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Using appropriate literature this paper will examine intermediate care and critically analyse interprofessional working in the care of adults. An introduction to the area of intermediate care will be given and Interprofessional care will then be examined using various sources of literature. This paper will conclude by looking at the implications raised and examine future implications for nursing practice.
Making a Difference (Department of Health (DH) 1999) suggests that effective care is the product of interagency working. Professionals working in collaboration provide care which is designed to meet the needs of the patient. This concept was further promoted with the publication of The NHS Plan (DH 2000a) a ten year programme of reform practice. The NHS Plan (DH 2000a) aimed to create a service designed around patient needs, encouraging professionals to work together to meet the needs of patients. This shift in attitudes towards healthcare was instrumental in shaping the way in which interprofessional working is viewed and adopted today.
The NHS plan (DH 2000a) introduced the involvement of interprofessional education within healthcare. Investment and Reform for NHS Staff – Taking Forward the NHS Plan (DH 2001a) has since been produced and confirms a continuing commitment to developing and introducing common learning programmes in healthcare. Undergraduate education now incorporates interprofessional modules within programmes in an attempt to introduce students to the concept of accepting interprofessional working and promote understanding of roles within healthcare. It is thought that this understanding encourages a team approach to patient needs where information and knowledge is shared to enable improved decision making regarding patient care (Spry 2006). Meeting the Challenge: A Strategy for the Allied Health Professions was also produced and gave guidance on interprofessional education and training whilst stating that this was a sign of the governments’ commitment to modernisation to meet the needs of patients (DH 200b). However this undergraduate education is offered within universities whom may choose not to incorporate a fully interprofessional level of education. It can therefore be assumed that not all healthcare professionals within undergraduate education are involved in interprofessional education.
Barr (2004) points out that interprofessional working enables professional benefits, with reference being given to the sharing of knowledge and the opportunities to experience areas of work outside ones own remit. It is suggested that professionals may have levels of improved job satisfaction and increased levels of confidence in dealing with difficult situations. Barr (2004) also expresses a view that interprofessional education is collaborating learning in order to enable collaborative practice.
McWilliam et al (2003) suggest that interprofessional working is extremely challenging in the workplace, and not an easy concept for healthcare professionals to adopt. It is argued that interprofessional working is not being delivered to patients within hospital environments due to healthcare professionals misunderstanding the policies, education and research regarding interprofessional working. It has been suggested that this is due to the lack of support and training from managers and that managers should involve staff in changes within practice and that this involvement facilitates co-operation (Deegan et al 2004).
Intermediate care is described as the provision of care in a setting which is between the home and hospital and is designed to manage inappropriate hospital admissions within the care of older people (Hancock 2003). It is suggested that as there is an aging society this provision of care meets the needs of older people whilst ensuring adequate care is provided (Wade & Lees 2002, Hancock 2003) Patients within intermediate care do not require a high level of medical input and often require rehabilitation following an episode of illness ( Neno 2005). It is recognised that intermediate care involves a system of interprofessional team working (Hancock 2003) and intermediate care always includes a form of rehabilitation with the involvement of professionals such as occupational therapists, physiotherapists, and speech and language therapists (DH 2001).
Plans for improvement and investment in intermediate care were identified within The NHS Plan (DH 2000a) and extra funding was supplied to meet this improvement. The NHS Plan (2000a) suggested that providing increased levels of intermediate care would enable patients to gain quick access to healthcare when needed and enable patients to return to independent living quickly. It is also suggested that health and social services working together can improve the patient journey within intermediate care (Hancock 2003).
The National Service Framework (NSF) for Older People (DH 2001) identifies eight standards and standard two is person – centred care. This standard aims to ensure that older people are treated as individuals and that they receive appropriate and timely packages of care which meet their needs as individuals, regardless of health and social services boundaries. This is suggestive of interprofessional care, where the needs of the patient are met by a team of various professionals (Neno 2005). Intermediate care is the focus of standard three of the NSF for Older People and aims to provide an integrated service to support discharge from acute hospitals and a return to independent living (DH 2001b). A single multi-professional document should be in use within intermediate care identifying clear goals and individual patient needs (DH 2001b)
A study by Nancarrow (2004) looked at the impact of intermediate care delivery on role boundaries of service providers. It was found that members of the interprofessional team were not threatened by role overlap and that role overlap was commonly undertaken. It is further suggested that this role overlap can have a positive effect on service delivery and has the potential to optimise service provision (Nancarrow 2004).
