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 Community Nursing
A Textbook of
A Textbook of
Community Nursing

A Textbook of
A Textbook of Community Nursing is a comprehensive and evidence-based
introduction covering the full range of professional issues, including community nursing
roles, personal safety, public health and health promotion.

Community Nursing
This is an essential text for all pre-registration nursing students, students on specialist
community nursing courses and qualified nurses entering community practice for the first
time.

Key features:
● Completely up to date with current theory, policy and guidelines for practice and all
chapters are underpinned by a strong evidence base Sue Chilton, Heather Bain,
● User-friendly and accessible, with learning objectives for each chapter, plus exercises Ann Clarridge and Karen Melling
and activities to test understanding, promote reflective practice and encourage
further reading
● Case studies and examples drawn from all branches of community nursing illustrate

Chilton, Bain, Clarridge, Melling

practical application of theory

About the authors:

Sue Chilton, BNurs RN DN HV MSc PGCE DNT Senior Lecturer in Health Studies,
University of Gloucestershire; Staff Nurse, District Nursing Service, Gloucestershire
Care Services, Gloucester, UK

Heather Bain, RGN DipDN BA PGCert HELT Lecturer/Course Leader, Health Studies,

School of Nursing and Midwifery, Robert Gordon University, Aberdeen; Chair of the
Association of District Nurse Educators, London, UK ● Practical and evidence-based
Reverend Ann Clarridge, MSc BSc (Hons ) Dip Th PCCEA RN DN Assistant Priest, ● Learning objectives, exercises and activities
Holy Trinity Church, Northwood, Diocese of London
● Case studies and examples from practice
Formerly Principal Lecturer, London South Bank University, UK

Karen Melling, MA PGCEA RDNT PWT DN RN Formerly Senior Lecturer, University of

Gloucestershire, Gloucester, UK

ISBN 978-1-4441-2150-6

9 781444 121506

spine 15mm
A Textbook of
Community Nursing
Edited by
SUE CHILTON, HEATHER BAIN,
ANN CLARRIDGE and KAREN MELLING
CRC Press
Taylor & Francis Group
6000 Broken Sound Parkway NW, Suite 300
Boca Raton, FL 33487-2742

© 2013 by Taylor & Francis Group, LLC

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Version Date: 20150220

International Standard Book Number-13: 978-1-4441-6483-1 (eBook - PDF)

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CONTENTS
Contributors iv
Foreword vi
Introduction viii

1 Nursing in a community environment 1

Sue Chilton
2 Public health and the promotion of wellbeing 20
Mark Rawlinson, Donna Baker, Margaret Fergus
3 Professional approaches to care 36
Jo Skinner
4 Managing risk 57
Dee Drew, Debra Smith
5 Therapeutic relationship 74
Patricia Wilson, Sue Miller
6 Care across the lifespan 90
Helen McVeigh
7 Community nursing assessment 104
Helen Gough
8 Carers: the keystone of communities and families 123
Fiona Baguley
9 Spirituality: a neglected aspect of care 136
Ann Clarridge
10 Collaborative working: benefits and barriers 151
Sally Sprung, Sue Harness
11 Approaches to acute care in the community 165
Linda Watson
12 Emerging issues in long-term conditions 183
Rose Stark
13 Providing quality in end-of-life care 198
Gina King
14 Organization and management of care 214
Jill Gould
15 Clinical leadership and quality care 234
Caroline AW Dickson
16 Learning and teaching in the community 253
Virginia Radcliffe
17 eHealth 271
Heather Bain
18 Development of community nursing in the context of changing times 286
Anne Smith, Kirsten Jack
CONTRIBUTORS
Fiona Baguley MSC
Lecturer in Public Health/Community
School of Nursing and Midwifery
Robert Gordon University
Aberdeen
Heather Bain
Lecturer/Course Leader BN (HONS) Community Health
School of Nursing and Midwifery
Robert Gordon University
Aberdeen
Chair of the Association of District Nurse Educators
Donna Baker DIP HE NURSING CERT ED BSC (HONS) RN SCPHN (HV)
Learning Environment Lead
NHS Isle of Wight
Sue Chilton
Senior Lecturer in Health
University of Gloucestershire
Staff Nurse
District Nursing Service
Gloucestershire Care Services
Reverend Ann Clarridge MSC BSC (HONS) DIP TH PCCEA RN DN
Assistant Priest
Holy Trinity Church
Northwood, Diocese of London
formerly Principal Lecturer
London South Bank University
Caroline A W Dickson MSC PG CERT PROF ED BA RN DIP DN RNT
Lecturer in Nursing/Programme Leader for Community Health Nursing: SPQ Community Nursing
in the Home/District Nursing, Division of Nursing
Occupational Therapy and Arts Therapies, School of Health Sciences
Queen Margaret University
Edinburgh
Dee Drew (Dr) PHD MSc DN RN
Award Leader Doctorate in Health and Wellbeing
School of Health and Wellbeing
University of Wolverhampton
West Midlands
Margaret Fergus SRN RHV PGCE(A)
Lecturer in Nursing Studies
University of Southampton
Helen Gough RGN RM DN BSC HEALTH STUDIES PGC RNT MED
Programme Leader MSc Healthcare Education
Programme Leader BSc/BSc Hons Health Studies
School of Health and Life Sciences
Glasgow Caledonian University
Jill Y Gould RGN DN BSc (HONS) CSPPGD Primary Care Studies
Msc Healthcare Education
SPQ/Teacher/Nurse Prescriber NMC
Treasurer ADNE Programme Leader
MSc/BSc Hons Community Specialist Primary Care Nursing
Sheffield Hallam University
Sue Harness PGCE Bsc (HONS)
Community Specialist Practice RGN
Senior Lecturer in Community and Public Health
Programme Lead Community Specialist Practice
University of Cumbria
 Contributors v
Kirsten Jack RN BA (HONS) MSC PHD
Senior Lecturer, Adult Nursing
Department of Nursing
Manchester Metropolitan University
Gina King RN DN DIP BSC
Clinical Facilitator for End of Life Care
NHS Gloucestershire(HONS)
Chair of the EoLC Facilitators Regional Network (South West)
Helen R McVeigh MA BSC (HONS) RNT RGN
Senior Lecturer in Primary Care
School of Nursing and Midwifery
De Montfort University
Leicester
Karen Melling TD MA PGCEA RDNT PWT DN RN SEN
Formerly Course Leader Specialist
Practitioner Community Nursing Programme
Sue Miller RGN RSCN, DN, CERT ED, BSC (HONS), MSC
Virginia Radcliffe MA BSC (HONS) SPDN N PRESCRIBER RNT RN
Senior Lecturer in Nursing and Prescribing
Centre for Primary Health & Social Care
London Metropolitan University
Mark Rawlinson RGN DNCERT/DIP BA (HONS) PCED CPT
Pathway Leader
District Nursing Faculty of Health Sciences
University of Southampton
Jo Skinner
Director of the Centre for Health and Social Care
London Metropolitan University
Anne Smith MSC BSC (HONS) (DIST NURS) PGCHE QN RN
Honorary Fellow
University of Reading
Berkshire
Debra Smith MA BSC (HONS) DN RN
Senior Lecturer in Primary Care
School of Health and Wellbeing
University of Wolverhampton
West Midlands
Sally Sprung MA BSC (HONS) SPDN RNT QN
Programme leader for Specialist Community Practitioner Programmes
Liverpool John Moores University
Member of the Association of District Nurse Educators
Rose Stark BSC (HONS) MA PGCE
Senior Lecturer, Primary Care
Faculty of Health & Social Care
London South Bank University
London
Linda Watson PGCERT HELT MSN-FNP BSN BSCPODM DIPPODM
Clinical Tutor
Aberdeen Medical School
Aberdeen
Patricia M Wilson PHD MSC BED (HONS) RN NDN
Research Lead Patient Experience & Public Involvement
Centre for Research in Primary & Community Care
University of Hertfordshire
Hatfield
FOREWORD

Community nursing is a specialism whose time has come. It is the lifeboat to the
health services’ Titanic. After decades of lip service to the movement of healthcare
out of hospitals and into people’s homes and community settings, there is now real
recognition that this must and will happen.
Community-based care is the future. It is no longer a matter of policy or political
ideology. It is a matter of demography, technology and economics. The UK has a
rapidly growing population of older people, and a continuing rise in the number of
people living with long-term conditions. No government can afford to continue to
use hospitals as the default option for healthcare delivery. Instead, they must
develop, resource and improve community-based services, if people are to receive
the care they need and the national health systems – in their different forms across
the UK – are to remain solvent and successful.
This is not a new idea. Florence Nightingale called hospitals ‘an intermediate stage
of civilization’ and held the view that ‘the ultimate object is to nurse all sick at home’.
Similarly, the man who invented organized district nursing in Liverpool in the
1870s, William Rathbone, wrote in his 1890 history of the movement of the reasons
why patients should be cared for at home: it would be their choice, rather than to go
into hospital; the hospitals lacked capacity to deal with the demand, and anyway
were unsuitable for people with chronic conditions; and home-based care was
cheaper than institutional care.
It took 100 years for healthcare policy to begin to catch up. Now we can add three
more reasons for the move to community-based health care. First, technology has
made highly complex care possible outside of acute settings, and freed patients with
serious, even life-threatening conditions from the misery of months or years in
hospital. Second, the increasing professional freedom of community nurses, and
their allied health professional colleagues, has expanded their scope to care. They
can assess, diagnose, prescribe, follow up and discharge, completing the healthcare
journey with the patient or client. And lastly, but importantly, we are now much
more aware of the causes of disease and ill health than the Victorians Rathbone and
Nightingale were. We know that the public health, health promotion and safe-
guarding roles of nurses in the community are vital to reduce the burdens of disease,
injury, social isolation and the health consequences of deprivation.
So community nursing today is more important than ever before. And without a
doubt, the demands on its practitioners, so well described in this book, make it a
specialist area of practice, for which specialist preparation is needed. How that
specialist preparation is delivered has been the subject of intense debate across the
four countries of the UK for decades. There have been many changes of approach,
and there is now great diversity in opportunity for the aspiring community nurse.
 Foreword vii
Any nurse in the community, or contemplating a move into community-based
nursing, would be well advised to study this book. It maps the territory, explores the
professional requirements, and shares the wisdom and learning of expert
practitioners. It shows just how different community nursing is from hospital
nursing, and introduces the new and different skills a nurse will need. It will help the
community novice to chart a safe course across some of the most exciting,
challenging and rewarding waters in a nursing career.

Rosemary Cook CBE

Director, Queen’s Nursing Institute
INTRODUCTION

Sue Chilton, Heather Bain, Ann Clarridge and Karen

Melling
This book has been designed to support staff who may be new to working in a
community setting and is an essential guide to practice. We envisage that it will be
useful for pre-registration students on community placement, community staff
nurses and nurses moving from an acute work environment to take up a community
post. The aim of the book is to develop and support nurses to work safely and
effectively in a range of community locations.
Community nurses work in a great diversity of roles and a variety of settings
– including schools, the workplace, health clinics and the home (Naidoo and Wills,
2009). They empower individuals, families and communities to have control
over their health and to improve their wellbeing. They also work across the
lifespan, and with a range of social groups that includes those who are
vulnerable, experience inequalities and are socially excluded. Not only do
community nurses work autonomously in leading, managing and providing
acute and long-term health and social care, anticipatory care and palliative care,
but they also have a public health remit. They have a pivotal role in health
protection, ill-health prevention and health improvement.
Community practice is dynamic, forever changing and in a constant state of flux.
Baguley et al. (2010) have conceptualized community nursing in Fig. 1, which
illustrates that, in the promotion of optimum health and wellbeing, community
practitioners work in a range of locations – with individuals, families and
communities. The overlapping spheres demonstrate the intricacies and relationships
between individuals, families and communities.
Community nursing is complex but essentially falls within the following four
continuums, which are all addressed within this book:

• Birth to death: they work with all ages across the lifespan.
• Vulnerability and resilience: individuals, families and communities fluctuate in
and out of vulnerability and resilience throughout their life.
• Assessment and intervention: community practitioners work within a cycle of
assessment of needs and interventions to address the needs and support
individuals, families and communities.
• Leadership and autonomy: community practitioners work in varying degrees of
autonomy and leadership in advancing practice, evidencing practice and providing
the best practice.
 Introduction ix

Res
ility ilie
erab nce
V uln

Bir
t
en

th
ssm

Individual
se
As

Community Family
Int

th
a
e

De
rve
nti
on

Lea
der my
shi
p ono
Aut

Figure 1 Promotion of optimum health and wellbeing (Baguley et al., 2010).

A range of topics relating to professional issues in community nursing is addressed

within the book. The text reflects recent and current government health and social
care policy reforms and the effect of these on the roles and responsibilities of
community nurses. It is acknowledged that the devolution of political power to the
four countries within the UK has influenced health policies. There is now a much
greater degree of freedom in relation to the health policies they produce. All
recognize the shifting balance of care from the acute sector to the community, with
an increasing focus on the management of long-term conditions to reduce hospital
admissions. There are, however, various political stances providing differing
opinions on how to develop their own health services that take the demographics of
each of the four countries into consideration (Jervis, 2008).
Community nursing is seen in the context of not only political but also social and
environmental influences. The authors take an inclusive approach, working from a
health and social care perspective to meet the needs of service users. Interpersonal
and practical skills, as well as the knowledge base required by community nurses, are
critically analyzed and linked to relevant theory. The use of activities, examples and
case studies/scenarios relating to the range of community nursing disciplines are
included throughout the book to stimulate the reader’s creative thinking. Themes
running through the text are evidence-based practice, reflection, vulnerability and
current government policy drivers across the four UK countries. Each chapter has
been written by a contributor(s) with in-depth knowledge and experience of the
specific subject area, resulting in a range of writing styles.
 x Introduction

Topics covered within this text inform key aspects of the community nurse’s role.
A brief summary of each chapter is detailed below:

Chapter 1 – Nursing in a community environment – explores definitions of

‘community’ and acknowledges its complex nature. A range of factors
influencing the delivery of community healthcare services and the expertise
required of community nurses is discussed.
Chapter 2 – Public health and the promotion of wellbeing – analyzes the role of
Public Health in community nursing and ways of determining health need.
Opportunities for positively influencing care delivery are explored.
Chapter 3 – Professional approaches to care – discusses the concept of
‘professionalism’, comparing and contrasting the traditional, hierarchical and
individualistic model of professional practice with a more inclusive partnership
model.
Chapter 4 – Managing risk – explores health and safety considerations in
relation to community nursing with particular emphasis upon vulnerable
groups – people with mental health issues, older people and children.
Chapter 5 – Therapeutic relationships – discusses the challenges and issues
involved in establishing therapeutic relationships between service users and
community nurses.
Chapter 6 – Care across the lifespan – considers how an understanding of the
lifespan can enhance the quality of care provision by exploring different
theories of growth and development.
Chapter 7 – Community nursing assessment – explores the notion of
‘assessment’ and the concept of need. Assessment frameworks and decision-
making processes are discussed.
Chapter 8 – Carers – the keystone of communities and families – discusses the
role of carers identifying some of the inherent challenges and rewards. Carer
assessment tools and carer support networks are considered.
Chapter 9 – Spirituality: a neglected aspect of care – highlights the importance
of developing self awareness and using appropriate tools to assess and address a
person’s spiritual needs.
Chapter 10 – Collaborative working: benefits and barriers – examines the importance
of collaborative working including some of the opportunities and constraints.
Chapter 11 – Approaches to acute care in the community – defines acute care
in the community setting and identifies the knowledge and skills required by
community nurses to manage it.
Chapter 12 – Emerging issues in long-term conditions – describes contributing
factors and the potential impact of a long-term condition on individuals,
families and communities.
Chapter 13 – Providing quality in end-of-life care – highlights the importance
of a holistic and timely assessment in order to effectively manage the end-of-life
care needs.
 Introduction xi
Chapter 14 – Organization and management of care – critically analyzes work
organization and care delivery in the community setting with particular
reference to prioritization, delegation and skill mix.
Chapter 15 – Clinical leadership and quality care – explores the role of
leadership and clinical governance at practice level within community nursing.
Chapter 16 – Learning and teaching in the community – discusses the
importance of identifying learning needs and exploiting clinical learning
opportunities.
Chapter 17 – eHealth – defines the terminology used in telehealth and telecare
and appraises its potential use in community nursing practice.
Chapter 18 – Development of community nursing in the context of changing
times – identifies contemporary political influences and discusses new ways of
working and responding as community nurses.

Within each chapter further reading and resources are suggested. You may also
find it useful to access the NHS Education for Scotland (2012) toolkit to support
Modernising Nursing in the Community, at www.mnic.nes.scot.nhs.uk. This is a
developing resource which is presented in three platforms: adults and older people;
children and young people; and work and well being. Within each platform there are
elements to support safe and effective person-centred care. Although the resource
focuses on Scottish policy there are useful sections on supporting evidence and
examples from practice which can be applied equally across the four countries of the
UK, and will complement many of the theories and concepts considered within this
book.

