coordination of records within and across social care and healthcare providers continues to be challenging. Activity 14.9 Implementation of electronically held records Allow 1 hour Arrange to speak with someone in your organisation who has been involved in considering (if not actually implementing) electronic health or social care records. Explore with them the potential benefits of introducing them and also the potential obstacles. From your discussion, consider whether the issues surrounding electronically held records are any different to any other means of record keeping and storage. Discussion Benefits These include: Unit 14 Interpreting and managing information 21 of 25 Monday 8 February 2016 l easier access to fellow practitioners’ records l the potential for service users to access their records from home l a reduction in the volume of paper-based records and physical storage demands. Obstacles These include: l lack of staff competence and confidence in electronic-record keeping l managing levels of staff access to confidential and potentially very sensitive information l security of records, particularly for community-based services when the practitioner’s office may be the car l lack of control for service users over what is held. These lists are not exhaustive, but it does seem that the underpinning principles of security, access and disposal are issues for record keeping, however those records are kept. You may wish to access the websites of statutory and professional bodies related to your field of practice as several provide specific guidance on electronic record keeping. Collective records Activity 14.10 A case for collective records? Allow 1 hour Read Resource 14.3: An outline of record contents. As you read, decide what you think are relevant points for your own practice in favour of collective records. Consider record keeping where you practice, in terms of the following questions: l Is there any duplication of records? l To what extent are the records collective (or multidisciplinary)? l Are there any barriers to the creation of multidisciplinary records? l What are the issues of confidentiality and data protection in this context? l What are the benefits to people accessing your service? Make summary notes which you can use as evidence for your Portfolio. Discussion Traditionally, practitioner groupings in healthcare, social care and the independent sector have recorded their interventions separately. For example, an older person living at home who has a long-term condition may have several services available to them with different practitioners delivering the services. If each service has its own record keeping system, how can the services be delivered coherently in a personcentred way? There is a great deal of debate about the pros and cons of different documentation systems. Unit 14 Interpreting and managing information 22 of 25 Monday 8 February 2016 Perhaps you think that multidisciplinary records work well only if there is already strong multidisciplinary team work. It could be, though, that the introduction of multidisciplinary records would strengthen team work. For example, in Northern Ireland there are integrated health and social care teams who work together and use shared documentation. Where notes are held on paper, it is impractical to share them if members of the team are based in different locations, unless those notes are held by the service user – which seems to hold particular advantages where home visits are made, but there are also issues of privacy, in this context, in that records kept at home may be seen by other people without the person’s permission. Electronic records present their own opportunities and challenges – it might be easier to share them at a distance, but only if the technology is available. Increasingly, people are using ICT for data recording, storing and sharing. ICT usage is also becoming much more the norm as evidenced by government statistics: In 2011, 19 million households in the UK had an Internet connection. This represented 77 per cent of households, up from 73 per cent in 2010. (Office for National Statistics, 2011) You may, however, still come across colleagues who declare themselves to be ‘computer-phobic’. In addition a significant challenge to services and organisations is that organisations often have different computer systems which don’t ‘talk to each other’ or do not allow access by practitioners from other organisations. The purpose of this section was to get you thinking more consciously about the situation in your practice setting in relation to the trend towards multidisciplinary and electronic records. This will have helped you to further develop the skill of critical thinking. It is hoped that you have gained some insight into the benefits and drawbacks of these trends, and considered some of the ways in which developments in record keeping have the potential to improve the way information is managed and communicated. Unit 14 summary This unit made explicit the links between some government legislation around management of information and your practice. At every level, information is interpreted, shared and recorded in ways that are in line with current international and national legislation, standards, and guidance from a range of sources. The records kept by your practice setting are a crucial element of the information that is available to you. Being aware of the relative power of practitioner roles can help you to take a balanced view of all the information available to you. For record keeping to be valid, all entries need to be dated, signed, accurate and legible. Practice-based activities Practice-based activities in this unit have supported your exploration of how information is collected, used, recorded and managed in practice, to ensure practitioners have access to service user data that is specific, relevant and appropriate. In addition you explored the policy context of records management drilling down to local practice. A key message to inform your ongoing practice is the need to protect Unit 14 Interpreting and managing information 23 of 25 Monday 8 February 2016 data and the rights of people to have access to data about them, but not about others. The activities you completed in practice should have highlighted the fundamental importance of data protection at all levels: service users, practitioners, organisations, nationally and internationally. Sharing the notes you have made in relation to the practice activities with your supervisor should provide robust evidence of your development and progression. This written evidence will support your supervisor assessing your knowledge and understanding about safe and appropriate practice, a key element in demonstrating the level at which you are practising. References Department for Constitutional Affairs (2006) A Guide to the Human Rights Act 1998, Third Edition, London, DCA. Department of Health (2000) The NHS Plan: A Plan for Investment, a Plan for Reform, Cm 4818-I, London, The Stationery Office. Department of Health (2003) Confidentiality: The NHS Code of Practice, London, COI. Department of Health (2006) Records Management: NHS Code of Practice Part 1, London COI. Department of Health (2009) Records Management: NHS Code of Practice Part 2 (2nd Edition), London, COI. Department of Health (2010) Essence of Care: Benchmarks for record keeping, Norwich, The Stationary Office. Department of Health, Royal College of General Practitioners and the British Medical Association (2009) ‘The Good Practice Guidelines for GP electronic patient records v4’ [online], dh_125350.pdf (Accessed 30 April 2011). Information Commissioner’s Office (2010) Subject access to health records by members of the public, technical guidance note [online], Protection/Detailed_specialist_guides/subject_access_requests_for_health_records. ashx (Accessed 11 October 2011). NHS Education Scotland (2011) Information Governance in NHS Scotland: A Competency Framework, Edinburgh, NHS Education Scotland; also available online, (Accessed 11 October 2011). Office for National Statistics (2011) Internet Access – Households andIndividuals, 2011 [online], London, ONS, (Accessed 11 October 2011). The Office of the Data Protection Commissioner (2005) Data Protection (Jersey) Law 2005 [online], (Accessed 11 October 2011). References 24 of 25 Monday 8 February 2016 Scottish Government (2010) Records Management: NHS Code of Practice (Scotland) Version 2.0 [online], (Accessed 3 October 2011). Scottish Human Rights Commission (Undated) What are Human Rights? [online], (Accessed 6 May 2011). The Scottish Office (1999) Protecting and Using Patient Information, a Manual for Caldicott, The Scottish Office. Simpson, M. (2003) ‘Multidisciplinary patient records in a palliative care setting’, Nursing Times, vol. 99, no. 3, 21–7 January, pp. 33–34. Acknowledgements Unit 14 banner photo – Copyright © Iurli Sokolov/iStockphoto Activity 14.1 photos – Copyright © Denise Hager, Catchlight Visual Services/Alamy, Copyright © Paul Doyle/Alamy Image before Activity 14.3 – Southern Health and Social Care Trust (2010) Patient Centred Care Record, Copyright © Southern Health and Care Trust Image before Activity 14.4 – Southern Health and Social Care Trust (2010) Patient Centred Care Record, Copyright © Southern Health and Care Trust All rights including copyright in these materials are owned or controlled by The Open University and are protected by copyright in the United Kingdom and by international treaties worldwide. In accessing these materials, you agree that you may only use the materials for your own personal non-commercial use. You are not permitted to copy, broadcast, download, store (in any medium), transmit, show or play in public, adapt or change in any way these materials, in whole or in part, for any purpose whatsoever without the prior written permission of The Open University. WEB 04102 0 4.1 Acknowledgements 25 of 25 Monday 8 February 2016K117 Enhancing your healthcare practice Unit 15 Risk management and assessing individuals Copyright © 2015 The Open University Contents Unit 15 Risk management and assessing individuals 2 15.1 The policy context of promoting a safe environment 3 15.2 Risk management 7 15.3 Safeguarding service users 11 15.4 Assessing individuals 15 15.5 Handling confidential information 21 15.6 Evaluating assessment 23 Unit 15 summary 24 References 25 Acknowledgements 26 Unit 15 Risk management and assessing individuals Healthcare can only be delivered effectively when there is a process of assessment. This is a continuous process that begins as soon as a person is referred to a service, and ends with the person’s discharge. You should, therefore, think of assessment not just as a preliminary part of the intervention but also as an ongoing component within the cycle of care delivery. Assessment and evaluation are important for several reasons, including: l ensuring that individual needs are accommodated l agreeing any interventions with the service user/carer and with the rest of the team l minimising risk l ensuring accountability obligations are met l supporting your practice development. During this unit you will explore the fundamental importance of ensuring a safe environment to support person-centred practice and effective healthcare delivery that does not put anyone – service users, carers, colleagues, the organisation and not least you – at avoidable risk. You will be considering the policy context of promoting a safe environment, practitioner interventions to ensure a safe environment and what actions should be taken when there is potential risk to individuals through a systematic and cyclical process of assessment, planning, implementation and evaluation. Interactive content is not available in this format. Animation 15.1 The cyclical process of assessment, planning, implementation and evaluation According to the World Health Organization: Unit 15 Risk management and assessing individuals 2 of 26 Tuesday 9 February 2016 Patient safety is a fundamental principle of health care. Every point in the process of care-giving contains a certain degree of inherent unsafety. Adverse events may result from problems in practice, products, procedures or systems. Patient safety improvements demand a complex system-wide effort, involving a wide range of actions in performance improvement, environmental safety and risk management, including infection control, safe use of medicines, equipment safety, safe clinical practice and safe environment of care. World Health Organization, 2011 Practice activities Please note, in this unit Activities 15.4, 15.6, 15.9 and 15.10 need to be completed in practice. You may wish to review the requirements of these activities and start preparation for these now. If you are unsure about anything, check with your supervisor first. 15.1 The policy context of promoting a safe environment Health, safety and risk are important issues in all healthcare settings. The provision of a safe environment, including safe working practices for all, is a concern at international, national, regional and local levels. Policies, standards and guidelines relating to safety and risk are published at international, national and regional levels and within organisations. These strategic and operational levels of activity indicate how seriously the safety of individuals in care environments is taken, and also the challenges keeping people safe can present. International policy Increasingly, nations are working together to develop policies for implementation across national groups. Searching the internet for ‘patient safety’ I found a whole raft of international organisations working across countries to promote patient safety. For example: In October 2004 WHO launched a patient safety programme in response to a World Health Assembly (2002) Resolution urging WHO and Member States to pay the closest possible attention to the problem of patient safety. Its establishment underlined the importance of patient safety as a global healthcare issue. The programme, WHO Patient Safety, aims to coordinate, disseminate and accelerate improvements in patient safety worldwide. It also provides a vehicle for international collaboration and action between WHO Member States, WHO’s Secretariat, technical experts, and consumers, as well as professionals and industry groups. Each year, WHO Patient Safety delivers a number of programmes covering systemic and technical aspects to improve patient safety around the world. World Health Organization, 2011 Unit 15 Risk management and assessing individuals 3 of 26 Tuesday 9 February 2016 The European Commission defines patient safety as: Freedom for a patient from unnecessary harm or potential harm associated with healthcare. It goes on to state that: It is a serious concern in the European Union. Recent studies consistently show, in an increasing number of countries, that healthcare errors occur in around 10% of hospitalisations, although adverse events take place in all settings where healthcare is delivered, including in primary care, secondary care, community care, social care and private care, in acute and chronic care. European Union, 2011 National policy Once international policy agreements have been reached, it is the responsibility of each nation to translate that policy so that it works in a nation-specific context, informed by such as nationally determined legal requirements. For example, in the context of the management of risk in the United Kingdom, Acts such as the following would need to be considered: l The Health and Safety at Work Act 1974 Application to Environmentally Hazardous Substances (Amendment) Regulations 2009 l Safeguarding Vulnerable Groups Act 2006 l Control of Substances Hazardous to Health (Amendment) Regulations 2004. The Health and Safety Executive (HSE) is the national, independent watchdog for workrelated health, safety and illness. It is an independent regulator and acts in the public interest to reduce work-related death and serious injury across Great Britain’s workplaces. Its website holds a wealth of information and resources some of which are specific to healthcare environments. As explored earlier in the block, often particular terminology is used to communicate specific meanings in particular contexts. This also applies to risk management. Activity 15.1 introduces you to key concepts, terms used in risk management and their meanings. Activity 15.1 Some key concepts and meanings Allow 45 minutes Go to the ‘ALARP “at a glance”’ section of the HSE website. Read the guidance on ALARP and answer the first four questions below. Then read Resource 15.1: Health and Safety Law – what you need to know to answer the remaining questions. 1. What does the term ‘hazard’ mean? List some hazards in your practice setting. 