Delivering health promotion within Primary Healthcare (PHC) has many advantages. The Primary Healthcare Team (PHCT) has access to the whole population. 97% of the population is registered with General Practitioner (GP) and over 70% of patients consult their GP at least once per year (Office of Health Economics 1994). Doctors and nurses are seen as highly credible sources of information and advice on health. PHC practitioners already work in teams, the core team of GP, practice nurse, practice manager are often complimented by a broader team which would include community-based nurses, specialist nurse practitioners, occupational therapists (OT), dieticians, speech and language therapists (SALT), physiotherapists and welfare workers such as health visitors and social workers. The PHCT provide continuity of service together with easy access, which is highly valued by clients. As the NHS is encouraged more towards evidence-based practice, supporters of health promotion claim health promotion in PHC is an effective use of resources, using recent studies to support their claim (MacPherson 1994, Doyle and Thomas 1996). The 1999 public health white paper included recognition that ‘new major Government policies should be assessed for their impact on health ‘ (DoH 1999).
Accidents are the commonest cause of death among people under 30 years in England and Wales, but the absolute number of deaths is greatest in people aged 65 years or over (OPCS 1991). Accidents represent on of the greatest public health problems. The ‘Health of the Nation Strategy’ (DoH 1992) set targets for reducing the mortality rate for people over the age of 65 years by at least 33% by the year2005. In 1991, 4626 people over the age of 64 years died as a result of accidents (OPCS 1991) with falls accounting for the majority of accidents in this age group. The Family Policy Studies Centre (FPSC 1994) states,
‘with the consequences of falling becoming more severe with advancing age, demographic projections of a relative increase in the number of people over the age of 75 years in the population suggests the problem will become worse in years to come’.
International literature reviews have considered the effectiveness of interventions to reduce and prevent falls and subsequent injury among older people (NHS Centre for Reviews and Dissemination 1996b). Over 85% of all fatal falls in the home in England and Wales are in people over the age of 65 years (Lilley, Arie and Chilvers 1995). Falls are also by far the most important cause of hospitalisation for older people (Cryer, Davidson and Sykes 1993). The most common serious injuries are fractures (Hindmarsh and Estes 1993).
The risk assessment function of the community nurse is intricately interwoven to search for health needs and their role in health promotion (Sines, Appleby and Raymond 2001). Community nurses are equipped to offer insights into threats to health by virtue of their daily contact with their clients. Sines, Appleby and Raymond (2001) infer ‘they have the capacity to act as an early warning system, but only if they remain alert to this aspect of their role’.
The government introduced the National Service Framework for Older People in 2001 (NSF). It outlines 8 national standards to improve care for the elderly. One of the main emphases is on falls. The NSF section 6 states
‘preventing falls in older people depends on identifying those most at risk of falling and coordinating appropriate preventative action, the most effective way would be interventions that target both multiple risk factors, intrinsic and environmental factors’.
Intrinsic factors include: balance or mobility problems, taking four or more medicines, i.e. sedating or blood pressure lowering medications, visual impairment, postural hypertension and impaired cognition i.e. depression, Alzheimer’s disease, memory loss. Environmental risk factors within the home include: poor lighting, steep stairs, loose carpets or rugs, badly fitting footwear or clothing and lack of safety equipment. To identify those older people at risk of falling assessing these factors may help: have they had previous fragility fractures? Have they attended an Accident and Emergency department as the result of a fall? Do they have two or more of the intrinsic factors documented above? Are they afraid of falling after a previous fall?
Home visits and surveillance to assess, and where appropriate, modify environmental and personal risk factors can be effective in reducing falls. This can be carried out by nurses, health visitors, occupational therapists or trained volunteers (NHS 1996b).
With regard to the individual patients’ previous medical history, Mrs Pugh has a diagnosis of osteoporosis. This can increase the potential for serous fractures if she falls, this is due to the osteoporosis reducing bone mass and density. Fractures occur most commonly in the hips, spine and wrist (Alexander, Fawcett and Runciman 2000). Consequences for an individual falling or not being able to get up after a fall can include: psychological problems i.e. fear of falling again, loss of confidence, loss of mobility leading to social isolation and depression, increased disability, dependency, hypothermia, infection and pressure related injury. After an osteoporatic fracture 50% of people can no longer live independently (DoH 2001). Hip fractures are the most common serious injury related to falls in the elderly, which costs the NHS around £1.7 billion per year. 45% of the cost is for acute care, 50% for social care and long term hospitalisation and 5% for medications and follow up (DoH 2001).
Older people who fall should, with their consent, be referred to a specialist falls service for specialist assessment. This should include primary and social care professionals. It should build on the single assessment process, identifying risk factors associated with their health and environment (DoH 2001). The assessment needs to identify and diagnose any risk factors for falls associated with the clients’ health and those factors likely to respond to intervention. It should establish how the client and/or carer cope and if they have any strategies for coping with a fall in the future, it should identify any psychological effect of the fall that may lead to self-imposed restriction of activity (DoH 2001). Any interventions should be agreed with the client and may include rehabilitation, social care support, equipment to improve the safety of the client at home and home repairs or improvements if warranted.