We hope you find this book informative and inspirational in developing your
professional practice.
The editors would like to thank colleagues from the Association of District Nurse
Educators (ADNE), many of whom have contributed to the book. The ADNE
(www.adne.co.uk) is committed to raising the profile of district nursing and its
purpose is the educational preparation and support of district nurses and other
health professionals working in primary and community care across the UK. At
various stages along the way, members of this professional group have offered
guidance and support.

REFERENCES
Baguley F, Bain H and Cowie, J (2010) Concept of Community Nursing, Aberdeen: Robert
Gordon University
Jervis P (2008) Devolution and Health. London: Nuffield Trust
Naidoo J and Wills J (2009) Health Promotion, 3rd edn. Edinburgh: Elsevier

FURTHER RESOURCES
www.mnic.nes.scot.nhs.uk – NHS Education for Scotland toolkit to support
Modernising Nursing in the Community
This page intentionally left blank
CHAPTER

1 Nursing in a community
environment
Sue Chilton

LEARNING OUTCOMES
• Compare and contrast definitions of ‘community’, exploring the contexts in
which the term is used and, specifically, how it is interpreted within
community nursing
• Explore the environmental, social, economic, professional and political factors
influencing the delivery of community healthcare services and critically
appraise ways in which local services aim to be responsive to the specific
needs of their population
• Develop insight into the complex nature of the environment of community
healthcare
• Identify the skills and qualities required of nurses working in the community
and describe a range of community nursing roles, including the key
responsibilities of the eight community specialist practitioner nursing
disciplines

INTRODUCTION
This chapter considers the complex environment within which community nurses
practise and offers some definitions of ‘community’ and ways in which the term is
used. It explores the wide range of factors impacting upon the services community
nurses provide for patients and discusses ways of tailoring care to respond to local
needs. Key skills and qualities required by community nurses are identified and a
variety of roles is described, including the eight community specialist practice
disciplines.

DEFINITIONS OF ‘COMMUNITY’
Changes in terms of the location and nature of community nursing care provision
have occurred over the years in response to a variety of influencing factors. More
recently, we have seen a distinct shift of services from the hospital setting to primary
care and community locations (McGarry, 2003). Current health and social care
policy directives indicate that still more services will be provided within the
community context in the future (Scottish Government, 2007; Welsh Assembly,
2009; Scottish Government, 2010; DHSSPS, 2010; DH, 2010a). In order to provide
2 Nursing in a community environment

the required administrative and managerial infrastructure to accommodate these

changes, several major organizational reconfigurations have taken place across the
UK in recent years. In England, for example, GP Fundholding was replaced by
Primary Care Groups, which then developed into Primary Care Trusts (DH, 1997).
Currently, we are witnessing the largest structural reorganization of the NHS since
its inception in 1948, involving the development of GP consortia (DH, 2010a),
which will have wide-ranging responsibilities for commissioning services and
managing 80% of the NHS budget.
Although, from an academic perspective, the notion of ‘community’ has been
discussed widely across a range of disciplines, including sociology and anthropology
(Cohen, 1985), clarity with regard to a definitive definition eludes us.

ACTIVITY 1.1 Reflection point

Compile a list of words that helps to define ‘community’ for you. Identify any
recurring themes that emerge when considering different types of community
or different contexts within which the term is used.

Laverack (2009) offers four key characteristics of a ‘community’ which help to

summarize many of the definitions found in the literature. These are:
• spatial dimension – referring to a place or location
• interests, issues or identities that heterogeneous groups of people share
• social interactions that are often powerful in nature and tie people into
relationships or strong bonds with each other
• shared needs and concerns that can be addressed by collective and collaborative
actions.

Although the essence of ‘community’ is difficult to capture within a definition, the

word itself largely conveys a positive impression conjuring up feelings of harmony
and cooperation. It is unsurprising to find that it is a word used frequently by
politicians within government documents to create just that effect.
The uncertainty with regard to the true meaning of the word ‘community’ also
applies within community nursing (Hickey and Hardyman, 2000). It is pivotal
(Carr, 2001) that the context within which care takes place, including physical and
social aspects among many others, is considered alongside the geographical
location of care. By attempting to include the wide array of elements involved, the
true complexity of nursing within the community begins to emerge. Although
some of the challenges, such as interacting with patients and families in their own
homes, are acknowledged within the literature (Luker et al., 2000), the meaning of
community within community nursing is often assumed and taken for granted (St
John, 1998).
St John (1998: 63) interviewed community nurses who explained the nature of
the communities they worked within in terms of ‘geography; provision of resources;
a network and target groups’. Some nurses described their communities as a ‘client’
or an entity, particularly where members of the community were connected. If a
 Definitions of ‘Community’ 3
population was not connected, nurses defined community as the next largest
connected element such as a group or family.
It would appear that definitions of community often include the dimensions of
people, geography or space; shared elements, relationships or interests; and
incorporate some form of interaction. Many of these common themes are captured
in the following definition of ‘community’ as:

... a social group determined by geographical boundaries and/or common

values and interests. Its members know and interact with each other. It
functions within a particular social structure and exhibits and creates certain
norms, values and social institutions.
(WHO, 1974)

Awareness of the networks that exist within a community helps in identifying

opportunities or strategies to engage ‘hidden’ members of the population. ‘Social
capital’ is a term used to explain networks and shared norms that form an essential
component of effective community development (Wills, 2009). It is proposed that
poor health is linked to low social capital and social exclusion where poverty or
discrimination exist (Wilkinson, 2005). According to the National Occupational
Standards in Community Development Work, the main aim of community
development work is
collectively to bring about social change and justice by working with
communities to identify their needs, opportunities, rights and responsibilities;
plan, organise and take action and evaluate the effectiveness and impact of
the action all in ways which challenge oppressions and tackle inequalities.
(Lifelong Learning UK, 2009)

Community development work is inclusive, empowering and collaborative in

nature and is underpinned by the principles of equality and anti-discrimination,
social justice, collective action, community empowerment, and working and
learning together.
A study by McGarry (2003) identifies the central position of the home and
relationships that take place within it in defining the community nurse’s role. Four
key themes emerging from her research are ‘being a guest’ within the home, the
maintenance of personal–professional boundaries, notions of holistic care and
professional definitions of community. The findings highlight the tensions for nurses
in embracing their personal perceptions of community nursing while trying to work
effectively within the constraints of organizational and professional boundaries.
Kelly and Symonds (2003), in their exploration of the social construction of
community nursing, discuss three key perspectives of the community nurse as carer,
the community nurse as an agent of social control and community nursing as a
unified discipline. The authors discuss the proposition that community nurses are
still reliant on others to present the public image of community nursing that is
portrayed. They argue, interestingly, that community nurses may not possess
enough autonomy to define their own constructs and articulate these to others.
4 Nursing in a community environment

FACTORS INFLUENCING THE DELIVERY OF COMMUNITY

HEALTHCARE SERVICES
Community nurses face many challenges within their evolving roles. The transition
from working in an institutional setting to working in the community can be
somewhat daunting at first (Drennan et al., 2005). As a student on community
placement or a newly employed staff nurse, it soon becomes apparent that there is a
wide range of factors influencing the planning and delivery of community healthcare
services. Within the home/community context, those issues that impact upon an
individual’s health are more apparent. People are encountered in their natural
habitats rather than being isolated within the hospital setting. Assessment is so much
more complex in the community, as the nurse must consider the interconnections
between the various elements of a person’s lifestyle. Chapter 7 explores the concept
of assessment in more detail. In addition, community nurses are often working
independently, making complex clinical decisions without the immediate support of
the wider multidisciplinary team or access to a range of equipment and resources as
would be the case in a hospital or other institutional healthcare environment. It is
recognized, for example, that district nurses are frequently challenged with managing
very complex care situations which require advanced clinical skills, sophisticated
decision-making and expert care planning (Baid et al., 2009). Barret et al. (2007) also
acknowledge the need for specialist district nurse practitioners to have expert
knowledge and advanced clinical skills as well as highly developed interpersonal skills
and a clear understanding of a whole systems approach.
Defining health is complex as it involves multiple factors. According to Blaxter
(1990), health can be defined from four different perspectives: an absence of disease,
fitness, ability to function and general wellbeing. The concept of health has many
dimensions such as physical, mental, emotional, social, spiritual and societal. All
aspects of health are interdependent in a holistic approach. It is prudent to view an
individual within the context of their wider socioeconomic situation when
considering issues relating to their health (Fig. 1.1).
There are acknowledged inequalities in health status between different people
within society and major determinants include social class, culture, occupation,
income, gender and geographical location. Several reports have been published since
the 1980s, across the countries making up the UK, providing comprehensive reviews
of the literature/research available on inequalities in health (DHSS, 1980; Acheson
Report, 1998; Welsh Assembly, 2005; DHSSPS, 2007; Scottish Government, 2008;
Marmot Review, 2010). Although these documents have sought to inform the national
public health agenda of the day, the reality is that unacceptable inequalities remain.
In England, Fair Society, Healthy Lives is the title of the most recent of these
reports by Marmot (2010). The main recommendations are:
• giving every child the best start in life
• enabling all children, young people and adults to maximize their capabilities and
have control over their lives
• creating fair employment and good work for all
 Factors Influencing the Delivery of Community Healthcare Services 5

AL ECOSYSTEM
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Figure 1.1 The health map (Barton and Grant, 2010). The determinants of health and
wellbeing in our neighbourhoods.

• ensuring a healthy standard of living for all

• creating and developing healthy and sustainable places and communities
• strengthening the role and impact of ill-health prevention.
The report states that people living in more disadvantaged communities die 7 years
earlier on average than people living in more prosperous communities. Those in the
poorest neighbourhoods will also experience more of their lives with a disability – an
average difference of 17 years.
In order to improve health inequalities, Marmot (2010) suggests that health
professionals, including community nurses, can contribute in three ways. First, they
can help to remove any social and ethnic barriers to receiving healthcare. Second,
they should act as advocates for their service users and work in collaboration with
other health and social care providers. Finally, they should base health improvement
initiatives/best practice on rigorous evidence and research so that strategies used are
effective and replicable. In response to this, the DH (2010b) recognizes that dis-
advantaged areas face the toughest challenges and are set to receive greater rewards
for any health improvements made.
The increased emphasis lately on the development of a primary care-led NHS has
come about in response to demographic, technological, political and financial
influences, among others. An increasing population of older people, shorter hospital
6 Nursing in a community environment

stays, improvements in technology and patient preference have all contributed to

the movement of resources from the acute to the primary care sector.
The development of new competencies to provide services away from hospital
settings means that an increasing number of people with both acute and long-term
conditions will eventually receive care at home or in a range of other locations
within the community. It is envisaged that hospitals will mainly provide diagnostic
and specialist services in the future (DH, 2010a).

MEETING THE NEEDS OF THE LOCAL POPULATION

Community nurses can identify the needs of their given population by conducting a
health needs assessment, which is a process of gathering information from a variety
of sources in order to assist the planning and development of services. As society is
constantly changing, health needs assessment is not a static exercise. According to the
King’s Fund (1994), data are required regarding disease patterns (epidemiology) and
public health in a particular area (locality/community/neighbourhood) as well as
information regarding local environmental factors/resources (knowledge base/
experience of community service providers). In other words, a combination of ‘hard’
(statistical/research-based/quantitative) data and ‘soft’ (experiential/anecdotal/
qualitative) data.
Qualitative information may include newspapers; meetings of agencies; diaries,
meeting notes of local workers; projects undertaken by students on programmes of
study; photographs and videos. Quantitative data will be obtained from a variety of
sources but will consist mainly of statistical evidence and research-based studies
(Hawtin and Percy-Smith, 2007).
Three key approaches to health needs assessment described by Coles and Porter
(2008) are epidemiological, comparative and corporate. A comprehensive assessment
would normally incorporate more than one of these approaches.

ACTIVITY 1.2 Reflection point

Consider the area/team within which you are working at present. What
sources of information would help to inform you regarding the specific needs
of your client group/population? Make a list and try to divide the information
into either ‘hard’ or ‘soft’ data.
Explore the different sources of data available to inform a health and social
needs assessment of your local community. Much information can be obtained
from the local council, libraries and Internet sources (see list at the end of the
References list).

In capturing the ‘essence’ of a locality, the term ‘community profile’ is frequently

used to describe an area in relation to its amenities, demography (characteristics of
the population), public services, employment, transport and environment.
Traditionally, health visitors, in particular, have been required to produce community
profiles as a form of assessment during their training.
 Meeting the Needs of the Local Population 7
‘Community profiling’ can be defined as:
a comprehensive description of the needs of a population that is defined, or
defines itself, as a community and the resources that exist within that
community, carried out with the active involvement of the community itself,
for the purpose of developing an action plan or other means of improving the
quality of life of the community.
(Hawtin and Percy-Smith, 2007: 10)
There are three interacting levels identified within profiling, which are:

• community – assessment of need within a locality/neighbourhood

• practice – assessment of need within a GP practice
• caseload – assessment of need within a health professional’s caseload.
Any attempt to analyze the series of complex processes that makes up a living
community without the participation of local residents/consumers is a fairly
fruitless exercise. In gathering information from a large community population, a
variety of methods may prove useful. An approach entitled Participatory Rapid
Appraisal has been described elsewhere (Coles and Porter, 2008) and involves
community members in the collection of information and related decision-making.
Originally used in developing countries to assess need within poor rural populations,
it has been employed in deprived urban areas. A wide variety of data-collection
methods is used and Participatory Rapid Appraisal involves local agencies and
organizations working together. By working in partnership with local residents,
action is taken by community members who have identified issues of local concern/
interest and discussed potential solutions. Clearly, Participatory Rapid Appraisal
could be used to help tackle specific issues as well as large-scale assessments.
Current government policy (DH, 2010a,b) stresses the importance of a localized
approach to community healthcare service provision. Each locality is different in
terms of its characteristics, which might include its demography, geographical
location, environment, amenities, transport systems, unemployment levels, depriva-
tion scores, work opportunities and access to services, for example. As a result of these
potential variations, it is important to interpret national guidelines according to local
needs. Each locality will have its own individualized local targets for public health
tailored to the specific requirements of the local population. Such targets are usually
chosen following an examination of local information sources, such as epidemiological
data collected by the Public Health department, general practice profiles and caseload
analysis data obtained from local healthcare practitioners, for example.
By systematically reviewing local information sources and working within
government/professional guidelines, community nurses have an opportunity to
develop practice and more collaborative ways of working.

Example 1.1
From general practice profile information, one locality identified a significantly high
percentage of the older population with dementia. As a result, the community
8 Nursing in a community environment

psychiatric nurse team working with older people in the locality liaised with the
district nurses and practice nurses across the identified GP practices with a view
to discussing the provision of support for the carers involved.

DH (2010a) highlights the importance of frontline staff taking responsibility for

implementing changes in the NHS. This will involve community nurses becoming
more actively involved in health needs assessment. It has been recognized that there
are populations whose healthcare needs are unmet (Coles and Porter, 2008), which
presents community nurses with the challenge of redefining their services to more
accurately respond to the needs of their particular patient group. Responding more
appropriately is not an easy task as many of these unmet needs often require seeking
out and might exist within the more disadvantaged sectors of society. It is not
unreasonable to assume that many community nurses will require a greater
understanding of different cultural issues and social value systems before they are
able to identify specific unmet needs. The inverse care law means that, ironically, the
more advantaged people in society tend to receive better healthcare services
(Acheson, 1998). Current NHS policy is attempting to rectify this anomaly and end
the so-called ‘postcode lottery’, which suggests you are able to determine your health
status from the place where you live.
Although National Service Frameworks (NSFs) are national guidelines produced
to encourage the dissemination of best practice in relation to particular conditions
or client groups, it is the responsibility of frontline staff to implement them locally
and interpret them according to local conditions.

ACTIVITY 1.3 Action point

In relation to the locality in which you are based within the community, find
out about ways in which the NSFs are being implemented at a local level.
Gather information regarding local initiatives and examples of any community
nurses working in collaboration with other individuals/organizations/agencies in
addressing the NSF guidelines.

THE COMPLEX NATURE OF THE ENVIRONMENT OF

COMMUNITY HEALTHCARE
Kelly and Symonds (2003) discuss how community nurses have been obliged to
conform to current views and power structures since the beginning of the nineteenth
century. Even the caring nature of their role has been often overlooked as a result of
influence from more powerful groups to conform to more stereotypical female roles
and medical models of care. Recent shifts into community and primary healthcare
have prompted community nurses to re-examine their position, which has involved
empowering the more disadvantaged groups within society in the form of ‘social
support’. However, the development of the caring aspect of community nursing has
been compromised by models of primary healthcare delivery in favour of activity
that is more medically rather than socially focused.
 The Complex Nature of the Environment of Community Healthcare 9
A new understanding of community care as ‘process’ rather than ‘context’ is
proposed by Clarke (1999) to enable us to value community nursing as advanced
specialist practice in its own right rather than as institutional or acute care nursing
in another setting. Appreciation of the true complexity of meeting the health and
social care needs of service users in the community only really becomes evident with
experience. Eng et al. (1992) encourage an ‘understanding that a community is a
“living” organism with interactive webs of ties among organisations, neighbourhoods,
families and friends’.