2. What does the term ‘risk’ mean? List some potential risks arising from the hazards you identified. Unit 15 Risk management and assessing individuals 4 of 26 Tuesday 9 February 2016 3. What does the acronym ‘ALARP’ stand for? 4. What does the acronym ‘SFAIRP’ stand for? 5. What is the purpose of the Health and Safety at Work Act? 6. What are your employer’s duties under the Act? 7. What are your responsibilities under the Act? Discussion The HSE distinguishes between hazard and risk. A hazard is something that has the potential to cause harm. A risk refers to the likelihood that the hazard in question will cause harm. The HSE advises that: ‘ALARP’ is short for ‘as low as reasonably practicable’. ‘SFAIRP’ is short for ‘so far as is reasonably practicable’. The two terms mean essentially the same thing and at their core is the concept of ‘reasonably practicable’; this involves weighing a risk against the trouble, time and money needed to control it. Thus, ALARP describes the level to which we expect to see workplace risks controlled. The HSE highlights the fact that you, your fellow practitioners – including your supervisor – and your organisation have responsibilities with regards to managing risk. When applying what you have read to your own practice, you might want to give special consideration to those issues in your practice environment which, if not effectively managed as a hazard, could become a risk which will cause harm. Your risk management practice should be informed by local policy, so you need to find out where relevant policy documents are located and how you might access them. Another matter to consider concerns the procedures and routines that are built into your daily practice. Regardless of your practice context, the cleanliness of the environment is a key factor in optimising health and minimising risk. It would therefore be beneficial to your developing knowledge and understanding to discuss with your supervisor the relationship of cleanliness in your practice setting to health and safety risks. To manage risk of whatever nature, an underpinning principle is systematic: l assessment – of risk l planning – actions to be taken l implementation – of actions planned l evaluation – of success or not. Interactive content is not available in this format. Animation 15.2 Hazard, risk and harm Unit 15 Risk management and assessing individuals 5 of 26 Tuesday 9 February 2016 Local policy Just as nations have to interpret international law and policies to apply them nationally, so organisations have to interpret national laws, standards and guidelines in relation to the local context. In Activity 15.2, you explore the harmony (or disharmony) between one of your organisation’s policies and nationally provided guidance. Activity 15.2 Local policy Allow 45 minutes Obtain a copy of your organisation’s risk management policy and then review it against Resource 15.2: Five steps to risk assessment published by the HSE (2011). Using the table below, map the stages specified in your local policy against the HSE’s five steps. You may wish to make notes on what you find. Then check whether your local policy reflects the HSE guidance. We have created a Word document containing the table if you wish to fill it in electronically. HSE step Local policy stages Notes Step 1 Identify the hazards Step 2 Decide who might be harmed Step 3 Evaluate the risks and decide on precautions Step 4 Record your findings and implement them Step 5 Review your assessment and update if necessary Discussion Risk is effectively managed by organisations clearly stating their policy on risk management and providing a systematic risk management process for practitioners to Unit 15 Risk management and assessing individuals 6 of 26 Tuesday 9 February 2016 follow, and so the wellbeing of all is optimised. If you discover any omissions in your local policy stages, or you have any questions about it, it is important to discuss this with your supervisor. International initiatives, nationally-determined legal requirements, policies, standards and guidelines are all ineffective if they are not enacted in practice. In the next section you explore the concept of risk, balancing risks, and risks in practice. 15.2 Risk management Figure 15.1 Risk management To understand how practitioners can successfully make evidence-based judgements about care so that interventions are not a risk, it helps to think about some of the factors that need to be considered. We begin by considering the concept of risk. The concept of risk Everything people do has an element of risk attached to it, and some things are seen as more ‘risky’ than others. With repeated experience, most of the time a person weighs up the degree of risk associated with a familiar situation without thinking too hard about it, such as crossing the road. But in new or unfamiliar situations, they usually have to take more time to consider options and the implications of their decisions. As described earlier in this unit, ‘hazard’ means anything that can cause harm, while ‘risk’ is the chance, high or low, that somebody will be harmed by the hazard. So now you focus on risk and the potential to cause harm. First of all, to gain insights into risk, we consider aspects of risk in daily life. Unit 15 Risk management and assessing individuals 7 of 26 Tuesday 9 February 2016 Activity 15.3 What does risk mean to you? Allow 40 minutes Think of something you do in your daily life that is a hazard, and so carries a risk to your safety or the safety of someone you know. Ask yourself the following questions: l What is the hazard? What are the associated risks? l How do you adapt your behaviour or approach to manage the hazard and so reduce the risk? l How do other people approach the same hazard and what do they do to reduce the risk? Discussion To take the example of crossing the road, the risks could be: l If you misjudge it, you could be hit by a vehicle such as a car or bicycle. l In the case of an accident, you might not be the only person injured. In view of this, you might reduce the risk by looking for a designated crossing, or being more cautious at a spot where it is less usual for pedestrians to cross. Some people cross the road seemingly regardless of the traffic, and get away with it. People who supervise young children or who support people with disabilities may be more cautious than others when crossing, and may look for opportunities to teach safe practice to children, for instance. If you have a disability, there may be special considerations that you need to apply. You are probably aware that different people view risk differently – indeed, some people are thought of as ‘risk takers’. However, in order to exercise a ‘duty of care’, practitioners in healthcare must be able to recognise the potential for harm and act appropriately. The UNISON handbook on ‘duty of care’ is a very helpful resource to not only read but also to dip into. If you are not familiar with the concept of a ‘duty of care’ you are advised to access the resource. Sections 2 and 3 are of particular relevance. Unit 15 Risk management and assessing individuals 8 of 26 Tuesday 9 February 2016 Recognising risk in practice Activity 15.4 Recognising risk in practice Allow 1 hour Choose a convenient time to explore with your practice colleagues how they view risk in their practice. This could involve spending five minutes each with, say, three individuals, or having a discussion with a small group during a coffee or meal break. In preparation for your discussions with your practice colleagues, reread Resource 14.1: Collecting verbal information as this will help you to manage the discussions and get the information most relevant to your task. Make a list of practice situations that your colleagues consider carry risk, and note any possible harmful consequences. Discussion Were you surprised by your colleagues’ responses? You probably came up with a mix of activities that could cause harm to service users and those that could harm practitioners. You might have been told stories of times when people were harmed in some way. If so, how did that make you feel? Your list may contain some of the points included in Table 15.1. Table 15.1 Risk in practice-based activities Activity Possible harmful consequences Moving an object or assisting people to move Injury, including back injury, to the