Community Care’ is a term used in various settings of the health care system. However, for the purpose of this assignment, Community based care (CBC)’ would be solely applied to the nursing role context. The objectives of this assignment are to explore the unique role of the community mental health nurse (CMHN) working in the memory service and dementia care. However, it will create a vivid picture on the current context CBC including the emerging issues and the professional shared challenges faced by the CMHN such as medication management, lone working, safeguarding, and caseload management as a result of older people using services and the increase in their long-term conditions (LTC).
Solutions to these challenges including the necessary skills and knowledge required by the CMHN would be explored. Additionally, the assignment will explore the effectiveness of communication within multidisciplinary team (MDT) including the importance of inter-professional working. It will again emphasis the CMHN role in promoting health and self-care in patient as well as addressing health inequalities predicaments.
It must, however, be emphasised that all interventions and practices by the CMHN in the clinical area will be backed evidenced-based practice (EBP).CBC according to Charles (2018) covers a range of services which include; mental health services, primary care, public health as well the voluntary and charitable organisations. Sonola et al (2014) affirm that the primary objective is to help service users cope well with their chronic health issues in their home environment. This is reiterated by Charles (2018) about the crucial role that community-based care play in keeping people well whilst treating and managing service user’s acute illness and their LTC with the view of empowering people to live an independent life in their own homes. CMHN’s help champion the cause of this in a person-centred way (Alzheimer’s Society, 2016) requiring them to be flexible, proactive, innovative in care delivery (The Royal College of Nursing (RCN, 2013) (Nursing and Midwifery Council NMC, 2018). According to Chambers (2017), as the life expectancy of people increases, it is essential that healthy life expectancy also increases including the mental health of individuals. Funding pressures have had a substantial impact on CBC hence community health service budgets are not able to sustain the increasing demand, affecting the quality of care of service users (Robertson et al 2017). One of the greatest challenges facing the health care system across the globe is that the general population are now living much longer which comes with complicated and increased health care needs (Chambers, 2017).As a result of this, the government through its policies highlighted the need to improve dementia by launching the Prime Minister’s Challenge on Dementia 2020 which is committed in making England the best country in the world for dementia care and support including patients’ carers and families through risk reduction and research (Department of Health and Social Care, 2015). The National Dementia Strategy (NDS) Living Well with Dementia (2011b) spells out the national vision to improve the general awareness of dementia, early diagnosis and treatments. The Five Year Forward View Report aim to upgrade the quality of care and access to mental health and dementia services by addressing the gap between health and well-being. CMHN’s will be vital in bringing about the changes and improvements in the report (Mental Health Taskforce, 2016).In the face of the shift in care to people in their own homes, community nurses including CMHN’s are only 21% (out of the total 306,346 registered nurses) as compared to the increase in nurses working in the acute and general area which is 54.7%. To add to that, there are about 850,000 people with dementia in the United Kingdom who might be living at homes with their families (NHS England, 2019). CMHN’s are therefore expected to respond to the requests for support and advice from people caring for dementia patients. Addressing the physical health issues of patients is one of the challenges facing the CMHN. People with mental health issues have the propensity to suffer from poor physical health compared to the general population (Robson and Gray, 2007). The risk of developing dementia increases as people get older (Akushevich et al 2013) and may develop LTC such as diabetes, respiratory and cardiovascular diseases (Naylor et al, 2016). More people are likely to need support from community health services in the future as a result of that (Charles, 2019). Therefore, it is very necessary for CMHN to acquire the skills to identify the actual and potential physical health issues by detecting it early, undertaken a physical health assessment, putting plans and interventions in place (Goddard, 2018). Hunter (2016) established that there is a comprehensive evidence to justify the health benefits that comes along with regular exercise for individuals living with dementia such as cognitive functioning improvement and general well-being which also provides a means of socialisation to minimise isolation (Alzheimer’s Society 2009). One of the unique roles of the CMHN working in the memory service and dementia care is to professionally conduct and carry out a holistic assessment as well as developing a robust care planning for