Chapter 54 – Marie Nolan (D3SOP14)
Domain 3 Standard of Proficiency 14
Be able to establish safe environments for practice which minimises risks to service users, those treating them and others including the use of infection prevention and control strategies.
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KEY TERMS Safe environments Minimising risk Infection prevention and control
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Social care is … a vocation. It is a discipline that represents a better future, determination, vision and change for vulnerable and marginalised groups in society. |
Before embarking on a career in social care, you must be willing to commit to a challenging but rewarding journey. Social care services require professionals who are open-minded, non-judgemental, positive, empathic and driven. The social care sector is ever-evolving, so you also need to be resilient and resourceful in your approach. Working in social care provides a great sense of purpose, and the dedication invested is reciprocated in the small successes achieved daily.
Risk and Safe Environments
Establishing safe environments in social care practice is very important, especially when some service users may not have the capacity to be accountable for their own safety. In social care settings, the responsibility to provide a safe environment lies with both the employers and employees. The social care sector is driven by a changing legislative and practice framework. Guiding policies include the Health Act 2007, the Health and Social Care Professionals (Amendment) Act 2019, and the Equal Status Acts 2000-2018. Social care workers are faced with the challenge of maintaining a safe working environment that is consistent with changing policies, procedures and legislation. For example, the understanding of risk is influenced by the litigation that shapes it.
Factors to consider when developing a risk assessment in social care settings include:
- a knowledge of potential hazards
- an openness to reflect and learn from mistakes
- adherence to legislation through the application of relevant policies and procedures
- the provision of appropriate information and training to staff and service users such as manual handling, and
- the development of risk assessments, as required. (OCR 2012)
The term ‘risk’ is commonly used in association with an action that has an element of danger or potential loss. We are involved in the process of assessing risk when we ask ourselves the question, ‘Is this too risky?’ Some people choose to take more risks in their everyday lives than others. Equally, some people choose to take actions without considering any risks at all (Anderson et al. 2014). However, in the professional context of social care, frontline staff are expected, and have a duty of care, to undertake risk assessment and risk management every day. All services that provide care to vulnerable groups are regulated by a relevant statutory body, such as the Health Information and Quality Authority (HIQA), Tusla or the Mental Health Commission. These bodies’ mandatory monitoring systems place a legal obligation on organisations to implement and adhere to policies and procedures that promote safe environments for service users. These policies include medication management, risk management, fire safety, finance management, safeguarding of vulnerable persons, and health and safety. It is therefore vitally important that all employees who are new to a service should receive an induction on and become familiar with all relevant guiding documents adapted to that service before they begin work.
There are other, less formal, contributing factors to establishing a safe working environment. Possessing an in-depth knowledge and understanding of the individuals being supported can be significant in the delivery of safe and effective services. Social care workers need to be aware of the environment in which they work. In context, it is imperative that, as a social care worker, you are tuned in to the environment in which you work and alert to the needs of the individuals you support. One way this can be achieved is through a consistency within the team approach to care in your service. Maintaining a familiar and regular staff team is an integral factor in building trusting relationships with service users and their families. Additionally, being familiar with personal files such as person-centred support plans and behaviour support plans will provide important information on individuals’ interests, preferences, physical, mental and social health care needs. However, knowing relevant care plans is not sufficient on its own to promote a safe environment for service users and support staff. The application of non-verbal communication skills such as active listening, eye contact, empathy and close observation maximises understanding in care staff, and in turn promotes safety and trust for service users.
Minimising Risk
A risk assessment can be developed either orally with a colleague or written on a relevant template. Risk assessments should be based on the premise of creating opportunities for an individual rather than used as evidence to prohibit an activity taking place. The format of a typical risk assessment includes the identification of the risk/hazard; a description of the control measures put in place to minimise the risk; further considerations and an action plan; benefits to the individual of accessing the risk; and a review date.
Control measures are the steps that are introduced to avoid or minimise any potential risk associated with the activity for those involved. Which types of control measures are decided on depend solely on the nature of the risk identified. For example:
- Physical hazards: Considerations may include access to buildings, such as ramps; availability of assistive equipment such as hoists, wheelchairs, support bars.
- Educational requirements: Teaching the person about healthy eating, money management, infection control.
- Behaviour support plan: If the risk is due to behavioural issues or concerns, the control measures may incorporate elements of the individual’s behaviour support plan, such as proactive and reactive strategies implemented to identify and manage behaviours of concern.
When developing risk assessments, ethical considerations of the rights of the individual involved should be given priority. Any control measures implemented should never intentionally infringe on the human rights of that individual. HIQA use the acronym FREDA as a guide to a human rights-based approach to care in health and social care settings:
- Fairness: The individual’s wishes are known and any decision made is communicated to the service user in a way in which they understand how it impacts them personally.
