Primary Care is described as comprehensive health care for individuals and families in the community provided through an integrated network of services covering the common illnesses and injuries, maternal and child health problems, the care and rehabilitation of people with long- and short-term handicaps and disabilities, and health education. (Oxford Dictionary for Nurses, 2003)
For the purpose of this paper, the issues being discussed will be; safety, communication, collaboration, assessments and referrals. Each issue will be discussed in detail and explore why it is important that these topics are followed.
There are several issues surrounding safety in the community that a nurse must consider when making a visit. These issues include:
1. home setting of the patient;
2. social influences including drug use and violence;
3. health and safety regulations;
4. Nursing supervision and backup.
Burton et al suggest that nursing supervision in primary care is different to that of hospital care due to the Nurses close relationship with the General Practitioners (GPs), and the isolation which a Nurse working in primary care has to endure. Clinical supervision is described as “a method of support which enables nurses to develop their skills, knowledge and professional understanding.” (UKCC 1996)
All Nurses working in primary care has some sort of supervision whether it is senior members of staff or GPs.
Proctor, 2001, suggests that supervision has three main purposes which include;
1. Normative – helping people to aspire to quality standards
2. Formative – helping people in their professional development
3. Restorative – offering people support in the difficulties they experience
In Proctors thinking, supervision is about empowerment of nurses and helping them be safe and competent at all times.
It is paramount that a patient, and a nurse, remains safe at all times during a visit, whether it be a District Nurse (DN) a health visitor (HV) or a Midwife. In the case of a DN visiting a patients home, safety measures would be put in place as to moving and handling, if necessary, such as Slide sheets and Hoists, etc.
Health and Safety Regulations
In terms of safeguarding themselves, Nurses must be aware of the Health and Safety Act (1974). The Health and Safety Act states that “it is the responsibility of individual employees at every level to take care of their own health and safety at work and that of others who may be affected by their acts at work.”
A nurse must be aware at all times of a patient’s home setting. This could be the most dangerous setting that a community nurse has to encounter.
The Health and Safety Executive (1998) document suggests seven aims in which to improve safety in the workplace for nurses and other occupations. These include:
1. introduction of sustainable procedures;
2. systems and campaigns to address specific occupational health issues;
3. Assessment of workplace health and potential risks to the health of employees.
When a nurse enters a home environment, they must make a first assessment of the home and see if it is a suitable workplace for them and if not would urge to patient to visit the clinic for treatment. If this is impossible for the patient to do, then more risk assessments would be needed and the appropriate equipment would have to be ordered.
An example of this is the use of hospital beds at home for palliative care patients and also the use of hoists and slide sheets. This not only promotes the health of the nurse, but the health of the patient.
Social Influences to care
This includes the use of drugs in the home and what a nurse should do to safeguard herself and the patient.
Andalo (2004) states “Nurses can refuse to make home visits to patients who smoke, according to new guidelines to be issued by the Royal College of Nursing. The move follows the government’s public health white paper which promised to create a smoke-free NHS work environment by 2006.” It has been suggested that many nurses feel uncomfortable asking a patient to stop smoking in their own home whilst they are on a visit there and this ruling should make it easier for the patients home to be a smoke free environment in time for the nurses arrival.
Communication is one of the most important skills a nurse will have to learn throughout her career. This is even more important in primary care and a community setting. Sometimes the isolation in which a primary care nurse encounters can make it increasingly difficult to communicate effectively.
Burke (2001), suggests that communication between nurses and doctors is not straight forward due to the differences in power and status. Salvage et al (2001), agrees with this notion and believe that there comes a time when doctors and nurses have to let go of their issues with eachother and try and resolve situations to improve the health of the patient.
Ways of communicating
There are several different ways of communicating. The main ways are verbal, non-verbal and written.
Verbal communication would include talking to the patient and asking them for information about their care needs and also personal information. Non-verbal includes the use of open edened questions, the use of empathy, listening to the patients needs and reflecting on what the patient has said. Listening creates empathy, unconditional positive regard and genuininess. This helps build relationships and trust with the patient and is a key factor when treating a patient. Written communication would be used when referring a patient onto another section of the Multidisciplinary Team for specialist care, or writing a prescription request for the patient.
Problems with Communication
Unfortunately, there are barriers to listening such as, some features of the patient which makes it hard to listen (speech impediment), concentration starts to wonder to other things and something said that may trigger off personal experiences and make the converstion then focus on the nurse, rather than the patient.