patients including their family members and informal carers (Carrier and Newbury, 2016). It is important that initial assessment and subsequent reviews are carried out with the patient, family members and their carers (Dixon, 2018). Several studies have shown that General Practitioners and other primary care professionals find themselves not sufficiently trained to assess dementia patients. CMHN’s are in the best position to recognise the early warning signs by supporting the patients through the referral, assessment process and living well with dementia after diagnosis (Kaduszkiewicz et al, 2008). Hodge et al (2015) resonated that the average waiting time from referral to assessment in the memory service increased from 5.2 weeks in 2013 to 5.4 weeks in 2014 whilst waiting times increased from 8.4 to 8.6 weeks from assessment to diagnosis respectively- an emerging issue in the memory service.There are several shared challenges faced by the CMHN when practicing in the community. One of these is medicine management (MM). It is undeniable that medicines are largely used in all health and social care settings; however, it is crucial to note that safe and secure handling of medicine is very vital in ensuring the safeness of the patient (The Royal Pharmaceutical Society RPS, 2018). As a result of this, it is very vital for nurses to have the requisite knowledge of the professional, legal and ethical issues that govern the administration, safe disposal of drugs, prescribing and compliance (Pegram and Bloomfield, 2015). CMHN’s are involved in the administration of controlled drug which they can do individually in patients’ home (Pegram and Bloomfield, 2015). However, in the acute setting, a second signatory is required (Nursing and Midwifery Council NMC, 2007). Additional safeguards should be taken into consideration by the CMHN through regular stock checks. It is very important for CMHN’s to be familiar with the local standard operating policies regarding medicine management with guidance on the storage, disposal, transportation and administration of controlled drugs (NMC, 2007). CMHN’s can manage and minimise some of the likely risks associated with medicine management by practicing within their scope of practice and being mindful of their level of responsibilities and accountability (NMC, 2018). It is the responsibility of the CMHN to clearly explain the medication regimens to the dementia patient (Pegram and Bloomfield, 2015). In doing so, it will help the patient in their health care as well as decision-making thereby encouraging medication adherence which is a challenge in the community (Gurvey, 2013). However, it must be noted that non-adherence with prescribed medication may be as a result of disease and lifestyle-related issues (National Institute of Clinical Excellence, 2009). To manage non-adherence issues among patients, a CMHN working with a dementia patient can adopt appropriate interventions like the supply of dosette boxes, medication storage boxes with alarms to help ease access to medication as they might be having cognitive problems (Pegram and Bloomfield, 2015). Moreover, CMHN’s may use other therapies along with prescribed medication such as distraction techniques, relaxation for therapeutic effect (NMC, 2010). Providing education and training for CMHN’s should have some precedence due to the complexities around MM (Hemingway et al, 2011).Safeguarding is another shared challenge in the community setting. According to National Health Service Digital (NHS Digital, 2019), there were 394,655 concerns of abuse raised during 2017-2018 which is an increase of 8.2% from the previous year. The most common risk identified was that of neglect and Acts of omission (NHS Digital, 2019). A CMHN working with vulnerable adults should ensure that these individuals are protected and kept safe in their living environment (Department of Health DH, 2014) (NMC (2018). Nurses including CMHN’s have a moral duty to take all reasonable measures to raise and escalate their concerns with social services, police or the Care Quality Commission (CQC) when an abuse is suspected (CQC, 2018). One way of safeguarding individuals with dementia is using assistive technology like electronic tracking which could be part of the patients care package to enable them stay in their own homes (The Lancet Neurology, 2008). The Lancet Neurology (2008) see this as the least restrictive means of managing dementia patient who wanders mostly and put themselves at risk. However, critics argue that this could be considered as a restriction to their freedom of movement and a threat to their liberty as they have every right to explore their surroundings (The Lancet Neurology, 2008).Lone working is also another shared challenge faced by nurses in the community. The Health and Safety Executive (2013) classify a health care professional as a lone worker when they are working alone and not being observed directly in their work. According to Kleebauer and Duffin (2015), large numbers of community nurses usually experience verbal and physical abuse whilst at work and only a few of them are protected with personal alarms by their employees to deal with such situations. For this reason, the RCN guidance (2016) for nurses working alone in the community entreat employers to implement safe systems of work for community nurses as a means of reducing