Only took on core work of nurses, not other groups

While the IPCCs provided administrative support to all core members of the

interprofessional team (that is, doctors, nurses, social workers, physiotherapists and occupational therapists), their role shift towards discharge planning represented a role shift towards the core work of nursing, more so than that of the other staff groups. The concentration on discharge planning was also seen by some social workers in interviews early in the study as an inappropriate overlap of the IPCCs into core social work. IPCC activities identified by social workers as problematic included assessing patients prior to their social work assessment to determine what level of post-discharge support may be required, promising services like housework to patients, and keeping up patient and family contact once a social worker had taken on the case.

There are disadvantages in the way work has been performed by certain individuals. They have overstepped the mark. They approach patients as potential social work referrals and patients get the impression that the [IPCC] is a social worker. There are occasions when the [IPCC] promises services. This causes problems when the social worker goes to do an

assessment. The social worker does an assessment of patient needs then has to prioritise. It’s not the [IPCC’s] role to go up to someone and say we’ll sort out someone to do your housework. (Social worker, 02128, Int) Observation data indicate that some of these practices identified by social workers were a part of IPCC practice. The field notes reflect that IPCCs raised the prospect of placement with patients during their initial assessment and kept patient

involvement going after a social worker became involved with that patient. As with the work the IPCCs carried out that was previously nursing work, these activities are not reflected in the IPCC job description or in the Trust discharge planning policy.

However, the findings reflect key differences between the IPCCs undertaking nursing work and social work. Staffing shortages were a feature in both staff groups, although in nursing they were more consistently present. While some IPCC work may have pre-empted social work input, it did not alter the work the social workers then carried out in terms of patient assessment and input. This was clear from the way social workers described their work in relation to IPCC work. The first quote below reflects how IPCCs were able to improve the quality of referrals to social work, but implies that social workers continue to assess patients for themselves once the referral has been received. The second quote (by a different social worker) questions what the IPCCs have to offer that is different from the contributions of the team members already attending case conferences for individual patients. This implies that the social workers do not view the IPCCs as substituting for them.

I had a session with [two of the IPCCs] and we looked at what would be appropriate referrals to social work in the light of our eligibility criteria within the borough. So the [IPCCs] got an idea of what our limitations were and gave it a bit of a framework, and I think that really did improve the referrals that we assess. (Social worker, 05039A, FG)

This is a bit specific, but are they actually meant to come to the case conferences? Because that's quite a big dilemma for me, because [another social worker] and I had a husband and wife who we were working with, so there was a husband and wife, there were two house officers, there was only one OT and one physiotherapist and then the two [IPCCs] wanted to come as well. The husband and wife were quite elderly and quite sick, and it was a bit of a difficult situation, I weren't sure of the reasons for the [IPCCs] being there, necessarily. The husband came in and sort of made reference to “oh, is it us against you lot?”, and it really felt like that,

was really good - that they had that insight to see that. But I've been told by the [IPCCs] that I need to invite them to case conferences. (Social worker, 05039A, FG)

The ‘social work’ the IPCCs carried out could therefore be seen as supplementary to regular social work input. In contrast, the ‘nursing’ work the IPCCs carried out was, as reflected above, to compensate for staffing shortages and was therefore carried out instead of what nurses would have done in terms of assessment and input.

5.4 Chapter summary

This chapter has addressed the first objective of this study and has described the characteristics of the IPCC role. Findings show how the role has shifted from its original job description from a purely administrative role to one that includes significant patient contact, leadership over interprofessional colleagues and independent decision-making. This shift was enabled by the role’s key characteristic of flexibility, a characteristic encouraged by managers.

Nursing shortages meant that IPCCs had taken on the lead in discharge planning from nurses, although this was not reflected in Trust policy. Nurses gave a higher priority to technical medical care than to discharge planning, although they retained more routine discharges while handing over the complex cases for IPCCs to

handle. Neither Trust discharge policy nor the IPCC job description reflect these important shifts in practice.

The next chapter explores the impact of the IPCC role and the issues that have arisen.

6

Impact and issues: positive contribution but lack of

managerial systems

This chapter addresses the second and third research objectives and explores the impact of the IPCC role on patient care and interprofessional working, and the issues arising from the role. Data sets from the exploration and action phases of the study are mainly drawn on in this chapter, and these include data from my field notes (total n=110), interviews (total n=37), focus groups (total n=16), and the documentary analysis (n=83).

The first section in the chapter looks at the impact of the IPCC role on

interprofessional practice. The second section examines the impact on patient care, focusing particularly on the issues that have arisen about IPCC competency and accountability. The third section uses my perspectives on the observation data to re-examine manager and practitioner accounts of competency and accountability to reach an overall conclusion on the impact of the IPCC role.

The findings in this chapter illustrate that while the actual contribution that IPCCs make to patient care is generally very positive, a lack of attention to the

requirements of the role for competency, regulation and supervision could have negative consequences for patient care.