ACTIVITY 1.4 Reflection point

Reflect on a health problem/issue that you or a family member or friend may
have experienced. Consider the effects of this experience on everybody
involved and the health and social care needs that resulted.
• Make a list of the identified health and social care needs of all those people involved.
• Were all of the needs addressed or met? If not, why not?
• Who was involved in meeting these needs?
• Consider the different sources of support, information, care, treatment and
advice offered and given. Was the overall package of care well coordinated?
• Were there other potential sources of help that were untapped at the time?
• Were sources of care and support readily available or did they need seeking out?
• Were self-care strategies employed in any way?
• With hindsight, how would you rate the quality of care and support received/
obtained?
• What do you consider to be the most important elements of high-quality
care provision?

On reflecting on the above activity, you may have identified service providers from
statutory, voluntary or charitable agencies and organizations. Individuals responsible
for assessing, planning, delivering and evaluating care based on apparent needs may
have been professionally qualified or not. Sources of support may have come from
recognized services or consisted of more informal networks. Information to help you
make sense of the experience could be accessed in a variety of ways. Frustrations,
concerns and reassurance at the time will probably have linked to a range of factors –
such as interpersonal communication, transport, accessibility of services, effectiveness
of treatment, information available and financial issues, for example.
The National Nursing Research Unit (NNRU) (2011) has conducted research
measuring patient experience in the primary care sector that included patients with
different illnesses/conditions. Generic themes that were important to patients
included being treated as a person; staff who listen and spend time; individualized
treatment and no labelling; feeling informed, receiving information and given
options; patient involvement in care-efficient processes; and emotional and
psychological support. The authors highlight the need for policy-makers to start to
consider the relational aspects of a patient’s experience more – such as compassion,
empathy and emotional support – as well as the functional aspects of service
10 Nursing in a community environment

provision – such as access, waiting and food. Such information can only be collected
from patients and carers themselves.
The community environment is a fascinating yet complicated matrix of elements.
There are myriad individuals, groups, agencies and organizations involved in the
delivery of health and social care. Potential barriers to effective coordination of
services and support include different management systems and ways of working
between organizations, conflicting ideologies or philosophies of care of service
providers, a variety of communication networks and channels, and power
differentials and stereotyping between different groups in society.

COMMUNITY NURSES: KEEPING THE FOCUS ON

PERSON-CENTRED CARE
Clearly, there are differences between communities in terms of the locations in
which community healthcare services are offered to service users. Provision will vary
considerably between a very rural community as opposed to an urban one. For
example, in a rural location, there might tend to be more community hospitals,
providing more accessible local services that are not of a specialist nature whereas
walk-in centres, for example, tend to be located in more densely populated areas
such as city centres and airports.
Community nursing takes place in a wide variety of settings.

ACTIVITY 1.5 Action point

From personal or professional experience, list as many different locations as
you can where community nurses provide care. This might help you to identify
a wide range of community nursing roles.

In the early 1990s, the United Kingdom Central Council for Nursing, Midwifery and
Health Visiting (UKCC) conducted the PREP project to clarify the future training
requirements for post-registration nurses in terms of education and practice. At the
time, eight community specialist practice disciplines were identified and included
occupational health nursing, community children’s nursing, community nursing
learning disability, community mental health nursing, general practice nursing,
school nursing, health visiting and district nursing. The UKCC (1994) proposed a
common core-centred course for all specialities, which was to be at first degree level
at least and 1 year in length. According to the UKCC (1994), the remit of community
specialist practice embraces ‘clinical nursing care, risk identification, disease
prevention, health promotion, needs assessment and a contribution to the
development of public health services and policy’. Clearly, a higher level of decision-
making is involved in specialist community nursing practice.
A brief synopsis of each of the eight community specialist practice nursing roles
is offered below. For a more detailed discussion of the roles of these community
nurses, please refer to Sines et al. (2009).
 Community Nurses: Keeping the Focus on Person-centred Care 11
Occupational health nursing
Occupational health nursing is a relatively new nursing discipline that has
developed from its origins in ‘industrial nursing’ in the mid-nineteenth century
when the role was mainly curative rather than preventative (Chorley, 2001).
Occupational health nurses (OHNs) work within the wider occupational health
services and engage in preventative activities to advise employers, employees and
their representatives on health and safety issues in the working environment and
the adaptation of the working environment to the capabilities of the employees
(RCN, 2005).
Key skills of the OHN include risk assessment, health surveillance and health
promotion and health protection. Attendance management and the use of strategies
to enable a successful return to work following an accident or serious illness are seen
as important elements of the role of the OHN (Harriss, 2009).
OHNs holding an appropriate qualification are eligible for registration on the
third part of the NMC register for Specialist Community Public Health Nursing
(SCPHN), which was established in 2004.

Community children’s nursing

Over the past decade, there has been a rapid expansion of community children’s
nursing (CCN) services with a current total of 243 CCN services throughout the UK
(RCN, 2008). This development has been supported by a number of pertinent
government reports.
There are three key elements within the delivery of CCN services, which are
(1) first contact/acute assessment, diagnosis, treatment and referral of children;
(2) continuing care, chronic disease management and meeting the imperatives of
the Children’s National Service Framework; and (3) public health/health protection
and promotion programmes – working with children and families to improve health
and reduce the impact of illness and disability (DH/DfES, 2004).
It has been acknowledged that if they are to meet the wide-ranging needs of local
child populations in the future, ‘CCNs will need to change and adapt to new models
of service delivery, taking on novel and emerging roles in order to ensure that all
children with nursing are managed closer to home’ (Whiting et al., 2009: 159).

Community nursing learning disability

According to Barr (2009), there was recognition of the need for more community-
based services to be provided for people with learning disabilities living at home and
their families in the mid-1970s. Around this time, different models of service were
developing around the notion of ‘normalization’, which is the underlying philosophy
of many of the services provided for people with learning disabilities. Normalization
may be defined as ‘a complex system which sets out to value positively devalued
individuals and groups’ (Race, 1999).
12 Nursing in a community environment

Service principles for learning disability services should place people with learning
disabilities at the centre of care; provide care in an attractive environment; have clear
arrangements for safeguarding; provide access to independent advocacy services; be
open to internal and external scrutiny; and have comprehensive training in place for
staff (HCC, 2007).
The role of community nursing learning disability nurses (CNLDs) has changed
markedly over the past few years. It is becoming more health focused and a
particular emphasis in the future will be with people who have increasingly complex
physical and mental health needs. CNLDs must ‘take seriously their role to support
people with learning disabilities and their families through the provision of high-
quality, person focused and coordinated services’ (Barr, 2009: 231).

Community mental health nursing

The community mental health nursing (CMHN) service has been well documented
since its inception in the mid-1950s. The expertise of the CMHN lies in assessing the
mental health of an individual within a family and social context. CMHNs may be
located in health centres, GP practices, voluntary organizations and accident and
emergency departments. They represent people with mental health needs and
provide high-quality therapeutic care. Five elements underpin the professional
practice of CMHNs (McLaughlin and Long, 2009). First, a guiding paradigm, which
within CMHN involves respecting, valuing and facilitating the growth unique
within each individual (Rogers, 1990). Second, therapeutic presence is needed to
restore clients’ dignity and worth as healthy, unique human beings. Third, the
therapeutic encounter, which is essential for healing and growth. Fourth, the
principles of CMHN, which include the search for recognized and unrecognized
mental health needs; the prevention of a disequilibrium in mental health; the
facilitation of mental health-enhancing activities; therapeutic approaches to mental
healthcare and influences on policies affecting mental health, and, finally, the
National Service Framework (DH, 1999).
Although several models are emerging in the organization, delivery and evaluation
of community mental health services, the guiding principles remain the same.
Collaboration between government, local authorities, the voluntary and statutory
services, and community groups both nationally and locally is pivotal in improving
the nation’s mental health (McLaughlin and Long, 2009).

General practice nursing

Nurses have been working in general practice for almost 100 years (Selvey and
Saunders, 2009). Since the early 1990s, the number of practice nurses has grown
considerably in response to the demands of general practice. The full-time equivalent
workforce has expanded by 23% since 1996 (Drennan and Davis, 2008).
Practice nurses frequently fulfil the role of ‘gatekeeper’ and are relatively easily
accessible and acceptable to patients as they are located within GP surgeries. The role
of the practice nurse is wide ranging and covers all age groups within the practice
 Community Nurses: Keeping the Focus on Person-centred Care 13
population. Three key aspects of the role are first contact, public health and long-
term condition management (Selvey and Saunders, 2009). Practice nurses have
become involved in the implementation of National Service Framework guidelines
at a local level and often play a key role in establishing nurse-led clinics to tackle
public health targets.
In order to develop innovative ways of delivering services with a changing skill
mix within general practice, practice nurses will require well-developed leadership
and management skills in the future (Selvey and Saunders, 2009).

School nursing
School nurses have been employed within the school health service for more than
100 years and are seen as central to child-focused public health practice (Jameson
and Thurtle, 2009).
Key aspects of the school nurse’s role include the assessment of health needs of
children and school communities, agreement of individual and school plans and
delivery of these through multidisciplinary partnerships; playing a key role in
immunization and vaccination programmes; contributing to personal and health
and social education and to citizenship training; working with parents to promote
positive parenting; offering support and counselling, promoting positive mental
health in young people and advising and coordinating healthcare to children with
medical needs.
School nurses holding an appropriate qualification are eligible for registration on
the third part of the NMC register for SCPHN:

With the development of children’s trusts and the provision of statutory

guidance on interagency working and cooperation to improve the well-being
of children and young people, school nurses need to work hard to build links
with education and social care teams.
(Jameson and Thurtle, 2009)

Health visiting
The health visiting service has been in existence for more than 100 years and has its
roots in public health and concern about poor health. The overall aim of the service
is the promotion of health and the prevention of ill health. According to the CETHV
(1977) the four main elements of the health visitor’s (HV) role include the search
for health needs; stimulation of awareness of health needs; influence on policies
affecting health; and facilitation of health-enhancing activities.
HVs holding an appropriate qualification are eligible for registration on the third
part of the NMC register for SCPHN.
HVs need to engage actively in public health work, with individuals, families,
groups and communities working collaboratively with the full range of community
services (Frost and Horner, 2009). Recent government directives (DH, 2010a) have
highlighted the need for HVs to maintain a focus on children and families. At the
14 Nursing in a community environment

same time, the profession is keen to develop their future roles in consultation with
the public they serve.

District nursing
District nurses can trace their roots back to the mid-1800s at least, and the historical
development of the service is well recorded. They used to work in relative isolation
but are more likely nowadays to work within a team. The role of the district nurse has
evolved over time in response to political influences and the changing needs of the
populations served. Although it is acknowledged that the role of the district nursing
service is not clearly defined, it involves the assessment, organization and delivery of
care to support people living in their own homes (Audit Commission, 1999). The
current work of the district nurse includes responsibility for providing pathways of
nursing care during acute, long-term and terminal illness (Boran, 2009). The
majority of people on the district nurse’s caseload tend to be from the older
generation – an often vulnerable and marginalized group of people within society.
The Queen’s Nursing Institute (2010) is currently lobbying to maintain and
develop the role of the district nurse, and Smith (2010) and Cook et al. (2011)
highlight the need for clear policy, professional standards and funding to support
district nurse education in the future.
In addition to the community specialist practitioner nursing roles identified
above, there are, of course, many other community nursing roles. Numerous
specialist nurses work within the community environment and these include roles
that link specifically to a particular condition or illness (such as the specialist nurse
for diabetes) or to a group of conditions, such as long-term conditions (Community
Matron). Other community nurses work with specific client groups, such as
homeless or older people. A range of different titles exists for various roles and often
the terms ‘specialist’ or ‘advanced’ practitioner are applied. Such a plethora of titles
can cause confusion and forms part of the wider ongoing specialist–generalist
debate within community nursing circles (McKenna and Bradley, 2003).

THE FUTURE VISION

In order to provide high-quality care to patients, community nurses need the
necessary skills, knowledge and expertise, and it is the responsibility of individual
practitioners and their employing authority to ensure that appropriate preparatory
education and training are organized. Workforce planning assists employing
authorities in predicting future demand in terms of recruitment and education of
new staff and the continuing professional development of existing staff. In addition,
employers develop and update policies and procedures in relation to the clinical
responsibilities of community nurses, and these should relate to the latest
benchmarking criteria and government/professional guidelines. The views of service
users and carers should influence the preparation of health and social care service
providers (NNRU, 2011) and evidence will be required that this is the case in the
future (DH, 2010a).
 The Future Vision 15
Recent government reforms in terms of the structures and systems that form the
NHS (DH, 2010a) have led to an acknowledgement by community nurses that their
roles and responsibilities need to be examined and redefined in preparation for the
new challenges ahead. Leadership, practice development and partnership working
are key elements within the roles of all community nurses (QNI, 2010).
Hyde (1995) states that applying the concept ‘community nurse’ across all the
different community nursing disciplines is unhelpful and confusing and that the
concept has become popular as a result of the following myths:
• Community nursing is the same as hospital nursing: skills are simply transferred
to a different setting.
• Community nursing is peripheral to the centrality of hospital nursing.
• Community nursing is primarily about visiting the sick.
• All community nurses share a unified vision of the nature of care.
(Hyde, 1995: 2)

Kelly and Symonds (2003) suggest it is important for community nurses to critically
examine the concept of ‘community nurse’ and how it has evolved over time if they
are to influence their future professional development and emphasize their caring role.
At present, the future educational preparation of many community nursing
disciplines is under review by the government, relevant professional bodies and
community nurses themselves as current professional standards are no longer
relevant and require updating (Cook et al., 2011). At a time of qualified staff
reductions due to the economic climate, increasing demand for health services is
leading to an emphasis on improving productivity by changing the skill mix within
community nursing teams and working in different ways. Many community nurses
are fearful that care will be compromised if person-centred approaches are replaced
by task allocation models of care. Concerns revolve around the potential loss of a
holistic approach, which would lead to fragmentation of care, lack of continuity and
poorer quality services.
A recent report by the Parliamentary and Health Service Ombudsman (2011) on
the treatment of older people by institutions within the NHS concluded that it too
often failed to treat them with ‘care, compassion and respect’. Many community
nurses are concerned that these findings will be replicated in the community if
nurses are not adequately prepared for their demanding and challenging roles.
Interestingly, Community Links (2011) has produced a literature review of the role
of effective relationships in public services entitled Deep Value. This review describes
the value created when relationships in public services are effective, including both
improved service outcomes and wider benefits for service users. It concludes that
improving the effectiveness of relationships is therefore an important strategy for
improving quality and performance.
DH (2008: 1) proposes that:

Community services are in a central position … and of critical importance in

delivering our vision for the future of primary and community care …
16 Nursing in a community environment

increased influence for community staff in service transformation, through a

commitment to multi-professional engagement in practice based comm-
issioning and the piloting of more integrated clinical collaborations.

In rising to such challenges and embracing these opportunities, Sines et al. (2009)
stress the importance for community nurses of developing effective leadership and
innovative approaches to practice. They state that nurses must continue to act as
advocates for their service users, families and communities and influence local and
government policy agendas. In addition, they should maintain confidence and
competence in performing risk assessment and delivering safe practice.