practitioner. Loss of earning. Service user falling and becoming injured and/ or losing confidence. Damage to the object if dropped. Unit 15 Risk management and assessing individuals 9 of 26 Tuesday 9 February 2016 Teaching someone a self-care skill such as cooking Cuts, burns Supervising a group outing Someone getting lost or hurt. Members of the public being offensive causing emotional harm. Administering medication Medicines error, adverse reaction, deterioration, needle stick injury, service user’s wellbeing, death. Dealing with aggressive people Physical or verbal attack leading to injury and distress. Supporting a person who is expressing suicidal intentions Person self-harming, becoming distressed, anxiety in the practitioner, death. Going into homes where there is a dog Practitioner being attacked by the dog: physical injury, emotional distress and loss of confidence in entering people’s homes. Supervising a person in a hydrotherapy pool Drowning/near-drowning, especially if someone panics, loses consciousness or becomes difficult to support. Caring for a person with an infectious illness Transmission of infection to practitioner, the person’s family or other service users. There also has to be the consideration that, in some instances, the risk is too great and therefore not appropriate to take. Part of the skill of a competent practitioner is to make informed judgements about whether an intervention is more beneficial than harmful and how to minimise risk. There are parallels here with the concept of non-maleficence – not doing harm – one of the four professional values identified by Beauchamp and Childress (2009). Mindfulness about hazards and potential risks are integral to every practitioner’s day-to-day practice. Balancing risk in practice Consider Mick’s position. Mick is responsible for a group of young adults with a range of physical and learning disabilities. Together they are planning to go horse riding. A hazard for one of the young adults, Julie, is that she is vulnerable to losing her balance and so falling from the horse. To minimise the risk and manage it effectively, Mick judges that two helpers are needed to provide appropriate supervision and support to Julia. As only one helper is available, he decides the risk of harm is too great for Julia to join the horse-riding activity. Mick’s judgement is based on a combination of previous experience and training, formal organisational guidelines and a practitioner responsibility to ‘do no harm’. Activity 15.5 Balancing risk in practice Allow 45 minutes Revisit the practice situations on your list from Activity 15.4. Then address the following questions: 1 Can you identify organisational policies or guidelines that relate to these activities? 2 Which activities are restricted to people who have certain qualifications? 3 What staff development opportunities are available to support staff to practise safely? 4 To what extent do you consider service users are aware of risk? Unit 15 Risk management and assessing individuals 10 of 26 Tuesday 9 February 2016 Discussion 1 Your organisation and practice setting are likely to have policies and guidelines on a range of key activities relevant to the service they deliver. It is also likely to have guidelines on risk assessment. 2 Some interventions require a certain level of skill, knowledge and judgement that is developed through either professional education or training, perhaps in using specialised equipment. Different professions have different areas of expertise. Professionals are required to keep their competence up to date, to recognise their limitations and to be accountable for their actions (Health Professions Council, 2008; Nursing and Midwifery Council, 2015). 3 The training that is available to staff is likely to reflect areas covered by policy and guidelines and will arise in response to developments in practice (for instance, new equipment, changes in service demands, new ways of working). As you worked through this activity, you might have identified needs for yourself personally. These might include the need for information, or they might be more to do with learning or enhancing further a practice skill. 4 You might be able to think of service users who prefer not to know the details of their health issues and the treatment required, while others might ask a lot of questions about the options and the risks involved in any situation. This might have raised another question for you – what information regarding risk is provided for people accessing your service? Wherever risk is identified, or before any intervention is performed on behalf of a person, the practitioner must have the appropriate knowledge and skills to handle the situation as safely as possible and to make judgements about the risks involved. You have now identified elements of risk in your practice and begun to think about safeguards that are put in place to reduce the likelihood of harm. Professional accountability is a key consideration when making decisions that involve risk. You may have come across examples of practice in which you consider the risk to be unduly high. You may be asking how you might change risky practice, or what the statutory/ professional bodies or your organisation say about it, or who is accountable. One of the reasons risk assessment can create difficulty and discomfort is the fact that it involves a balancing act. It is possible that all the available options carry risk, including doing nothing. In the example given earlier, what if Mick knew that denying Julia her riding lesson would cause her great distress, leading her to becoming withdrawn? He might still have made the same decision, but taken further action to ensure that Julia understood the reasons for his decision, and offered her an alternative activity. People who access healthcare services expect that sufficient attention will be paid to their safety and sense of wellbeing. 15.3 Safeguarding service users The National Patient Safety Agency (NPSA) is an organisation that is dedicated to safety issues for NHS health service users. The Care Quality Commission (CQC) manages service user safety issues in the voluntary and independent sectors. The NPSA is an ‘arms length body’ (also referred to as a ‘Quango’, a semi-public administrative body that is financed by the government, and whose members are appointed by the government) of Unit 15 Risk management and assessing individuals 11 of 26 Tuesday 9 February 2016 the Department of Health and covers the whole of the United Kingdom health service. It is the lead body for patient safety, and contributes to monitoring patient safety issues and promoting improvements. It does this by: informing, supporting and influencing organisations and people working in the health sector NPSA, 2011 It is made up of three divisions providing UK-wide services. Each division has a specific remit: 1 The Reporting and Learning Service, which aims to minimise risk to people accessing NHS services and improve the standard of safety. 2 The Clinical Assessment Service, which supports the resolution of concerns about the performance of individual practitioners. 