A World Apart: How Occupational Therapists, Nurses and Care Managers Perceive Each other in Acute Health Care

Multidisciplinary teamwork is one of the key processes through which care is managed in the British National Health Service. Working in a multidisciplinary team requires many skills, which include understanding not only one's own role but also that of other professionals. The aim of this paper is to provide an understanding of occupational therapists', nurses' and care managers' perceptions of each other and how these influence interprofessional relationships.

In total, nine occupational therapists, nine care managers and 19 nurses within an acute physical health care setting were interviewed using the critical incident approach. The findings revealed that the interprofessional relationships between nurses, care managers and occupational therapists were often problematic owing to role confusion and competing priorities, which influenced communication.

To prevent role ambiguity, occupational therapists must define their role clearly. It is suggested that multidisciplinary team members need continuing interprofessional education in order to understand the changing roles in the National Health Service.

A poststructural rethinking of the ethics of technology in relation to the provision of palliative home care by district nurses

Technology and its interfaces with nursing care, patients and carers, and the home are many and varied. To date, healthcare services research has generally focussed on pragmatic issues such access to and the optimization of technology, while philosophical inquiry has tended to focus on the ethics of how technology makes the home more hospital like. However, the ethical implications of the ways in which technology shapes the subjectivities of patients and carers have not been explored. In order to explore this, poststructural theory, in particular the work of Butler, Foucault, and Deleuze, is used to theorize the relationship between subjectivity and materiality as ethically mandated on producing rather than precluding the development of subjectivities in novel ways. This theoretical understanding is then utilized through a process of 'plugged in' as described by Jackson and Massie that aims to link empirical data, research, and philosophical inquiry. Through this process, it is suggested that power, which the empirical data demonstrate, is frequently exercised through medical discourses and restricts patients' and carers' ability to shape the material environment of the home as a place to live and be cared for in palliative stages of illness. Alternative discourses are suggested both from the empirical data as well as other research, which may offer patients and carers the possibility of reclaiming power over the home and their subjectivities. Finally, the dichotomy between the home and hospital, mediated via technology, is posited as being problematic. It is argued the dichotomy is false and should be moved away from in order to allow an ethical embrace of technology in palliative care.

'I can't walk away': understanding the complexities in embedding a new nurse role

BACKGROUND

The community matron (CM) role was introduced in England to provide a single point of access to patients living with comorbid long-term conditions who had, or were at risk of, frequent emergency hospitalisation.

AIM

This study explored the factors that affected embedding of the CM role. The qualitative study was undertaken in community health services in two cities and a rural area in central England.

METHOD

Participants comprised health professionals (n=30) including CMs, community service managers, and service commissioners; patients (n=10); and their family carers (n=5).

RESULTS

Findings reveal that participants were largely positive about the role. However, difficulties with role setup had led to numerous changes in service delivery, which affected how the role has embedded.

CONCLUSION

Many aspects of the CM role are invisible to other health professionals. Invisibility of community nursing, rather than autonomy of the CM role, seems to be a key factor in the challenges of embedding the role.

Does nursing leadership affect the quality of care in the community setting?

AIM

To examine perceptions about how nursing leadership affects quality of care in the community setting.

BACKGROUND

Quality care is considered an essential component of nursing work and recent policy has emphasized the role of leadership in meeting the quality agenda. As shifting the balance of nursing care from the hospital to the community occurs in the UK, there is an imperative to confirm more effectively the quality of care that patients and families receive from nurses working in the community.

METHODS

A qualitative study involving community nurse leaders (n = 12) and community nurses (n = 27) in semi-structured individual interviews (n = 31) and three focus groups (n = 13).

RESULTS

Tensions exist between 'leading' for quality care and 'delivering' for quality care. Organisational decision making is challenged by limited measures of quality of care in the diverse roles of community nursing.

CONCLUSIONS

Frontline community nurses and nurse leaders need to articulate how they intend quality of nursing care to be appreciated and actively indicate ways to show this.

IMPLICATIONS FOR NURSING MANAGEMENT

Mechanisms to monitor patient safety, a key aspect of the policy agenda for quality care and other technical aspects of care are important for nurse leaders to develop with frontline community nurses.

Maintaining the continuity of care in community children's nursing caseloads in a service for children with life-limiting, life-threatening or chronic health conditions: a qualitative analysis

AIMS AND OBJECTIVES

To explore the factors that influence community children's nurses' (CCNs') perceptions of their workload. To identify ways that CCNs develop and maintain continuity of care and carer.