REFERENCES
Acheson D (1998) Independent Inquiry into Inequalities in Health Report. London: The
Stationery Office.
Audit Commission (1999) First Assessment: a Review of District Nursing Services in England
and Wales. London: Audit Commission.
Baid H, Bartlett C, Gilhooly S, Illingworth A and Winder S (2009) Advanced physical
assessment: the role of the district nurse. Nursing Standard 23:41–6.
Barr, O (2009) Community Nursing Learning Disability. In: Sines D, Saunders M and
Forbes-Burford J (eds) Community Health Care Nursing, 4th edn. Chichester: Wiley-
Blackwell.
Barret, A, Latham, D and Levermore, J (2007) Defining the unique role of the specialist
district nurse practitioner. British Journal of Community Nursing 12:442–8.
Barton H and Grant M (2006) A health map for the local human habitat. The Journal of the
Royal Society for the Promotion of Health 126:252–3.
Blaxter M (1990) Health and Lifestyles. London: Routledge.
Boran S (2009) Contemporary issues in district nursing. In Sines D, Saunders M and
Forbes-Burford J (eds) Community Health Care Nursing, 4th edn. Chichester: Wiley-
Blackwell.
Carr S (2001) Nursing in the community – impact of context on the practice agenda.
Journal of Clinical Nursing 10: 330–6.
Chorley A (2001) Occupational health nursing. In Sines D, Appleby F and Raymond E (eds)
Community Health Care Nursing, 2nd edn. Oxford: Blackwell Science.
Clarke J (1999) Revisiting the concepts of community care and community health care
nursing. Nursing Standard 14:34–6.
Cohen AP (1985) The Symbolic Construction of Community. London: Routledge.
Coles L and Porter E (eds) (2008) Public Health Skills: a Practical Guide for Nurses and
Public Health Practitioners. Oxford: Blackwell Publishing.
Community Links (2011) Deep Value. A Literature Review of the Role of Effective
Relationships in Public Services. London: Community Links.
Cook R, Bain H and Smith A (2011) Educating community nurses. Nursing Times 107:20–2.
Council for the Education and Training of Health Visitors (CETHV) (1977) An
Investigation into the Principles of Health Visiting. London: CETHV.
Department of Health (DH) (1997) The New NHS: Modern, Dependable. London: HMSO.
DH (1999) National Service Framework for Mental Health: Modern Standards and Service
Models. London: Department of Health.
 References 17
DH (2008) NHS Next Stage Review: Our Vision for Primary and Community Care: What It
Means for Nurses, Midwives, Health Visitors and AHPs. London: The Stationery Office.
DH (2010a) Equity and Excellence: Liberating the NHS. London: HMSO.
DH (2010b) Healthy Lives, Healthy People. London: HMSO.
Department of Health/Department for Education and Skills (DH/DfES) (2004) National
Service Framework for Children, Young People and Maternity Services: Core Standards.
London: The Stationery Office.
Department of Health and Social Security (DHSS) (1980) Inequalities in Health (The Black
Report). London: HMSO.
Department of Health, Social Services and Public Safety (DHSSPS) (2007) Health
Inequalities Report: Second Update Bulletin. Belfast: DHSSPSNI.
DHSSPS (2010) Healthy Futures 2010–2015: The Contribution of Health Visitors and School
Nurses in Northern Ireland. Belfast: DHSSPSNI.
Drennan V and Davis K (2008) Trends Over 10 Years in the Primary Care and Community
Nurse Workforce in England. London: DH.
Drennan V, Goodman C and Leyshon S (2005) Supporting People with Long Term
Conditions: Supporting Experienced Hospital Nurses to Move into Community Matron
Roles. London: DH.
Eng E, Salmon ME and Mullan F (1992) Community empowerment: the critical base for
primary health care. Family and Community Health 15:1–12.
Frost M and Horner S (2009) Health visiting. In Sines D, Saunders M and Forbes-Burford J
(2009) (eds) Community Health Care Nursing, 4th edn. Chichester: Wiley-Blackwell.
Harriss A (2009) Occupational health nursing. In Sines, D, Saunders M and Forbes-Burford J
(2009) (eds) Community Health Care Nursing, 4th edn. Chichester: Wiley-Blackwell.
Hawtin M and Percy-Smith J (2007) Community Profiling: A Practical Guide. Milton
Keynes: Open University Press.
Healthcare Commission (HCC) (2007) A Life Like No Other: A National Audit of Specialist
Inpatient Healthcare Services for People with Learning Difficulties in England. London:
Healthcare Commission.
Hickey G and Hardyman R (2000) Using questionnaires to ask nurses about working in
the community: problems of definition. Health and Social Care in the Community
8:70–8.
Hyde V (1995) Community nursing: a unified discipline? In Cain P, Hyde V and Howkins E
(eds) Community Nursing: Dimensions and Dilemmas. London: Arnold.
Jameson M and Thurtle V (2009) School nursing. In Sines D, Saunders M and Forbes-
Burford J (eds) Community Health Care Nursing, 4th edn. Chichester: Wiley-
Blackwell.
Kelly A and Symonds A (2003) The Social Construction of Community Nursing. Basingstoke:
Palgrave Macmillan.
King’s Fund (1994) Community-oriented Primary Care. London: King’s Fund.
Laverack G (2009) Public Health. Power, Empowerment and Professional Practice.
Basingstoke: Palgrave Macmillan.
Lifelong Learning UK (2009) National Occupational Standards for Community Development.
London: Lifelong Learning UK.
Luker K, Austin L, Caress A and Hallett C (2000) The importance of ‘knowing the patient’:
community nurses’ constructions of quality in providing palliative care. Journal of
Advanced Nursing 31:775–82.
18 Nursing in a community environment

Marmot Review (2010) Fair Society, Healthy Lives: Strategic Review of Health Inequalities in
England post-2010. London: The Marmot Review.
McGarry J (2003) The essence of ‘community’ within community nursing: a district nursing
perspective. Health and Social Care in the Community 11:423–30.
McKenna H and Bradley M (2003) Generic and specialist nursing roles in the community:
an investigation of professional and lay views. Health and Social Care in the Community
11:537–45.
McLaughlin D and Long A (2009) Community mental health nursing. In Sines D, Saunders M
and Forbes-Burford J (eds) Community Health Care Nursing, 4th edn. Chichester:
Wiley-Blackwell.
National Nursing Research Unit (NNRU) (2011) Measuring Patient Experience in the
Primary Care Sector: Does a Patient’s Condition Influence What Matters? London: NNRU.
Parliamentary and Health Service Ombudsman (2011) Care and Compassion? Report of the
Health Service Ombudsman on Ten Investigations into NHS Care of Older People.
London: The Stationery Office.
Queen’s Nursing Institute (QNI) (2010) Position Statement March 2010. Nursing People in
their Own Homes – Key Issues for the Future of Care. London: QNI.
Race DG (1999) Social Role Valorisation and the English Experience. London: Whiting and
Birch.
Rogers CR (1990) Client Centred Therapy. London: Constable.
Royal College of Nursing (RCN) (2005) Competencies: An Integrated Career and Competency
Framework for Occupational Health Nursing. London: Royal College of Nursing.
RCN (2008) Directory of Community Children’s Nursing Services. www.rcn.org.uk.
Scottish Government (2007) Better Health, Better Care: Action Plan. www.scotland.gov.uk/
Publications/2007/12/11103453/0.
Scottish Government (2008) Equally Well: Report of the Ministerial Task Force on Health
Inequalities. Edinburgh: Scottish Government.
Scottish Government (2010) The Healthcare Quality Strategy for NHS Scotland. Edinburgh:
Scottish Government.
Selvey K and Saunders M (2009) General practice nursing. In Sines D, Saunders M and
Forbes-Burford J (eds) Community Health Care Nursing, 4th edn. Chichester: Wiley-
Blackwell.
Sines D, Saunders M and Forbes-Burford J (2009) (eds) Community Health Care Nursing,
4th edn. Chichester: Wiley-Blackwell.
Smith A (2010) District nursing: an endangered species? Journal of Community Nursing
24:44.
St John W (1998) Just what do we mean by community? Conceptualisations from the field.
Health and Social Care in the Community 6:63–70.
UKCC (1994) Standards for Specialist Education and Practice. London: UKCC.
Welsh Assembly (2005) Inequalities in Health: The Welsh Dimension 2002–5. Cardiff: Welsh
Assembly Government.
Welsh Assembly (2009) Setting the Direction: Primary and Community Services Strategic
Delivery Programme. Cardiff: Welsh Assembly Government.
Whiting M, Myers J and Widdas D (2009) Community children’s nursing. In Sines D,
Saunders M and Forbes-Burford J (eds) Community Health Care Nursing, 4th edn.
Chichester: Wiley-Blackwell.
 Further Resources 19
Wilkinson R (2005) The Impact of Inequality. How to Make Sick Societies Healthier. London:
Routledge.
Wills J (2009) Community development. In Sines D, Saunders M and Forbes-Burford J
(eds) Community Health Care Nursing, 4th edn. Chichester: Wiley-Blackwell.
World Health Organization (WHO) Expert Committee on Community Health Nursing
(1974) Community Health Nursing, Report of a WHO Expert Committee (Technical
Report Series no. 558). Geneva: World Health Organization.

FURTHER RESOURCES
www.ons.gov.uk – Independent information to improve our understanding of the UK’s
economy and society
www.neighbourhood.statistics.gov.uk – Detailed statistics within specific geographical areas
www.imd.communities.gov.uk
www.census.gov.uk – Index of Multiple Deprivation – statistics available at ward level
www.poverty.org.uk – UK site for statistics on poverty and social exclusion
www.direct.gov.uk – Public services all in one place – according to postcode
www.ic.nhs.uk – NHS Information Centre for health and social care
www.qof.ic.nhs.uk – Quality and Outcomes Framework – GP practice results database
www.marmotreview.org – Baseline figures for some key indicators of the social
determinants of health, health outcomes and social inequalities for specific geographical
areas
CHAPTER

2 Public health and the

promotion of wellbeing
Mark Rawlinson, Donna Baker and Margaret Fergus

LEARNING OUTCOMES
• Critically analyze why public health is an everyday part of community nursing
• Critically analyze the concept of health and ways of determining health need
• Explore opportunities to positively influence care delivery in order to
improve health and wellbeing

INTRODUCTION
Public health is everyone’ business according to Cowley (2007). The aim of this
chapter is to encourage all nurses (including pre-registration nurses) to reflect upon
the relevance of this statement, and to explore their understanding of and identify
their current involvement in public health. The intention is to reaffirm the
importance and highlight the opportunities you have as a community nurse or any
practitioner experiencing community nursing to positively influence the health of
the public and promote wellbeing. This could be at an individual level through
opportunistic health promotion, which is the main focus of discussion in the second
half of the chapter, or at a community (population) level identified through needs
analysis and delivered and evaluated through planned interventions. Throughout
the chapter reference to the four underpinning tenets of public health (health
protection, health promotion, illness prevention and reducing inequalities (Skills for
Health, 2008)) will also be made.
The chapter will initially discuss ‘what’ public health might be (then and now) by
presenting a very brief history about its development, highlighting current
government policy. It will go on to explore ‘why’ public health is important and to
whom by considering the determinants of health and the need for the community
nurse to be politically aware of such influences, for example how lifestyle choices
and living conditions can combine to affect health and illness. Finally the chapter
will address (through the presentation of a case study) the challenge of ‘how’ you
can be involved in public health as a community nurse by promoting health and
wellbeing.
The activities presented throughout the chapter are there to act as stimuli for
personal learning and development; they are also intended to act as catalysts to foster
a deeper understanding of public health through reflection and informed discussion.
 Public Health: Then and Now 21
PUBLIC HEALTH: THEN AND NOW
The concept of health and, conversely, illness has been the subject of much debate
in society, both before and after the inception of the NHS in 1948. A major criticism
of contemporary healthcare provision was made by Lord Darzi, who observed that
the NHS has been overwhelmingly concerned with treatment of the sick, and that it
should move from a ‘sickness service to a wellbeing service’ (Darzi, 2007: 37). This
inclusion of wellbeing in policy acts to encourage services to be organized in such a
way as to place greater emphasis on social health.
According to Raymond (2005), health has been conceptualized from the
perspectives shown in Box 2.1.

Box 2.1 Concepts of health (Raymond 2005)

• A biomedical point of view, which emphasizes medical interventions to treat

disease, and is mainly concerned with functional capacity.
• A behavioural point of view, which emphasizes individual responsibility for
health-influencing behaviour.
• A social point of view, which focuses on social and political determinants of
health and emphasizes social justice.
• A postmodernist point of view, which according to Naidoo and Wills (1998,
cited in Raymond, 2005) challenges the adequacy of the preceding
perspectives and suggests that no single theory sufficiently explains health
experience.

Although this typology does not define what health actually is, it does indicate the
differing views from which health can be examined. The World Health Organization
(WHO) however did define health in 1946 in its constitution document; its
definition came into effect in 1948 and remains unchanged:
Health is a state of complete physical, mental and social well-being and not
merely the absence of disease or infirmity.
(WHO 1946: 2)
Even though the deconstruction of health as a concept is not the focus of this
chapter, it is however a relevant point to be cognisant of. The WHO definition
reflects a somewhat idealistic view of health, although it does acknowledge that it is
a multidimensional issue. Subsequent WHO publications have contextualized this
definition and presented it in light of the importance of recognizing the underpinning
determinants of health (WHO, 2006). This is particularly relevant when it comes to
discussing public health: that being, that health is determined by the wider social
milieu within which populations live (Reading, 2008).
In modern times the association between health and social determinants can be
traced back in policy to some of the work of the early social reformers. Edwin
Chadwick, one of the more well known, produced a report in 1842 entitled Report
of the Sanitary Conditions of the Labouring Population of Great Britain, (Chadwick,
1965) in which the relevance of social conditions of the poor and their ability to
22 Public health and the promotion of wellbeing

influence their plight were made explicit in relationship to individuals’ health.

This report to the poor law commissioners resulted in the first Public Health Act
in 1884.
Since then public health has been part of (although not always at the centre of) this
country’s healthcare provision. The UK has seen many different approaches (emphases)
to public health over the past 150 years, each reflecting a more detailed/broader
understanding of health and illness in society. Activities have included interventions to
address inequalities on a population level, through the provision of state education and
increased employment opportunities, to programmes of illness prevention through
mass vaccination of children. More recently there has been increased recognition of the
need to engage in more active health protection, resulting in the establishment of the
Health Protection Agency in 2003. Although it would seem that the state has adopted
the position of being responsible for the health of the nation, this has obvious
limitations, one being that you cannot legislate for all eventualities, especially when it
comes down to individual choice! It would therefore seem that if society is to become
‘healthier’ the state and individuals need to work together to achieve the long-term aim
of reducing inequalities and improving life opportunities for all.

ACTIVITY 2.1 The development of public health

The table below identifies key developments in public health over the last
century. Consider these developments in relation to the facets of health as
purported by Raymond 2005. How has the focus of public health developed
over the years?
Nineteenth Century Twentieth Century Twenty-first Century
John Snow, Edwin First BCG vaccine for Acheson Report (1998)
Chadwick (The Sanitary TB (1921)
Movement 1842)
Beveridge Report Health Protection
First Public Health Act (1942) Agency (2003)
(1848)
Founding of the NHS Choosing Health (2004)
(1948)
Healthy lives, Healthy
Vaccines for Children people (2010)
Programme (1960s)

Acheson (1988) defined public health as ‘the science and art of preventing disease,
prolonging life and promoting health through the organised efforts of society’. This
conceptualization became a major influence in the development of what became
known as new public health, and ultimately was a main building block of New
Labour’s health reforms (1997–2010). This vision of the collective efforts of society
empowering individuals and groups was clearly expressed in the White Paper Saving
Lives: Our Healthier Nation (DH, 1999: 3), in which the strategic intent of the
government was set out as that being
 Public Health 23
to improve the health of the population as a whole by increasing the length
of life and the number of years people spend free from illness; to improve the
health of the worst off in society and to narrow the health gap.

This intent was further enhanced by Wanless (2004: 27), who went on to define
public health as

the science and art of preventing disease, prolonging life and promoting
health through the organised efforts and informed choices of society,
organisation, public and private communities and individuals.

Wanless’s definition builds upon Acheson’s ideas by expanding the definition to

include the idea that choice is a critical component when discussing health and the
public. This emphasis on personal responsibility signifies the importance of the role
of the individual and not the healthcare practitioner when it comes to making
lifestyle decisions. However, the role of the healthcare practitioner (in this case the
community nurse) is crucial to achieving health-related goals, as community nurses
are often in a position to assist individuals to either access services or support
individuals in making informed decisions about their health and wellbeing.
In 2010 the coalition government clearly stated its commitment to developing a
public health service by producing its vision in the form of a White Paper (DH,
2010a) in which it set out a strategy for improving the nation’s health by preventing
illness. Central to this guidance is the idea that promoting health and wellbeing
through prevention of illness is achievable through the collective efforts of society.
Furthermore, it emphasizes that everyone (not just a select articulate few) should
have services tailored for them at the right times in their life from the professionals
closest to them.
On a global level public health is an omnipresent issue, with the WHO in 2006
reaffirming its commitment to improve the health of all by setting out a framework
to achieve the millennium development goals in its eleventh programme of work
entitled Engaging for Health: A Global Health Agenda 2006–2015. This document, as
well as stating an understanding of the determinants of health and the measures
required to improve health, recognizes health as a shared resource and a shared
responsibility.

PUBLIC HEALTH
Simply put, public health strategies exist to improve and protect health and
wellbeing in a population. To apply a degree of depth to this statement, the UK’s
Public Health Skills and Career Framework broadens this intention through
expressing that

the purpose of public health should improve health and wellbeing in the
population, prevent disease and minimise its consequences, thus prolonging
valued life and reducing inequalities in health.
(Skills for Health, 2008)
24 Public health and the promotion of wellbeing

Furthermore they consider that this is achieved through a culture which ‘mobilises
the organised efforts of society’ (Skills for Health, 2008) by empowering individuals
and by tackling the wider social, economic, environmental and biological
determinants of health and wellbeing.