risk. This include; visiting or working in pairs, a means of raising an alarm, buddy systems, access to electronic diaries showing times of visits and regular checks by work colleague. Therefore, it is very critical for employers to conduct risk assessments for lone workers to ensure their safeness in their place of practice (Health, Safety and Executive (HSE, 2019). On the other hand, it is also important for the community lone worker to also take care of their own health and safety (HSE, 2019). Munday (2010) reinforced the need for community nurses to follow the lone working policies and procedures to ensure personal safety and others who may be affected by what they do or what they failed to do (Social Care Institute for Excellence (SCIE, 2018).Finally, is caseload management. The closure of mental health hospital beds and patients being discharged early from in-patient setting have accounted to the rise in the workload of CMHN’s (Henderson et al, 2008). Henderson et al (2008) noted that there is a poor integration between hospital and community services as a result of service change. According to him, this has created tension in case management and specialist roles leading to CMHN’s carrying out tasks meant for other case managers. This together with staff recruitment and retention issues have contributed to the rise in CMHN’s workload leading to a crisis response to care with limited time for interventions (Henderson et al, 2008). In order to meet the requirement of higher caseloads, CMHN’s are forced to spend less time with their patient (RCN, 2012). The RCN (2012) again noted that one of the factors leading to staff shortages in the community is an aging workforce. Nurses in the community have a higher age profile than the general workforce (RCN, 2012). Currently, there are 38% of community nurses including CMHN’s who are aged 50 and above. This is significantly higher compared to 23.6% of nurses in the acute and general nursing workforce (RCN, 2012). The implication here is that nurses in the community including CMHN’s would retire in the next decade creating enormous caseloads if new registered nurses are not recruited to deal with this problem (RCN, 2012).Miller (2016) emphasised that multi-disciplinary collaboration between health and social care services is essential in providing integrated care. Interprofessional team work and multi-disciplinary collaboration improve patient outcomes (Archer et al, 2012). A CMHN will usually work with social workers, occupational therapists, medical practitioners, community support workers, adult patients and their carers as part of MDT (Sines et al, 2013). Collaboration is defined by D’Amour et al (2005) as sharing of ideas which indicates collective action geared towards a common ambition, in a spirit of harmony and trust. This indicates team working and healthcare professionals must be collectively accountable and responsible in attaining such common objectives. Coulter et al (2013) reinforced that collaboration is paramount to person-centred practice and the formulating of care programme for service users with LTC. Working in an interprofessional team can be demanding and complex (Donnison et al, 2009) due to directions from government legislation (Walsh, 2013). CMHN’s play a vital in MDT working through the role of care coordinating (Walsh, 2013). A well-coordinated, team-based and individualised care that integrates with other health services is very crucial in promoting of recovery among service users as well their quality of life and community reintegration (Mental Health Commission, 2008). A case in point will be a CMHN liaising with General Practitioners and the primary care team which Hemingway (2016) classified it as part of roles of a CMHN within MDT. A CMHN who might be a patient’s care coordinator is responsible in making sure that the service users care plan is collaborative (Walsh, 2013). Team skills required of a CMHN’s working with a dementia patient with co-morbidities include; leadership, situation monitoring, mutual support and communication (Gluyas and Morrisson, 2013). Communication is fundamental in the nurse-patient relationship which is one of core values of nursing to deliver compassionate and a high-quality care to patients (DH, 2012). Where communication between team members is respectful, then the effectiveness of care coordination is enhanced to support changes to practice (Simpson, 2007). Ineffective communication within teams may lead to poor care-coordination and co-operation which may cause severe errors in patients care (World Health Organisation, 2009). Wong et al (2008) emphasised on that they usually result in wrong patient diagnosis and treatment which may compromise patient’s safety. Nevertheless, the NMC (2018) entreats nurses to prioritise patient safety. In a nut shell, Bunnell et al (2013) suggested training and education as strategies to improve team communication. In connection to that, Lyons and Popejoy (2014) added that implementing practices like team briefing and debriefing, shared assessment documents, telephone calls help MDT communication. Ndoro (2014) asserted that the 6Cs (NHS England, 2013) should form an integral part of MDT working as a means of attaining high standard of quality care for service users.Finkelman (2006) encapsulated that improved and good decisions are made within MDT working since