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In this month's Policy column, the author explores the concepts of duty of care, forseeability and proximity, and how the community nurse can be better prepared when caring for the patient.

Consent is an essential part of healthcare practice, allowing patients to make autonomous decisions. However, this changes when a patient has mental incapacity or is unable to make decisions for themselves for a duration of time. This month's Policy column looks at some of the key principles of the Mental Capacity Act 2005, and how this can be applied in community nursing practice.

Richard Griffith , Senior Lecturer in Health Law at Swansea University, discusses the positive obligation to protect vulnerable people from unauthorised deprivations of liberty in various community settings.

It is the mission of the Community and Family Nurse through an integral and holistic approach to accompany people from cradle to death in developing their health potential, and promote different family, work and social environments to facilitate this development. Throughout history, various international, European and national organizations have regulated the figure of the Community and Family Nurse, and now their functions, powers and professional performance are fully regulated. The Community and Family Nurse can respond to the needs of a changing population and take on new responsibilities in management and research. Their extensive basic and advanced skills gathered under a rigorous training programme, benefit the health system, the nursing profession, citizenry and its communities. Many challenges remain for the Health Departments of each Autonomous Region to make it possible for this specialty to develop its full potential for improving care., (Copyright © 2019 Elsevier España, S.L.U. All rights reserved.)

Health systems have a responsibility to respond to the new health needs of the population, which are characterized by factors such as aging, chronicity and/or dependency situations and which requires quality and specialized care adapted to different areas where care is provided, care offered by trained and increasingly qualified professionals to improve the health outcomes of the caregivers. In 2016, in Andalusia the regulatory framework by which is created the statutory professional category of nurse/specialists is published, including the specialty of Mental Health Nursing in the Andalusian Health Service. In the field of Mental Health, the development of this normative framework and the definition and occupation of positions, will allow the health system to combine the role of nurse specialist nurses with that of nurses who provide general care, registered nurses, in order to advance in the best response to the health needs of citizens in this area of care. The development of the specialty will be an added value both to improve the health outcomes of people with mental health problems, and to improve the quality of care, efficiency and sustainability of health systems., (Copyright © 2019. Published by Elsevier España, S.L.U.)

More the 30 years have passed since the first Royal Decree that regulated nursing specialties was published in 1987. It is the Royal Decree published in 2005 that really allowed the training development of part of the specialties recognized in it (family and community nursing, paediatric nursing, geriatric nursing and occupational health nursing) since the obstetric-gynaecological specialist nurses (midwives) and mental health specialists had long since already started their training processes through the resident internal nurse model, today, training in the specialty of family and community nursing has been implemented in all the autonomous communities, but has not had the same development in terms of the incorporation of specialists in the health institutions of the respective health services of the autonomous communities This circumstance is generating a great lack of motivation among community nurses, both specialists and those who hope to obtain the qualification through a specialty exam. Many of the objectives achieved to date have been made possible thanks to the work of the scientific societies of community nursing (Association of Community Nursing [AEC] and Federation of Associations of Community Nursing and Primary Care [FAECAP]), which have allowed progress to be made and the process not to be halted, although there are still many achievements to be made on which the aforementioned scientific societies continue to work. In a society in which nursing care is increasingly necessary and demanded, it must have greater consideration and position in health policies, since it has demonstrated its effectiveness and can be the model that allows the health system to be sustainable. Therefore, nurses who specialize in family and community nursing must cease constituting an opportunity and become a reality., (Copyright © 2019 Elsevier España, S.L.U. All rights reserved.)

There have been two widely reported criminal cases where informal carers, including family members, have been found guilty of the gross negligence manslaughter of the vulnerable person in their care. In this article, Richard Griffith considers the duty on informal carers when caring for a person and the duty on district nurses to protect vulnerable persons from harm.

In this article the author discusses the Court of Appeal decision in R v Rose [2017] that redefines the threshold for prosecution for gross negligence manslaughter. The impact on district nurses will be that they are unlikely to face prosecution where a careless error contributed to a patient's death unless there was a serious and obvious risk of death at the time the error was made.

Obtaining a real consent is fundamental to the propriety of treatment given by district nurses. Real consent respects patient autonomy and is underpinned by three key elements. In this article, on the principles of patient consent, Richard Griffith outlines the elements of a real consent and the importance of obtaining consent to district nurse practice.

The Declaration of Helsinki requires that health care research takes place with the informed consent of those who participate in the study. This approach upholds the autonomy of the participants, but restricts research to subjects who have decision-making capacity. The Mental Capacity Act 2005 introduced safeguards that enable researchers to investigate the care and treatment of people with incapacity, while protecting this vulnerable patient group. These safeguards allow people who lack decision-making capacity to benefit from research findings. In this article, Richard Griffith outlines the requirements that must be met when district nurses conduct research on subjects who lack decision-making capacity.

