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"Discuss how age discrimination can influence the role of the nurse with particular reference to health promotion and rehabilitation in older people" The promotion of independence is a key objective within the contemporary health and social care policy agenda, leading to an increased interest in rehabilitation and intermediate care (Department of Health, 2002). But earlier, an apparent decline in the attention paid to rehabilitation was evident. There are authors who describe how the rehabilitation of older people was gradually eroded within acute hospital care, resulting in the comprehensive care of older people being marginalised. This coincided with an increase in the number of older people, and an increased emphasis on bed management, capacity problems and the drive to reduce lengths of stay in acute settings (Nazarko 2001).
The National Beds Inquiry (Department of Health, 2002) showed that two-thirds of hospital beds were occupied by people over 65 years, and that half of the recent growth in admissions involved those over 75 years. Following this inquiry, intermediate care emerged as central to resolving some of these capacity problems and the concept of rehabilitation has become synonymous with it (Martin, 2001). The rehabilitation of older people can take place in a wide range of settings, including acute and community hospitals, day hospitals, outpatients, GP surgeries, nursing and residential homes and individuals' homes. Rehabilitation is a broad term and is interpreted in a variety of ways. Some definitions suggest that rehabilitation always results in the regaining of independence.
For example, the Oxford Dictionary (1994) defines it as: 'Restoring a person to a normal life. ' But the reality is that many patients make only a limited or slow recovery, and for others there may be no recovery at all (Edwards, 2002). Rehabilitation can be described as an active process; that is, deliberate, planned, skilled and continuous. While the focus may be on functional abilities, restoring well-being and maintaining social roles so as to enhance the quality of life of the older person, who remains central, is paramount. Older people have been identified as prime candidates for intermediate care (Martin 2001), although it is not aimed at them exclusively.
A key reason for this is that older people are significant users of health services and, for many, remaining in an 'acute' bed once the acute phase of care is over may not be in their best interests. These are very busy and noisy environments, and may actually inhibit their recovery. Bland R asserts that the lack of attention to the particular activity needs of older people in acute settings contributes to their increased dependency. (Bland R, 1985). Intermediate care has been described as: 'Those services that do not require the resources of an acute general hospital but are beyond the scope of the traditional primary care team'. (Edwards, 2002). The National Service Framework for Older People set the target for an additional 150, 000 people to receive intermediate care services by March 2004. However, there is little data available to facilitate capacity planning for these services and an over-reliance on simple assumptions derived from length of hospital stays.
They conducted a study to provide a needs estimate for post-acute intermediate care for older patients admitted to a district general hospital and found that 25 per cent of patients needed post acute rehabilitation care, suggesting that intermediate care services needed to be provided on this scale. (Easton, 1999). In summary, intermediate care is time-limited rehabilitation that is not means tested and is provided closer to home Emphasis is placed on promoting the independence of the older person so as to maximise an individual's ability and therefore bring an improvement in quality of life A range of services may be provided that either prevent admission or speed up discharge. The nursing role in rehabilitation is key to the government's agenda of modernization. Nurses have a unique place within the rehabilitation team. Their 24 -hour contact with the patient, seven days a week, provides a chance to use this time therapeutically. Nurses also have the greatest opportunity for contact with patients' families as visiting often takes place outside the working hours of other members of the multi-disciplinary team.
This contact provides opportunities for building close relationships with family members. Moulder states: 'The rehabilitation nurse is in a pivotal position to function as the patient advocate and care co-ordinator. ' Benbow and Bowers suggest that if there is effective co-ordination and communication, then the patient and family will be active participants in the rehabilitative process. The nurse is the communication link between all those involved. (Department of Health, 2002). The wide-ranging needs of older people signify the importance of effective teamwork as well as the skills of a range of different professional disciplines. Critical members are older people themselves and their families. The team's united purpose is achieving rehabilitation outcomes for patients.
Multi-disciplinary teams combine the efforts of each member of the team. Their work is characterised by working towards discipline-specific goals with clear boundaries between disciplines, such that the team's outcomes are the sum of each discipline's efforts (Human 1996). The risk with multi-disciplinary working is that it does not provide for the holistic needs of an individual to be met, since the efforts of each discipline may be addressed separately, with each isolating their goals and taking responsibility solely for that goal and failing to integrate them with those of other team members. Communication is essential for effective multi-disciplinary working.
Collaboration is key to the success of interdisciplinary working. The whole team agrees goals with the client and therefore avoids duplication or conflict in goals. A key principle within inter-disciplinary working is the blurring of professional roles while preserving the separate identity and expertise of individual professions. (Hanford Let al, 1999). It is likely that inter-disciplinary working will lead to greater synergy due to the way the team interacts and works, so that more comprehensive outcomes are achieved than would be possible otherwise. This approach may be enhanced by the appointment of a key worker.
This type of teamwork is not easily achievable as it requires members to work together with shared philosophies as well as goals, having mutual respect and trust, and a clear understanding of the expertise of each discipline and team member. Many authors adamant that rehabilitation is about inter-disciplinary and not multi-disciplinary working. (Moulder, 1988). In rehabilitation, the goals and desired outcomes for each individual will be unique. Easton states that goal planning should be part of the overall care plan in which the client's own values, beliefs and aspirations are recognised and valued, and form the central focus of the rehabilitation process. All members of the rehabilitation team, although concentrating on a particular area, share similar goals for the client. These include promoting self-care, maximising independence, maintaining and restoring optimum function, preventing complications and encouraging adaptation (Easton 1999).
The long-term goal of rehabilitation is described as 'the expected level of performance when therapy services are terminated' (Kumar 2000). Short -term goals are the specific measurable activities designed to meet the long-term goal. (Hanford Let al, 1999). Patients are likely to have a variety of short-term goals, which may be sequential and concurrent. Mobility is an example of a sequential short-term goal, which is likely to include the achievement of standing balance, walking a few steps with a frame, walking longer distances, walking with a stick and climbing stairs. At the same time, patient and staff may be working towards the achievement of other short-term goals such as achieving continence and independence with washing and dressing. Overall responsibility for supporting the patient to achieve particular goals is often the role of specific disciplines, but will usually involve collaboration between disciplines. (Kumar, 2000).
The rehabilitation process should help individuals adjust or adapt to life-altering situations, with improved acceptance of their new roles and self-image. Professionals can accentuate the positive, emphasise abilities and offer hope, without giving false hope, of full recovery. Rehabilitation often makes the difference between positive adjustment and negative coping (Easton 1999). Nazarko argues that the main aim of rehabilitation for older people should be to help them realise their full potential, to resettle in the community if possible and to find role fulfilment. It must be of therapeutic value, be meaningful to them and be aimed at maintaining or improving quality of life. This will require the creation of a therapeutic relationship with the older person, recognising their emotional needs in planning care and interventions (Nazarko, 2001).
Opportunities now exist to develop a range of services to meet the needs of older people. Nurses will be crucial to their success but will need to adopt a rehabilitative approach in all healthcare settings if the needs of all older people are to be met. The normal processes of ageing may impact on the competence of organs to respond to the toxic effects of anti-cancer drugs. Doses need to be calculated based on the body's ability to break down and excrete the toxins. Chemotherapy that is cardio toxic should be avoided. Treatment of possible side effects should be commenced early and, in some instances, as a prophylactic.
For example, the use of hematopoietic growth hormones and antibiotics should be considered if the patient should become susceptible to infection due to bone marrow suppression. As normal cells age they appear to lose the capacity to divide. However, cancer cells will undergo cell division indefinitely. The genetic material of the cell, DNA, is carried...
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