Determinants of health
There is growing recognition of the impact of the wider determinants of health and
health inequalities, in addition to the acknowledgement that addressing these root
causes of ill health requires public health to be everyone’s business and responsibility
(Wilkinson and Marmot, 2003).
The social determinants of health have been described as ‘the causes of the causes’
(LGID, 2010). They are the social, economic and environmental conditions that
influence the health of individuals and populations. They include the conditions of daily
life and the influences upon them, and determine the extent to which a person has the
resources to meet needs and deal with changes to their circumstances (LGID, 2010).
Dahlgren and Whitehead (1991) developed a model demonstrating how health is
influenced, either positively or negatively, by a variety of factors (Fig. 2.1).

ura
mic, cult l and envi
o ron
con me
cioe Living and working n
o conditions

ta
s

lc
ral

Unemployment

on
Work
mmunity
ne

environment d co n
diti
n
Ge

l a al lifestyle et
idu fa ons
Ind a

wo rs
i
Soc

rks

Water &
iv

cto

sanitation

Education

Age, sex & Healthcare

hereditary services
factors
Agriculture
and food
production Housing

Figure 2.1 Social determinants of health (Dahlgren and Whitehead, 1991).

The centre of the model represents age, sex and hereditary factors, which are genetic
or biological in nature. These are by and large fixed entities; however, they lie within
the wider determinants of health arising from social, environmental, economic and
cultural conditions. Such factors can directly influence our health, or have a bearing
on the lifestyle decisions we make and our ability to make such choices. The
 Public Health 25
existence in the UK of inequity in health (unfair differences in health between
different sectors of the population) has been well documented in successive surveys
of the nation’s health, such as the Black Report (1980), the Acheson Report (1998),
the Wanless Report (2004) and the Marmot Review (2010). All these reports
indicated that socioeconomic factors were strong indicators for health. The negative
impact from these determinants leads to disadvantage which can take on many
forms. It may be absolute or relative, affecting individuals and communities, for
example a single parent living in isolated, low-quality housing, a teenager having a
poor education, or communities and populations whose economy is compromised
from insecure employment opportunities.
The social gradient, in which social and economic circumstances impact upon
health, is viewed as a highly significant measurement of health inequality (Wilkin-
son and Marmot, 2003). There is a substantial body of evidence which indicates that
individuals further down the social ladder have more disease and die earlier (Donkin
et al., 2002). This trend within the social gradient and its relation to health is evident
among the most affluent countries where measurable differences exist not just in
health. These differences are inextricably linked to income and power distribution
(Wilkinson and Pickett, 2009).

ACTIVITY 2.2 The spirit level

Visit the website www.equalitytrust.org.uk/resource/the-spirit-level. Watch the
short film, summarizing the findings of a book entitled The Spirit Level
(Wilkinson and Pickett, 2009). This book has been described as ‘profoundly
important’ (Richard Layard, London School of Economics), with the potential
to change political thinking on both sides of the Atlantic. Initially the book
united the political classes; however, more recently this position has begun to
be challenged.

Closer to home the pattern is similar, drawing attention to the evidence that most
people in the UK are not living as long as the best off in society and spend longer in
ill health. Tackling these persistent health inequalities has traditionally seen government
policy funnel resources towards specific individuals or groups within society through
targeted services. Public health requires services to focus upon the underlying social
and contextual causes of the problems, suggesting that to improve health for all of us
action is needed across the social gradient (Marmot, 2010). The previous Labour
administration, through key social policies, sought to promote and protect health. The
Health Act (1999) saw specific ‘partnership arrangements’ designed to develop multi-
agency services to address the wider determinants of health. However, subsequent
health policy (DH, 2000) focused less on public health and health promotion.
Recognition of wide and increasing health inequalities (DH, 2003) led to the
development of a plethora of policies to address them. The recommendation that
public, private and voluntary sectors work together to adopt a ‘public health mindset’
(DH, 2004, 2006) enabled greater collaboration through the creation of local strategic
partnerships in England.
26 Public health and the promotion of wellbeing

There is evidence that the coalition government’s Secretary of State for Health is
placing tackling health inequalities high on the political agenda. The White Paper
Equity and Excellence: Liberating the NHS (DH, 2010b) with its ambitious objectives
certainly places public health at the centre of this particular government’s agenda for
reforming the NHS through plans to devolve greater responsibility to Local
Authorities for improving public health.
Complementing this vision, the White Paper Healthy Lives, Healthy People (DH,
2010a) claims to be the life course framework for tackling the wider social
determinants of health. Underpinned by an empowerment approach, it sets out to
harness a population resilient to the determinants affecting health. The principles
behind the idea of their ‘Big Society’, which propose that private and voluntary
sectors mobilize to provide a network of effective and sustainable support, will be
imperative towards achieving this aim.

Assessing community health needs

As previously discussed, many people, through the influence of social determinants,
have measurable differences in their health status. All too often this is compounded by
inequitable access to healthcare. Disadvantaged individuals and groups, despite having
the greatest overall need, are the least likely to access services (Tudor-Hart, 1971).
It is generally viewed that a need, if met, will result in an improvement in people’s
health (Haughey, 2008); however, what constitutes need is widely contested. Needs
are variable; they can be objective and measurable, obvious or hidden. Conversely,
they too are subjective, personal and interchangeable according to context (Cowley,
2008). Taxonomies exist (Bradshaw, 1972, cited in Haughey, 2008) that capture the
wider dimensions of need, thus compounding the complexity of it as a concept.
Despite this, undertaking an assessment of needs and priorities within populations
is essential to improve and protect health and wellbeing as a result of meeting the
public health agenda.
Cowley (2008) implies that the contested concept of health, coupled with the added
dimensions of what constitutes need, lends a significant degree of complexity to this
task. In recent years there has been an increased fusion between health and social care
services, a pattern set to increase with local authorities being given lead responsibility
for public health and for the first time a ring-fenced budget. However, not all services
involved in the delivery of public health will be under the control of local authorities.
Community nurses and specialist community practice public health nurses, e.g. health
visitors and occupational health nurses, are likely to remain outside the control of local
authorities. This fragmentation of service provision, combined with the differing
underpinning values, may well pose a particular challenge to conducting needs
assessments, in particular when it comes to developing a consensus of what the need is
and how to respond to it. The health needs assessment (HNA) has been described as ‘a
systematic method of identifying the health and healthcare needs of a population and
making recommendations for changes to meet these needs’ (Wright, 2001). The
evolution of the HNA as a tool has provided public health practitioners with a
framework for undertaking this complex and important task in an evidence-based way.
 Promoting Health and Wellbeing 27
Approaches to assessing need
Stevens and Raftery (1994) depict three main approaches to needs assessment
characterized as epidemiological, comparative and corporate.
An epidemiological approach to needs assessment, proposed by Williams and
Wright (1998), combines the three elements of identifying health status through
incidence/prevalence data, effectiveness and cost-effectiveness of interventions, and
the current level of service provision. The benefit of this approach is that its systematic
and objective method quickly identifies specific problems; however, it can assume
uniform prevalence and focus upon medical rather than social need (Haughey, 2008).
A comparative approach can be used cross-nationally and locally and compares levels
of service provision between these localities, for example the service provision in one
town compared with another of similar demography. Thus it is often used to provide
a timely and inexpensive assessment. An approach which considers making the needs
assessment responsive to local concerns is characterized as corporate. This approach
collects the knowledge and views of the stakeholders of the issues being addressed
in the needs assessment. The stakeholders can be a collective of practitioners, in both
primary and secondary care settings, health and social care service managers,
commissioners of services, experts in the field and service users.
Stevens and Raftery (1994), recognizing the limitations of each of the three
approaches above, developed the pragmatic approach to needs assessment. This
process combines all of the above approaches, drawing upon evidence from a variety
of sources, thus offering a more realistic assessment, which, they argue, is needed to
support interventions that focus upon the wide-ranging needs of specific communities
(Stevens and Raftery, 1994).
Identifying individual and public health needs through the use of assessment
affords nurses the opportunity to promote health and wellbeing in the communities
within which they work. This can be on an individual level – for example while
undertaking a routine wound dressing an assessment of need may identify the
opportunity for health promotion in relation to healthy eating. This could then lead
the community nurse to investigate the individual’s circumstances pertaining to
their lifestyle choices surrounding diet and nutrition and in addition give them the
opportunity to discuss with the individual how this may impact upon their wound
healing. Additionally there are numerous examples of nurse-led projects (www.qni
.org.uk/project-funding/funded-projects.html) that illustrate the positive impact
nurses can have on improving the public’s health at a community and population
level, thus demonstrating that when equipped with the appropriate knowledge and
skills nurses have the capacity and the capability to influence behaviour change
within a health-promoting milieu.

PROMOTING HEALTH AND WELLBEING

Community nurses are involved in public health activity through their day-to-day
contact with patients, clients, families and carers; delivering health promotion
activity, planned or unplanned.
28 Public health and the promotion of wellbeing

By its very nature health and the associated term wellbeing are both very difficult
to define. Health (as previously discussed) comprises both objective and subjective
components and is informed by theories from biological sciences, psychology,
sociology, epidemiology and health sciences which all contribute to the understan-
ding of health and the barriers to achieving it for individuals, populations and
societies (Seedhouse, 2001).
The term wellbeing was analyzed by the Sustainable Development Research
Network (SDRN, 2005), finding that the term encompassed the concepts of life
satisfaction (happiness, quality of life), physical health, income and wealth,
relationships, work and leisure, personal stability and lack of depression. The idea of
health and wellbeing has been embedded in government policy, for example the
DfES (2004) document Every Child Matters, which set goals in the following areas:
for children to be healthy, stay safe, enjoy and achieve, make a positive contribution
and achieve economic wellbeing. Additionally health and wellbeing were identified
in the Key Stage Skills Framework (2004) as a key skill area for all nurses to achieve
and the DH (2010b) document Equity and Excellence directed local authorities to set
up Health and Wellbeing Boards to commission and to ensure delivery of
appropriate services for local public health.

Contribution of community nurses in promoting health and

wellbeing
Community nurses are in a strong position to promote health and wellbeing.
Their knowledge of the local community and access to clients and their families
in their own homes enables community nurses to develop a deep understanding
of the factors that influence the health of individuals, families and communities.
Their ability to influence the care received by individuals and to influence local
health policy development is high. However, the extent of the contribution of
community nurses to the public health agenda has been the subject of much debate
in relation to its role (WHO, 2001; Clarke, 2004; Carr, 2005), and its contribution
(Poulton et al., 2000; Turner et al., 2003; Poulton, 2008).
Poulton et al.’s (2000) study explored the contribution of community nurses to
the public health agenda and found that activity relating to primary prevention
techniques fell more to nurses undertaking health visiting and school nursing roles
in contrast to GP practice nurses and district nurses, whose activity was focused
more within secondary and tertiary prevention techniques and chronic disease
management. While this may be as expected as health visitors and school nurses fall
under the umbrella term of the Specialist Community Public Health Nurse
(SCPHN), what became apparent in a later study by Poulton (2008) was the
contribution of more community-focused public health nursing practice among
district nurses. Public health nursing practice should address the needs of populations
as well as individuals; however, evidence suggests that a trend exists towards more
individual-focused as opposed to community-focused activity (Turner et al., 2003;
Poulton, 2008), thus indicating a gap between the rhetoric and the reality of
community public health nursing.
 Promoting Health and Wellbeing 29
For community nurses (at every level) the challenge will be to articulate their
contribution to promoting health and wellbeing, not just to commissioners but to
other health and social care professionals, through effective leadership and use of
evidenced-based practice.

Health promotion
The WHO (1984) succinctly defined health promotion as ‘the process of enabling
people to increase control over and to improve their health’. This definition is still
relevant today, underpinning current government policy, actively placing the
patient/client at the centre of care and encouraging patient involvement in the
decision processes in order to take control of health decisions: ‘No decision about
me without me’ (DH, 2010b). Therefore, it can be concluded that health promoters
(such as community nurses) should aim to enhance participation, equity and
fairness to improve the health of individuals, families and communities.
However, a complex theoretical picture of health promotion has emerged from a
wide variety of academic disciplines. The following models represent a small selection
of those available – most seek to describe health promotion activity at individual,
group and population levels. Ewles and Simnett (2003) proposed a model that
described five approaches to health promotion: medical, behaviour change,
educational, client centred and societal change. The values which underpinned the
approaches were represented in a corresponding gradient from professional-led to
client-led activity. Tonnes and Tilford (2001) identified educational, preventative,
empowerment and radical approaches but viewed empowerment as central to health
promotion. Tannahill (1985) identified prevention, health education and health
protection in overlapping spheres to describe the services and activities that
constituted health promotion practice. Beatie (1991, cited in Katz et al., 2000)
developed an analytical model that highlighted the interplay of intervention
(authoritative or negotiated which equates to professional or client led) and the focus
of intervention (individual or society). Other theories that contribute towards the
understanding of the effect of health promotion interventions on the client and why
people seek help are the psychological theories of behaviour change which aim to
explain why and how people can change their behaviour. Examples are Becker’s
Health Belief Model (cited in Wills and Earle, 2007), Ajzen and Fishbein’s Theory of
Reasoned and Planned Action (cited in Wills and Earle, 2007), and Prochaska and
DiClemente’s (1983) Transtheoretical Stages of Change Theory.

ACTIVITY 2.3 Promoting health

Think of a patient/client or family you have been regularly involved with
recently. Make a list of the needs identified in partnership with the
individual(s). What opportunities were there to promote health and wellbeing?

In order for community nurses to have a positive impact on the health of individuals
it is necessary to have the underpinning knowledge and skills associated with
30 Public health and the promotion of wellbeing

promoting health and wellbeing; central to this is having a developed understanding

of the importance of effective communication.
Communication theory underpins the delivery of health promotion; communi-
cation between the professional and the client is the main determinant of success.
Most of the above theories describe or analyze health promotion practice, but the
skill of health promotion practice requires a deep understanding of communication
and partnership working theory to achieve the goal, which is to enable people to
increase control over and to improve their health. Rollnick et al. (1999) proposed
a client-centred model of partnership working (Motivational Interviewing) to
complement Prochaska and DeClemente’s (1983) Transtheoretical (stages of change)
Theory. The aim was to facilitate individuals to move through the stages of
precontemplation – contemplation – making changes – maintaining changes. Rollnick
et al. suggested that a practitioner could reduce resistance to change by relationship
building using a therapeutic approach based on trust and information exchange to
negotiate the agenda and to set achievable goals based on the individual’s vision of
importance and their confidence to make the change. Gallant et al. (2002) conducted
a very informative concept analysis of partnership working which identified three
phases to the partnership working relationship: the initiating phase, the working phase
and an evaluation phase. To work in partnership one needs to build a professional
therapeutic relationship based on trust. The professional must be competent and
honest and display professional integrity (to work in the best interests of the client/
patient) at all times and the client must be a willing partner (Pilgrim et al., 2011).

APPLYING THEORY TO PRACTICE

The framework in Figure 2.2 has been heavily influenced by the work of Rollnick,
Gallant, Prochaska and DiClemente, Ewles and Simnett, Becker and Tonnes and
Telford, and as such is an eclectic representation of existing theoretical approaches.
Community nurses usually either work in the client’s own home or a location
nearby. They develop very complex relationships with the client and often other
family members. For clients who rely on their family for care the nurse must assess
and work with the client, being respectful of the needs of both client and carer/
family. Many clients may also have other professionals involved in their care.
Community nurses as the principal care providers in the client’s home need to work
in partnership with other professionals who may work for health, other statutory
agencies, the voluntary or independent sectors, although this can be difficult to
achieve at times. When working with other professionals in partnership the same
principles of trust, which include honesty, competence and integrity, apply.
Communication between professionals that is respectful, open and honest is
essential to achieve the best outcomes for clients and their families. Although health
promotion is often defined in terms of work with populations and work with
individuals is defined as health education, all interventions that aim to enable people
to take control over their own health on an individual or population basis are
considered to be health-promoting interventions (Whitehead and Irvine, 2010).
 Applying Theory to Practice 31
In order to assist established community nurses or those experiencing community
nursing, the case study, and subsequent analysis and action planning, have been
developed around the framework for promoting health and wellbeing (Fig. 2.2). It
is anticipated that this simple practical example will assist community nurses in the
delivery of client-led health-promoting activity, which may also improve an
individual sense of wellbeing.

Initiating phase: building a rapport,

Reducing resistance – maintaining client/family relationship.

Working in partnership with other professionals.

Sharing power – building trust and confidence.
Sharing formal and experiental knowledge.
Exchanging information and maintaining dialogue.
Working with others:
negotiating roles
Nurse/facilitator role – resource and service provider
Client/family role – willing active participant determined
Recognizing influences on health: socioeconomic, to solve problems/find solutions.
Reinforcing progress – supporting decisions.

Working phase: negotiate agenda and goals

Set small achievable goals
The role of the community nurse

Relapse Regular
can contact
happen at and
any stage evaluation
Final goal
cultural, personal.

Final evaluation phase:

Were the goals met? Relationship to decrease
but the client to be informed that he/she can
return in case of relapse.
This is an eclectic framework based on existing
theoretical frameworks.

