South Bank University
Diploma in Higher Education
0500 (Adult)
Student Number: 9905890
Managing Care.
Unit 7a.
Unit Co-ordinator: Allan Gopal
Personal Tutor: Alma Ramnauth
Word Count: 2,133
(
Unit 7a
(
Managing Care.
CONTENTS
TITLE PAGE 2
CONTENTS 3
ASSIGNMENT ESSAY 4
APPENDIX ONE 13
APPENDIX TWO 14
APPENDIX THREE 15
APPENDIX FOUR 16
REFERENCE 17
BIBLIOGRAPHY 20
DECLARATION OF AUTHENTICITY 22
Word count (excluding references, appendices and charts) 2,133
In this assignment I will look at the role of the nurse in managing the care of stroke patients in the rehabilitation setting. By looking at the needs of dysphasic stroke patients of both sexes with ages ranging between 55 to 82years old on a 19 bed Stroke Unit I will demonstrate how their specific needs are being met by current nursing practice and how local and national policies are being implemented to improve stroke care nationally.
Many studies have looked at the role of the nurse; some from a management perspective and others focusing on rehabilitation, the findings differ only in the way they are expressed. The Royal College of Nursing identifies eight categories, others have identified between four and fourteen key roles [see appendix one] {RCN as cited in Edwards A. 2002:40}. All the studies recognise the roles as being inter-linked and all identify the following within the categories, co-ordination of care, educator, provider of clinical skills, emotional/psychological support and assessment/evaluation of needs. This assignment will focus on the nurse as the co-ordinator of care within the multidisciplinary team and as an educator of both patients and colleagues. The importance of these roles to nursing is highlighted in the National Clinical Guidelines (NCG) for Stroke {as cited in Irwin P. 2000:28}.
Stroke is an umbrella term for a range of conditions principally of the blood vessels that cause, "an insult to the central nervous system"{Kelley R. as cited in Weiner W. Goetz C. 1999:69}. As stroke is perceived to be synonymous with old age and negative outcomes {Smithard D. 2002:61} it has traditionally received less attention from the public and Government than Cancer and Coronary Heart Disease (CHD) {Farmer A. 2001:19}. The Department of Health (DoH) white paper Saving Lives: Our Healthier Nation (OHN) {1999} and the NHS Plan {2000} both devote large sections to cancer and CHD and the local Health Authority report for 2001{Redbridge and Waltham Forest Health Authority} places CHD as it's top priority, where stroke is included it is as an adjunct to CHD and smoking cessation.
Costing more than £2.3 billion a year {Martell R. 2001:12} stroke consumes over 4% of the total National Health budget {Bendall J. as cited in Davis S. O'Connor S. 1999:37} and over 7% of the community health and social care budget for adults {DoH 1999a:2.9}. It is the "third highest cause of death" affecting two in every 1000 people in the UK directly {Smithard D.2002:61}, and as the "single biggest cause of severe disability in the UK" countless relatives and carers indirectly {The Intercollegiate Working Party for Stroke (IWPS). 2000:1.1}.
OHN proposes National Service Frameworks (NSF) to "set national standards...and improve service quality". Stroke is again included as an adjunct to another agenda; the NSF's for Older People and Diabetes. Implementing the frameworks is expected to "reduce the impact of stroke", and to limit long-term disability by providing "well-targeted rehabilitation and follow up care" {DoH 1999a:6.16, 6.17,6.20}.
The analogies of stroke as a "heart attack of the brain" and "Time = Brain" are now being used to emphasise the necessity of immediate care and the potential for rehabilitation {Kelley R. as cited in Weiner W. Goetz C.1999:69, Hyde S. Dowell M. 2002:10, Smithard D. 2002:63} Studies have shown that early admission to dedicated stroke rehabilitation units improves long-term outcomes and results in lower mortality and morbidity rates {Stroke Trialists' Collaboration 1998 as cited in The IWPS. 2000:1.1}.
'Rehabilitation' literally means "to live again". In the context of health rehabilitation it is defined by the World Health Organisation (WHO){1969} as,
"the combined and co-ordinated use of medical, social, educational and vocational measures for retraining the individual to the highest possible level of functional ability" {as cited in Davis S. O'Connor S. 1999:5}.
