A disease state management (DSM) Essay

TASK 6
A disease state management (DSM) nurse is the identified community health care nurse, who provides the mobile nursing service in my primary care setting. The services provided by the DSM nurse are primarily for Maori, but do not exclude people of other cultures (). However, as a priority, the services delivered are aimed at Maori health gain in the area of lung disease, diabetes and heart disease (). She provides effective chronic disease and risk factor management and fosters clients and their families to participate in health services ().
The DSM nurse has various nursing roles in the community (). Mainly, the DSM Nurse liaises between the client, whanau and other services. These services include the general practitioners and the practice nurse, district nurse, community occupational therapist, social worker and any other community service necessary to meet the client and whanau needs (). She performs complete health assessment of clients, frames and modifies nursing care plan based on identified needs (). Also, she makes health service referrals, provides health education on a one to one basis, and does regular home visit that require follow-up (). She provides nursing care, which facilitates active participation and empowers clients to make informed choices regarding their health care. The DSM nurse establishes and maintains links with other community groups such as schools, police, C. Y and family service within the city and surrounding areas (). She also undertakes random surveys to identify the level of client satisfaction ().
The main responsibility of the DSM nurse is to work within the scope of practice and protocols, codes and regulation of the organization. It is essential that she provides culturally safe practices by incorporating the principles of the Treaty of Waitangi (). She needs to provide culturally sensitive, professional and appropriate nursing care to meet the need of whanau, hapu, iwi (). It is also important to collaborate with other team members and report clients' progress regularly. She has accountability for the tasks when she directs and delegates her duties to enrolled nurses and other support workers. It is significant that she ensures safe and secure storage of all information related to clients. The DSM nurse also has the responsibility of advocating for her clients and addresses health disparities among the community.
There are enormous challenges faced by the DSM nurse in the community. She sometimes needs to drive long distances to visit clients and feels isolated. Working in isolation for long periods and without adequate communication increases the DSM nurse's stress (). Unpredictable work environment is another challenge, due to the inability to be prepared and often not well equipped to provide certain types of care adequately (). Aggressive behavior from a client or their family members is a common issue faced by DSM nurse. The time required delivering care to clients varies depending on their individual care needs and the impact of the overall workload (). Unanticipated situations occur suddenly that may impact their work day even when carefully planned in advance ().
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