Figure 2.2 A framework for promoting health and wellbeing.

CASE STUDY Mr John Smith is an 82-year-old gentleman who lives with his wife Mary (72 years
old) in a semi-detached house. The house has one bathroom situated upstairs
and no toilet downstairs. Mr Smith is a retired dockyard worker who smokes 20
cigarettes per day and used to enjoy an active social life centred on the local
social club. An extended family comprising a son and his wife also lives nearby.

Mr Smith’s mobility has gradually declined over the last 5 years and he is
presently housebound because of chronic obstructive pulmonary disease
(COPD). He is able to walk around the house but becomes very breathless when
walking upstairs. He is reliant on Mary as his main carer. Mr Smith has a
history of chronic bronchitis for 20 years and two episodes of pneumonia in
the last 5 years; he is not oxygen dependent but maintained on inhaled
steroids and bronchodilators; he has smoked since he was a child; he is
partially deaf and wears hearing aids.

Mr Smith had recently suffered a bout of pneumonia, which was treated in

hospital, where he was advised to seek support with stopping smoking. He has
also developed a leg ulcer that requires weekly dressings.

After a comprehensive assessment the nurse in partnership with Mr Smith

may decide that it would be beneficial for him to consider changing his health
behaviour to improve his quality of life.
32 Public health and the promotion of wellbeing

During the ‘initiating phase’ one would attempt to build a relationship with Mr Smith
and his wife using the assessment documentation as a focus for discussion, asking
about their life present and past.

Examples of open questions that may help in the initiating phase

Nurse: I see that you were advised to seek support with giving up smoking
while in hospital. How do you feel about this?
Client: It’s probably too late to make any difference now.
Nurse: In my experience if a person in your situation can stop or cut down
on smoking this does improve their quality of life (Include his wife in the
conversation)
Nurse: How you tried to give up smoking before?
Nurse: Stopping smoking is a really hard thing to do but there is support
available.

Moving into the working phase:

Nurse: There are lots of support services available today, for example there
are trained professionals who could help you by phone.
Nurse: Would you like to take one of these cards which has the local NHS
stop smoking helpline numbers on it?

Next visit: working phase continued:

Nurse: How did you get on with the helpline?

Client: It was really helpful. The counsellor and I have made an action plan.
He said that I should ask you to prescribe Nicorette patches and to try to
cut down gradually by one per day for a week and then another one.
Nurse: Yes, I am a nurse prescriber and will be delighted to do this for you.
This would entail us working together with your counsellor to ensure that
the treatment is effective. How do you feel about that?

As can be seen from the communication above the nurse is allowing the client to take
control, to make the decisions, and is being open and honest about her involvement
with other professionals. This way power can be shared. The client shared his
experiences of trying to give up smoking in the past and the nurse shared her formal
knowledge in a working partnership and the roles of both client and professional
were being established.
As part of the weekly intervention (for his leg ulcer treatment) there will be an
evaluation of success and support to achieve the small realistic goals which will build
the client’s confidence, and as Mr Smith starts to see positive results in his health this
will hopefully be a driver to continue.
 References 33
At the end the success of the intervention will be evaluated with the client. The nurse
may need to discuss the possibility of relapse with Mr Smith while reassuring him
that support is always available to him should this occur.

CONCLUSION
As services are redesigned to deliver care closer to home, there is an increased
emphasis upon the next generation of nurses to experience the delivery of
nursing care in community environments. It is widely acknowledged that
community environments are where there is an emphasis on health promotion
and prevention of ill health and a recognition of how ‘external influences and
social factors can impact upon nursing assessment, interventions and activities’
(NMC, 2010: 38). It is therefore incumbent on the current nursing workforce to
develop an approach to community nursing that goes beyond the idea that
nursing is just about assessing, planning and implementing/evaluating the
delivery of care associated with a set of clinical tasks. Effective community
nursing must identify and engage in public health activity, in order to promote
health and wellbeing in society.
Through the presentation of relevant underpinning theory/policy and the use of
the case study this chapter has demonstrated that public health is everyone’s
business and that community nurses are in a position to enable and empower
individuals and communities across all levels, from some of the hard-to-reach
groups in the population, such as the housebound, to those eagerly involved with
promoting their own health and improving their own sense of wellbeing.
It is hoped that this exposure will embed a public health mindset into all nurses
and future graduate nurses, who will in turn rise to the challenge of improving the
health and wellbeing of the population.

REFERENCES
Acheson D (1988) Public Health in England. London: HMSO.
Acheson D (1998) Independent Inquiry into Inequalities in Health. London: HMSO.
Black Report (1980) Inequalities in Health – Report of the Research Working Group. London:
DHSS.
Carr SM (2005) Refocusing health visiting: sharpening the vision and facilitating the process.
Journal of Nursing Management 13(3):249–56.
Chadwick E (1965 [1842]) Report of the Sanitary Conditions of the Labouring Population of
Great Britain. Edinburgh: Edinburgh University Press.
Clarke J (2004) Public health nursing in Ireland: a critical Overview … developed from a
presentation made at the Annual Conference of the Institute of Community Health
Nursing, Ireland, 29 September 2001. Public Health Nursing 21(2):191–8.
Cowley S. (2007) Foreword. In Coles L and Porter E (eds) (2008) Public Health Skills: A
Practical Guide for Nurses and Public Health Practitioners. Oxford: Blackwell, p. vii.
Cowley, S. (2008) Community Public Health in Policy and Practice: A Sourcebook, 2nd edn.
London: Bailliere Tindall.
34 Public health and the promotion of wellbeing

Dahlgren G and Whitehead M (1991) In Acheson D (1998) Part 1 Independent Inquiry into
Inequalities in Health. London: HMSO.
Darzi A (2007) Our NHS Our Future: The Next Stage Review Interim Report. London: NHS
COI for the Department of Health.
Department for Education and Skills (DfES) (2004) Every Child Matters: Change for
Children. Nottingham: DfES Publications.
Department of Health (DH) (1999) Saving Lives: Our Healthier Nation. London:
Department of Health.
DH (2000) The NHS Plan. A Plan for Investment. A Plan for Reform. Cm 4818-I. London:
The Stationery Office.
DH (2003) Tackling Health Inequalities. London: Department of Health.
DH (2004) Choosing Health: Making Healthier Choices Easier. London: The Stationery
Office.
DH (2006) Our Health, Our Care, Our Say: A New Direction for Community Services.
London: The Stationery Office.
DH (2010a) Healthy Lives, Healthy People. London: The Stationery Office.
DH (2010b) Equity and Excellence: Liberating the NHS. London: The Stationery Office.
Donkin A, Goldblatt P and Lynch K (2002) Inequalities in life expectancy by social class
1972–1999. Health Statistics Quarterly 15:5–15.
Ewles L and Simnett I (2003) Promoting Health: A Practical Guide, 5th edn. Edinburgh:
Bailliere Tindall.
Gallant H, Marcia C and Carnevale F (2002) Partnership: an analysis of the concept within
the nurse–client relationship. Journal of Advanced Nursing 40:149–57.
Haughey R (2008) Assessing and Identifying Health Needs. In Coles L and Porter E (eds)
Public Health Skills: A Practical Guide for Nurses and Public Health Practitioners. Oxford:
Blackwell.
HM Government (2010) Healthy Lives, Healthy People. Our Strategy for Public Health in
England. (Accessed 14 December 2010) www.dh.gov.uk/prod_consum_dh/groups/dh_
digitalassets/@dh/@en/@ps/documents/digitalasset/dh_122347.pdf.
Katz J, Peberdy A and Douglas J (2000) Promoting Health: Knowledge and Practice, 2nd edn.
Milton Keynes: Open University Press.
Local Government Improvement and Development (LGID) (2010) Understanding and
Tackling the Wider Social Determinants of Health. (Accessed 12 October 2010) www.idea.
gov.uk/idk/core/page.do?pageId=14114189.
Marmot M (2010) Fair Society, Healthy Lives. (Accessed 10 June 2010) www.ucl.ac.uk/gheg/
marmotreview/FairSocietyHealthyLivesExecSummary.
Nursing and Midwifery Council (NMC) (2010) Advice and Supporting Information for
Implementing NMC Standards for Pre-registration Nursing Education. London: NMC.
Pilgrim D, Tomasini F and Vassiley I (2011) Examining Trust in Healthcare. Basingstoke:
Palgrave MacMillan.
Poulton BC (2008) Barriers and facilitators to the achievement of community-focused public
health nursing practice: a UK perspective. Journal of Nursing Management 17:74–83.
Poulton BC, Mason C, McKenna H, Lynch C and Keeney S (2000) The Contribution of
Nurses, Midwives and Health Visitors to the Public Health Agenda. Belfast: DHSSPS.
Prochaska JO and DiClemente CC (1983) Stages and processes of self change of smoking:
toward an integrative model of change. Journal of Consulting and Clinical Psychology
51:390–5.
 References 35
Raymond B (2005) Health needs assessment, risk assessment and public health. In Sines D,
Appleby F and Frost M (eds) Community Health Care Nursing, 3rd edn. Oxford: Blackwell,
pp. 70–88.
Reading S (2008) Research and Development: Analysis and Interpretation of Evidence. In Coles L
and Porter E (eds) Public Health Skills: A Practical Guide for Nurses and Public Health
Practitioners. Oxford: Blackwell, pp. 170–89.
Rollnick S, Mason P and Butler C (1999) Health Behaviour Change: A Guide to Practitioners.
London: Churchill Livingstone.
Seedhouse D (2001) Health: The Foundations for Achievement, 2nd edn. Chichester: John
Wiley & Sons.
Skills for Health (2008) Skills and Career Framework. (Accessed 5 November 2010)
www.skillsforhealth.org.uk/workforce-design-development/workforce-design-and-
planning/tools-and-methodologies/career-frameworks/~/media/Resource-Library/
PDF/Public_Health_Report_Web-April_09.ashx.
Stevens A and Raftery J (1994) Introduction to Health Care Needs Assessment, vol. 1. Oxford:
Radcliffe Medical Press, pp. 1–30.
Sustainable Development Research Network (2005) Wellbeing Concepts and Challenges:
Discussion Paper by Fiona McAllister for SDRN. DEFRA.
Tannahill A (1985) What is Health Promotion? Health Education Journal 44:167–8.
Tonnes K and Tilford S (2001) Health Promotion Effectiveness, Efficiency and Equity, 3rd
edn. Cheltenham: Nelson Thornes.
Tudor-Hart J (1971) The inverse care law. Lancet 1:405–12.
Wanless D, HM Treasury (2004) Securing Good Health for the Whole Population: Final
Report. London: The Stationery Office.
Whitehead D and Irvine F (2010) Health Promotion and Health Education in Nursing.
Basingstoke: Palgrave Macmillan.
Wilkinson R and Marmot M (2003) Social Determinants of Health. The Solid Facts, 2nd edn.
Geneva: WHO Europe International Centre for Health and Society.
Wilkinson R and Pickett K (2009) The Spirit Level. Why More Equal Societies Almost Always
Do Better. London: Allen Lane.
Williams R and Wright J (1998) Epidemiological issues in health needs assessment, British
Medical Journal 316:1379–82.
Wills J and Earle S (2007) Theoretical perspectives on promoting public health. In Earle S,
Lloyd C, Sidell M and Spurr S (eds) Theory and Research in Promoting Public Health.
Milton Keynes: Open University Press, Chapter 5.
World Health Organization (WHO) (1946) Constitution. Geneva: WHO, p. 2.
WHO (1984) Health Promotion: A Discussion Document on the Concepts and Principles.
Copenhagen: WHO.
WHO (1986) Ottawa Charter for Health Promotion. Canada: WHO.
WHO (2001) Public Health Nursing: Past and Future. A Review of the Literature. Copenhagen:
WHO.
WHO (2006) Engaging for Health: A Global Health Agenda 2006–2015. WHO Library
Cataloguing-in-Publication Data.
Wright J (2001) Assessing health needs. In Pencheon D, Guest C, Melzer D and Gray JAM
(eds) The Oxford Handbook of Public Health Practice. Oxford: Oxford University Press.
CHAPTER

3 Professional approaches
to care
Jo Skinner

LEARNING OUTCOMES
• Discuss the factors that influence being a professional in the context of
current healthcare practice
• Analyze and apply ethical principles drawing on codes of practice in relation
to providing care in the community
• Reflect critically on professionalism in relation to service user and carer
involvement and partnership working

INTRODUCTION
The relationship between professionals and clients has been the central feature of
professional practice throughout history. Professionalism has never been more
important regarding public trust and care quality. The nature of professional
practice in the community is particularly challenging given the complex care needs,
diverse organizations and professions, as well as the need to demonstrate cost-
effective health outcomes. The relationship between service users and professionals
is changing radically.
This chapter explores the transition in professional practice from a traditional,
hierarchical and individualistic model to a more inclusive partnership model. The
partnership model includes extended service user and carer involvement,
interprofessional working and a wider public health approach. Throughout the
chapter, issues relating to both models and ethical principles underpinning practice
are highlighted; and a case study and examples from different areas of community
practice are used to illustrate principles. There are three sections: the first presents
an overview of the traditional model of professional practice, followed by principles
informing professional practice and finally factors influencing the development of a
new extended partnership model of professional practice.

CASE STUDY Marjory Davies is 85 years old and lives alone in a three-bedroom house with
four flights of stairs. Miss Davies has had a series of falls; the most recent fall
required several weeks in hospital. Ahmed, her neighbour, had noticed her
curtains were not drawn and he alerted Miss Davies’ GP. Miss Davies has
returned home and the district nurse has assessed Miss Davies to plan her
 The Traditional Model of Professional Practice 37

rehabilitation. Her social worker has advised Miss Davies about her options for
residential care. Miss Davies has consistently refused any suggestions that she
should move out of her home.

THE TRADITIONAL MODEL OF PROFESSIONAL PRACTICE

It is not easy to define precisely what a professional is or indeed what professionalism
is–both concepts are fluid and contested areas (Evetts, 1999). Traditionally, a
professional is someone who is associated with being part of an élite group of
experts with claims to specialist knowledge and skills that license their practice. The
nature of the work is vocational and like professional roles, such as law and
medicine, is valued within society. Professionals exercise their duty in the best
interests of their clients and thereby their approach is intentionally altruistic. In
that sense professionals may see themselves as the ideal advocates for their clients,
being able to define their clients’ needs and determine any solutions based on their
expertise. Such attributes result in a high degree of professional autonomy and
particular trusting relationships with their clients. In healthcare, licensed
practitioners are permitted access to the human body in order to undertake
intimate or intrusive assessments, clinical examinations and treatments. Thus,
higher moral standards are expected of professionals to do what is best for patients;
this is enshrined in law as a duty of care owed to patients (Dimond, 1997). In the
case of Miss Davies (case study), she is owed a duty of care by all three professionals:
district nurse, social worker and GP. Therefore, all professionals, and those who are
members of recognized professions, share certain characteristics (Box 3.1).

Box 3.1 Characteristics of professions

A distinct body of specialist knowledge and skills (often rooted in ancient
practice or tradition)
A lengthy and exclusive training leading to registration
Altruism
Code of practice
Duty of care
Autonomy
Accountability
Privileged access to and trusting relationship with clients
Public trust and good standing
Higher social status, pay, reward and career structure

Control over who may enter these elite professions is strictly governed, usually
through a rigorous selection process. This keeps up demand for such skills by
reinforcing their status, value and power (Finlay, 2000). Professionals can make
certain demands, including control over the way they practise, in recognition of
their unique skills and status. The process of becoming a professional entails lengthy
and rigorous training validated by peers. Historically, those élite professions were
Other documents randomly have
different content
 "That may be according to one's own notion of 'harm.' Even the
most trifling approach to flirting is entirely unseemly in a married
woman."

"Are you quite a competent judge—not being married yourself?"

rejoined Adela. "See here, Grace—if you never flirt more with any
one than Charley flirts with me, you won't hurt."

"I am afraid he has learnt to love you, Adela."

"Then more silly, he, for his pains. Why, I am oceans of years
older than Charley is. He ought to think of me as his grandmother."

"Can't you be serious, child? I want you to see the thing in its
proper—or, rather, improper—light. When it comes to a man, other
than your husband, kissing you, it is time——

"Who said Charley kissed me?" retorted Adela, in a blaze of anger.

"He has never done such a thing—never dared to attempt it. I said
he kissed my hand sometimes—and then it has generally had a
glove upon it."

"Well, well, whatever the nonsense may be, you must give it up,
Adela. There can be no objection on your part to doing so, as you
say you do not care for Charles Cleveland."

"Incorrect, Lady Grace. I do care for him; I enjoy his friendship

amazingly. What I said was, that I did not love him. That would be
too absurd."

"Call it flirtation, don't call it friendship," wrathfully retorted Grace.