The Royal College of Physicians suggests that
"in an ideal world, all wards would be rehabilitative..."{as cited in Edwards A.2002:39}.
The stroke unit studied for this assignment aims to carryout a multidisciplinary assessment of stroke patients within ten days of admission to the acute medical wards. Suitable patients are selected for an eight-week extendable stay on the unit where they will undergo a planned programme of rehabilitation. Currently each discipline within the team carries out its own specific assessment.
The role of the nurses as co-ordination of individual patient care begins with the 'nursing process', accurate assessment enables appropriate planning and implementation and effective evaluation ensures efficient provision of care {Tahan H. as cited in Cohen E. Cesta T. 2001:283}.
In assessing and planning care it is important to focus on the needs of the specific patient/group and to provide the services to met those needs. This 'needs-led' approach was introduced in the National Health Service and Community Care Act 1990, previously care tended to be 'Service-led' where interventions were planned on the basis of available services {Forster D. et al. as cited in Edwards M. 1999:106}.
The model used for assessment and planning of nursing care in the unit is the Roper, Logan and Tierney (RLT) Model of Nursing based on the Activities of Living (AL's). The model considers the individual as a whole identifying actual and potential problems using the 12 AL's and associated factors to facilitate a holistic assessment [see Appendix Two]{Roper N. et al. 1985}.
Due to the word limit only two actual problems identified under separate AL's will be looked at. First under the AL of 'Communication,' this is especially relevant in stroke as all of the verbal and non-verbal processes required for effective communication can be affected, the actual problem identified for this assignment is dysphasia. Secondly using the AL 'Maintaining a safe environment' which encompasses everything from the physical ward setting through to homeostasis, this assignment will focus on the actual problem of hypertension, as it is one of the main risk factors for stroke {DoH2002:5.14}.
Dysphasia is a difficulty with communication it can be expressive where the patient has difficulty saying the words they are thinking, or receptive where the speech remains fluent but incoherent {Snell R. 2001:293-294}.
In co-ordinating the care of dysphasic patients the nurse must recognise the impact language has on social interaction {Durkin K. as cited in Hewstone M. Stroebe W. 2001:59}. We learn about and interpret the world around us with language, the way we use language denotes our place in society, we consider the articulate to be intelligent and worthy of respect {Fiedler K. Bless H. ...
This is a preview of the whole essay
Dysphasia is a difficulty with communication it can be expressive where the patient has difficulty saying the words they are thinking, or receptive where the speech remains fluent but incoherent {Snell R. 2001:293-294}.
In co-ordinating the care of dysphasic patients the nurse must recognise the impact language has on social interaction {Durkin K. as cited in Hewstone M. Stroebe W. 2001:59}. We learn about and interpret the world around us with language, the way we use language denotes our place in society, we consider the articulate to be intelligent and worthy of respect {Fiedler K. Bless H. as cited in Hewstone M. Stroebe W. 2001:143, Allan K. as cited in Miller L. 2002:49}. The inability to communicate creates feelings of isolation and frustration, this often leads to tearfulness and depression {Rees G. et al 2002:53}.
Approximately 20% of stroke patients will have dysphasia on assessment and half will still exhibit symptoms after six months {Warlow C. et al. 1996:516}. It is essential that assessment is carried out by an appropriately trained assessor as a priority to ensure correct diagnosis and limit the detrimental effects {Bowie I. as cited in Davis S. O'Connor S. 1999:87}. The NCG for Stroke recommends Speech and Language Therapists (SaLT) as the 'most competent' to assess patients with communication difficulties and implement appropriate strategies to cope {IWPS 2000:9.2}.
The nurse as co-ordinator must ensure a prompt referral to SaLT and following assessment work in close liaison, as dysphasia will effect all aspects of caring for the patient {IWPS as cited in Irwin P. 2000:30}. SaLT often provides patients with flashcards and prompts to aid communication. The nurse must ensure that any specific compensatory strategies are integrated into the patients care plan and are used correctly by all members of the care team {Gibbon B.2002:51}. Everyone must be made aware that sometimes when a dysphasic patient say's "no" they may mean "yes", only by assessing the non-verbal clues will communication be effective {IWPS 2000:9.2}. It is also important not to 'jump in' and finish a sentence as this can cause the patient to feel 'helpless' and 'inadequate' {Miller L. 2002:46}.