There are several influences in practice that a nurse must take into account when communicating with a patient and other colleagues. These include:
1. Education in theory and practice – learning how to communicate well;
2. NMC guidelines – communication must be confidential
3. Social background – how does the patient like to be spoken to, a nurse should be able to know their limitations with this
4. Peers – how to speak to people of the same age, some patients can feel intimidated by nurses and the way they are spoken to
5. Experiences and how we learn from our mistakes – learning through experience of how to speak to a patient and other health professionals.
These factors can be useful to remember when communicating with patients.
Collaboration is the process of two or more people working together aiming towards a common goal by sharing knowledge, learning from each other and building relationships.
Johnson (1994) argues that collaborating is the best way to avoid conflict and achieve long-term benefit for the patient’s health.
Langford (1981) has outlined nine key points which he believes are essential to the collaborating process. The nine points are:
1. Define a common goal on which both parties can agree;
2. Mutually respect the knowledge and expertise of all parties;
3. work together and review the goal once it is reached;
4. communicate honestly and openly;
5. have equitable, shared decision making powers;
6. share knowledge;
7. offer support;
8. understand the language and terms inherent;
9. have mutually acceptable roles.
Collaborating would include deciding the best treatment for a patient with other members of the MDT and then coming to a conclusion based on everyone’s opinion. Case conferences would also be a form of collaboration.
Problems with collaboration
Hollins (1998) notes that nurses working in primary care need access to both support and expertise regarding learning disabilities. This therefore proves that there needs to be an understanding of all the available support and specialist advice a nurse can access if they need to do so.
Zwarenstein suggests that problems with collaboration are common and widespread. This statement agrees with Hollins’s theory and shows that nurses need to be made more aware of services available to them and the patients.
Primary Care nurses have to complete many assessments for a patient when they have been admitted into their care.
Assessment tools are put in place for nurses to follow which help them make comprehensive decisions as to what the patient prefers and requires in regards to specialist care.
Types of Assessments
The Department of Health defines an assessment tool as a “collection of scales, questions and other information, to provide a rounded picture of an individuals needs.”
Examples of assessment tools are:
1. Pain assessment tool – a patient will be asked on a scale of one, being the least pain, and ten, being the most pain, how they feel. This will allow the nurse to collaborate with the GP and get the best pain control for the patients needs.
2. Continence assessment – a nurse will give the patient several pieces of documentation to follow through the course of a week, giving information about the urgency they feel when going to the toilet and how much they drink a day. This enables the nurse to make an informed decision as to what continence care is needed and if a specialist nurse needs to become involved.
3. Pressure sore risk assessment – this allows a nurse to decide what pressure relief a patient may require whether it is a cushion or a mattress etc. A nurse will ask the patient about their habits in terms of activity and then investigate the skin condition and make a decision from there. If it is needed, a referral to the Tissue Viability Nurse (TVN) will be made.
4. Nutritional assessments – these allow nurses to monitor the nutrition of the patient and this may then allow the nurse to prescribe build-up drinks to aid the nutrition of the patient and also a referral to the dietician would be performed.
These are just a few examples of the different scales a nurse must be aware of and know how to use effectively. All of these assessment tools can lead to referrals to promote the patients health and give them the specialist care they need.
Boaden, suggests that “GP awareness was high in relation to referral for secondary medical care… GPs were less aware in relation to other subsystems such as community services and wide areas of assossiated care.” This indicates that GPs are generally unaware of the referrals that they can make to Primary Care Trusts to reduce the number of patients in hospital. Boaden then goes on to say “the result has been highly diverse patterns of referral, with varying degrees of awareness about the suitability of a referral, with consequently varied health outcomes.”
This suggests that patients do not get the quality care they need due to uninformed and illogical referrals made to the wrong types of people. This is why nurses have assessment tools, to aid in making the correct referrals.
How referrals are made
Referrals can be made in different ways. A nurse generally makes referrals for the patient to specialist nurses such as the TVN or the Diabetes Nurses. These referrals can be done by fax, by letter or by phoning the nurses direct in extreme cases. However, a patient can self-refer to District Nurses and Social Services. This can be done directly to the district nursing team or through PALS (Patient Advice and Liason Service). Patient Advice and Liaison Services (PALS) provide information, advice and support to help patients, families and their carers.