Acute nurses' perceptions of assessment and rehabilitation

It is the Government's aim through the National Service Framework: Older People (DoH, 2001) to promote independence through effective rehabilitation services and to provide a cohesive service between the acute and community areas.

The author works in a general rehabilitation ward for older people in a local hospital that specialises in all types of rehabilitation and includes a day hospital and stroke unit. Patients are admitted for intensive rehabilitation from the acute care sector, which includes medical and surgical wards. It had been observed that some patients transferred to the unit for 'rehabilitation' had been told by nurses working in the acute sector that they were to be sent to the rehabilitation unit for 'assessment' and 'physiotherapy'. There is concern that acute nurses are purely looking to address the patients' functional abilities, primarily mobility, while having little understanding of what rehabilitation is (Nolan and Nolan, 1997).

This paper will attempt to define rehabilitation and why it has a low priority within nursing. It will discuss ways of improving the profile of rehabilitation and raising disability awareness among acute nurses. For the purpose of this paper 'acute nurses' are defined as those who work in acute settings caring for acutely ill patients (English National Board, 2001).

Literature review
A literature review using Cinahl and Medline was conducted using the following search strategy: all electronic searches initially were limited to British journals from 1995 to the present day. However, this proved too restrictive and therefore the search was expanded to 1987 and included the terms 'rehabilitation' and 'nurses' perceptions'. There was little specific information in these areas although the term 'rehabilitation' generated large volumes of material. The search facility offered by the Royal College of Nursing was used for a second search. Subject references given were 'nurse perceptions/ attitudes on what is the meaning of rehabilitation in the older person'. Research had been conducted in all four countries of the UK. This gave an overview of the views and perceptions that nurses have about rehabilitation.

Definition of rehabilitation
There is no one universal definition of rehabilitation. The one favoured by the King's Fund is: 'A process aiming to restore personal autonomy in those aspects of daily living considered most relevant by patients or service users and their family carers' (Sinclair and Dickinson, 1998).

This definition encapsulates the very essence of attempting to give back independence to the patient and his or her family in what is important to them. Rehabilitation is concerned largely with physical functioning, although other aspects of care are addressed, including hope and motivation (White and Johnson, 2000).

For some nurses the concept of rehabilitation is so unfamiliar that even experienced nurses require orientation when entering this specialty (Sheppard, 1994; Habel and Garland, 1990). Research suggests that nurses in a general nursing environment believed they gave appropriate care to the disabled client and did not identify disability as a problem (Davis and Marsden, 2001). The reality was different with the authors observing practice demonstrating a lack of disability awareness.

In a rehabilitation setting nurses found that the support and encouragement aspects of care took priority over the physical aspects, thus 'enabling' a patient to become independent to return home (Johnson, 1995). This is a very different way of nursing from acute care nurses' 'hands-on' approach, and one which does not sit comfortably with some nurses (Eshun, 1999).

The nurse's role in rehabilitation
Walker (1995) believes that the re-establishment of the activities of daily living after an illness brings all three therapists (nurses, physiotherapists and occupational therapists) together to assess and implement interventions required. However, this is where some confusion over roles occurs. Assessing dressing and undressing is part of the nurse's and of the occupational therapist's role, while an assessment of a patient getting in and out of bed crosses into the physiotherapist's province. In some studies nurses were unable to define their role in rehabilitation (Waters and Luker, 1996; Johnson, 1995). One study found nurses focused on the physical activities of daily living and staffing roles in rehabilitation. The role of the nurse in providing 'hands-on' care was described as 'general maintenance', where the nurse attended to the personal hygiene and nutritional status of the patient and guaranteed an unsoiled bed (Waters and Luker, 1996). Continence management was perceived by some to be 'dirty work', resulting in the low status of the rehabilitation nurse (Johnson, 1995).

Rehabilitation is perceived by some nurses to be physiotherapy (Walker, 1995). The Audit Commission (2000) depicts the role of the physiotherapist as attempting to decrease impairments associated with movement achieved through assessment and goal planning. This cannot be achieved by one profession. Goals may be planned but not implemented if team players do not appreciate the dynamics of other therapy disciplines.

Assessment
The preliminary stage in the rehabilitation process is assessment, a process that identifies impairments and disabilities to enable the multidisciplinary team to execute a plan of care (Sinclair and Dickinson, 1998). Cognitive status also needs to be determined during assessment, as this will affect the level of a patient's motivation (Resnick, 1998). The assessment process does not usually address the patient as a whole. This is due to the model of nursing/rehabilitation used.

Acute care has been described as having a visible role where nurses provide 'hands-on' physical care (Sheppard, 1994). With rehabilitation care, however, the opposite occurs with the nursing role becoming less visible over time as the patient progresses (Johnson, 1995; Woodrow, 1996). When this occurs the rehabilitation nurse intentionally steps back from providing physical 'hands-on' care and increases the provision of psychological and emotional support (Sheppard, 1994). An example in practice is withdrawing the offer of help with getting out of bed and going to the bathroom to get washed and dressed, a normal aspect of daily living. To those not used to rehabilitation nursing this could be perceived as the nurse not 'caring', whereas the nurse is in fact 'enabling' the patient to achieve full autonomy and as much independence as possible.