3 The Research Ethics Service, which protects the rights, safety, dignity and wellbeing of service users who agree to participate in clinical trials and other research within the NHS. The NPSA also commissions and monitors national, confidential enquiries into: l suicide and homicide by people with mental illness l maternal and child health l patient health intervention outcome and death. The Central Alerting System (CAS) was established in 2011, superceding previous organisations. The system distributes email alerts to registered users and through its website. The website enables alerts and urgent patient safety specific guidance to be accessed at any time: Safety alerts, emergency alerts, drug alerts, Dear Doctor letters and Medical Device Alerts are available on this website. They are issued on behalf of the Medicines and Healthcare Products Regulatory Agency, the National Patient Safety Agency, and the Department of Health. NHS, 2011 The Jersey government links directly to the NPSA. In Ireland, there is the Health Information and Quality Authority. National Campaigns In addition to the safety agencies at UK level, there are patient safety campaigns across the four countries of the UK. If you wish to find out about the campaigns click on the links below. l 1000 Lives Campaign – Wales l HSC Safety Forum – Northern Ireland l Scottish Patient Safety Alliance – Scotland Unit 15 Risk management and assessing individuals 12 of 26 Tuesday 9 February 2016 l Patient Safety First – England. Reporting risk In 2004 the NPSA stated that every day more than one million people are treated safely and successfully in the NHS. But the evidence tells us that in complex healthcare systems, things will and do go wrong, no matter how dedicated and professional the staff. And when things go wrong, patients (service users) are at risk of harm. For the staff involved too, incidents can be distressing, while members of their … teams can become demoralised and disaffected. The NPSA believes that tackling patient safety in the NHS collectively, and in a systematic way, can have a positive impact on the quality of care and efficiency of NHS organisations. NPSA, 2004, p. 3 Clinical governance is ‘the system through which NHS organisations are accountable for continuously monitoring and improving the quality of their services and safeguarding high standards of patient focused care and services’ (NHS Quality Improvement Scotland, 2005, p. 6). The NPSA asserts that a systematic approach can have a positive impact on service user safety. Activity 15.6 is designed to help you discover how systematic risk reporting is conducted in your organisation, and give you a sense of how it can impact on quality. Activity 15.6 Reporting risk Allow 1 hour Find out about the reporting procedures in your organisation for risks relating to the safety of service users. Locate the risk policy and/or strategy. The risk manager or your practice area’s health and safety representative could be a good starting point for these questions: l Who is responsible for risk reporting? l What are the lines of accountability? l What information do you need to provide in relation to the risk report? l What happens to the information given? l How effective is the risk reporting procedure (does it result in improved practice)? Discussion Did you find that everyone in your organisation has responsibility for reporting risk? Health and social care providers have both local and national reporting arrangements. Within your organisation, there will be a designated person responsible for cataloguing and reporting incidents. Some organisations or teams hold incident review meetings in order to facilitate learning from incidents. You are likely to find that, at a senior level in your organisation, there is one person who is held accountable for the performance of the organisation, in terms of both the systems in place for reporting risk and the actions to be taken to prevent or reduce harm. Unit 15 Risk management and assessing individuals 13 of 26 Tuesday 9 February 2016 The NPSA’s National Reporting and Learning System (NRLS) operates at a national level across the NHS. Through this system, NHS staff anywhere in the UK can report service user safety incidents, which they have been involved in or witnessed, including those that have been prevented (known as near-misses) and those that should never have occurred (known as never events). Never events are those incidents which would not have occurred if already-available preventative measures had been implemented. A list of ‘ never events’ is available from the NPSA website. Information provided to the NPSA is stored anonymously and analysed to identify national patterns, in order to identify patient safety priorities and develop practical solutions. It is not always easy to decide whether practice has improved. However, in order to be effective, risk reporting needs to result in a change in policy, procedure or practice that alleviates the source of the problem. Individual workers and teams have a responsibility for the quality of the service they provide. Key to this is the management of any risks to the quality of care. The following box lists points from a strategy for risk management. Box 15.1 Risk management policy All staff are responsible for:- l Carrying out their work in a safe and effective way l Being aware of the risks to discharging their duties, and reporting any new risks that come to their attention, to their Line Manager. l Where staff feel that raising issues may compromise them or may not be effective they should be aware of the Trust Hearing Staff’s Concerns policy, incorporating Trust guidance on raising concerns. l Contributing to their team’s routine assessment of risks, to determine their severity and likelihood. l Offering advice on how risks can be controlled. l Contributing to the development of action plans to reduce or remove risks. l Altering their way of working in line with these plans. l Comply with all Trust policies to minimise the occurrence of adverse events. (Leeds Teaching Hospitals NHS Trust, 2009, Section 4) At practitioner level, we also have the responsibility to alert our organisation to situations that are harmful or put service users at risk and that are not being addressed at the level of the practice setting. This is referred to formally as ‘escalating concerns’ and informally as ‘whistleblowing’. Taking such action can be challenging, but the primacy of service users’ and colleagues’ wellbeing must be at the forefront of our mind at all times. It is important that you make yourself familiar with your organisation’s policy and process for raising concerns (whistleblowing). Several professional organisations and statutory bodies provide guidance and development resources to support practitioners to manage such situations. In the next section, you consider guidance from the Nursing and Midwifery Council’s website. Whilst this resource is directed towards nurses and midwives, the learning is relevant to any practitioner group. Unit 15 Risk management and assessing individuals 14 of 26 Tuesday 9 February 2016 Raising concerns Activity 15.7 Raising concerns Allow 40 minutes Go to the ‘Guidance’ page of the Nursing and Midwifery Council (NMC) website. Download and read Raising and Escalating Concerns (NMC, 2010). Think about how you would respond if you had concerns that a colleague was practising inappropriately. Discuss any concerns or questions with your supervisor and module tutor. Discussion The thought of raising concerns about a colleague or other situation at work can create understandable anxiety. However, it is vital for the protection of service users that individuals are prepared to do so. Professional regulators such as the Health and Care Professions Council, the NMC and trade unions such as the Royal College of Nursing (RCN), and Unison, among others, offer advice for practitioners. Public Concern at Work is an independent organisation that offers advice to individuals with whistle-blowing concerns at work. More information about Public Concern at Work can be found on its website. You may wish to revisit the NMC website as you progress through the module and your career. There is also a safeguarding section which includes access to resources and best practice for each nation of the United Kingdom, so you may wish to access this too. An important element of safe practice is taking responsibility for your own learning and development. By deciding the extent to which you need to make use of the resources available through the NMC website, you are demonstrating growing independence in managing your learning and taking responsibility for the development of your person-centred practice. Having considered safety as a broad issue, we now move on to consider how you can approach the assessment of individual needs. 