- Respect: The service user is respected and any actions implemented are reflective of the individual’s values and beliefs, and are respectful of their personal belongings such as their property.
- Equality: Any decision or plan should not infringe any of the nine grounds of discrimination as set out in legislation (Equal Status Acts 2000-2018) such as age, i.e., activities should be age-appropriate and should offer opportunity on an equal par with a typical citizen of the same age/ gender in society.
- Dignity: Always endeavour to support the service user in a dignified manner. This involves putting appropriate measures in place which aim to empower the person in terms of their image and competency.
- Autonomy: Ensuring that the person is informed by providing information and education in an accessible manner. Encouraging service users to be as independent as possible in all activities of daily living. (HIQA 2019). Illustration included with permission.
TASK 1
Review a risk assessment in your workplace and determine whether human rights are being promoted in the risk management process. Explore ways in which the control measures can be re-evaluated to promote a rights-based approach.
On identifying control measures that are achievable and that all involved agree to, a risk rating must be determined, i.e., whether the risk is deemed high (e.g. ‘risk of injury to others’); medium (e.g. ‘risk associated with medical conditions such as asthma/epilepsy’); or low (e.g. ‘risk of injury due to use of equipment for work’). At this point, further considerations may be developed as additional measures, such as qualified assessments as needed, training schedules, and/or contingency plans (HSA 2020).
A review date is required so that the information is kept up to date and relevant. A regular review also ensures that the risk rating is maintained or, ideally, minimised due to the progress or success of implemented strategies.
It is important to be mindful that taking risks should not be viewed wholly as a negative experience: engaging in risk-taking has been found to enhance resilience (Coleman & Hagell 2007).
Case Study 1
A man with an intellectual disability chooses to live in a home of his own. Previously, he has resided in a group residential home setting. He is supported to move to an individualised set- up, which is a one-bedroom bungalow in a location of his choice. However, after transition he has expressed his wish to only have staff supporting him during the day, and would like to stay on his own independently at night.
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Identified risk |
Risk of injury/harm due to associated factors of living on own and unsupported by Staff such as sudden illness, fire safety, burglary. |
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Control measures |
Option 1: Minimises risk but infringes human rights Night staff rostered, as per former living arrangement, as risk is deemed too high Service user’s wishes denied in the interests of his own safety |
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Option 2: Minimises risk but promotes opportunity Explore local resources such as community police programmes and fire brigade to engage in basic training for the service user in neighbourhood watch and fire safety Staff to provide skills teaching in use of mobile phone to emergency numbers and use of personal alarm, and provide education on self- sufficiency skills for independent living Staff to role-play about stranger danger and managing unexpected visitors Risk rating: Medium-High |
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Further considerations/action plan |
Provide minimal support until relevant training is completed Trial independent living at night for three months with regular weekly reviews Risk rating: Low-Medium |
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Benefits to the individual |
The individual’s wish to live on his own at night is upheld and respected Human rights are exercised Any potential risk identified is minimised |
Discussion
Note that both control measure options minimise any potential risk for the service user; however, the latter option creates opportunity in doing so. Due to the nature of the work involved in the social care sector, the urge to protect and shield those cared for is almost unavoidable. However, all vulnerable persons using services have the right to exercise will and preference. Therefore, social care workers have a duty to support and advocate for service users in their quest. The process of risk assessment and risk management, when used appropriately, achieves a desirable balance between risk and opportunity.
Infection Prevention and Control
Infection prevention and control is the process of preventing infectious disease, in the first instance by exercising proactive measures; and, if a disease is contracted, by controlling the spread of infection by suppressing or eliminating the disease through the implementation of an appropriate action plan.
From December 2019, when the coronavirus pandemic began to spread globally, social care services had to develop new infection prevention and control policies. COVID-19, a new illness caused by the virus, is an infectious and contagious disease causing severe acute respiratory syndrome. The disease is spread through ingesting the virus, either directly, by inhaling airborne droplets; or indirectly, by coming into contact with contaminated surfaces. According to the World Health Organisation (WHO), COVID-19 is more contagious than many other common infectious diseases, such as influenza, spreading more easily and more quickly. It has a high mortality risk, and those who recover can experience long-term health problems due to the impact of the virus on vital organs such as heart and lungs. While research and development on a vaccine continued, the general population had to adapt to a new way of living with the virus (WHO 2020).