A coroner recently declared a district nursing service as unfit for purpose following the death of a patient and held the care given by district nurses was unprofessional and contributed to the patient's decline and death. In this article Richard Griffith considers the coroners concerns in relation to the professional standards imposed on district nurses.

Aim To explore the experiences of student and novice health visitors in implementing health visiting policy reform pre- and post-qualification., Background: In England, public health nursing has been subject to major policy reform. The Health Visitor Implementation Plan (2011) set out a plan to recruit increasing numbers of nurses and midwives to the profession to deliver an expanded and refocussed health visiting service. Exploring this policy change from the viewpoint of those new to health visiting offers a unique perspective into how a specific policy vision is translated into nursing practice., Methods: A descriptive qualitative study in which participants were enrolled on a one-year post-graduate health visiting course at a University in South West of England. Qualitative data were collected pre- and post-qualification. A total of 16 interviews and a focus group were conducted with nine participants between September 2012 and March 2013. Findings Descriptive data were interpreted using Lipsky's theoretical framework of street-level bureaucracy. Three themes emerged which relate to this 'bottom-up' perspective on policy implementation; readiness to operationalise policy, challenges in delivering the service vision; and using discretion in delivering the vision. Community public health nurses operate as street-level bureaucrats in negotiating the demands of policy and practice, and by this means, attempt to reconcile professional values with institutional constraints. Barriers to policy implementation at a local level mediate the effects of policy reform, ultimately impacting upon outcomes for children and families.

The clinical needs of patients can often be met by prescribing and administering a licensed medicine. District nurses will have some cases where a medicine cannot be used because the patient is unable to take it in its licensed form. In such situations, district nurses may be able to arrange for the patient to be supplied with an unlicensed medicine specifically made to meet that patient's special need. This article discusses the options available to district nurses to lawfully supply patients who have a special medication need due to, for example, an allergy to a particular ingredient or an inability to swallow solid oral medicines, such as tablets or capsules.

In this article Richard Griffith considers whether it is ever in a patient's best interests to be given medicine by covert means, such as disguising it in food.

The Mental Capacity Act (MCA) is a piece of statutory legislation which is designed to empower and protect those who are assessed as being unable to make decisions for themselves. At the time of implementation, the legislation was described as visionary and it had the potential to change the lives of many. However, a post-legislative scrutiny report published in 2014 concluded that there is a lack of knowledge among professionals of the MCA, and so it is not embedded into daily clinical practice. This review of literature has identified four key themes: assessment, training, knowledge and empowerment. These appear to concur with the findings of the House of Lords report. The successful integration of the MCA into professionals' everyday practice is high on the political agenda, thus reinforcing the message that following the guidance set out in the MCA legislation is mandatory and not a choice. A shift in culture and improvement in knowledge and understanding of the MCA is required in order for it to be used in the correct manner for which it was designed.

In this article Richard Griffith considers three recent developments in policy and law that have changed the nature of the relationship between district nurses and their patients. The traditional, often paternalistic, professional knows best approach must now give way to a patient focused partnership.

In its State of Care (2015) report the Care Quality Commission once again highlight unsafe management of medicines as a key concern in those care providers that require improvement. Underpinning the poor management of medicines is the unsafe and routine use of covert administration. In this article Richard Griffith looks at the legal and professional obligations for district nurses when they consider advising the use of covert medicines.

The revised Code of the Nursing and Midwifery Council (NMC), the statutory professional regulator for district nurses, makes clear that while district nurses can interpret the values and principles for medication use in community settings, the standards are not negotiable or discretionary. They must be applied or the district nurse's fitness to practice will be called into question. In the final article in the series analysing the legal implications of the NMC Code on district nurse practice, Richard Griffith considers standard 18 on medicines.

In his continuing series looking at the legal and professional implications of the Nursing and Midwifery Council's revised Code of Conduct, Richard Griffith discusses the elements of accurate record keeping under Standard 10 of the Code. This article considers the importance of accurate record keeping for the safety of patients and protection of district nurses. The legal implications of records are explained along with how district nurses should write records to ensure these legal requirements are met.

In his continuing series looking at the law underpinning the standards set out in the revised Code ( NMC, 2015 ), Richard Griffith considers standard 2, which requires district nurses to work in partnership with the people in their care. Although the right to self-determination and the requirement for consent has been a legal principle in health care for over 100 years, its emphasis has been on providing a defence for health professionals rather than promoting partnership in the district nurse-patient relationship. Recent developments in policy and law have begun to herald a change in emphasis from 'health professional knows best' to a more patient-focused approach to decisions about care and treatment.