15.4 Assessing individuals People are in your care because they have needs related to their health and welfare. With that in mind, this section is designed to help you consider how the practitioners in your service decide what care or intervention they should provide, and how much the service user is involved in these decisions. Unit 15 Risk management and assessing individuals 15 of 26 Tuesday 9 February 2016 Considering different people and different needs Through your life experiences, earlier study within this module and possibly practice experiences you should be aware that people have different ideas about what it means to be healthy. As people get older, they are more likely to value the opportunity to take part in social and cultural activities as they recognise that their health can be positively affected by experiences that are not just focused on physical exercise and physical activity (Tetley et al., 2007). Psychological wellbeing and happiness are also important for all age groups. A person’s identity can be linked to their health status or illness. When people are ill or ‘sick’ they may behave in ways that are expected of ill people and may be vulnerable to taking on the ‘sick role’. This might result in their becoming socially isolated and, in some situations, and in the context of their relationship with practitioners, may agree to interventions they may not normally have agreed to. The concept of the ‘sick role’ is helpful in highlighting how being ill can be observed as a social as much as a health condition, however it can distract attention from the need to focus on the whole person, not just their health issue. If the service user is to be the driving force behind their own care, and if you are to see the person behind the health need/issue, then interpersonal skills, such as developing rapport and showing empathy, become an essential part of your personal toolkit for practising effectively with people. You also need to be competent in relevant practice skills and the use of equipment to support your practice. If you were to ask an experienced practitioner how they approach a practice commitment, they might be at a loss to describe it in detail. But by observing them ‘in action’, you have a chance to study aspects of their environment, behaviour and actions that they hardly notice any more as they have become part of them, they have been internalised. Activity 15.8 Observing initial assessment or review Allow 1 hour Arrange to observe an experienced and qualified practitioner, within your practice team, undertaking an initial assessment or review of need with a service user. It is a good idea to agree beforehand whether the practitioner concerned would like feedback from you. People are often pleasantly surprised at the good things, Unit 15 Risk management and assessing individuals 16 of 26 Tuesday 9 February 2016 especially small details, that others notice about their practice. Agree in advance with the practitioner what you will do if you observe something that concerns you. Use the following prompt questions as a guide for structuring your notes: l In what setting or environment did the assessment take place? l Was it within sight or sound of others? l Was it the person’s own home or another setting? l Did you notice anything about the setting, such as whether the place was warm or cold, noisy or quiet, clean or dirty? l How were introductions made? l Did they appear formal or informal? l Was the nature of the conversation explained and understood? l What did you notice about the communication? l Were there any barriers to communication? l Did anything strike you about the body language of the service user, of other people present and of the practitioner? l Was there anything about the timing of the interactions that was noticeable? l What information or data was given and received? l What measuring or assessment equipment was used? l Was written information available about the service user? From where, and from whom? l What information was given to the service user, and in what form? l How was the information recorded? l Was it handwritten or recorded electronically? l Was a standard form used? l Was any particular assessment tool or scale applied, for example to assess nutritional needs, mobility, pain, mood? Arrange a convenient time to share and feedback your observations to your colleague if this was agreed prior to the assessment. Discussion Did you find yourself noticing things you hadn’t noticed before? Did you feel confident enough to share your observations with the practitioner you were observing (if that was appropriate)? By observing and feeding back, you might have been able to highlight details they were not aware of. The assessment or review is likely to have included information regarding the physical, social, psychological and emotional wellbeing of the service user, and may well have revealed something about their fears, expectations or wishes for the future. The cultural context of the person would also have been a consideration. There will have been ‘meaning’ attached to the things you observed, whether aspects of the environment, people’s behaviour or the equipment or tools used. You might have found that the setting helped to put people at ease, or signalled cleanliness and efficiency, or was not conducive to maintaining confidentiality. The exchange might Unit 15 Risk management and assessing individuals 17 of 26 Tuesday 9 February 2016 have been more or less formal than you’d expect, depending on how long the people involved had known each other or the reasons for the assessment or review. The production of paperwork might have signalled bureaucracy, efficiency, a professional approach or a lack of engagement with the service user and those present. In order to be successful, communication needs to be offered, received and understood by both parties. You may think that meaning needs to be shared in order for service users to exercise autonomy However, Figure 15.3 illustrates the idea that only some of our efforts to communicate may end up as shared meaning (as in the area of overlap between the two circles). Consider John Kelly’s assertion that communication is sharing meaning (Kelly, 1981) as represented in Figure 15.2. Figure 15.2 Sharing meaning in communication (adapted from Kelly, 1981) Assessment can happen as a noticeably separate part of a process, or it might be rolled in together with planning and action in one encounter. In an emergency, all this might happen in a matter of seconds. In acute situations, cycles of the intervention process can be measured in minutes or hours in response to changes in the status of a person’s wellbeing. There are no neat and easy ways of putting the interactions you have with people into boxes or of finding out what a person’s needs are. However, by being systematic in the use of equipment, tools and techniques and by making informed judgements you can find ways of getting the most out of the time and resources at your disposal. Unit 15 Risk management and assessing individuals 18 of 26 Tuesday 9 February 2016 Using equipment, tools and techniques Measurements or scores on initial assessment can provide the essential baseline from which to gauge progress towards specified outcome measures. Measurements can be quite specific – for example, a physiotherapist might measure knee flexion, or a nurse might measure someone’s blood pressure. Many assessment tools rely on a combination of professional judgement, measurements and history – for example, an occupational therapist might use an agreed series of criteria to assess patients in the context of their fear of falling, a nursing home might apply a nutritional risk scale to a person on admission to determine how best to address their nutritional needs, or a mental health practitioner might use a mood assessment questionnaire to assess the risk of self harm. Attributing a numerical scale to an aspect of the assessment can make it easier and more efficient to communicate the level of risk and to aid the planning of the level of intervention required. There are drawbacks to the use of scales, however. There is a danger that using them might result in a ‘reductionist’ approach to assessment, where you lose sight of the person as a whole or disregard independent professional judgement (Department of Health, 2004). Different tools may look at the same problem in different ways, asking different questions, so caution is needed before interpreting the results. Despite the drawbacks, however, scales can have valuable input into practice audits. Activity 15.9 helps you to consider the advantages and disadvantages of one approach to assessment. Activity 15.9 Using a systematic approach to assessment Allow 45 minutes Read Resource 15.3: Assessment of client mobility for moving and handling. This article describes a systematic approach to assessing moving and handling situations. Unit 15 Risk management and assessing individuals 19 of 26 Tuesday 9 February 2016 Consider the advantages and disadvantages of using a systematic approach such as this one. List your responses under the headings ‘Pros’ and ‘Cons’ and include a rationale for