The government white paper Our health, Our Care, Our say: A New Direction for Community Services (DH 2006) is an example of health and social care working together in partnership to meet the needs of patients in the delivery of services. With reference to intermediate care the paper asserts that service users should have access to the services they require and states that intermediate care is provided with joint funding from healthcare and social care. It is suggested that patients benefit from the provision of intermediate care as beds are provided in locations close to the home of the patient enabling interaction with family and with the local community, and that patients within intermediate care benefit form an interprofessional approach to care needs. It is suggested that intermediate care centres should actively develop interprofessional pathways which benefit patient care. It is expected that all local authorities and health care providers to have established interprofessional networks to support people (DH 2006).
The NSF for Older People (DH 2001b) also identifies intermediate care as an area in which it is expected that interprofessional networks will develop in order to deliver high quality care to patients. This network of professionals is stated to include general practitioners and hospital doctors, nurses, occupational therapists, language therapists, social workers and physiotherapists, with support from health care assistants and administrative staff.(DH 2001b) When older people access intermediate care they should be able to access all services working together with shared goals and a patient centred philosophy (DH 2001b). Within this shared partnership the needs of the patient are central to service provision and delivery.
However it has been noted that within interprofessional care there exists a degree of professional stereo typing and this is detrimental to the delivery of patient care (Mandy et al 2004). If team members are reluctant to work together and share knowledge then the interprofessional team will be ineffective in practice (Bailey 2004). It could be suggested that this is more likely to happen in teams which are new to the concept of interprofessional care, or uneducated in the benefits of interprofessional working, and therefore lack the skills to understand the benefits of adopting new ways of working (Kenny 2002a). However Whitehead (2001) suggests that nurses have experienced difficulties in adopting interprofessional working in practice, and in changing practice, and that some nurses have actively resisted this reform. Kenny (2002b) testifies that new ways of working may identify the need for new skills, knowledge and understanding. However it is argued that a change in working practice does not mean that the nursing contribution within healthcare is of any less importance (Kenny 2000b) It is suggested that interprofessional collaboration could enhance professional development in nursing (Kenny 2002b).
Kenny (2002b) testifies that new ways of working may identify the need for new skills, knowledge and understanding. However it is argued that a change in working practice does not mean that the nursing contribution within healthcare is of any less importance.
A qualitative study by Freeman et al (2000) looked at factors which inhibit and support interprofessional working. The study carried out case studies of six teams working in various settings. The case study was used to explore the issues surrounding professional interaction which inhibited or supported interprofessional working. The teams chosen to be studied included a range of professionals and were studied over a period of three months. The method of data collection used was direct observation, resulting in the observation of 100 hours of practice per team, and repeated interviews with members of the team. The study found that individuals’ philosophies of interprofessional working impacted on professional interactions within the teams. Communication was found to be an issue with teams not sharing information and Freeman et al (2000) point out that an increased level of communication was needed in order to facilitate enhanced team interactions.
Role overlap has been noted to exist in interprofessional care (Nancarrow 2004) however the issue of role protection should also be considered as a barrier to interprofessional working. Nancarrow (2004) found that nurses were highly protective of their role within intermediate care and believed that it was the role of the nurse to take responsibility for the management of the patients’ medical needs and viewed therapy needs as the remit of the therapists within the team. This would suggest that role overlap was not in existence and some what confuses the main findings of the study.
Many patients who attend intermediate care centres have long term health care needs due to their age (Hancock 2003). The NSF for Long term Conditions (DH 2005) recognises this and states that health care provision for people with long term conditions aims to transform the way in which people can access health and social care. Interprofessional working is recognised as being paramount in this provision of care and it is recommended that this involves all agencies and disciplines.
As a student nurse the author of this paper will be involved in service delivery and play a role within interprofessional health care in the future. Education and training is essential if all providers of services are to actively embrace interprofessional working. Teaching undergraduate students core skills together encourages appreciation and understanding of roles and responsibilities and may encourage role overlapping in practice. This will then impact on service provision and patients will benefit from a higher level of care delivery.
On a personal note the author of this paper has been actively involved in interprofessional education within an undergraduate course. The evidence used in this paper will further influence the authors’ future service delivery and interactions with interprofessional working. In nursing it is important to remember that providing holistic care often involves the use of other professionals and this concept should be encourage in order to facilitate the provision of patient care.
The evidence base regarding interprofessional working requires enhancing and the author found that although evidence was available regarding government documentation and the theory of the application of interprofessional working there was a lack of evidence regarding actual interprofessional working in practice. This suggests that there is a need for further research within this area. Now the author is aware of existing literature it will be interesting to observe how long it takes for more research to be carried out.
The author has personally developed through the production of this paper and personal involvement in interprofessional workshops arranged within university. An enhanced knowledge of the needs of patients within intermediate care has been developed along with an improved understanding of interprofessional working and its benefits in practice.
With healthcare becoming more integrated with social care and care moving out of hospitals and into the community and the wider area the author envisages interprofessional working becoming more prevalent in the care provided to patients.
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