Open Learning Editor, Words at Work, Brighton, has adapted this paper from the chapter ‘Policy and policy management’ in the Emap Healthcare Open Learning module General Nursing Perspectives in the Care of the Older Person
Several stages are involved in shaping care policies, and nurses can play an important role in all of these.
When trying to disentangle policies, it makes sense to look at the roles of the different organisations that develop them. Things that seem to be a matter of local decision-making, for example, what type of incontinence aids to use, can be determined by policies at a regional or national level. These might cover how suppliers or equipment should be chosen (for example, through tendering processes), or set budget or resource levels. In turn, national policies might be shaped by international policies: for example, a trade embargo might preclude the purchase of equipment from suppliers a certain country. One type of continence pad may be more comfortable for patients, more absorbent or more secure, but if it is too expensive, or made in a country that does not trade with the UK, it will not be used at local level.
National policy frameworks
National policies have a major impact on the resourcing of health-care services but, increasingly, they also set performance indicators and evaluation criteria. For example, if one criterion for evaluation is that every patient should have a ‘named nurse’, then this will affect how you organise work, or at least the way you welcome a patient into your unit. Similarly, if a set of performance indicators set by national government focuses on measuring ‘throughput’ of patients, you may find yourself under pressure to discharge people from your care more quickly than otherwise.
National service frameworks
Since 1998 the Government has been developing national service frameworks (NSFs) in England and Wales for a range of different areas of care, including the care of older people, to act as guidelines for practitioners. Different arrangements are in place in Scotland and Northern Ireland. In the words of the Department of Health: ‘National service frameworks set national standards and define service models for a specific service or care group, put in place programmes to support implementation and establish performance measures against which progress within an agreed timescale will be measured’ (DoH, 1998).
An NSF for older people was published in April 2001 and focuses on eight key areas (Box 1).
We tend to think of innovations as dramatic and radical, but many developments are gradual, long-term, or involve a low-key change in approach rather than drastic changes to practice. These may be more difficult to translate into policy.
Policies at organisational level
Your organisation and others that you work with will have developed policies to direct their activities. They may be very specific policies about practices and procedures or broader ones on, for example, monitoring procedures or management arrangements. But even though these policies are ‘local’, it is not always easy to trace their origins. They are sometimes lost in the mists of time (as you may have discovered when you did the first Activity in this article), and there may be no record of the groups or committees that developed them, or the rationales for the form they took.
However, evaluating their impact on practice is possible, and relatively straightforward. Because they are specific, it is possible to see whether they are followed and, if so, their effectiveness and impact. Of course, the impact may not be what was intended. A specific policy, say about food storage in a hospital ward, may have been developed for health-and-safety reasons to reduce the danger of food being stored in practice areas and posing a potential food-poisoning risk. But if the unit or area is trying to meet dietary needs or preferences, or to encourage older people to prepare their own food, this health-and-safety policy might conflict with policies on rehabilitation or promoting choice.
Agencies and organisations have systems for developing and disseminating policies. Some may be quite formal and structured, such as formal committees with minutes open to anyone who wants to read them, bulletins, newsletters or policy files describing policies. In other organisations, the process may be more ad hoc or organic, with people discussing ideas informally and adopting policies on the basis of consensus.
The first type of policy-making process has the advantage of transparency - everyone knows what the process and outcomes are. It can, however, be very slow to respond to changing circumstances. If every change has to be discussed and debated by the full committee, and then formally communicated across the organisation (perhaps with opportunities for people to give their responses before the policy is finally adopted), it can take a long time for things to change.
The second type of policy-making process is more flexible, and arguably more responsive to change, but its informality can mean people in the organisation are not clear about what policies are, or how they were developed. It can sometimes be difficult to have an open debate if there is no process for doing this, and it is difficult for people to be updated on policy change with no clear dissemination mechanisms.
Many organisations have ‘phantom policies’. In other words, people talk about a policy as being established, and sometimes about the penalties for infringing it. But if you follow it up you find that no such policy exists in any formal sense - what people are talking about is simply custom and practice.
This is a type of informal policy, but it does not have the weight of authority behind it (See Activity, above).
Policy-making: how things get changed
There are a number of possible strategies for changing policy. One way to think about them is in terms of ‘top-down’ and ‘bottom-up’ change.
Top-down policy change occurs when policy-makers set out to review and modify policy. Usually, this happens in response to problems (actual or potential) with existing policy which, they decide, require a response. The process of change may involve consultation and evidence gathering, or the policy-makers may change policy without much consultation, basing changes on the information they already have, or principles they have already adopted.