why you consider them to be pros or cons. Can you think of other situations in your practice setting for which you could apply a similar framework? Pros of a systematic approach: Cons of a systematic approach: Discussion The responsibility to complete assessments often rests with senior practitioners, many of whom will be registered professionals. It is important, as ever, that you only complete or contribute to activities that are within the remit of your role and that you have the knowledge, understanding and skills to undertake competently and confidently. The resource opens with a general statement about haste and pressure to get things done, which squeezes the time given to assessing situations. You may or may not agree that this is the case in your practice setting. Most situations can be dealt with in a reasonable amount of time with careful planning. Situations that involve moving and handling are ‘normally’ not urgent and staff should take time. Easier said than done! Practitioners need to recognise that they need to follow their organisation’s moving and handling policy and not be rushed into making a quick manoeuvre to satisfy other staff’s needs for a speedy resolution. They may become aware of situations where the hoists and the moving and handling equipment are stored in a cupboard and never see the light of day. Beds may be pushed up against the wall to allow for more space but reduce the safe handling area. How would they react to this? Following the moving and handling policy where they are employed means that if they injure themselves they have the opportunity of compensation. Regular annual updates in moving and handling are essential. Following a systematic approach to assessment, as proposed here (and as is common practice), is one way of safeguarding yourself and the people – service users, carers and colleagues – you work with. It ensures that nothing is overlooked. If adopted by whole teams or agencies, such an approach can ensure a commonly accepted way of working that could be reassuring for service users. A systematic approach such as this could seem like a burden, though. In urgent situations, there might not be time to apply conscious thought. Also, professional judgement might sometimes be at odds with the recommended approach. Moving and handling provide an example of a situation that carries an element of risk. As you have already identified, there are other activities that also carry risk in your dayto-day practice. You might have frequent contact with people who are HIV-positive, for instance, or you might want to decide whether it is safe to do a particular home visit alone. By asking the questions ‘What needs to be done?’, ‘What are my capabilities?’, ‘What do I need to know about the service user?’ and ‘What are the important factors in the environment and the equipment?’ you can provide yourself with a structure to help you explore different situations and manage them safely. Being both methodical and adaptable, then, is important in assessment. Now consider how the information needs to be handled. Unit 15 Risk management and assessing individuals 20 of 26 Tuesday 9 February 2016 Thinking back to the assessment you observed in Activity 15.8, it is possible that a tool or a scale was applied. 15.5 Handling confidential information The initial assessment may be the first contact between your service and the service user, and as such, it is a good time to consider how relationships are going to work. The service user is placing their trust in the service and the practitioners employed by it, and sharing personal, intimate details that they expect to be handled appropriately. They might already be wondering how many practitioners in the team will have access to their personal records during this particular episode of care. You have already considered confidentiality in Unit 14 when you considered record keeping. The Department of Health confidentiality model The Department of Health, naturally, takes a firm stand on the principles and practice of confidentiality. Its confidentiality model is shown in Figure 15.3. Figure 15.3 The Department of Health confidentiality model (Department of Health, 2003) The Department of Health model outlines the requirements that must be met in order to provide service users with a confidential service. Record holders must inform service users of the intended use of their information, give them the choice to grant or withhold their consent to such use, and protect their identifiable information from unwarranted disclosures. These processes are interlinked and should be ongoing to aid the improvement of a confidential service. The main requirements are: l to protect: to look after the service user’s information l to inform: to ensure that service users are aware of how their information is used Unit 15 Risk management and assessing individuals 21 of 26 Tuesday 9 February 2016 l to provide choice: to enable service users to decide whether their information can be disclosed or used in particular ways and, in support of these requirements: l to improve: always to look for better ways to protect, inform and provide choice. Confidentiality in your practice setting Activity 15.10 Confidentiality in your practice setting Allow 1 hour The Department of Health confidentiality model provides a useful framework for ensuring a confidential service. You are now asked to view your practice setting’s practices in terms of the four main processes of the model. First, read Resource 15.4: The DH confidentiality model, which explains the processes. Then make notes relating to your practice setting under the following headings: l Protect l Inform l Provide choice l Improve. In your notes, comment on the extent to which you think these principles are enacted in your practice setting. Don’t get too engrossed in the detail – aim rather to achieve an impression of how confidentiality is achieved and handled. You may wish to add these notes to your Portfolio, especially if you think there is a need to follow up your findings with further action. Discussion Confidentiality, despite being a legally binding obligation, is far from straightforward – the NHS operates under the rather paradoxical doctrine of implicit consent. It is paradoxical because it is a way of getting consent without consent having been given. Unless service users (or those consenting on their behalf) specify otherwise, they are deemed to have consented to the information they have given to one practitioner being shared with others. The potential to breach confidentiality is ever present in any practice situation be it in a healthcare establishment or a home setting. The nature of the work may mean that service users are discussed, often informally, with other practitioners. This may be done in all innocence to gain a colleague’s opinion and advice, etc. Inadvertent overheard comments may breach confidentiality. When the geographical area served by the healthcare team is small, people and names are well known to each other. It is one of the reasons why we are not allowed to treat relatives. Not only might we have a vested interest, but we may find out information about them that they would have preferred to remain unknown to us. On a security point, notes should be locked up securely at the end of the day. Information could be passed on to different hospital departments, social services and agencies such as Age Concern, or private home care companies. Unit 15 Risk management and assessing individuals 22 of 26 Tuesday 9 February 2016 This section has explored the assessment of the needs of individuals, taking into account a range of assessment skills as well as addressing the confidentiality of the information that is gathered. The next section offers you a chance to evaluate assessment in your practice setting. 