That nurses should be skilled interpersonal communicators is a commonly voiced directive (French 1994: Grogan 1999: Riley 2000). Dimbleby and Burton (1998) define skill as ‘an ability to use a means of communication effectively, with regard for the needs of those involved’. French (1994) suggested that nurses interact with patients in order to ‘provide social stimulation, give and receive information, control, facilitate patient self-expression, alleviate negative emotion and stress, thereby promoting recovery’. Communication is heavily context-bound. Interaction takes place within a person-situation context that shapes what unfolds (Endler and Magnusson 1976). Situational factors have particular bearing on working in the community. As Baly, Robottom and Clark (1987) suggest ‘it brings with it the role of ‘the guest’, with the possibility of role conflict and confusion’. The acceptance of the role of ‘the guest’ is said by Trojan and Yonge (1993) ‘to contribute to the initial phase of establishing a caring relationship when nursing older people in their homes’. There is some evidence that situations can arise where community nurses are very aware of a certain conflict between being ‘the guest’ and ‘being in charge’ (McIntosh 1981). Review by Kenny (1995), Ong et al (1995) and Dickson, Hargie and Morrow (1997) suggest that patients who experience good quality communication tend to be more satisfied with the care they receive, are more willing to cooperate with treatments and make a more speedy recovery. However, individual patients having differing information requirements need truly skilful interaction, which requires adaptive flexibility in reaching join goals (Dickson 2001).
The district nurse, assessing our client had to take into account she was a guest in Mrs Pugh’s home. There was an assessment, of the risk of further falls, to make the environment safer, but these goals had to be reconciled with Mrs Pugh’s values and independence. Kleinman, Dancy and Wynn-Dancy (1995) argue the role of the health professional is to empower the persons for whom they care by helping them assert what is important to them in their lives. The patient has the right to independence. It is vital for the nurse to involve the client, so she feels empowered in knowing that she has a responsibility for her own well-being and still has the right to make informed choices (Barnett 1999).
The assessment of the clients needs is vitally important; the nurse must first identify what the client needs to learn. The nurse should enter the process objectively; educating a client on something that is totally irrelevant to them can lead to time wasting and frustration (Spicer 1982b). The clients’ ability to learn must then be ascertained, the nurse must approach the client in a manner appropriate to the client, using language the client will understand. Finally, the nurse should assess the clients’ readiness to learn. Luker and Caress (1989) emphasise that the physical and psychological consequences of ill health can affect the learning process. The client’s carer and family will also require information, education and support from the nurse to enable them to provide the appropriate support for the client. The nurse may also have to make referrals to colleagues, such as the occupational therapist; so all the information should be available to other health professionals who may be involved in the clients’ care.
REFLECTION
Our presentation took place within the clients’ own home. The district nurse had been approached by Mrs Pugh’s carer regarding the ability of Mrs Pugh to mobilise around her home. Mrs Pugh had recently been discharged from hospital following a fractured tibia and fibula. Consequently she now needs a zimmer frame to assist with her mobility but she does have rather a lot of furniture, which is felt, contributed to her initial fall.
Stephanie and myself had discussed our topic and had both worked on researching Risk of Falling in the Elderly. From our research we agreed the content of our presentation. We carefully planned the content and chose to include the, often-difficult situation when the client is less receptive to ‘strangers’ in their home, and is very independent. I have experienced this situation whilst on my community placement and the nurse had to use all her communication skills to converse effectively with the client.
As our presentation was to be in a clients’ home environment, both Stephanie and I felt we should try to recreate a believable setting. The props we used, such as the zimmer frame, were organised well in advance, with the kind help of the physiotherapy department. We also bought things in from home. It was important for us to set the scene right, after our efforts to get the props, so we decided to arrive early and rearrange the room into our ‘set’. We rehearsed our dialogue well, although I think I still managed to surprise Stephanie a couple of times, and I feel the presentation clearly represented a challenging situation.
I feel the group enjoyed our presentation, as I did theirs, and was pleased with the feedback and the discussion our presentation prompted. There were some very good constructive opinions, which I have taken on board.
The topic was interesting to research and the actual performing of the scenario was enjoyable. Personally, I feel so much more confident liasing with my peer group and of speaking openly and honestly when offering opinions. Professionally, I have learnt, through my research into this topic and the presentation, that as a professional nurse, dealing with people, you have to be prepared to be able to deal with whatever situation you may find yourself in. communication skills are the nucleus of nurse-patient relationships, not every patient is willing to conform to what you maybe telling them, especially elderly patients who are living independently in the community.