Bottom-up policy change occurs when those affected by policy - patients and other interested parties - campaign for change because of problems they have identified. These campaigns may be welcomed by policy-makers or resisted strongly, in which case the campaigners may have to invest a lot of time and energy. In addition, bottom-up campaigns may involve a variety of groups with different views or agendas, and the debate may become a competition between these groups, or the differences may lead to internal disputes.
Top-down and bottom-up changes can also involve differences in power, influence and resources. Some consumer groups do not have the resources or the systems to mount co-ordinated campaigns, and have difficulty in marshalling support. Policy-makers, however, are not impregnable; they are vulnerable to such things as public opinion, which can affect the chances of re-election to government bodies, or to external inspection and regulatory bodies. An example of bottom-up policy change is the ‘Dignity on the Ward’ campaign.
The Dignity on the Ward campaign
This campaign is an example of how public opinion can result in policy changes. The campaign was sparked off by a series of reports in The Observer newspaper in 1997, which described poor care and conditions on hospital wards where older people were in-patients. These reports contained shocking and horrifying examples of older people being treated without respect or compassion, sometimes because of a lack of resources, but sometimes because of the callous attitudes of staff. The reports outraged many, and the Government responded by commissioning a Health Advisory Service enquiry into conditions for older people in hospital wards.
Campaign stages - The findings of the enquiry added fuel to the Dignity on the Ward campaign. The early part of the campaign had involved a listening exercise, inviting people who had concerns or examples of problems in care to contact the campaign team, set up by the charity Help the Aged and the Order of St John Trust.
The second part of the campaign involved raising public awareness more widely through press releases, conferences and workshops. A pack was produced for interested parties, for example, relatives and local voluntary groups, and older people themselves, with advice on how to improve care by making concerns known. An accompanying pack, The Dignity on the Ward Campaign Manual (Help the Aged, 1999), gave background information about the structure and organisation of the NHS, including information on NHS policies on openness, complaints procedures and The Patient’s Charter.
Strategies for improving practice - The campaign also commissioned a research study (Davies et al, 2000) to explore strategies for improving practice. A case study methodology was used to investigate examples and models of good practice, making the views of patients central. The study found that older people placed great importance on the relationships they had with staff, and that what had to be delivered was a sense of security, significance, belonging, purpose, continuity and achievement.
The researchers identified four key principles in developing a positive culture of care:
- Giving priority to the essential care needs of older patients. Senior staff should have direct contact with these patients and lead by example through being involved in giving them basic care
- Ensuring that older people have the same access to services as younger people and that they are involved and consulted at each step of their treatment
- Creating values that involve and consult patients and put their choices at the centre of ward activity
- Creating a stable ward team where staff initiative is welcomed.
Projects designed to change care - The final stage of the campaign, until the end of 2000, included:
- A project with the Royal College of Nursing Institute for Gerontological Nursing to provide hospital staff with information and advice for caring for older people with dementia or delirium
- A project with the Older People’s Advocacy Alliance to examine the nature and role of patient advocacy schemes for older people
- A project to highlight the need for hospital staff and managers to recognise the problems that older people from ethnic minorities can experience in hospital, and to promote consultation and involvement in service planning.
Points to note - The Dignity on the Ward campaign began with the lay person’s experiences of care. The first stage was to collect more information from patients; the second involved commissioned research to develop strategies for improving care and the final stage involved action projects. The campaign did not stop at identifying a problem, but went on to develop solutions and involved working across different agencies and organisations. It involved much organisation, time and resources.
The role of nurses in shaping policy
A number of stages are involved in shaping care policies, and nurses can play an important role in all of these. In common with changes in other areas the stages and considerations are as follows:
Analyse existing policy
- What were its aims?
- Are the aims reasonable, appropriate or desirable?
- What is the background and context from which the policy has developed?
- What core assumptions underpin the policy?
- Where is it not achieving its aims or causing unexpected or unintended outcomes?
Suggest and implement changes
- What do you aim to achieve by the policy change?
- Are the aims reasonable, appropriate or desirable?
- What are the specific changes you want to make?
- Who will be involved?
- What are the resource implications?
- What other organisations/groups will be affected?
- What is the best process for introducing change?
Evaluate policy change
- What sort of information would you use?
- Who needs to be involved?
- Have the changes achieved the aims? If so, how?
- What problems have occurred?
- Have there been any unexpected consequences and, if so, are they acceptable?