A philosophy of rehabilitation is required (Box 1).

Models of nursing/rehabilitation care.
To assess a patient the nurse needs to work from a model of care. The Roper, Logan and Tierney (1996) model of nursing is well known to all nurses in a variety of settings. However, it is often perceived to be deficient in rehabilitation because activities of daily living concentrate on physical aspects of care. An holistic approach containing psychosocial and spiritual aspects is required. Hoeman (1996) and Hancock (2000) state that Roy's Adaptation Model takes a more holistic approach in a rehabilitation setting but is limited if an interdisciplinary team model is used. A 'trajectory model' is a potential alternative. This incorporates the family's views and highlights coping mechanisms used by the patient (ENB, 1997a).

Nurses working in an acute care environment continue to use the medical model as a framework that is appropriate to their environment. Barnitt and Pomeroy (1995) suggest nurses, relatives and patients are looking for alternative ways of functioning jointly beyond a medical model of nursing, which they perceive as inappropriate in a rehabilitation setting. Patients should be empowered and given autonomy that could be explored in a social model. The medical model looks at the human body in systems; however, although functional status is perceived by the patient as important (Dewing, 1992) little thought is given to other concepts particularly relevant to the rehabilitation patient, including hope and motivation. Hope is entwined with a person's spirituality (Narayanasamy, 1996; Scrutton, 1995) and gives purpose to life. Morrison and Cowley (1999) suggests that nurses who choose to practise in acute care are acknowledging their preference for technological care at the expense of interpersonal facets of care. Cutcliffe (1996) suggests that this non-acute 'interpersonal' nursing could be perceived as being of low status.

Improving the profile of rehabilitation
Acute care has always been perceived as more prestigious than elderly/rehabilitation care, a view held by many nurses (Nolan and Nolan, 1999). Nurses used to working towards achieving a 'cure' may perceive elderly/rehabilitation care, where a cure is not the aim, of less importance. However, for a person who has had a stroke a cure is not an option. What the patient now needs is intensive rehabilitation to obtain his or her maximum functional ability with input from all therapists (nurses, physiotherapist and occupational therapists) and involvement of the family while coming to terms with an altered body image.

Communication is a key aspect of the rehabilitation nurse's role. Time spent with the patient can explore non-physical aspects of care, for example hope and motivation, which White and Johnstone (2000) believe assists emotional adjustment. However, it is this 'time' factor that may be lacking in the acute care role. Waters and Luker's (1996) study demonstrated that nurses perceived rehabilitation to be an extended role when time permitted instead of integral to their role. The nurses did not believe they made a major contribution to rehabilitation and considered the work of therapists to be more important. It could be argued that lack of time or inappropriate use of time prevents a cohesive service being provided.

The Royal College of Nursing (1997; 2000) has attempted to raise the profile of the rehabilitation nurse by identifying what it is that such nurses do. This is recommended reading for all nurses since rehabilitation affects all areas of nursing.

Disability awareness
Disability awareness among acute care staff will enhance the standard of care given to disabled patients who are nursed in the unsuitable environment of acute care while awaiting transfer to a rehabilitation unit (Davis and Marsden, 2001). This environment can be enabling or disabling to a person in maintaining their independence (Biley, 1995). There may be a lack of suitable equipment that allows a disabled person to maintain their independence, such as fixed bars on the walls in the toilets and washrooms.

Orientation programmes organised for new staff members on entering a trust should continue to include disability awareness. This will enlighten new staff, but what about existing staff? Spending a day rotating between disciplines would give some insight into the various roles therapists play and would acknowledge role overlap. This may prove useful in breaking down barriers.

Nurse education
There has been a lack of educational input into rehabilitation nursing (Smith, 1999; Thorn, 2000). The English National Board (1997b) commissioned a project to explore the nurse's role in rehabilitation within a multidisciplinary team to establish the educational input into pre- and post-registration courses. Their research acknowledged not only the lack of input needed into disability and chronic illness but identified the need for two distinct nursing roles - 'generalist' and 'specialist', the role of 'specialist' requiring further education and practice (Miller, 1995).

Conclusion
Action needs to be taken to raise the profile of rehabilitation in an acute care environment, giving it the importance that it deserves, improving the standards of patient care and providing the nurse with an understanding of rehabilitation and the assessment process involved. Research shows that acute nurses generally perceive rehabilitation in purely functional terms with 'time' quoted as a barrier to developing patient involvement. Holistic care is clearly lacking where areas of motivation and hope are concerned. The therapist roles overlap with those of the nurse and should not be viewed as separate but as complementary to each other. All parties should agree common goals with the patient. The Government has outlined its aims and objectives in achieving this (DoH, 2001), recognising individuality when providing quality of care. The nurse must be able to describe/define the nurse's role within the multidisciplinary team.

Further research is required in the area of nurses' perceptions and rehabilitation to gain greater insight and understanding in order to raise the profile of this much-needed service.

- For further details on the rehabilitation degree at Canterbury Christ Church University College, write to the college at North Holmes Road, Canterbury CT1 1QU, Kent, or:

Tel: 01227-782848 Fax: 01227-782632 www.cant.ac.uk

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