It is important to include those close to the patient, as they will require knowledge about the condition to resolve their own anxieties and to provide the patient with the appropriate physical and psychological support. The focus in rehabilitation is moving from 'patient centred' to 'family centred' care. 'Family' includes friends who provide support and care and are seen as part of the team working in partnership with the professionals {Nursing and Midwifery Council (NMC) 2002:21, Dean K. as cited in Smith M. 1999:chp3b}.
Shaver and Klinnert (1982) found that when individuals perceive a threat to themselves they instinctively "...seek out someone knowledgeable who may provide information..." they will often turn to someone who has already experienced what they are going through {as cited in Hewstone M. Stroebe W. 2001:376}. This theory is supported by studies that show stroke patients respond well to group sessions where observing the coping strategies of others "...encourages hope, adaptation and recovery..."{Pasquarello M. 1990 as cited in Barton J. 2002:34}.
Henderson {1966} recognised the importance of the nurses' role in promoting health over three decades ago {as cited in Smith M. 1999:53}, and Price writing in 1984 considers patient education as "the central component of the rehabilitation process"{as cited in Kershaw B. Salvage J. 1990:47}. The NMC and DoH papers OHN and Making a Difference restate this and require all nurses to be active in health promotion {NMC 2002:1.2,2.4, DoH 1999a:11.25, DoH 1999b:10.6}.
Health promotion is multidimensional, and nurses must participate in all areas, in primary care to prevent disease and ill health, in education to empower people and with legislation to protect communities [see Appendix Three]{Tannahill as cited in Pike S, Forester D. 1995: 40}. Education is always included in the role of the nurse; either as a heading other integrated it into other roles [see Appendix One]. Peplau considers education under two roles first the nurse as "resource person" able to answer patients direct questions and provide information. Then also as a "teacher" creating the learning environment and individual teaching programme by establishing what the patient needs to learn and how much they already know {as cited in Simpson H. 1991:23}.
The goal of health education is to promote independence by encouraging the patients to take responsibility for their own health. Following a stroke patients can feel helpless and that they have no control over their lives, providing health information and promoting healthier lifestyles empowers patients "...to increase control over and to improve their health" {Miller L. 2002:46, Davis S. O'Connor S. 1999:208, WHO1984 as cited in Able-Smith B. 1994:42}. Studies have shown that when patients understand their condition and treatment they are more satisfied with their care, more compliant with treatment and they experience lower levels of depression and anxiety {Reynolds M.1978. Ley P.1988, Morrison V. et al.1998 as cited in Barton J. 2002:34}.
Health education is very effective at preventing further strokes {IWPS as cited in Irwin P. 2000:30}. The management of hypertension is one of the health education priorities in of stroke patients, as around 50% of patients will have been diagnosed with hypertension prior to their first stroke {Warlow C. et al. 1996:486}. Hypertension is defined as,
"a condition of sustained elevated arterial pressure of 140/90 or higher"
in the majority of patients the cause of their hypertension can not be identified; lifestyle factors such as a poor diet, obesity, stress and smoking are thought to increase the incidence. Although the hypertension cannot be cured lifestyle changes can help to control it {Marieb E. 1998:709}.
The nurse as educator must do more than just supply the information, telling the patient to stop smoking and lose weight will rarely result in changed behaviour. The patient must be motivated to change; this motivation will depend on their individual concept of health and their perception of risk from the associated behaviour,
"health cannot be imposed on people. It has to be won in partnership with them"
{Able Smith B. 1994:chp3, Stroebe W. Jonas K as cited in Hewstone M. Stroebe W.2001: chp16}. The nurse must understand the process people go through, the motivation and barriers they encounter, when adapting to a new behaviour pattern [see Appendix Four].
