VOL: 99, ISSUE: 17, PAGE NO: 33
Bill Watson, MSc, RGN, is senior lecturer, Northumbria University
Alisa Mylotte, MSc, RGN, is respiratory nurse specialist, Northumbria Healthcare Trust;Susan Procter, BSc, PHD, CertEd, RGN, is associate nursing director, Gwent Healthcare NHS Trust
Chronic illness is increasingly recognised as one of the most important health issues facing western society (British Medical Journal, 2002; McWilliam et al, 1996; Newby, 1996). Chronic obstructive pulmonary disease (COPD) is a classic example of a chronic illness. Like other chronic conditions it requires ongoing input and support from a range of health care services.
- Promotion of activity - such as taking patients out for short walks on flat ground;
- Promotion of independence - actively encouraging patients to undertake activities of daily living (self-care, shopping, climbing stairs and gardening) with decreasing support and assistance over time;
- Increase of socialisation - such as taking patients out to the library or organising social activities for groups of users;
- Maintenance of physical health - such as promoting and supervising nutritional intake;
- Carer support - providing respite care so that the main carer could take time out.
- Provision of short-term input - where the service is being accessed for specific, time-limited reasons, such as following hospital discharge or temporary absence of the main carer;
- Provision of ongoing input - where disease severity, level of personal or family resources, or the patient’s concurrent medical or social situation requires a constant level of input from the service. A small number of people in this category were referred on to other services, such as residential care, when it became apparent that their needs could be met more efficiently elsewhere;
- Fluctuating provision - where patients determine their own level of access. This may mean that they effectively discharge and re-refer themselves over time, or that they receive a ‘baseline’ level of input, which is increased at times of greater need;
- Their current level of functioning;
- The types of input they had received from the service;
- The ways they felt the service had helped them;
- Their general perceptions of the service in terms of its impact on their quality of life and its importance to them.
- Funding streams: health and social care do not currently have shared funding. Tensions have arisen over the relative contributions each sector makes to the service budget.
- Genericism vs specialisation: policies founded upon a generic social care model may not recognise the scope of professional practice issues that arise from a clinical specialist model of practice. The Code of Professional Conduct specifically states that nurses must acknowledge the limits of their professional competence and only undertake practice and accept responsibilities for those activities in which they are competent (Nursing and Midwifery Council, 2002). The RNS has been asked by her social service manager to assess non-respiratory clients. She considers this outside her professional scope of practice and feels compromised by the request. Social services do not have the budgets required to recruit nurse specialists to cover every chronic disease and therefore the replication of this model of service provision to other chronic diseases is doubtful.
- Liability: an organisation’s policies provide safeguards for its ‘native’ forms of practice. They may not provide appropriate legal safeguards for the realities of multi-agency practice exemplified in the secondment described in this article.
- Outcomes: establishing this service within local authority community care effectively set up a two-tier local authority system with patients diagnosed with COPD receiving a highly individualised and responsive service known locally as the ‘deluxe’ service. This service replicates the principles of universal access based on need that characterises NHS provision.