As already mentioned, within community nursing there is a wide variety of contexts of practice in relation to the patient group and the discipline involved, for example, young children and the potential input from health visitors/public health nurses or community children’s nurses, those with mental health conditions and likely input from community mental health nurses and finally unwell older adults receiving care from district nurses and practice nurses. These contexts are important as they determine the skills and knowledge required to deliver care and are highlighted specifically in relation to decision making and healthcare by Croskerry (2009).
Croskerry (2009) highlights two main systems of decision making. The first is system one, the intuitive route, which relies on a reflexive approach that expends little effort and does not depend on evidence to underpin the decision. Although this will be familiar to community nurses, the problem is that it can be unreliable and errors are frequent, so relying on this approach is unlikely to provide quality patient care and in the extreme could be fatal. Errors in decision making are explained as slips, lapses and mistakes. Pearson (2013) has an alternative view of intuition and suggests that it is based on pattern recognition drawn from experience in clinical practice and is in fact a cognitive skill. However, Pearson (2013) does agree with Crosskerry that intuition should be used along with evidence-based practice. The scientific approach then described by Pearson (2013) that involves hypothesis and cue acquisition or gathering of objective and subjective data aligns to Crosskerry’s system two. Furthermore, mistakes take place when the practitioner’s thinking is faulty; for example, the diagnosis of a red painful wound as infected when it is actually inflamed.
System two described by Croskerry (2009) is the analytical route, which relies on a rule-based approach that requires significant effort and has a scientific base. The problem with this analytical approach is that although it is a more reliable system of decision making, there is an associated cost and time issue that cannot be ignored.
Therefore, a balance or blend between both systems needs to be considered. This is supported by Person (2009), who argues that a combination of intuition and scientific evidence-based approaches can be used successfully to achieve effective outcomes. The following case study illustrates this from a community nursing practice perspective.
Mrs Grant is aged 84 years and is unknown to you. She has requested that you visit as she would like some help and advice in relation to a problem with constipation.
Intuitive approach – Fast, reflexive with minimal effort
Your experience with patients in this age group links constipation to medication side effects, reduced fibre in the diet along with a lack of fluids and low mobility. This intuitive approach relies on the context to guide the
CASE STUDY
143
Conclusion
CONCLUSION
So it would seem that in order to deliver effective care to patients in the community, assessment needs to be placed under scrutiny. Determining existing assessment strategies and underpinning theory that supports assessment in practice is a starting point. Holistic assessment in community nursing practice involves a person-centred partnership approach where information is gathered in relation to the individual’s physical, psychological, social, environmental, spiritual and cultural well-being
decision and in this case it’s the gender, age and assumed co-morbidity of the patient.
Analytical approach – Slower, deliberate with considerable effort
Your experience with patients in this age group links constipation to medication side effects, reduced fibre in the diet along with a lack of fluids and low mobility. However, you are aware that a change in bowel habit and any bleeding could indicate bowel disease or cancer. This knowledge combined with the use of the Bristol Stool Chart and a history of the complaint will identify a normal bowel pattern and stool consistency.
It is not Mrs Grant who has constipation as you first thought, and it turns out that Mrs Grant would like some help and advice about her husband as she is his main carer. Mr Grant has multiple sclerosis and poor mobility, and he has had several recent falls. As a result he has stopped the osmotic laxative he had been taking for several months as his bowel movements are loose and he needs to rush to the toilet fairly frequently. He has been soiling underwear and sheets, which has been upsetting for them both, and now his normal bowel pattern has ceased. Mr Grant now feels very uncomfortable and nauseous. This analytical approach extracts any irrelevant information (in this case the patient with constipation is not Mrs Grant), does not focus on the specific context and uses guidelines to support clinical practice. While repeated specific experiences may convert analytical decisions into intuitive ones, a raised awareness of the context of situations, although helping us to make sense of the situation, can also provide a distraction from the reality and lead us to assumptions that are not accurate. Earlier work by Croskerry (2002) in relation to pattern recognition explains a situation whereby a patient presenting with particular visual aspects of a complaint and their appearance can trigger a bias in the decision making. Furthermore, any subsequent data gathered from the patient can be used to confirm the initial diagnosis, even when it is not accurate. For example, a patient presenting with a painful mouth with evidence of an ulcer and white plaques on their tongue who confirms that they have just completed a course of antibiotics may result in a bias towards oral thrush when the ulcer may actually be the beginnings of oral cancer. Although this article by Croskerry (2002) is aimed at medics and in particular those who work in emergency medicine, it can illustrate how a failed approach to decision making can occur, a fundamental message that community nurses need to be aware of.
using recognised evidence-based frameworks. Family and carers are included in the assessment where appropriate, and, depending on the needs prioritised, the focus of the assessment can move along a spectrum from concentrating on a physical assessment utilising advanced clinical skills with one individual, to focusing on a broad family assessment. It is this flexible approach practiced by a body of community nurses that is a real strength. Undertaking robust evidence-based assessments that have clinical decision making embedded in the process, evidences accountability and the essential underpinning knowledge and skills in relation to delivering patient care using shared decision making. This continued approach will facilitate community nurses to deliver the high-quality care that most patients expect and deserve. By revisiting theories of assessment, including assessment tools and decision-making frameworks, current and future community nurses will be able to provide a clear rationale for their practice and take responsibility for implementing any improvements within their own clinical area.