Health protection stems from national policies. OHN initiatives such as "Healthy Citizens programme, Healthy Schools programme, NHS Direct, Sure Start, Working Families tax credit and the minimum wage" all aim to "create the right conditions for individuals to make healthy decisions"{DoH 1999a:3.27,4.17,3.30,3.12,4.13}. The ONH philosophy of public involvement in health is borne out in the NHS Plan; this is a cohesive strategy for planning, investment and reform in the NHS based on the results of public consultation. 'Best practice' will be achieved by the implementation of "protocol based care" based on the recommendations of the National Institute of Clinical Excellence and implemented by the NHS Modernisation Agency {DoH 2000}
The essence of these policies is "Clinical Governance" as introduced by the DoH (1998) in
"A First Class Service-Quality in the New NHS" and "The New NHS: modern, dependable" It's defined as, "A framework through which NHS organisations are accountable for continuously
improving the quality of their services and safeguarding high standards of care, by creating an environment in which excellence in clinical care will flourish",
{DoH 1998 as cited in Bishop V. Scott I. 2001:39, Lilley R. 2000:6}.
A major part of Clinical Governance is Clinical Effectiveness, which is defined as,
"the extent to which specific clinical interventions when deployed for a particular patient or population do what they are intended to do"
{DoH. as cited in Hamer S. Collinson G. 1999:113}. The Commission for Health Improvement will monitor the implementation of NSF's and National Clinical Guidelines (NCG) to ensure standards of clinical effectiveness are maintained throughout the NHS {DoH 1998 as cited in Lilley R. 2000:6}.
Standard Five of the NSF for Older People aims to set the standard care that should be available all stroke patients. One of the 'Key interventions' in treatment is the implementation of the 'stroke care co-ordinator'. The co-ordinator is responsible for the co-ordination of assessment, documentation, patient education, and discharge planning and ensuring effective communication between all members of the multidisciplinary team and patients {DoH 2002:5.22}.
Although the NSF does not attribute the role to any one profession, nurses are increasingly being seen as the hub that connects the multidisciplinary team members. They reinforce the individual specialities by implementing their therapy recommendations over the full 24hr period, act as communication channels and as the one constant presence would seem to be ideally placed to act as co-ordinators and most already perform this role unofficially {Warlow C et al 1996:376, Smith M. 1999:196, Irwin P. 2000:28, Long A. et al. 2002:76}.
This challenges traditional hierarchy within hospitals, which places the Doctor automatically at the head of the team {Lawley as cited in Edwards M. 1999:42}, which is in line with the NHS Plan's commitment to "break down barriers between staff"{DoH 2000:9.2}.
In order to be an effective co-ordinator the nurse must appreciate the roles of the other members of the multidisciplinary team, and possess excellent communication skills {Bonney K. as cited in Davis S. O'Connor S. 1999:160}. Demonstrating competence in communication is now a prerequisite of qualifying as a nurse; further changes have been proposed to the training of all healthcare workers with the implementation of a cross professional common foundation programme to enhance inter-disciplinary communication {NHS Plan as cited in Lilley R. 2001:119}. Benner {1984:160} considers that,
"to provide continuity and safe care around the clock takes co-ordination and teamwork." In line with this the NMC requires registered nurses to co-operate with team members and to share their "...knowledge, skills and expertise..."{NMC 2002:4}.
The NSF for Older People and the NCG for Stroke stress the need for multidisciplinary teams to use a common vocabulary to set shared goals. They recommend the implementation of a 'stroke care pathway' {The IWPS 2000:2, DoH 2002:70, DoH 1999b:10.34/10.44}. A care pathway represents evidence based clinically effective care facilitating a continuum between disciplines throughout the patients' journey from identification of risk and prevention to acute care and long term rehabilitation {Benton D. as cited in Hamer S. Collinson G. 1999:97, DoH 1999b:10.41}.
The role of the nurse co-ordinator is not one who simply follows an established 'pathway' but someone who challenges existing practice and leads the way in developing new evidence based clinically effective care {Seaman A. as cited in Smith M: 1999:198}.
Nurses play an essential role in the management of care of stroke patients, as co-ordinators and educators they must keep up to date with the latest developments in care and Local and National policies, to ensure their practice conform to the standards of clinical governance. They must be central to the multidisciplinary team to ensure that the patient is the focus of that care. They are best placed to encourage interdisciplinary working and provide a channel for communication. These characteristics are essential to all nurses not just those working in the rehabilitation setting. Rehabilitation must be seen as integral to patient care as the Royal College of Nursing states,
"...rehabilitation should be part of every nurse's role" {as cited in Clay M. 2001:23}.
The Roles of the Nurse.