"And he must be devoid of brains as a calf, to attach himself to you,
if he has done it. I hope nothing of this will reach the ears of Mary
or of his father. They would not believe him capable of such folly.
From this hour, Adela, you must give it up."
 "Just what Mr. Grubb has been good enough to tell me; but 'must'
is a word I do not understand," lightly rejoined Adela. "Neither you
nor he will make me break off my flirtation with Charles Cleveland. I
shall go into it all the more to spite you."

"If I were Francis Grubb I should beat you, Adela."

"If!" laughingly echoed Lady Adela. "If you were Francis Grubb,
you would do as he does. Why, Gracie, girl, he loves me passionately
still, for all his assumed indifference. Do you think there are never
moments when he betrays it? He is jealous of Charley; that's what
he is, in spite of his dignified denial—and oh, the fun it is to me to
have made him so!"

"Adela," said Grace, sadly, "does it never occur to you that this
behaviour may tire your husband out?—that his love and his
patience may give way at last?"

"I wish they would!" cried the provoking girl, little seeing or
caring, in her reckless humour, what the wish might imply. "I wish he
would go his way and let me go mine, and give me hundreds of
thousands a-year for my own share. He should have the dull rooms
in the house and I the bright ones, and we would only meet at
dinner on state occasions, when the world and his wife came to us."

Lady Grace felt downright angry. She wondered whether Adela

spoke in her heart's true sincerity.

"There's no fear of it, Gracie: don't look at me like that. My

husband would no more part company with me, whatsoever I might
do, than he would part with his soul. He loves me too well."

"It is a positive disgrace to have one's married sister's name

coupled with a flirtation," grumbled Grace: for the Lady Acorn,
whatever might be her failings as to tongue and temper, had
brought her daughters up to the purest and best of notions. "That
reverend man, Dr. Short—I cannot think how it came to his ears—
hinted at it today in talking with mamma when they met at the
picture-galleries. He——"

"There it is!" shouted Adela, in glee; "the murder's out! So it is

you who have been putting mamma up to complain to Mr. Grubb!
You are setting your cap at that sanctimonious Dr. Short, and you
fear he won't see it if you have a naughty sister given to flirting. Oh,
Gracie!"

"You are wrong; you know you are wrong. How frivolous you are,
Adela! Dr. Short is going to be married to Miss Greatlands."

"Well, there's something of the sort in the wind, I know. If it's not
the Reverend Dr. Short, it's the Reverend Dr. Long; so don't shake
your head at me, Gracie."

Dancing across the room, Adela rang the bell. "My carriage," she
said to the servant.

"It has been waiting some time, my lady."

"Where are you going?" asked Grace, surprised:

"To Lady Sanely's."

"To Lady Sanely's," echoed the elder sister. Then, after a pause,
"Your husband did not know you were going there?"

"Do you suppose I tell him of my engagements? What next, I

wonder?"

"Oh, Adela!" uttered Grace, rising from her seat—and there was a
piercing sound of grief in her tone, deeper than any which had
characterized it throughout the interview—"do not say you are going
there! Another rumour is rife about you; worse than that half-
nonsensical one about Charles Cleveland; one likely to have a far
graver effect on your welfare and happiness."
 "I—I do not understand," repeated Adela; but her tone, in spite of
its display of haughtiness, betrayed that she did understand, and it
struck terror to the heart of her sister. "I think you are all beside
yourselves today!"

Grace, greatly agitated, clasped the other's arm as she was

turning away. "It is said, Adela—I have heard it, and papa has
confirmed it—it is rumoured that you have become addicted to a—a
—dangerous vice. Oh, forgive me, Adela! Is it so? You shall not go
until you have answered me."

The rich colour in Lady Adela's cheeks had faded to paleness; her
eyes dropped; she could not look her sister in the face. From this,
her manner of receiving the accusation, it might be seen how much
more real was this trouble, than the half-nonsensical one, as Grace
had called it, connected with Charles Cleveland.

"Vice!" she vaguely repeated.

"That of gaming," spoke Grace, her own voice unsteady in its

deep emotion. "That you play deeply, night by night, at Lady
Sanely's."

"What strong words you use!" gasped Adela, resentfully. "Vice!

Just because I may take a hand at cards now and then!"

"Oh, my poor sister, my dear sister, you do not know what it may
lead to!" pleaded Grace. "You shall not go forth to Lady Sanely's this
night—do not! do not! Break through this dreadful chain at once—
before it be too late."

Angry at hearing this amusement of hers had become known at

home, vexed and embarrassed at being pressed, almost by force, to
stay away from its fascinations, Adela flung her sister's arm from her
and moved forward with an impatient gesture of passion. They were
near a table, and her own hand, or that of Grace, neither well knew
which, caught in a beautiful inkstand, and turned it over. The ink
was scattered on the light carpet: an ugly, dark blotch.

What cared Adela? If the costly carpet was spoiled, his money
might purchase another. She moved on to her dressing-room,
caused her maid, waiting there, to envelop her in her evening
mantle, and then swept down to her carriage.

That Lady Adela did not care for Charles Cleveland was perfectly
true. She would have laughed at the very idea; she regarded him
but as a pleasant-mannered boy: nevertheless, partly to while away
the time, which sometimes hung heavily on her hands, partly
because she hoped it would vex her husband, whom she but lived to
annoy, she had plunged into the flirtation.

It was something more on Charley's part. For, while Adela cared

not for him, beyond the passing amusement of the moment, would
not have given to him a regretful thought had he suddenly been
removed from her sight for ever, he had grown to love her to
idolatry. It is a strong expression, but in this case justifiable. Almost
as the sun is to the world, bringing to it light and heat, life to
flowers, perfection to the corn, so had Lady Adela become to him. In
her presence he could alone be said to live; his heart then was at
rest, feeding on its own fulness of happiness, and there he could
thankfully have lived and died, and never asked for change: when
obliged to be absent from her, a miserable void was his, a feverish
yearning for the hour that should bring him to her again. Surely this
was most reprehensible on his part—to have become attached, in
this senseless manner, to a married woman! Reprehensible? Hear
what one says of another love; he who knew so much about love
himself—Lord Byron:
"Why did she love him? Curious fool, be still:
Is human love the growth of human will?"

Could the fault have lain with Lady Adela? Most undoubtedly. She,
not casting a thought to the effect it might have upon his heart, and
secure in her own supreme indifference, purposely threw out the
bait of her beauty and her manifold attractions, and so led him on to
love—a love as true and impassioned as was ever felt by man. What
did he promise himself by it?—what did he think could come of it?
Nothing. He was not capable of cherishing towards her a
dishonourable thought, he had never addressed to her a disloyal
word. It was not in the nature of Charles Cleveland to do anything of
the kind; he was single-minded, single-hearted, chivalrously
honourable. He thought of her as being all that was good and
beautiful: to him she seemed to be without fault, sweet and pure as
an angel. To conceal his deep love for her was beyond his power;
eye, tone, manner, tacitly and unconsciously betrayed it. And Lady
Adela, to give her her due, did not encourage him to more.

And so, while poor Charley was living on in his fool's paradise,
wishing for nothing, looking for nothing, beyond the exquisite sense
of bliss her daily presence brought him, supremely content could he
have lived on it for ever, Lady Adela already found the affair was
growing rather monotonous. The chances were that had her
husband and Grace not spoken to her, she would very speedily have
thrown off Charley and his allegiance. Adela had no special pursuit
whence to draw daily satisfaction. No home (the French would better
express it by the word ménage) to keep up and contrive for; the
hand of wealth was at work, and all was provided for her to satiety;
she had no children to train and love; she had no husband whom it
was a delight to her to yield to, to please and cherish: worse than
all, she had (let us say as yet) no sense of responsibility to a higher
Being, for time and talents wasted.

A woman cannot be truly happy (or a man either) unless she

possesses some aim in life, some daily source of occupation, be it
work or be it pleasure, to contrive, and act, and live for. Without it
she becomes a vapid, weary, discontented being, full of vague
longings for she knows not what. One of two results is pretty sure to
follow—mischief or misery. Lady Adela was too young and pretty to
be miserable, therefore she turned to mischief.
 Chance brought her an introduction to the Countess of Sanely,
with whom the Chenevix family had no previous acquaintance, and
who had a reputation for loving high card-playing and for
encouraging it at her house: she and Adela grew intimate, and Adela
was drawn into the disastrous pursuit. At first she liked it well
enough; it was fascinating, it was new: and now, when perhaps she
was beginning to be a little afraid and would fain have retreated, she
did not see her way clear to do so: for she owed money that she
could not pay.

Lady Grace Chenevix, unceremoniously left alone in her sister's

drawing-room, rang the bell. It was to tell them to attend to the ink.
The carriage was not coming for her till eleven o'clock, and it was
now but half-past ten. Hers were not very pleasant thoughts with
which to get through the solitary half-hour. Mr. Grubb came in, and
inquired for his wife. Grace said she had gone out.

"What, and left you alone! Where's she gone to?"

"To Lady Sanely's."

"Who are these Sanelys, Grace?" he inquired as he sat down.

"Adela passes four or five nights a-week there. The other evening I
took up my hat to accompany her, and she would not have it. What
sort of people are they?"

"Four or five nights a-week," mechanically repeated Grace,

passing over his question. "And at what time does she get home?"

"At all hours. Sometimes very late."

Grace sat communing with herself. Should she impart this matter
of uneasiness to Mr. Grubb, or should she be silent, and let things
take their chance; which of the two courses would be more
conducive to the interests of Adela; for she was indeed most anxious
for her. She looked up at him, at his noble countenance, betraying
commanding sense and intellect—surely to impart the truth to such
a man was to make a confidant of one able to do for her sister all
that could be done. Mr. Cleveland and Mary both said he ought to
hear it without delay. And Grace's resolution was taken.

"Mr. Grubb," she said, her voice somewhat unsteady, "Adela is

your wife and my sister; we have both, therefore, her true welfare at
heart. I have been deliberating whether I should speak to you upon
a subject which—which—gives me uneasiness, and I believe I ought
to do so."

"Stay, Grace," he interrupted. "If it is—about—Cleveland, I would

rather not enter upon it. Lady Acorn spoke to me today, and I have
given a hint to Adela."

"Oh no, it is not that. She goes on in a silly way with him, but
there's no harm in it, only thoughtlessness. I am sure of it."

He nodded his head, in acquiescence, and began pacing the room.

"It is of her intimacy with Lady Sanely that I would speak; these
frequent visits there. Do you know what they say?"

"No," he replied, assuming great indifference, his thoughts

apparently directed to placing his feet on one particular portion of
the pattern of the carpet, and to nothing else.

"They say—they do say"—Grace faltered, hesitated: she hated to

do this, and the question flashed across her, could she still avoid it?

"Say what?" said Mr. Grubb, carelessly.

"That play to an incredible extent is carried on there. And that

Adela has been induced to join in it."

His assumed indifference was forgotten now, and the carpet might
have been patternless for all he knew of it. He had stopped right
under the chandelier, its flood of light illumining his countenance as
he looked long and hard at Grace, as one in a maze.

Much that had been inexplicable in his wife's conduct for some
little time past was rendered clear now. Her feverish restlessness on
the evenings she was going to Lady Sanely's; her coming home at all
hours, jaded, sick, out of spirits, yet unable to sleep; her
extraordinary demands for money, latterly to an extent which had
puzzled and almost terrified him. But he had never yet refused it to
her.

"It must be put a stop to somehow," said Grace.

"It must," he answered, resuming his walk, and drawing a deep

breath. "What's all this wet on the carpet?"

"An accident this evening. Some ink was thrown down: my fault, I
believe. At any cost, any sacrifice," continued Lady Grace. "If the
habit should get hold of Adela, there is nothing but unhappiness
before her—perhaps ruin."

"Any cost, any sacrifice, that I can make, shall be made," repeated
Mr. Grubb. "But Adela will listen to no remonstrance from me. You
know that, Grace."

"You must—stop the supplies," suggested Grace, dropping her

voice to a confidential whisper. "Has she had much of late?"

"Yes."

"More than her allowance? Perhaps not, as that is so liberal."

"Her allowance!" half laughed her husband, not a happy laugh. "It
has been, to what she has drawn of me, as a silver coin in a purse of
gold."
 Grace clasped her hands. "And you let her have it! Did you
suspect nothing?"

"Not of this nature. I suspected that she might be buying costly

things—after the reckless fashion of Selina Dalrymple. Or else that—
forgive me, Grace, I would rather not say more."

"Nay," said Grace, rising to put her hand on his arm and meeting
his earnest glance, "let there be entire confidence between us; keep
nothing back."

"Well, Grace, I fancied she might be lending it to your mother."

"No, no; my mother has not borrowed from her lately. Oh, how
can we save her! This is an insinuating vice that gains upon its
votaries, they say, like the eating of opium."

"Your carriage, my lady," interrupted a servant, entering the room.

And Grace caught up her mantle.

"Must you go, Grace? It is scarcely eleven."

"Yes. If mamma does not have the carriage to the minute, she
won't cease scolding for days, and it must take me home first. Dear
Mr. Grubb, turn this over in your mind," she whispered, "and see
what you can do. Use your influence with her, and be firm."

"My influence, did you say?" And there was a touch of sarcasm in
his tone, mingled with a grief painful to hear. "What has my
influence with her ever been, Grace?"

"I know, I know," she cried, wringing his hand, and turning from
him towards the stairs, that he might not see the tears gathering in
her eyes. Tears of sympathy with his wrongs, and partly, perhaps, of
regret: for she was thinking of that curious misapprehension, years
ago, when she had been led to believe that it was herself who was
his chosen bride. "I would not have treated him so," her heart
murmured; "I would have made his life a happy one, as he deserves
it should be."

He gained upon her fast steps; and, drawing her arm within his,
led her downstairs, and placed her in the carriage.

"Dear Mr. Grubb," she whispered, as he clasped her hands, "do

not let what I have been obliged to say render you harsh with poor
Adela. Different days may be in store for you both; she may yet be
the mother of your children, when happiness in each other would
surely follow. Do not be unkind to her."

"Unkind to Adela! No, Grace. Separation, rather than unkindness."

"Separation!" gasped Grace, the ominous word affrighting her.

"I have thought sometimes that it may come to it. A man cannot
patiently endure contumely for ever, Grace."

He withdrew his hand from hers, and turned back into his desolate
home. Grace sank back in the carriage, with a mental prayer.

"God keep him; God comfort him, and help him to bear!"

CHAPTER XX.

A PRESENT OF COFFEE.

It was two o'clock when Lady Adela returned home. She ran
lightly upstairs and into the drawing-room, throwing off her mantle
as she came in. A tray of refreshments stood on a side-table.

Mr. Grubb rose from his chair. "It is very late, Adela."

"Late! Not at all. I wish to goodness you wouldn't sit up for me!"

She went to the table and stood looking at the decanters, as if

deliberating what she should take, murmuring something about
being "frightfully thirsty."

"What shall I give you?" he asked.

"Nothing," was the ungracious answer, most ungraciously spoken.

And she poured out a tumbler of weak sherry-and-water, and drank
it; a second, and drank that also. Then, without taking any notice of
him, she went up to her chamber. Anything more pointedly,
stingingly contemptuous than her behaviour to her husband now,
and for some time past, has never been exhibited by mortal woman.

Mr. Grubb rang for the servants to put out the wax-lights, and
went up in his turn. There was no sleep for him that night, whatever
there might have been for her. He knew not how to act, how to
arrest this new pursuit of hers; he scarcely knew even how to open
the matter to her. She appeared to be asleep when he rose in the
morning and passed into his dressing-room. She herself soon
afforded him the opportunity.

He was seated at his solitary breakfast, a meal his wife rarely

condescended to take with him, when her maid entered, bringing a
message from her lady—that she wished to see him before he left
for the City. Master Charley Cleveland, usually his breakfast
companion, had not made his appearance at home since the
previous night.

"Is your lady up, Darvy?"

"Oh dear yes, sir, and at breakfast in her dressing-room."

 He went up to it. How very lovely she looked, sitting there at her
coffee, in her embroidered white dress and pink ribbons, and the
delicate lace cap shading her sweet features. She had risen thus
early to get money from him; he knew that, before she asked for it.

"You wished to see me, Lady Adela."

"I want some money," she said in a light, flippant kind of tone, as
if it were the sole purpose of Mr. Grubb's existence to supply her
demands.

"Impossible," he rejoined. "You had two hundred pounds from me

the day before yesterday."

"I must have two hundred more this morning. I want it."

"What is it that you are doing with all this money? It has much
puzzled me."

"Oh—making a purse for myself," she answered saucily.

"You can trust to me to do that for you. I cannot continue to

supply you, Adela."

"But I must have it," she retorted, raising her voice, and speaking
as if he were the very dirt under her feet. "I will have it."

"No," he replied calmly, but with firm resolution in his tone. "I shall
give you no more until your allowance is due."

She looked up, quite a furious expression on her lovely face.

"Not give it me! Why, what do you suppose I married you for?"

"Adela!" came his reproof, almost whispered.

"I would not have taken you but for your money; you know that.
They promised me at home that I should have unlimited command
of it; and I will."