In response to the onset of the pandemic in Ireland from March 2020, there was a requirement at service level to implement comprehensive risk assessments, protocols and robust systems to reflect guidelines from the government, the National Public Health Emergency Team (NPHET) and the Health Service Executive (HSE) guidelines. The restrictions undoubtedly impacted on service users’ routines and constricted the dynamics of service provision. For example, something as common as facilitating visits from family and friends became a formality. This was part of the early introduction of infection prevention measures to keep the virus out of services.
The pressure of the COVID-19 pandemic was also felt greatly by social care workers. Individuals availing of service provision fell into the categories of those most vulnerable to contracting COVID-19 due to age, underlying health conditions and socioeconomic status (HPSC 2020a). In the early and unfamiliar phases of the pandemic, frontline workers ran tirelessly and dutifully in an effort to protect service users from contracting the disease. Unfortunately, it seemed at the time that their efforts went unnoticed publicly, in contrast to their colleagues at a multidisciplinary level – nurses, doctors and paramedics. Social care workers felt like the unsung heroes of the pandemic; but perhaps that is a perception that will change when the registration of social care workers as healthcare professionals has been completed (CORU 2020).
TASK 2
HSELanD (www.hseland.ie) is an online resource for free training that is available to employees in health and social care services. The course catalogue includes modules on Breaking the Chain of Infection; Infection Prevention and Control; National Standards for Infection Prevention and Control in Community Settings: Putting the Standards into Practice (module developed by HIQA); and Do the Right Thing: HSE Risk and Incident Management. Completion of relevant modules in advance of employment is recommended.
In emergency circumstances such as an unprecedented global pandemic, it is important that services implement the process of infection control promptly and efficiently. Exercising and embedding standard infection control precautions is significant in minimising contamination and spread of a virus.
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Standard precautions include: |
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A focus on education and training for frontline staff in infection prevention and control and cross-contamination |
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Provision of relevant information to staff and service users in relation to specific infection |
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Access and information on available vaccines and supports |
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Providing and wearing appropriate personal protective equipment (PPE), including putting it on and taking it off correctly |
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Maintaining clean and disinfected working environments and equipment |
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Setting up the work environment with clear systems/protocols in place to guide staff in safe practice |
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Prompt execution of effective reactive strategies. |
The HSE is a reliable advocate and resource for guidance on infection prevention and control. However, it does warn that local protocols and procedures should be developed without implementing ‘unnecessary barriers to care as barriers to care can be as harmful as infection’ (AMRIC 2020). Once again, this demonstrates the importance of developing risk assessments that balance minimising risk and upholding autonomy.
At the onset of the pandemic and to respond to the pressures it presented to social care providers, the Department of Health published the ‘Ethical framework for decision-making in a pandemic’ in March 2020. The framework is aimed at assisting frontline workers, management and policymakers in health and social care settings with decision-making in difficult circumstances. It identifies seven ethical principles that should be considered when planning for and responding to decisions in crises.
Two of the principles – minimising harm and proportionality – are relevant when considering infection prevention and control:
- The principle on minimising harm reiterates the point that health and social care workers have a duty of care to inform and support service users in engaging in certain behaviours that reduce potential risks associated with the spread of infection; for example, supporting service users to avail of vaccinations.
- However, the principle on proportionality advises that restrictions to one’s liberty, as a result of control measures introduced to minimise risk, should not exceed what is required to address the actual level of risk to those whom the restrictions are designed to protect. For example, during a national lockdown, the highest level of restrictions should not be maintained longer than necessary just because it is felt that this is in the best interests of the individuals supported. Hence, government advice should be interpreted consistently with typical citizens of society, albeit occurring in a more strategic manner (DoH 2020).
TASK 3
Download and read the ‘Ethical framework of decision-making in a pandemic’ from https://www.gov.ie/en/publication/dbf3fb-ethical-framework-for-decision- making-in-a-pandemic/. Examine the seven key principles of decision-making during a pandemic. Consider how these principles might positively influence decisions impacting service users in relation to the introduction of infection prevention and control strategies.
In the unfortunate circumstances that an infectious disease is contracted in a care setting, an appropriate response plan is required to manage the spread of infection. Systems such as contingency-plans and risk assessments on cleaning, laundry and waste management should be considered. Standard precautions should be intensified. Maintaining a calm approach and clear communication with service users, staff and family is key to collectively overcoming a potential outbreak.
Tips for Practice Educators
In supporting students to achieve proficiency 14 under domain 3, it is helpful to commence placements by identifying risk assessments that are currently in place, and by providing information on any relevant policies and procedures present. The risk assessment folder contains significant information on safety and can be useful as a starting point for students to become familiar with the work environment and service users. As available, provide any inspection reports for the service which highlight areas of compliance in providing a safe environment; for example, HIQA inspection reports and annual audits. This will help students put the proficiency into perspective from a frontline point of view. If possible, protected time should be provided at induction stage, i.e., time allocated just to read files and interpret new information.