BACKGROUND

The notion of continuity of care/carer has been central to nursing development for the last 30 years. In the literature, community nursing is used to illustrate the concepts of responsibility relationships and continuity of care/carer. However, an assumption is made that the case allocation method is assumed to be the norm in community nursing. The recent UK literature indicates that the case allocation method is not necessarily working in community nursing. It suggests that there may be continuity of care via teams of community nurses and health care assistants, but not necessarily continuity of carer. This seems to reinforce the notion that ideas about the nature of nursing work, the relationship between nurse and client and the mode of care are constructed, contextual and not self-evident. Little has been written about this regarding CCN work.

DESIGN

Collaborative action research design using qualitative methods.

METHODS

In depth interviews with six CCNs drawn from a NHS funded, PCT hosted CCN service in the West of England; documentary analysis of caseload data; thematic analysis of analytical memos and field-notes.

RESULTS

The analysis of the CCNs' interviews identified the mechanisms and strategies they used for managing their work, meeting clients' needs while ensuring that continuity of care and carer was maintained. From their responses to questions, the responsibility relationship and autonomy characteristics of their role were perceived to be a good thing. However, they acknowledged that working in such a way is stressful and provided examples from their everyday working lives. They emphasised the role of support from colleagues as an important way of maintaining and sustaining the responsibility relationships inherent in their work pattern.

CONCLUSIONS

The findings from this study seem to support the notions prevalent in the literature that ideas about the nature of nursing work, the relationship between nurse and client and the mode of care are socially constructed and automatically given. The group of CCNs in this project actively manage their caseloads to maintain the continuity of care and carer in a particular model of service delivery.

RELEVANCE TO CLINICAL PRACTICE

This project provides some illustrations of the way continuity of care may be achieved at the informational, management and relational levels of practice. The typology of continuity of care allows the discrete areas of CCN work to be highlighted and explored, providing insights on an area of practice that is under-reported. The study provides a basis for future research to examine the different configurations of CCN services for the same client group or services for different clients, e.g. diabetes care, so that service providers may configure provision to meet children's and their family's needs.

Changes in patterns of knowing the patient: the case of British district nurses

British district or home nurses, have until recent years been hidden from the wider context of the British National Health Service. Policy changes in UK over the last two decades of the 20th century have increasingly focussed on Primary Care Services and district nurses (DNs) have seen substantial changes to their workload. This paper addresses the question of how the changes in the organisation of Primary Care Services affected some aspects of DNs' work. Thus, the focus of this paper is an examination of the relationship DNs had with patients through a period of turbulent change. Knowing the patient is a central element of nursing practice. Data are presented here form a multi-site ethnographic study of DNs' work undertaken in four purposively sampled study sites. Applying Carper's (1978) framework, the data presented here show that there has been a shifting emphasis in knowing the patient from aesthetic and personal knowing to knowing about and empirical knowing.

The role of district nursing: perspectives of cancer patients and their carers before and after hospital discharge

The role of the district nurse (DN) is difficult to define. Knowledge about the perspectives of patients with cancer, and their informal carers, on the roles of DNs and community services is lacking. The aim of this study is to identify the roles of DNs and community services as perceived by patients with cancer and their carers before and after hospital discharge. Seventy-one pre- and post-discharge conversational interviews were conducted with cancer patients and carers, and analysed thematically. Some interviewees lacked knowledge about services, were confused about differential roles and/or held stereotypical views. Some failed to disclose needs to services, received insufficient support or experienced unnecessary and inconvenient visits. Patients with few or no physical care needs were surprised to receive DN visits. Those receiving personal care from agency carers expressed dissatisfaction. Cancer patients and carers may benefit from post-discharge/ongoing assessment by DNs. However, effectiveness could be inhibited by limited disclosure caused by confusion, stereotyping, negative experiences and ideas that other patients have greater needs. Information might diminish these factors but, first, services need to clarify their roles. Organization and delivery of personal care services varies locally and DNs provide personal care during terminal illness. Community services should perform intra- and interservice clarification before publicizing differential roles to cancer patients and carers. This might facilitate disclosure of need to DNs. Patient and carer needs for information on service roles, and patients' preferred roles in self-care are under-researched.