Despite the HSWs daily involvement in skin inspection, the research findings point to an insufficient ability to accurately identify and assess early pressure ulcer damage, with the overall score for study subjects being 58% (M=11.56, SD=2.439). The indicators in this pre-test highlight the general trend in relation to how HSWs are currently performing skin assessment in the community setting in Ireland. However, due to the small sample size, any generalised conclusions in relation to the findings must be drawn with caution. Although only an observation, the writer noted that the HSWs experienced difficulty differentiating between stages 1 and stage 4, especially where necrotic tissue or eschar was evident. Accurate recognition of a stage 1 pressure ulcer is vital for timely implementation of
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preventative and therapeutic measures in pressure ulcer management (Bruce et al, 2012). Difficulty in differentiating between stage 1 and stage 4 is not an uncommon finding. Aydin and Karadag (2010) concluded that nurses have difficulty recognising stage 4 where there is no disruption of the skin integrity. If a stage 4 pressure ulcer is misidentified the resulting deficiencies in patient care could mean that not all the skin damage is reversible (Aydin and Karadag, 2010).
Within the Irish community, if a nurse makes this clinical decision to delegate the responsibility to the HSW, and the HSW undertakes this delegated task of skin assessment, then they are taking on the decision making authority to know what to do if an adverse outcome occurs (Gravlin and Bittner, 2010). If the HSW is unable to differentiate between a stage 1 and stage 4 pressure ulcer, this could possibly lead to an adverse event. This serious reportable event could lead to extensive pain and suffering for a patient. Hopkins et al (2006) illustrated that pain intensifies the greater the severity of the pressure ulcer is and reduces the quality of life for that patient. The sample size in this study is small, yet, this could possibly highlight trends in relation to how HSWs are currently performing skin assessment within the community setting in Ireland. It is important to note that if the nurse delegates to the HSW then they must be confident that the HSW is competent to take on this duty. If not, then it is a failing on the nurse’s behalf in addition to the HSW. In Ireland the healthcare provision in the community setting is in a state of flux, due, primarily, to an ageing population which is living longer and has complex needs, in tandem with a drive to keep patients at home (DoH, 2015). The population’s health needs have grown at a fast pace, and Lang (2010) makes the point that no research has been carried out on the safety and competency of the HSWs’ to capably care for patients in the home setting, such as skin assessment.
5.3.1 Person-Centred
Within the current discourse from the Department of Health in Ireland (DoH, 2015) and subsequently the World Health Organisations (WHO, 2016) global strategy on human resources for health directions, care provision is the vision of offering person centred care. In practice this means there should be delivery of service that is generic in provision but individually specific. Studies by McDermott-Scales et al (2009), Skerritt and Moore (2014), and Jordan O’Brien et al (2016) found that
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pressure ulcers are a common feature within the community setting in Ireland. Training for skin assessment is notably intermittent, vague and in this study produced an overall score of 58% for the accurate detection of skin damage for study subjects. Additionally, the service delivery is not individually specific. Internationally, dissatisfaction is expressed in relation to training and educational inadequacies for HSWs working within a wide range of clinical areas of care, such as palliative care, chronic disease management and dysphagia management (Dryden and Addicott, 2009, Llott et al, 2013, Pesut et al, 2015). In Ireland the formal training of HSWs is conducted as part of the Fetac Level 5 (Kyle et al, 2014). Many of these courses are delivered outside of formal institutions. Credibility and the extent of exposure to competent environments and practices is open to question. In the UK, Cavendish (2013), expresses discontent with the manner in which training for HSWs is outsourced to private companies not directly linked to nursing expertise. Worryingly, training is completed without any formal knowledge measurement to ensure that on completion of formal education HSWs have the ability to carry out their duties in a competent manner.
