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Nursing today is at the heart of healthcare provision in the United Kingdom, and nurses are the largest group of clinical employees (www.nhs.uk) in the NHS. Many factors, from political to economic, from social to technological, shape and direct the nature of healthcare provision and so also affect nursing and the context in which it takes place. These factors are continually changing and evolving and therefore affecting the quality of care for patients.

This chapter will set out the factors that nurses working in hospital settings need to be aware of as they plan, deliver and develop patient care. The factors are discussed under four headings: Political, Economic, Social and Technological, or PEST, a popular model used to structure decision making (Barr and Dowding 2008). The headings are nominal as many factors are complex and overlap with each other. This chapter will also include an explanation of the structure of the rest of the manual, the order of the chapters and the grading system for the evidence of the rationale accompanying the steps in the procedures.

Political factors

High Quality Care for All

Political factors include strategies of the government that impact directly on the current context of health and therefore nursing care. Current national provision has been influenced by High Quality Care for All (Darzi 2008), the final report of the NHS Next Stage Review, co-produced by Lord Darzi with the NHS during a year-long process involving more than 2000 clinicians and 60,000 NHS staff, patients, stakeholders and members of the public. The core purpose of this strategy is to increase the quality of all aspects of the health service. Lord Darzi defines quality of care as ‘clinically effective, personal and safe’ (Darzi 2008, pp.8–9). It is about effectiveness of care, from the clinical procedure the patient receives to their quality of life after treatment. It is also about the patient’s entire experience of the NHS and ensuring they are treated with compassion, dignity and respect in a clean, safe and well-managed environment.

In practice, this strategy has meant that resources have been invested in standardizing treatment across the UK and in time may extend to standardizing the practices, procedures and equipment used in treatment. A key strategic aim is to get the basics right first time (Darzi 2008, p.5), that is, protecting patient safety by eradicating healthcare-acquired infections and avoidable accidents.

With the change of government in May 2010, the political emphasis shifted to focusing specifically on ‘continuously improving those things that really matter to patients – the outcome of their healthcare’ (DH 2010b, p.1). This means that the end-result of procedures is going to be more important than the process of achieving them.

‘The NHS will be held to account against clinically credible and evidence-based outcome measures, not process targets. We will remove targets with no clinical justification’ (DH 2010b, p.4).

For example, in nursing, this may mean an increased analysis of the outcome of the use of certain types of wound care products, the length of time catheters are in situ and the effectiveness of pain management processes. However, this approach will be accompanied by a commitment to ‘empower and liberate clinicians to innovate, with the freedom to focus on improving healthcare services’ (DH 2010b, p.1).

Care Quality Commission

The Care Quality Commission (www.cqc.org.uk), the independent regulator of all health and adult social care in England, is charged with monitoring all healthcare providers across England against the new standards of quality.

Its aim is to make sure better care is provided for everyone, whether that’s in hospital, in care homes, in people’s own homes or elsewhere. It has a vision of high-quality care, meaning care that:

is safe

has the right outcomes, including clinical outcomes (for example, do people get the right treatment and are they well cared for?)

is a good experience for the people who use it,