Community Nursing & Interdisciplinary working

Community Nursing & Interdisciplinary working

1. Interdisciplinary working

   • as apposed to InterPROFESSIONAL
     • Interdisciplinary involves non-professionals
   • What makes a good team?
     • joint decision making
     • good communication
       • reflecting back
       • listening
       • open to critisism
     • shared goals, clarity of vision
     • appropriate resources & procedures
       • e.g sick cover, your role is valued and they don't just crack on without you
     • The converse = poor morale + poor patient care
   • challenges
   • benefits
   • policies/strategies
     • Carers strategy
     • dementia strategy
     • E-health strategy
     • mental health strategy
     • changing Scotlands relationship with alcohol: framework for action
     • National drugs strategy for Scotland
     • Protecting vulnerable adults in Tayside/Fife. Inter agency adult support & protection guidance

2. Importance of the 2020 Vision

   • strain on resources
   • ongoing public health issues
     • drug & alcohol
     • obsesity
     • LTCs
       • cancer (now a LTC because people survive)
       • mental health
       • dementia
       • CHD
       • diabetes
     • ageing population
       • older carers
       • shift in demographic
       • more LTCs
     • co-morbidities
       • polypharmacy
       • physical/mental/social (think holistic)

3. Current challenges

   • lack of resources
     • while workload gets bigger
   • mixed, complicated packages of care
     • communication
       • difficulties sharing information
     • Remember sculpting. Do people want to deal with people they don't know? Especially if it's hard for them. Good to receive services from people they trust.
     • complex for staff, patients & co-ordinators
   • low morale due to organisational changes
     • leads to poor care
   • valuing advocating, education & EoL care, but lacking the time and therapeutic relationships
   • environment
     • resources, support, cleanliness etc.
   • concordance
     • instead of the word 'compliance', which sounds judgemental
   • short visits
     • not picking up on complexities
     • affects holistic care
   • health inequalities
     • lack of education/literacy
     • poor diet/lifestyle
     • not accessing services
       • reactive, not proactive
         • doesn't attend screening, accesses services inappropriately. more likely to present at A&E
       • doesn't want to be physically examined
       • not feeling empowered

4. Role of the nurse

   • assessment
     • carefully judged referrals
       • patient-centred
       • appropriate
       • lack of resources so may not get what you need
         • negotiation
       • Case Study - Harry, diabetic, doesn't take meds.
         • Social work
         • OT & PT
           • work together on balance
         • Day centre for socialising
         • venolink
       • specialist nurses as valuable resources
         • call for advice can be more appropriate than a referral

5. case conferences

   • meetings with all agencies present - WHO?
     • chair
       • can be anyone
     • care manager
     • client/patient
     • family
     • KEY WORKER
       • advocacy officer
       • police officer
       • housing officer
       • teacher/headmaster
     • HCPs
       • GP
         • often not available
       • DN
       • HV
       • AHPs
       • specialist nurse
     • Social care professionals
       • social worker
       • social care officer
   • why?
     • help resolve complex situations
     • safeguarding concerns
     • crisis/emergency
     • non-urgent
     • routine follow-up
   • What's discussed?
     • current situation
     • purpose of meeting
     • subjective experience
     • objective evidence
     • expectations
     • Assets
     • Challenges
     • options
   • Where?
     • home
     • ward
     • school
     • 3rd sector service
     • GP practice
     • SW department
     • care home

6. Different Roles

   • Specialist Nurse
     • dedicated area
     • often LTCs
     • experts
     • prescribers
     • referring patients for additional assessment
     • hospital or community based
     • What do they do?
       • e.g COPD
         • spirometry
         • diagnose COPD/asthma
         • prescribe inhaled meds
         • discuss self-management
         • referral to..
           • pulmonary rehab
           • smoking cessation
         • care from diagnosis to death
         • reduce hosp. admissions
   • Community Mental Health Nurse (CMHN)
     • plan & provide care at home
     • help people recover from illness/come to terms with it
     • can specialise e.g kids/older people/eating disorders
     • What do they do?
       • assess & monitor progress
       • medication management
       • evidence-based behavioural therapies
       • promote social activites
       • work with individuals, families, in conjunction with other professionals
       • aware of legal imperatives, act accordingly
   • School Nurse
     • work across education & health
     • link between school, home & community
     • from 5-19
     • additional public health training
     • healthy lifestyle choices
     • help kids reach potential
     • What do they do?
       • primary, secondary & tertiary health promotion
       • drop in for 1:1 support
       • jags
       • support kids with behavioural difficulties/additional health needs
       • support vulnerable kids/young people