"You have had unlimited command," he observed, and there was

no irritation suffered to appear in his tone, whatever may have been
his inward pain. "It is for your own sake I must discontinue to supply
it."

"You are intelligible!" was her scornful rejoinder: for, in good truth,
this refusal was making havoc of her temper.

"All that you can need in every way shall be yours, Adela.
Purchase what you like, order what you like; I will pay the bills
without a murmur. But I will not give you money to waste, as you
have latterly wasted it, at Lady Sanely's."

She rose from her seat, pale with anger. "First Charles Cleveland,
then Lady Sanely: what else am I to be lectured upon? How dare
you presume to interfere with my pursuits?"

"I should ill be fulfilling my duty to you, or my love either, Adela,

what is left of it, if I did not interfere."

"I will not listen, Mr. Grubb: if you attempt to preach to me, as you
did last night, I will run away. Sit down and write me a cheque for
the money."

"There is no necessity for me to repeat my refusal, Adela. Until I

have reason to believe that this new liking for PLAY has left you, you
should draw my blood from me, sooner than money to pursue it. But
remember," he impressively added, "that I say this in all kindness."

She looked at him, her delicate throat working, her breath growing
short with passion.

"Will you give me the cheque?"

"I will not. Anything more, Adela, for I am late?"

 There was no answer in words, but she suddenly raised the cup,
which chanced to be in her hand and was half full of coffee and
flung it at him. It struck him on the chin, the coffee falling upon his
clothes.

It was a moment of embarrassment for them both. He looked

steadfastly at her, with a calm, despairing sorrow, and then quitted
the room. Lady Adela, her senses returning, sank back in her chair;
and in the reaction of her inexcusable passion, she sobbed aloud.

It was quite a violent fit of sobbing: and she smothered her head
up that he should not hear. She did feel ashamed of herself, felt
even a little honest shame at her general treatment of him. As her
sobs subsided, she heard him in his dressing-room, changing his
things, and she wished she had not done it. But she must have the
money; that, and more; and without it, she should be in a frightful
dilemma, and might have her name posted up as a card-playing
defaulter in the drawing-rooms of society. So she determined to
have another battle for it with her husband, and she dried the tears
on her fair young face, and opened his dressing-room door quite
humbly, so to say, and went into it.

It was empty. Mr. Grubb's movements had been rapid, and he was
already gone. He had put out of sight the stained things taken off,
removed all traces of them. Was she not sensible even of this? Did
she not know that he was thus cautious for her own sake—that no
scandal might be given to the servants? Not she. With his
disappearance, and the consequent failure of her hope, all her
resentment was returning. Her foot kicked against something on the
floor, and she stooped to pick it up. It was her husband's cheque-
book, which he must have unconsciously dropped when transferring
things from one pocket to another.

Was a demon just then at Lady Adela's side?—what else could

have impelled her?—what else whispered to her of a way to supply
the money she wanted? Once only a momentary hesitation crossed
her; but she drove it away, and carried the cheques to her writing-
table and used one of them.

She drew it for five hundred pounds, a heavy sum, and she boldly
signed it "Grubb and Howard." For it happened to be the cheque-
book of the firm, not of her husband's private account. She was
clever at drawing, clever at imitating styles of writing—not that she
had ever turned her talent to its present use, or thought so to turn it
—and the signature, when finished, looked very like her husband's
own. Then she carried back the cheque-book, and laid it on the floor
where she found it.

Some time after all this was accomplished, she was passing
downstairs, deliberating upon whether she could dare to go to the
bank herself to get the cheque cashed, when Charles Cleveland
came in, and bounded up the stairs.

"Where did Mr. Grubb breakfast this morning?" he inquired,

apparently in a desperate hurry, as they shook hands, and turned
into one of the sitting-rooms, Charley devouring her with his eyes all
the time. Little blame to him either, for she was looking most lovely:
the excitement, arising from what she had done, glowing in her
cheeks like a sweet blush rose.

"What a question! He breakfasted at home."

"Yes, yes, dear Lady Adela. I meant in which room." For Mr. Grubb
sometimes breakfasted in the regular breakfast-room, and
sometimes in his library.

"I really don't know, and don't care," returned Adela, connecting
the question somehow, in her own mind, with the present of coffee
he had received. "His breakfasting is a matter of indifference to me.
And pray, Mr. Charley, where did you breakfast this morning?—and
what became of you last night? Have you been making a night of it
with the owls and the bats?"
 "I went to my brother's. Harry had some fellows with him, and we,
as you express it, dear Lady Adela, made a night of it. That is, we
broke up so late that I would not disturb your house by returning
here: Harry gave me a sofa, and I went direct from him to
Leadenhall Street this morning."

"And what have you come back for?"

"For Mr. Grubb's cheque-book. He has missed it, and thinks he

must have left it on the breakfast-table."

"Charley," she said, "I was just wanting you. Will you do me a
favour?"

"I will do everything you wish," he answered, his tones literally

trembling with tenderness.

"I want you to go to the bank in Lombard Street, and got me a

cheque cashed. Mr. Grubb gave it me this morning, and I am in a
hurry for the money, for I expect people here every minute with
some accounts. It is not crossed. Take a cab, and go at once."

"I will. I can leave the cheque-book in Leadenhall Street first."

"No, you must not wait to find the cheque-book. I will look for it
whilst you are gone. You will not be many minutes, I am sure, and I
tell you I am all impatience."

Charley Cleveland hesitated. "I scarcely know what to say," he

replied, dubiously, to this. "Mr. Grubb is waiting for the cheque-book.
This is Saturday, you know."

"What if it is?"

"We are always so busy on Saturdays."

 "Very well, Charles," she returned in hurt, resentful tones. "If you
like Mr. Grubb better than you do me, you will oblige him first. You
would be there and back in no time."

"Dearest Lady Adela! Like Mr. Grubb better than—— Well, I will do
it, though I dare say I shall get into a row. Have the cheque-book
ready, that I may not lose a moment when I get back." And Adela
nodded assent.

"A confounded row, too," he muttered to himself, as he tore down

the stairs, and into the cab; "but I will go through a thundercloud
full of rows for her." Charley gave a concise word to the driver, and
away dashed the cab towards Lombard Street, at a pace which
terrified the road generally, and greatly astonished the apple-stalls.

He was back in an incredibly short space of time, and paid the

notes over to her. "Have you found the cheque-book?" he asked
then.

"I declare I never thought about it," was Lady Adela's reply. "But
he breakfasted in the library, I hear. Perhaps you will find it there."

He rushed into the library. And there, on the table, was the
missing cheque-book. Oh, wary Lady Adela!

She followed him into the room. "Charley," she whispered, "don't
say you have been out for me—no need to say you have seen me.
The fact is, that staid husband of mine had a grumbling fit upon him
last night, and accused me of talking and laughing too much with
the world in general and Mr. Charles Cleveland in particular. If they
find fault with you for loitering, say you were detained on some
matter of your own."

He nodded in the affirmative. But a red vermilion was stealing

over his face, dyeing it to the very roots of his hair, and his heart's
pulses were rising high. For surely in that last speech she meant to
imply that she loved him. And Master Charles felt his brain turn
round as it had never turned before, and he bent that flushed face
down upon her hand, and left on it an impassioned, though very
respectful kiss, by way of adieu.

"What a young goose he is!" thought Adela.

Very ill at ease, that day, was the Lady Adela. Reckless though she
might be as to her husband's good opinion, implicitly secure though
she felt that he would hush up the matter and shield her from
consequences, she could not help being dissatisfied with what she
had done. Suppose exposure came?—she would not like that. She
had written Mr. Howard's name, as well as her husband's! She lost
herself in a reverie, her mind running from one ugly point to another.
Try as she would, she could not drive the thoughts away, and by the
afternoon she had become seriously uneasy. Was such a case ever
known as that of a wife being brought to trial for—— "Whatever
possesses me to dwell upon such things?" she mentally queried,
starting up in anger with herself. "Rather order the carriage and go
and pay my last night's losses."

From Lady Sanely's she went to her mother's, intending to stay

and dine there. Somehow she was already beginning to shrink from
meeting her husband's face. However, she found they were all
engaged to dine at Colonel Hope's, including her sister Mary. So
Adela had to return home: but she took care not to do it until close
upon the dinner hour.

Mr. Grubb and Charles Cleveland were both at table. Neither of

them alluded to the unpleasant topic uppermost in her mind, so she
concluded that as yet nothing had come out. Mr. Grubb was very
silent—the result no doubt of the coffee in the morning.

"I am going to Netherleigh tomorrow morning, sir," observed

Charles; "shall try to get there in time for church. My father has
written to ask me. Could you allow me to remain for Monday also?
Harry means to run down that day, to say good-bye."
 "Monday?" considered Mr. Grubb. "Yes, I suppose you can. There's
nothing particular that you will be required for on Monday, that I
know of. You may stay."

"Thank you, sir."

"When does your brother leave?"

"I think on Tuesday morning."

Accordingly, on the following morning, Sunday, Charley left the

house to go to Netherleigh. Mr. Grubb went to church, as usual;
Adela made excuse—said her head ached. When he returned home
at one o'clock, he found she had gone to her mother's; and, without
saying to him with your leave, or by your leave, without, in fact,
giving him any intimation whatever, she remained at Chenevix House
for the rest of the day.

On the Monday, Mr. Grubb went to business at the customary

hour, but returned early in the afternoon to attend some public
meeting in Westminster, connected with politics. Influential people—
Conservatives: who were called Tories then—had for some time past
been soliciting him to go into Parliament; he had not quite made up
his mind yet whether he would, or not.

He and his wife dined alone. Lord and Lady Kindon, with whom
they were intimate, were to have dined with them; but only a few
minutes before the time of sitting down, a note came to say they
had received ill news of one of their children, who was at school at
Twickenham, and had to hasten thither. Adela was tryingly cross and
contrary at table: she had not wished to be alone with her husband,
lest he should have found out what she had done, and begin upon
it. So, after the first few minutes, the meal proceeded nearly in
silence. She did not fear the explosion quite as much as she did at
first: each hour, as it went on smoothly, helped to make her
uneasiness less.
 But she was not to escape long. Just as the servants were quitting
the room, leaving the wine on the table, one of them came back
again.

"Mr. Howard has called, sir. He says he would not disturb you at
this hour, but he must see you on a matter of pressing business."

"Pressing business!" echoed Mr. Grubb. "Show Mr. Howard in. A

chair, Richard, and glasses."

The stiff and stern old man entered, bowing to Lady Adela. His
iron-grey hair looked greyer than usual, and his black coat rusty.
Rusty coats are worn by more than one millionaire.

"Why, Howard, this is quite an event for you! Why did you not
come in time for dinner? Sit down. Anything new? Anything
happened?"

"Why, yes," replied Mr. Howard, who was a slow-speaking man,

giving one the idea that the bump of caution must be large on his
head. "Thank you, port."

"What is it?" inquired the senior partner.

"I will enter upon the matter presently," replied James Howard,
deliberately sipping his wine. By which answer Mr. Grubb of course
understood that he would only speak when they were alone.

Lady Adela swallowed her strawberries and left her seat so quickly
that Mr. Grubb could hardly get to the door in time to open it, and
she went up to the drawing-room. She felt sure, as sure as though
she could read his very thoughts, that "that horrid Howard" had
come about the cheque. She did not care so much that her husband
should find it out; he might do his best and his worst, and the worst
from him she did not dread greatly; but that that old ogre should
know it, perhaps take steps—oh, that was quite another thing. Could
he take steps?—would the law justify it? Adela did not know; but she
began to give the reins to her imagination, and cowered in terror.

As she thus sat, her ears painfully alive to every sound, a cab
rattled into the square, and stopped at the door. It brought Charles
Cleveland. Charley had just come up from Netherleigh; the train was
late, and he was in a desperate hurry to get into his dress-clothes,
to attend a "spread"—it was what Charley called it—given by his
brother. Adela ran out, and arrested him as he was making for his
room, three stairs at a time.

"Charley, I want to speak to you—just for a moment. What mortal

haste you are in!"

To be invited thus into the drawing-room by her, to meet her again

after this temporary absence, was to him as light breaking in upon
darkness. "Oh, Charles," she added, giving him both her hands, in
the moment's agitation, "surely some good fairy sent you! I am in
distress."

"Can I soothe it?" he asked, wondering at her emotion, and

retaining her hands in his. "Can I do anything for you?"

"I am in sore need of a friend—to—to shelter me," she continued.

"Great, desperate need!"

"Can I be that friend? Suffer me, if you can. Suffer me to be, Lady
Adela. Dear! dear! what can have happened?"

"But it may bring danger upon you, difficulty, even disgrace. I

believe I ought not to ask it of you."

"Danger and difficulty would be welcome, borne for you," returned

Charley, in his loyalty. "Believe that, Lady Adela."

He could not imagine what was amiss, and he caught somewhat

of her agitation. That she was in real trouble, nay, in terror, was all
too plain. For a moment the thought occurred—was Mr. Grubb angry
with her on his account? Oh, what a privilege it appeared to him,
foolish but honest-hearted fellow, to be asked to shield her!

"I will trust you," she cried, her emotion increasing. "That cheque
— but oh, Charles, do not you think ill of me! It was done in a
moment of irritation."

"Say on, dear Lady Adela."

"That cheque—he did not give it me. I had asked for money, and
he refused. I wanted it badly; and I was angry with him: so I drew
out the cheque."

Charley felt all at sea: not comprehending in the least. She saw it:
and was forced to go on with her painful explanation. The colour
was coming and going in her cheek; now white as a lily, now rose-
red.

"That cheque you cashed for me on Saturday morning, Charley.

Mr. Grubb did not draw it. Mr. Howard's name was signed as well as
his; and—and he is with my husband in the dining-room, and I am
frightened to death."

There was a momentary pause. Charley understood now; and saw

all the difficulty of the matter, as she had lightly called it. But his
honest love for her was working strongly in his heart, and he formed
a hasty, chivalrous resolve to shield her if he could. Had she not
appealed to him?

"I want you not to say that it was from me you had the cheque,
Charley."

"I never will say it. Rely upon me."

"They cannot do anything to me, I suppose; or to anyone else,"

she went on. "It is the exposure that would drive me wild. I could
not bear that even that old Howard should know it was I. Oh,
Charles, what can be done?"

"Be at ease, Lady Adela. You shall never repent your confidence.
Not a breath of suspicion shall come near you. I will shield you; I am
proud to do it: shield you, if need be, with my life. You little know
how valueless that life would be without your society, dear Lady
Adela."

"Now, Charles, hold your tongue. You must not take to say such
things to me. They are not right—and are all nonsense besides.
What would Mr. Grubb think?"

"Forgive me," murmured Charley, all repentance. "I did not mean
to say aught that was disloyal to him or you, Lady Adela: I could not
be capable of it, now, or ever. And I will keep my word—to shield
you through this trouble. I repeat it. I swear it."

He wrung her hand in token of good-faith, and escaped to prepare

for his engagement. She sat down, somewhat reassured, but not at
all easy in her conscience. The world just now seemed rather hard to
the Lady Adela.

CHAPTER XXI.

GIVEN INTO CUSTODY.

They sat at the well-spread dessert-table in Grosvenor Square,

those two gentlemen, the sole partners of almost the wealthiest
house in London; keen, honourable, first-rate men of business, yet
presenting somewhat of a contrast in themselves. He at the table
head, Francis Grubb, was fine and stately, wearing in his
countenance, in its expression of form and feature, the impress of
true nobility—nature's nobility, not that of the peerage—and young
yet. James Howard, who might be called the chief partner, so far as
work and constant, regular attendance in the City went, though he
did not receive anything like an equal share of the profits, was an
elderly man, high-shouldered, his face hard and stern, his hair iron-
grey, and his black coat rusty. Mr. Howard had walked up from his
house in Russell Square this evening to confer with his chief upon
some matter of business. It a little surprised Mr. Grubb: for, with
them, business discussions were always confined to their legitimate
province—the City.

The Lady Adela, Mr. Grubb's rebellious but very charming wife,
quitted the room speedily, leaving them to the discussion that Mr.
Howard had intimated he wished for. But Mr. Howard did not show
himself in any haste to enter upon it. He sat on, surveying
abstractedly the glittering table before him, with its rich cut glass, its
silver, its china, and its sweet flowers, talking—abstractedly also—of
the passing topics of the day, more particularly of a political meeting
which had taken place that afternoon. Mr. Grubb was a
Conservative; he a Liberal; or, as it was more often styled in those
days, Tory and Whig.

"What news is it that you have brought me, Howard?" began Mr.
Grubb, at last, breaking a pause of silence.

"Ay—my news," returned Mr. Howard, as though recalled to the

thought. "Did you draw a cheque on Saturday morning, before
leaving home, in favour of self, and get it cashed at Glyn's?"

Mr. Grubb threw his thoughts back on Saturday morning. The

reminiscence was unpleasant. The scene which had taken place with
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