Swedberg et al (2013) and Mc Kenna et al (2005) outline that current recognised HSW courses are once off and in some cases involve no clinical supervision. Cavendish (2013) expressed continuing dissatisfaction with the current systematic approach to educational training, not solely with the lack of training or theoretical components, but also an uneasiness surrounding how this training design can lead to a propensity to introduce one size fits all industrial-style training, which is not person-centred. Justification for these deficits by employers include time and budgetary constraints. This reasoning contradicts the Department of Health workforce planning document (DoH, 2016), which places a key focus on ensuring that the correct workforce is in place to supply the patients’ needs in their home. If the skill mix is to be developed in the community, then the service must assess the population needs and deliver the service accordingly (DoH, 2016). For HSWs this may mean development of skills specifically for a young child health care service, for an ageing demographic, or for patients along the lifespan with complexity of needs. Therefore, the service to society will dictate which type of HSW will evolve. In the UK, an example of a good career pathway for HSWs can be seen in the Department of Health’s 2011 establishment of Community Children’s Nursing
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Teams service. This service has nurses and HSWs delivering intensive care to very young babies with complex needs in the home setting. The HSW begins working with the baby in the acute setting, gains the skills and knowledge needed, the trust of the parents and then progresses to care for the child as required (Carter and et al, 2012). Although we want a nationally consistent health service with appropriate staffing and skill mix, we also need to be regionally and locally specific. This will involve adapting to trends and needs as deemed necessary. In this way we will develop person-centred care services.
5.3.2 Practice Role
There was variance noted in the frequency of accurate responses. For instance, in this study, 22% of respondents classified 14-16 pictures out of 20 correctly. Cavendish (2013) recognised this variance in HSW quality of work, which occurred due to the presence of pockets of excellence. In contrast the DoH (2015) could view this indicator as a possible discrepancy in practice. In this study 33% of HSWs classified 6-10 pictures correctly. In line with these findings Beeckman et al (2008) expressed dissatisfaction with registered nurses’ and student nurses’ ability to accurately assess various stages of skin damage using the EPUAP classification tool. Discontent with outcomes is compounded by the fact that all staff in the Beeckman et al (2008) study were familiar with the classification system, whereas in this research study HSWs were not familiar with the classification tool. This unfamiliarity could explain the negative effects on pre-test results.
However, Hayes (2014) believes that HSW work experience in itself cannot be ignored, and stated that learning through practice is a valuable means of education. Swedberg et al (2013) noted that self-learning is not to be disregarded in the community setting: large geographical areas and unreasonable staff ratios lead favourably to this approach. In a recent strategic document by the DoH (2016), patient safety is noted as of utmost importance. However, caution must be exercised if self-learning is common practice for HSWs, as this can lead to peer learning (Swedberg et al, 2013). Peer learning could lead to a proliferation of poor practice (Francis, 2013), and a workforce with wide disparities in knowledge (Hewko et al, 2015) operating with little clinical supervision (Westberg and Tafvelin, 2013). Therefore, patient safety in a ‘learn on the job’ approach must be questioned. If a
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poor standard of care is evident, this will not comply with the three values underpinning the professional practice of nursing and midwifery: compassion, care and commitment (DoH, 2016). Nonetheless, the existence of pockets of excellence do warrant further exploration in terms of career pathway development and progression. Internationally, expanding and developing the role of the HSWs is central to ease problems associated with nursing shortages (WHO, 2006). This has been identified in the UK in community based rehabilitation centres (Moran et al, 2015), in the army within critical care (Carter, 2011), and in pressure ulcer prevention strategies such as skin champions (Ellis and Price, 2015). The need to develop the HSW role has been acknowledged with the introduction of compulsory certified training in the UK (Cavendish. 2013), and, for example, the further development of practitioner level within the endoscopy setting (Gardiner and Coulten, 2008).
As already outlined in the UK, the establishment of Community Children’s Nursing Teams service has developed the HSW role, delivering complex care to babies in the home setting (DoH, 2011). The pathway begins for the HSW through gaining skills and knowledge in relation to complex care requirements. This progresses upwards as competencies develop. After a period of time opportunities become available to enter the children’s nursing course, an opportunity that would not have been afforded to them earlier in their adult lives (DoH, 2011). Therefore, the skilled workforce is ‘grown’ into the service. Recruitment is usually from among local staff and this aids staff retention post qualification. The process of combining certified training with career progression while meeting population health needs, places real value on the HSW’s role