15.6 Evaluating assessment The process of evaluating assessment is an opportunity to take stock of how well you have gathered and handled information. Safety issues for you, your colleagues and service users, as well as the need for intervention, will have been assessed and documented. How effective was the communication with the service user during assessment? Did you really find out about them as a person? Consider whether you were able to discover information about the service user’s health, social and family circumstances in sufficient depth to take the next step – planning the right and most effective interventions. In order to make the assessment, you may have collaborated within your team, with friends and family of the person, and with other practitioners, services or agencies. Information is likely to have been provided in a mix of verbal and written formats. Data might have been available as a result of using a specific tool or equipment for measurement. Your evaluation might ask whether the tool was the most appropriate for the situation. People receiving an intervention often have different priorities from those of service providers, so it is a good idea to take stock and ask whether their priorities have been captured in the assessment. Does the person concerned think that you really care about their needs and trust you to organise appropriate care? How would you make sure of this? Activity 15.11 Evaluating assessment Allow 1 hour This activity is designed to help you evaluate how well certain principles of assessment translate into action in your practice. Either find someone to assess or review, or focus on a service user you know or have helped recently – with their freely given and fully informed consent, of course. Answer the following questions in relation to the assessment you have chosen: 1 How were safety issues handled? 2 How was numerical data handled? 3 How was confidentiality ensured? 4 How much acknowledgement was made of the person’s individual circumstances and concerns? Discussion How were safety issues handled? When considering safety issues, there might have been special concerns to address, or the process might have felt more like simply going through formalities. How was numerical data handled? Unit 15 Risk management and assessing individuals 23 of 26 Tuesday 9 February 2016 Numerical data might, for example, have been recorded as a baseline assessment, or inserted on to a chart for easy tracking, or presented in the form of a score on a scale. It might have provided the basis for an outcome measure. How was confidentiality ensured? You might have noted what information was provided to the service user regarding confidentiality and sharing of the information collected. You might have commented here about the storage and retrieval of records. How much acknowledgement was made of the person’s individual circumstances and concerns? In addressing this point, you will be building on the concepts of person-centred practice and the skills required for effective communication. Your knowledge and understanding of diversity will help you to recognise different service user perspectives. To be an effective practitioner, you need to have a conscious awareness of what the gaps are in your knowledge, behaviours and attitudes before moving forward. Unit 15 summary In this unit you have considered the concepts of risk, health and safety, individuality and diversity, confidentiality, and communication. You have had the opportunity to examine tools and techniques used for assessment in your practice setting, and should be able to apply these (as appropriate) with a new insight as your learning continues. The impact of safety and confidentiality on the way care is delivered is an overarching consideration for healthcare practice. In this context you have been able to consider the policy links to practice while considering that the service user involved in the assessment or review should never be far from the centre of focus. Throughout this unit, you have been balancing considerations for the individual within the constraints of policy, standards and guidelines. Practice-based activities In this unit you have been presented with practice-based opportunities to support your further development of safe practice by exploring policy requirements with regards to risk management. Through the practice activities you are able to consider the risk management in the context of your own practice environment. This should have sensitised you to the need to manage risk proactively and to seek to minimise risk as much as possible. You are further developing the completeness of your practitioner profile so that within the parameters of your role, your practice is increasingly evidencebased and informed by sound knowledge and understanding. If you are successfully engaging with exploration of practice, and your practice in particular, the evidence available to your supervisor should be demonstrating you are progressing through and within the levels of practice. If you have any concerns about your practice, do discuss them with your supervisor and if necessary seek the support of your practice tutor. Unit 15 Risk management and assessing individuals 24 of 26 Tuesday 9 February 2016 References Beauchamp, T.L. and Childress, J.F. (2009) Principles of Biomedical Ethics (6th edn), New York and Oxford, Oxford University Press. Department of Health (2003) Confidentiality: NHS Code of Practice [Online]. Available at (Accessed 26 June 2011). Department of Health (2004) Single Assessment Process for Older People: Assessment Scales [Online]. Available at (Accessed 24 June 2011). European Union (2011) Patient Safety [Online]. Available at (Accessed 21 June 2011). Health Professions Council (2008) Standards of conduct, performance and ethics [Online]. Available at (Accessed 22 June 2011). Health and Safety Executive (2011) Five steps to risk assessment, London, HSE. Kelly, J.C. (1981) A Philosophy of Communication, London, Centre for the Study of Communication and Culture. Leeds Teaching Hospitals NHS Trust (2009) Risk Management Policy. National Patient Safety Agency (2004) Seven Steps to Patient Safety – An Overview Guide for NHS staff, London, NPSA. National Patient Safety Agency (2011) About us [Online]. Available at (Accessed 12 December 2011). NHS (2011) Central Alerting System [Online]. Available at (Accessed 23 June 2011). NHS Quality Improvement Scotland (2005) Clinical Governance & Risk Management: Achieving safe, effective, patient-focused care and services, national standards, Edinburgh, NHS Quality Improvement Scotland. Nursing and Midwifery Council (2015) The Code: Standards of practice and behaviour for nurses and midwives London, NMC. Nursing and Midwifery Council (2010) Raising and Escalating Concerns: Guidance for Nurses and Midwives [Online]. Available at (Accessed 26 February 2013). Tetley, J. Mountain, G., Clarke, A., James, J., Wilson, J., Hockney, C. and Gamble, J. (2007) ‘Activity and culture the contribution to health and well-being in later life’ in Shaw, T. and Sanders, K. (eds) Foundation of Nursing Studies Dissemination Series, vol.4. no. 4. World Health Assembly (2002) Quality of care: patient safety [Online]. Available at (Accessed 26 June 2011). World Health Organization (2011) Patient safety [Online]. (Accessed 21 June 2011). References 25 of 26 Tuesday 9 February 2016 Acknowledgements Unit 15 banner photo – Copyright © Lisa Gagne/iStockphoto Activity 15.3 photo – Copyright © Saukkomaa/Rex Features Activity 15.4 photo – Copyright © Evirgen/iStockphoto Section 15.4 photo – Copyright © Nullplus/iStockphoto Figure 15.4 – Department of Health (2003) Confidentiality: NHS Code of Practice, Department of Health. Crown copyright material is reproduced under Class Licence No C01W0000065 with the permission of the Controller, Office of Public Sector Information (OPSI). All rights including copyright in these materials are owned or controlled by The Open University and are protected by copyright in the United Kingdom and by international treaties worldwide. In accessing these materials, you agree that you may only use the materials for your own personal non-commercial use. You are not permitted to copy, broadcast, download, store (in any medium), transmit, show or play in public, adapt or change in any way these materials, in whole or in part, for any purpose whatsoever without the prior written permission of The Open University. WEB 04102 0 4.1 Acknowledgements 26 of 26 Tuesday 9 February 2016




The post provide evidence of the care planned, the decisions made, the care delivered and the information shared; l provide evidence of actions agreed with the patient (including consent to treatment and/or consent to disclose information). And include l medical observations: examinations, tests, diagnoses, prognoses, prescriptions and other treatments appeared first on Term Paper Tutors.

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