Consejos para mantener la salud de sus pies

In the previous chapter, interview and patient profile data were used to illustrate the complexity of the discharge planning work undertaken by the IPCCs. Earlier in this chapter, we saw that the IPCCs and their managers did not believe that training was required for the IPCC role. Social workers, however, had concerns about IPCC competence particularly in relation to direct working with patients and the flexible boundaries to the role. This section builds on these finding by using observation data to illustrate the level of skills and knowledge that the IPCCs possessed for this work.

The perception of the IPCCs and their managers that their skills and knowledge could be expressed merely in terms of life experience and administrative experience in the hospital does not stand up when compared against the

observation findings. For example, the following illustrates an IPCC’s assessment of a new patient.

Went to see patient (Mrs E29) and daughter on Ward 7. Asked patient what services she had. Personal care in the mornings 7 days a week. IPCC asked if she thought she needed it in evening. Also has one hour of home help per week. Patient said home help was variable, sometimes not good. IPCC said it was up to patient to complain. IPCC asked what about shopping, patient said daughter did it. IPCC said if more input were needed, they should let her know.

IPCC found out that patient has trouble getting in bath. She has bath board and seat but still difficult to get out of bath. Daughter does cooking and IPCC asked how patient would cope with that if/when daughter leaves. IPCC suggested they need to get Borough E to re-assess. She also suggested getting a microwave and getting frozen meals-on-wheels. Daughter going away for a few weeks, IPCC didn’t know if meals-on- wheels were provided short-term. IPCC suggested microwave because patient wouldn’t be safe bending over to use oven. IPCC: ‘Perhaps you need to think about these things’. IPCC asked if patient had seen

occupational therapist (OT) during recent admission to [Trust’s other hospital] - she had not. IPCC said she would refer to OT for assessment while patient was still an in-patient. Started filling in form. Invited patient to ask the nurses for her if she thought of anything else. (Field note extract, 23089:125-145)

In my view, the nature of this assessment reflects not only common sense, but also a high level of skill and knowledge. In this interaction the IPCC is using highly developed interpersonal skills to sensitively question a patient and her daughter about her home needs. The line of questioning was revised in the light of emerging information and answers were interpreted to indicate what support that patient might require on going home. The skills involved here are interpersonal (gently probing for information and making suggestions), interpretation (using knowledge of mobility status to suggest cooking arrangements) and decision-making (using information gathered to decide OT assessment needed). A wide breadth of knowledge about coping abilities, family care and community services is also evident.

The field notes also reflect many other examples of IPCCs using high levels of skill and knowledge in the discharge planning work they did with patients. For instance, their frequent practice of adding information to that already documented by nurses on social work referral forms suggests a level of expertise that is, in this domain, at least as good as many registered nurses:

Following her assessment of Mr C30, the [IPCC] retrieved the social work referral form that the nurses had filled out. They had given the following reason for referral: ‘Assessment of housing situation. General social services’. [IPCC] added: ‘Has recurrent falls at home. Has no social service input at present, but did have them in the past’. (Field note extract, 10089: 38-42)

In the above extract from the field notes, the IPCC was able to supplement the general request made by the referring nurse with pertinent and specific information that she had gathered during her assessment of Mr C.

In another example, a man who had been admitted previously to the hospital with a stroke had been discharged to a rehabilitation unit and had then been discharged home. After one week at home, he had a further stroke and was admitted back to the hospital. Knowing how long the waiting list was for the rehabilitation unit, the IPCC independently contacted the rehabilitation unit he had been on to see if they would take him back following his acute stay.

Field notes also reflect a case in which an IPCC's clinical knowledge and observations led to a decision by the interprofessional team to delay someone’s discharge to ensure that he was well enough:

House officer: [Patient B31] for discharge tomorrow

IPCC: he was very confused when I saw him on the ward this morning Registrar: we’ll have a word with the family. He seemed compus mentus to me on ward this morning. We’ll do a septic screen32.

OT: I could get [an OT colleague] to check him out

IPCC: I don't think she could at the moment, she’s too busy. If you send him home and the family’s not happy, they’ll come and scalp you!

30 _{Name has been changed.}

31 _{Code allocated to patient in field notes and unrelated to patient’s actual name.}

General agreement to delay discharge until septic screen results come back.

(Field note extract of weekly interprofessional meeting, 19089: 217-223) The findings that discharge planning requires a high level of knowledge and skills are supported by recent government policy which states that a high level of skills and knowledge are required to co-ordinate patient discharges (Department of Health 2003b). However, the policy also states that such work should only be performed by a registered nurse, or, in some non-acute settings, a therapist or social worker.

In spite of these national policy requirements, the IPCCs are evidence that such work can be conducted skilfully without a registered qualification. However, it is important to emphasise that it was these individuals on this occasion who, by whatever means, possessed the necessary skills. What cannot be assumed is that others without a registered qualification would perform the work as competently. The IPCCs had taken on discharge planning from nurses but had not received any formal training to undertake this role. This, and the tendency for the IPCCs to call their skills ‘common sense’ suggests a low value has been ascribed to the

knowledge base associated with this aspect of patient care. A perception is implied that physical patient care is more important than discharge planning, and that discharge planning does not really require any training or development. IPCCs and their managers felt that the IPCCs’ work is dependent on their life experience and knowledge of a hospital environment, but the observation work reflected that the IPCCs did, in fact, possess other knowledge and skills. In addition, they worked with patients with more complex needs. In this sense, their work cannot be described as merely clerical, a view that is reflected in their job description and through their true role in discharge planning not being reflected in Trust policy. While these IPCCs on these occasions seemed to possess the

necessary skills and knowledge, this does not guarantee that others with a similar lack of formal training would also be competent to take on work of such

The above examples that illustrate high levels of skills and knowledge by the IPCCs suggest a positive impact on patient care, and lend support to manager and practitioner views that the IPCC role makes a positive contribution.