RCN. Categories in Rehabilitation Nursing. as cited in Edwards A. 2002:40
.
. Therapeutic practice
2. Co-ordinator
3. Advocacy
4. Clinical Governance
5. Advice and counselling
6. Political awareness
7. Education
8. Essential nursing skills
Long A. Interlinked roles. Long A. et al 2002:70
.
. assessment
2. co-ordination and communication
3. technical and physical care
4. therapy integration and carry-on
5. emotional support
6. involving the family
Smith M. Key nursing roles. Smith M.1999:36
.
. Technical expert and provider of care
2. Psychological support
3. Educator
4. Co-ordinator
5. Team worker
6. Evaluator
Warlow C. Nursing roles. Warlow C et al 1996:377
.
. Daily assessment
2. Provision of basic needs
3. Provision of skilled nursing
4. Supporting patient and family.
Bonney K. Skills of rehabilitation nursing. as cited in Davis S. O'Connor S. 1999:chp7
.
. Communicator
2. Listener
3. Facilitator
4. Enabler
5. Co-ordinator
6. Leader
7. Collaborator
8. Empowerer
9. Liaison
0. Advocate
1. Educator
2. Planner
3. Consultant
4. Researcher
Kitson A. The essential elements. Kitson A. 1999:44
.
. Essential care
2. Technological care
3. Psychosocial/emotional care
4. Information and education
5. Continuity and co-ordination
Peplau. Nursing roles. as cited in Simpson H. 1991:23
.
. the nurse as Stranger
2. the nurse as a Resource person
3. the nurse as Teacher
4. the nurse as Leader
5. the nurse as Counsellor
6. the nurse as Surrogate
Tahan. Role dimensions. as cited in Cohen E. Cesta T. 2001:283
.
. Clinical / patient care
2. Managerial / leadership
3. Financial / business
4. Information management / communication
5. Professional development / advancement
Benner. Domains of Nursing Practice. Benner P. 1984:46
.
. The Helping Role
2. The Teaching-Coaching Function
3. The Diagnostic & patient-Monitoring Function
4. Effective Management of Rapidly Changing Situations
5. Administering & Monitoring Therapeutic Interventions & Regimens
6. Monitoring & Ensuring the Quality of Health Care Practices
7. Organizational & Work-Role Competencies
The Roper Logan and Tierney 12 Activities of Living.
.
. Maintaining a safe environment
2. Communicating
3. Breathing
4. Eating and drinking
5. Eliminating
6. Personal cleansing and dressing
7. Controlling body temperature
8. Mobilising
9. Working and playing
0. Expressing sexuality
1. Sleeping
2. Dying
Lifespan, Dependence - Independence,
Factors
Biological
Psychological
Sociocultural
Environmental
Politicoeconomic
Roper N. Logan W. Tierney A. 1985
Health Promotion
Tannahill's overlapping spheres illustrate the multidimensions of health promotion.
The prevention sphere attempts to protect good health by screening for, immunising against and providing help for known health risks.
The education sphere focuses on empowering communities and individuals to take control of there own health needs.
The health protection sphere concentrates on legal and financial aspects to shape the environment in which communities live {as cited in Pike S, Forester D. 1995: 40}.
[Source: Downie et al cited in Naidoo J, Wills J. 2000: 107]
[source: Ewles L, Simnett I. 1999: 264]
The process can be though of as a 'revolving door'; patient's will only enter when they know were it leads. Once in, it may take several turns to negotiate the exit successfully.
Pre-contemplation: Smoking, poor diet, obesity, stress, and lack of exercise.
Contemplation: made aware of the risks they have entered the 'door'; they may still choose to ignore or reject the risks.
Commitment: when they have accepted the risks and the need to change they progress,
Action: active changes in behaviour and attitudes.
Maintenance: peers may support or sabotage the new behaviour, at this stage there are two outcomes exit or relapse,
Exit: if the individual is encouraged to maintain the new safer lifestyle they exit the cycle.
Relapse: this may occur for a variety of reasons, social pressure, emotional state or lack of access to services; the 'door' continues round and hopefully by the next turn they will be able to exit.
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Unit 7a - Managing Care - 9905890
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Unit 7a - Managing Care- 9905890
Unit 7a - Managing Care- 9905890