The publication of the fourth edition of Health for all children (Hall 4) in 2003 marked a shift in health visiting towards a more targeted service. This paper aims to explore, through the accounts of health visitors, the impacts of this changed policy context for health visiting practice and for the health visiting profession. The study, upon which this paper is based, was a qualitative exploration carried out in one NHS locality with broad socioeconomic diversity. Semi-structured interviews were undertaken with 16 health visitors. The data was analysed using thematic and narrative techniques. In the study health visitors expressed concerns about the impacts of Hall 4 on health visiting practice, particularly in relation to health visiting expertise and the increase focus on child protection work shaping health visiting practice. In conjunction, health visitors'accounts suggest low morale as a profession.The paper concludes that the impacts of future policy change on health visiting practice must be fully considered; and, measures taken to prepare and support health visitors through periods of policy change.

Following a ruling by the House of Lords in 2009, the Director of Public Prosecutions issued guidance setting out the circumstances that would be likely to lead to the prosecution of a person for encouraging or assisting suicide under the Suicide Act 1961, section 2. In that guidance, a district nurse assisting a person to commit suicide would be one of the circumstances that would lead to prosecution. The Director of Public Prosecutions recently unexpectedly amended her guidance in relation to health professionals. This article discusses the implications of the amendment and argues that it will cause confusion among district nurses and give rise to an unrealistic expectation about the role a district nurse can lawfully take in assisting a person to die.

The Court of Appeal has ruled that patients and their relatives have the right to be consulted prior to a 'do not attempt resuscitation' notice being placed on file by a health professional. Failing to do so would be in breach of the patient's right to respect for a private and family life under the European Convention of Human Rights, article 8. This article sets out the steps that district nurses must take to ensure that 'do not attempt resuscitation' notices placed on the file of their patients are lawful.

The need to share information about patients is vital to effective care and protection, especially where it relates to adults who lack decision-making capacity but it has to be balanced against the right to confidentiality. Like other health professionals, district nurses have a duty to maintain the confidentiality of patient information, and incapable adults have the right to expect their personal health information to be kept private. This right is guaranteed by the common-law duty of confidence, the Data Protection Act 1998 and the NHS Care Record Guarantee and confidentiality policy. This article discusses the district nurse's legal obligations when considering sharing information in relation to an incapable adult

The Human Medicines Regulations 2012 are a major consolidation of medicines law. They largely replace the Medicines Act 1968 and some 200 further pieces of secondary legislation, including the Prescription Only Medicines (Human Use) Order 1997 that defined and set out the authority of non-medical prescribers. Although the 2012 regulations mainly consolidate medicines law into one piece of secondary legislation it does introduce some policy changes that will influence district nurse practice by allowing non-medical prescribers to issue patient-specific directions in primary care settings and allowing community pharmacists to make changes to a prescription without the need to contact the prescriber beforehand.

There are persistent calls from Government, health regulators and even the Parliamentary health select committee for health professionals to report poor practice. The Government argues that district nurses who blow the whistle on substandard care will be protected by changes to the NHS Constitution for England. However, a recent decision of the Court of Appeal shows that whistleblowers who are subject to bullying and recriminations from colleagues are not protected by the law and cannot claim compensation. In this article Richard Griffith and Cassam Tengnah review the law protecting whistleblowers, and discusses ways in which district nurses who have concerns can safely report poor practice.

This article, the second in a series on consent to examination and treatment, considers a district nurse's duty to warn patients of the risks inherent in treatment. The article discusses whether patients are entitled to full and honest answers to their questions about risks, and whether district nurses can lie to anxious patients about the risks of treatment.

Community nursing and public health work provided many Victorian and Edwardian women in Britain with the opportunity of a career and professional training. Such work created contradictions, not least the tension between 'inherent' female skills and the role of learnt professionalism. This article discusses Manchester's neglected district nurses alongside the city's more well-studied health visiting scheme. Comparing these occupations in one city highlights continuities in origins and practice, but a clear divergence in terms of class and purpose. These differences provide historians with opportunities to reconsider the inherent tensions and varied identities of employed women in Victorian and Edwardian Britain.

Nurse prescribing has been established in the UK since 1994, however, limited focus has been placed on the experiences of district nurses adopting this additional role. This phenomenological study explores the experiences of district nurses prescribing as nurse independent prescribers across the West of Scotland. A qualitative Heideggarian approach examined the every-day experiences of independent prescribing among district nurses. A purposive sample was used and data collected using audio taped one-to-one informal interviews. The data was analysed thematically using Colaizzi's seven procedural steps. Overall these nurses reported that nurse prescribing was a predominantly positive experience. Participants identified improvements in patient care, job satisfaction, level of autonomy and role development. However, some of the participants indicated that issues such as support, record keeping, confidence and ongoing education are all major influences on prescribing practices.