health services. The current organisation of primary health care in the NHS was set
up in the white paper published in 1997 (DOH 1997, working together for better
health).
In order to maintain that collaborative work is successful, it is important to have
effective communication. District Nurses have stated that patient care can often be
missed and/or repeated unnecessarily. This means that there have been
communication breakdowns (Aitken et al 1999). Cowley (1993) states although
there may be collaborative problems between workers of various professions and
training, these are compounded by the need to work across the agency or departmental
boundary. In the recent publication of the National Service Framework for Older
people (DOH 2001) the government aim to set new standards for the health and social
care for elderly people, it also aims to ensure that older people get better health care,
through innovative working and a more multi agency collaboration.Hindrances to
collaboration can be reduced by efficient procedures and the development of
organisational structures designed to encourage interprofessional relationships, such
as health centres, the sitting of various agencies in close proximity (Blackie 1998).
Roberts and Priest (1997) says that collaborative working within nursing is not
something that can be achieved by legislation alone
Collaboration and team work have been described by Brechin et al (2000) as a group
of individuals with varying backgrounds, perspective skills and training who work
together towards a common goal of delivering health or social care service to the
service user. Successful collaboration can have many benefits, which include
improved standards, and a greater efficiency and community. The effectiveness of this
team working is dependant upon a common objective that is understood and accepted
by all members, a clear understanding by each team member of the role, function,
skills and responsibilities of other team members and a mutual respect for each other.
The cumberledge report (1986) concluded that unfortunately many disciplines did not
possess these skills. The Audit Commission (1997) also found this kind of teamwork
elusive and recognized rigidity amongst PHCT members was a common problem,
with individuals adhering to narrow dimensions of their roles and concluded that
multidisciplinary working is particularly difficult in primary care as there are many
barriers, which include separate management, diverse objectives and professional
demarcation which all may play an important part in limiting effective collaboration
On reflection whilst working in my community placement I did find that poor
collaboration did occur. During a home visit the information that the district nurse
received was that the patient had a leg ulcer which would require twice weekly
dressings. On arrival to the patients home we found the severity of the ulcer was a lot
worse than anticipated, it was also leaking profusely, so much that the patients
dressing and bed were completely saturated.
District nurses have stated that patient care can often be missed and/or repeated
unnecessarily. This means that there have been communication breakdowns (Aitken
et al 1999). Ovetviet (1993) says that an everyday communication problem is that too
much information is necessary therefore the significant information often gets
“watered down” in the bulk of it all. Information overload can be equally a barrier to
effective communication as insufficient information. Whilst working alongside the
district nurse, I observed that the communication was excellent between the nurse and
the patient, however I feel it lacked communication between other members of the
primary care team.
A minor example was when there was a problem in ordering dressings to get them in
on time, I also observed some issues with respect to referrals from the hospital. It
maybe the staff in the hospital are not fully aware of the specific need of information
which is crucial to the district nurse. Whilst visiting a patient who had several agency
inputs the district nurse identified the communication breakdown which affected
patient care either by omission or duplication. This then enabled a communication to
be developed. The procedure was held in a ring binder and formed part of the patient
care plan.
There were however some positives I was able to take from my assignment with the
Primary Health Care Team. Reflecting on my experience of working in this context I
did see the advantages of collaborative working through being able to provide
continuity of care when a patient was admitted or discharged from hospital providing
what I would describe as providing a seamless patient journey. I could see the
benefits of continuity of treatment and the essential transfer of information. The
greatest benefit for me was the sharing of clinical knowledge and patient
understanding and that patients could benefit from combined knowledge and skills in
the new developing services giving them increased confidence in the services and
reassurance that the patient needs are met.
There are still barriers rooted in history and a “them and us” culture which means it
comes to a head from time to time as the different agencies have different priorities.
A lack of resourcing in General Practitioners can bring blockages in the care process.
The G P had competing pressures from the community, hospitals, patients and
Patient’s families. My Primary Care Trust assignment brought me into contact with a
couple of G.P.s in the area and through my interaction with them an seeing competing
pressures at work I was able to form this view. On attending a staff meeting with the
district nurses, G.P. and social workers I felt it was an excellent opportunity for them
to discuss problems, Roberts (1997) says rather than communicating via telephone
conversations, maybe it would be more effective to have joint visiting, face to face
interactions and regular meetings: communication was seen to be an important factor
for collaborative working.
The best experience for me on reflection was during my time spent at the walk in
centre. These are centres that are nurse led where people can get advice for minor
illnesses and minor injuries without an appointment. The idea is to help people to
make the best use of health care services by educating and redirecting them to the most
appropriate level of care. The nurses that worked here had a broad range of nursing
skills an experience, had excellent communication skills, where autonomous and had
a good knowledge of the community and primary care issues. I feel that although
staff here had developed excellent assessment skills, nurse training is very different to
the training of what a doctor receives and that if mistakes were made it may leave
them open to litigation. If anyone was unsure of a patients problem, all members
would work extremely well together in order to decide either what was wrong or the
best course of action to take and where to refer them onto. Although Sinnes et al
(2002) suggests a common criticism of walk in centres is that they duplicate existing
services, the DOH state they are designed to provide a service that is complimentary
to the service provided by G.P.s and are not intended to replicate or duplicate existing
primary care services.
Another positive example for me was Sure Start, Sure Start is a radical an innovative
national strategy to improve services for children under four and their families. Sure
Start in North Huyton is a trailblazer programme and was established following
approval of the delivery plan in January 2000. The intention of sure start is to build
on and add value to local services for families through the provision of a more co-
ordinated approach to the planning and delivery of health and social care for parents
an carers where families are in great need, sure start will provide further support and
advise on parenting, primary health, early learning, play opportunity and childcare.
Sure start schemes also involve parents in supporting literacy, numeracy and life skills
training which can improve future employment prospects (Home Office 1998) and are
premised on all agency collaboration.
In accordance with the White Paper (DOTL 1997) it builds on existing local services
and partnership working between voluntary and statutory agencies, local business,
parents, community, voluntary primary health care teams, education and other care
professionals within the community, provide an integrated service that concentrates
resources on those in greatest need and promotes social change by addressing the
deficiencies associated with law social economic status (Whitehead 1992.). I found
sure start to be a help to families, single parents and foster parents. It can benefit the
children in terms of education and can bring parents all in different situations
together. I went along to baby massage, this was a group of mothers and their babies
being taught the technique of baby massage, developing confidence in responding
more sensitively to their children’s needs, and aiding attachment. During this group
session all the mothers were getting to know on another, one couple had met a few
weeks previously and had exchanged phone numbers, they had now become good
friends. I found this an excellent opportunity for the parents to make new friends. I
also went along to an aqua tots group were all parents, sure start reps, and children
played in the pool and sang songs which is educational for the younger children.
In conclusion, clearly collaboration has many benefits and during my placement
within the primary care I gained evidence to believe this. I feel that although there
has been a range of legalisation which places a great deal of emphasis on a
commitment to partnership between multi-professional teams there is still confusion
surrounding the boundaries of different services. Although the role of the nurse is
changing to fully and actively engage in collaborative practice it is essential that they
develop an understanding and awareness of the dimension and limitations of the
dimensions and limitations of other members of the multidisciplinary team. During
my placement, on the whole the experience was one of effective communication and
collaboration but there is obviously room for improvement.