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The role of the community nurse in mental health
INTRODUCTION
Community nurses are involved with a range of care provision including support and care for patients who are unwell, including those with end-of-life care needs, as well as supporting independence and self-care (Department of Health Public Health Nursing, 2013). This remit includes increasing the quality of life of people living with long-term conditions. In order to improve the quality of life for people living with a long-term condition, and their families, it is important that the district nurse is able to work collaboratively with other healthcare professionals and across health and social care (Queen’s Nursing Institute & Queen’s Nursing Institute Scotland, 2015). In 2008, the Department of Health reported that the number of people with a long-term condition would increase by 23% by 2033 (Department of Health, 2008b). Taking into consideration the increase in the number of people, this chapter examines the relationship between long-term conditions and mental health and examines the role of the community nurse.
The World Health Organization (WHO) states that
Mental health can be conceptualised as a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribu- tion to his or her community.
(World Health Organization, 2007: 1) Keyes (2002) identified six feelings that foster psychological well-being, see Box 8.1. It is perhaps unsurprising that living with one or more long-term conditions, which may impact upon independence and quality of life, can be linked to mental health challenges.
CHAPTER
8
•
Explore the relationship between physical and mental health.•
Critically examine mental health assessment and the role of the community nurse.•
Review mental health interventions available to community nurses.•
Critically explore the need for collaborative working and referral to specialist mental health services.LEARNING OUTCOMES
The evidence regarding the relationship between long-term conditions and men- tal health identifies that affective disorders such as depression and anxiety are more prevalent (Naylor et al., 2012). Furthermore, while depression and anxiety are expe- rienced by people living with a long-term condition it is important to acknowledge that for some long-term conditions such as diabetes and cardiovascular disease there is also an increased risk of cognitive impairment including Alzheimer’s and vascular dementia (Velayudhan et al., 2010).
The relationship between physical and mental health
An understanding of the link between physical and mental health is important for community nurses. Mental health problems are two to three more times likely to be experienced by people living with a long-term condition compared with the general population. Co-morbid mental health problems have a number of serious implica- tions for people with long-term conditions, including poorer clinical outcomes, lower quality of life and reduced ability to manage physical symptoms effectively resulting in unhelpful health behaviours and poorer self-care (Naylor et al., 2012).
There is a correlation between co-morbid mental health problems and the motiva- tion and ability to manage self-care for people living with a long-term condition.
The mechanisms underlying the relationship between mental and physical health are complex, and evidence suggests that a combination of biological, psychosocial, environmental and behavioural factors may all be involved (Prince et al., 2007). The community nurse often providing care in the home setting is well placed to assess these aspects of patient-centred care in practice. Evidence suggests that quality of life, dietary control, relationships with healthcare professionals and carers along- side overall prognosis can be improved by consideration of the psychological needs of people with diabetes (NHS Diabetes and Diabetes UK, 2010). Mental health problems are experienced in a range of long-term conditions, see Table 8.1.
Anxiety and depression, in conjunction with reduced social skills and an impact upon concentration, are also components of a range of psychological distress expe- rienced by people with a diagnosis of cancer (Macmillan Cancer Support, 2011). It is likely that anxiety and depression may also affect the families of people living with long-term conditions and cancer. While people with a long-term condition experi- ence mental health problems, it is important to recognise that people with mental health problems have an increased risk of physical health problems. Consequently
Box 8.1 Feelings that foster psychological well-being
•
Self-acceptance•
Positive relations with others•
Autonomy (or ability to think for yourself)•
Environmental mastery (the sense that you can change your circumstances for the better)•
Life purpose (having goals and feeling helpful)•
Personal growth (being able to learn from the stresses and challenges of life) (Keyes, 2002)149
Introduction
premature death from natural causes such as cardiovascular disease is two to four times more likely for people with mental health problems (Eaton et al., 2008).
Mental health assessment and the role of the community nurse Having explored the relationship between physical and mental health, it is impor- tant to examine mental health assessment tools and consider how they can be used by community nurses. The Voluntary Standards for District Nurse Education and Practice identify the promotion of
mental health and well-being of people and carers in conjunction with men- tal health professionals and GPs, identifying needs and mental capacity, using recognised assessment and referral pathways and best interest decision making and providing appropriate emotional support.
(Queen’s Nursing Institute & Queen’s Nursing Institute Scotland, 2015: 3) Primary care can play a key role in supporting people with mental health prob- lems and is the main source of formal support for mental health problems with only 10% of individuals with a mental health problem being referred to specialist mental health services (Naylor et al., 2012). Primary care provision with support from specialist mental healthcare professionals if appropriate can support people’s needs more appropriately. However, in a King’s Fund report, looking at long-term condi- tions and mental health, a separation between physical and mental health in the Table 8.1 Research evidence on the prevalence of co-morbid mental health problems
Cardiovascular disease (CVD)
• Depression is two to three times more common in a range of CVD including stroke, angina, congestive cardiac failure and following a heart attack
• Prevalence estimates vary between 20% and 50%
• Anxiety problems also common in CVD
Diabetes • Two to three times more likely to have depression than the general population
• Also an independent association with anxiety Chronic obstructive
pulmonary disease • Mental health problems three times more likely than the general population
• Anxiety disorders particularly common, for example, panic disorder is 10 times more prevalent Chronic musculo-
skeletal disorders • Up to 33% of women and more than 20% of men with arthritis may have a co-morbid depression
• More than one in five people over the age of 55 with chronic arthritis of the knee have been reported to have a co-morbid depression
Source: Naylor C, Parsonage M, McDaid D et al., (2012) Long-term Conditions and Mental Health The Cost of Co-morbidities. London: King’s Fund Centre for Mental Health (p. 4).
Take some time to reflect on two people whom you have worked with who have a long-term condition. In relation to each of the people you identify answer the following three questions:
1. Could they have been depressed or anxious?
2. How did you consider the impact of their long-term condition on their psychological well-being?
3. Did they raise the issue of their mental health with you?
ACTIVITY 8.1