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Improving rehabilitation care

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VOL: 97, ISSUE: 04, PAGE NO: 37

Jackie Bridges, BNurs, MSN, RN, RHV, is lead research and development nurse, care for older people, Barts and The London NHS Trust

Jasmine Smith, RGN, is ward manager, Homerton Hospital, London;Julienne Meyer, PhD, RN, RNT, is professor of adult nursing andChristine Carter, MSc, BSc, RMN, is a lecturer, Barts and The London NHS Trust

The forthcoming National Service Framework for Older People will focus on the need to ensure the quality of long-term care for elderly patients, but research has revealed a gap between what is known to be best practice and the care that is delivered.

The forthcoming National Service Framework for Older People will focus on the need to ensure the quality of long-term care for elderly patients, but research has revealed a gap between what is known to be best practice and the care that is delivered.

In an action research study carried out on a rehabilitation ward for older people, patients' accounts of their experiences were used to prompt reflection and changes in care by nurses (see the first article in this series for details of the study's background and methodology).

Three main sets of data emerged from the findings. These were:

- Nurses' accuracy when referring;

- The unmet psychological needs of patients;

Barriers to the provision of psychological care.
This article will discuss these barriers.

Barriers to psychological care

The study identified a number of factors that contributed to the psychological needs of some patients not being met. These included:

- Changing roles in the nursing team;

- Lack of time;

- Communication difficulties;

- Lack of skills or knowledge in some areas.

Changing roles in the nursing team

High sickness and vacancy levels meant that care was often supervised by only one of the ward's nurses, with most of it being delivered by health care assistants (HCAs) and agency staff. Nurses compensated for a lack of time to spend on direct patient care mainly by trying to influence the practice of other staff members (Box 1).

Although both the nurses and HCAs had devised ways to ensure that acceptable physical care was provided within a rehabilitation model, it was more difficult for the nurses to coach the HCAs in quality psychological care.

One nurse mentioned that direct care activities, such as bathing, could be used to develop relationships with patients and encourage them to explore their concerns, but discussions with the HCAs revealed that their priority was physical care.

The findings also reflect the challenges nurses faced in their developing role as supervisors of care and reveal that the HCAs used their personal knowledge of individual patients' needs to inform their care delivery.

Lack of time

Nurses and HCAs continually pointed out that it was difficult to find the time to sit down and talk to patients. One charge nurse commented: 'There are patients that want your attention for 10 or 20 minutes and you are aware that you have somebody else waiting. I still sometimes see talking to patients as a hurdle as you are always struggling to get away. I think the downside is that you spend more and more time with them and less and less time doing what you know you have to do.'

Communication difficulties

Many patients had difficulties communicating the nature of their experiences or understanding the questions put to them. This was usually because of deafness, speech difficulties and/or cognitive impairment.

The researchers, all highly skilled nurses, sometimes spent up to 45 minutes with one patient but emerged with little information. They then had to return later to gather more information.

These difficulties reveal the obstacles that nurses, who are often short of time, may face in communicating and developing relationships with patients.

Lack of skills or knowledge in some areas

The nurses were confident of their ability to provide physical care and identify patients whose psychological needs were not being met. But they were less confident of their ability to provide advanced psychological care.

This was partly due to the high proportion of patients on the ward with a cognitive impairment and prompted the staff to invite input from Christine Carter, a specialist nurse and lecturer in the mental health of older people. Although she was asked to focus on patients with a cognitive impairment, the nurses found that she also offered expert advice on psychological care (Box 2).

There was never a lack of patients to refer to Ms Carter, raising questions about the split in service delivery between mental and physical care.

These findings reflect those of Bennett (1996), who found that nurses on a stroke rehabilitation unit felt they lacked the skills to manage patients who became depressed after a stroke. It may be unreasonable to expect ward nurses to possess a full range of psychological skills (Cotter, 1998). Widely available input from specialist mental health nurses may be more effective.

Other barriers
Some studies have shown that health care professionals may unconsciously avoid meaningful interactions with patients to prevent psychological or emotional pain (Cotter, 1998). Although those involved in this study did not believe that this was the case, all nurses should be aware that it could influence their practice decisions. This also highlights the need for nurses to receive psychological support at work, an issue that will be explored in the final article in this series.

Conclusion
This article explores the gap between some patients' need for more advanced psychological care and nurses' ability to deliver it.

The ward's skill mix and recruitment problems prompted staff to extend their roles to counteract the nurses' lack of direct patient contact. Although these role developments ensured good physical care, other factors meant that nurses were unable to meet patients' psychological needs.

- The first article in this series appeared on January 11. Next week: The study outcomes and other lessons learned

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