- How will you address differences of opinion?
The strength of the nursing contribution to policy development is the practice experience that underpins it: nurses’ experiential and detailed knowledge of policy implementation in providing day-to-day care for older people. While many policies are developed by people who do not have this immediate experience, the nurse’s view is vital in ensuring policies are appropriate, realistic and likely to have the intended effect.
Consider your practice setting and try to identify the policies that shape your activities in relation to older people. These might include policies which:
- Established the service in the first place
- Set aims and goals
- Monitor and regulate
- Set out relationships with other agencies or services
- Set out lines of accountability
- Determine the way you practise.
Are all of the policies compatible? Can you identify conflicts, anomalies or problems?
Choose one particular policy - it can relate to any aspect of the care of older people, from ensuring privacy and dignity to making sure their floor space is kept clean and dry. Find out how the policy originated, what purpose it now serves, and the benefits it brings to patients. In doing so, try to form some views on the importance of policy in underpinning care given to older people in your organisation.
As part of the consultation process for developing the NSF for the care of older people, there was an open invitation for people to provide examples of good practice.Bearing in mind that the aim of the NSF is to provide a framework for all services, can you identify examples of good practice in your work (within or outside the NHS)? This might be something that you are directly involved in, or that you know about through your networks. Prepare a description of this activity, including:
- The problem or identified need or issue that led to its development
- How it has improved the quality of care for older people
- The key principles it demonstrates that could be applied to services elsewhere.
Look back at your example of good practice from the last Activity. What would be the content of a policy based on this example?
In your own practice situation, are there any policies that clash with others and have a detrimental effect on the care you give to older people?
In order to complete this Activity you may need to make some enquiries in other parts of your organisation and in other organisations. In your organisation:
- How are policies developed? Is there a formal system? Are different sorts of policy developed differently (for example, practice policies and budgetary policies)?
- How do you know when a policy has changed? What are the systems for dissemination?
- If you disagree with a policy, what can you do? Who would you have to discuss it with? Can you opt out?
Thinking about the interfaces between your practice area and others:
- What other organisations or departments do you have contact with?
- What activities are involved, and how is contact made (face-to-face or by telephone, letter or memo)?
- Are there areas where policies are not integrated, with conflict between departments or organisations?
- Are there areas where policies have been developed in partnership or consultation with other services? How does this work?
- Are there areas where you think this would be a useful strategy?
Compare the impact of the Dignity on the Ward campaign - a bottom-up initiative to change policy - with the top-down changes heralded by the NSF for older people. What are the differences and similarities? What lessons do you think these hold for organisations and for government?
You may find it helpful to discuss this Activity with colleagues.
- Have any new policies been introduced in your workplace in response to the Dignity on the Ward campaign?
- What differences have these policies made to the care of older people?
- Look at the four principles identified by the Help the Aged research team. For each one, devise a policy to help ensure these principles are part of the care you give. You might want to start the policy statement with the words ‘Staff will’ or ‘Patients will’.
- What would you need to change to ensure these policies are implemented?
- How could you tell whether a policy was being followed?
- Are some of the principles more difficult to write policies for than others?
- How many policies have to include people other than the nurses in your unit/team?
You may need colleagues’ help. Take one policy that affects your care of older people and that you would like to see changed. Analyse it in relation to the questions under the heading ‘Analyse existing policy’. Consider the changes you want, and how you would go about making them (see ‘Suggest and implement changes’), taking into account the accepted process in your organisation. Finally, consider how you might evaluate the success of this policy change.
Standing Nursing and Midwifery Advisory Committee (2001) Caring for Older People: A nursing priority. London: SNMAC.
Standing Nursing and Midwifery Advisory Committee (2001) Practice Guidance: Principles, standards and indicators. London: SNMAC.
National Service Framework for Older People: http://www.doh.gov.uk/nsf/olderpeople.htm
Standing Nursing and Midwifery Advisory Committee publications: http://www.doh.gov.uk/snmacpubs.htmAnswer
Davies, S., Nolan, M., Brown, J., Wilson, F. (2000) Dignity on the Ward: Promoting excellence in care. Good practice in acute hospital care for older people. London: Help the Aged and the Order of St John Trust.
Department of Health (1998) National Service Frameworks (Health Service Circular HSC 1988/074). London: The Stationery Office.
Department of Health (2001) National Service Framework for Older People. London: The Stationery Office.
Help the Aged (1999) Dignity on the Ward Campaign Manual. London: Help the Aged.