Students should be provided with the appropriate means to perform high standards of infection control practices while on placement. For example, they should know how to access PPE such as gloves/masks when needed; be informed about current systems pertaining to infection control procedures, e.g., COVID-19 management plans; be aware of any potential risks associated with infectious diseases such as hepatitis B for which they require additional protection; and be familiar with any cleaning procedures necessary.
When setting placement goals, it would be beneficial for the student to be assigned a goal specifically to develop a risk assessment. It is important that students can apply current risk assessments to their work practice but are also able to identify an activity that requires a new risk assessment or a review of an existing one. Practice educators could arrange for the student to assist planning an activity which requires a risk assessment in advance. Assess whether the student can identify potential hazards, determine the level of risk involved, accurately record findings and identify control measures that either minimise or eliminate the risk, while taking consideration of practical use of available resources, local policies and procedures and possible modifications of activity as required. On completion of the activity, the student should be given the opportunity to reflect on what worked and what could have gone better, and how the risk assessment impacted on the success of the activity.
Relevant training is required and beneficial for specific roles. As most training programmes are accessible online on HSELanD or via other online resources, an achievable training plan should be developed at the outset to help the student fulfil their role while on placement as best as possible.
References
AMRIC (Antimicrobial Resistance and Infection Control Team, HSE) (2020) Infection Prevention and Control: Guidance for Resumption of Healthcare Services (PowerPoint slides) <https://www.hpsc.
ie/a-z/respiratory/coronavirus/novelcoronavirus/guidance/infectionpreventionandcontrolguidance/ webinarresourcesforipc/IPC%20guiding%20framework%20webinar.pdf>.
Anderson, T.J., Garvey, M. and Roggi, O. (2014) Managing Risk and Opportunity: The Governance of Strategic Risk-taking. Oxford: Oxford University Press.
Coleman, J. and Hagell, A. (eds) (2007) Adolescence, Risk and Resilience: Against the Odds. West Sussex: John Wiley & Sons.
CORU (2020) Social Care Workers Registration Board. Available at: <https://www.coru.ie/about-us/ registration-boards/social-care-workers-registration-board> [accessed 25 December 2020].
DoH (Department of Health) (2020) ‘Ethical framework of decision-making in a pandemic’. Available at:
<https://www.gov.ie/en/publication/dbf3fb-ethical-framework-for-decision-making-in-a-pandemic/#> [accessed 28 October 2020].
HIQA (Health Information and Quality Authority) (2019). Background document to inform the development of guidance on a human rights-based approach to care and support in health and social care settings. Available at: <https://www.hiqa.ie/sites/default/files/2019-06/Draft_Guidance_Human_Rights- Based_Approach_to_Care_Background_Document.pdf> [accessed 29 September 2020].
HPSC (Health Protection Surveillance Centre, HSE) (2020a) COVID-19 Guidance for International Protection Accommodation Service (IPAS) Settings (V5 01/10/2020). Available at: <https://www.hpsc.ie/a-z/ respiratory/coronavirus/novelcoronavirus/guidance/vulnerablegroupsguidance/Guidance%20for%20 IPAS.pdf> [accessed 29 October 2020].
HPSC (2020b) Epidemiology of COVID-19 Outbreaks/Clusters in Ireland. Available at: <https://www.hpsc. ie/a-z/respiratory/coronavirus/novelcoronavirus/surveillance/covid-19outbreaksclustersinireland/ COVID-19%20Weekly%20Outbreak%20Highlights_Week392020_web%20version_v1.0_28092020.pdf> [accessed 5 October 2020].
HSA (Health and Safety Authority) (2020) Risk Assessments Made Easy. Available at: <https://www.hsa.ie/ eng/supports_for_business/getting_started/risk_assessments_made_easy/> [accessed 30 September 2020].
OCR (Oxford, Cambridge and RSA) (2012). Ensuring Safe Environments in Health and Social Care (Level 2, Unit 4). Available at: <https://ocr.org.uk/Images/139857-ensuring-safe-environments-in-health-and-social-care.pdf> [accessed 22 November 2020].
WHO (World Health Organisation) (2020) Considerations for Public Health and Social Measures in the Workplace in the Context of Covid-19. Available at: <https://www.who.int/publications/i/item/
considerations-for-public-health-and-social-measures-in-the-workplace-in-the-context-of-covid-19> [accessed 13 October 2020].
