Free Nursing Essays - Analyse the effectiveness of a current health promotion strategy from within your field of practice, supporting your discussion with reference to current government initiatives
Introduction
This essay will revolve around a Mrs.B. a 54 yr. old married housewife who has presented in the casualty dept with a first episode of severe central chest pain and a degree of dyspnoea which has already lasted over two hours. She has been otherwise well, but at 108kg and 5’4” she is clearly overweight. She has been a smoker for 30 yrs. Her initial assessment shows that the pain is not cardiac and a working diagnosis of acute reflux oesophagitis is made. Routine screening has shown that she as a random blood sugar of 18mmol/l.
Focus essay on health promotion activities with patients or their relatives.
There are several distinct health issues that are highlighted by this one case. In this essay we shall focus on Mrs.B’s predisposition to Type II diabetes mellitus because of her obesity. There is a lot of evidence to suggest that her eventual outcome (in terms of complications) will be determined by many factors including weight loss (Hughes 2002) and the degree of her control over her blood sugar levels in the long term (Stratton et al 2000). The major health promotion activity that relates to Mrs B is therefore giving her advice on weight reduction to improve her diabetic control. (Terry et al 2003)
It is not to be suggested that there are not other health promotion issues such as smoking to be addressed, but they will not be specifically covered in this essay.
Refer to the difficulties of defining health at the start of the essay.
When trying to decide upon Mrs B’s state of health we have a problem. On one hand, an authoritative definition of health comes from the WHO which defines health as being "a state of complete physical, mental and social well being and not merely the absence of disease or infirmity." (WHO 1992). Although undoubtedly accurate, and including both the sociological and psychological components of health, it is far from precise. (WHO 1996)
As Freud pointed out, many years previously, that well-being equated more closely to happiness than to health (Freud 1975) in his observation when he had been advised to give up cigars for the sake of his health. He commented that he was undoubtedly healthier but much less happy. (Saracci 1997)
This difficulty is amplified by the consideration that today many people confuse the pursuit of happiness with the pursuit of health. (Kemm 2001). In specific relation to our consideration of Mrs B., she is clearly not well as she demonstrably has Type II diabetes mellitus, but an assessment of her “mental and social well being” may well reveal other areas where there are problems to be addressed.
Identify and define your chosen health promotion strategy
In the case of Mrs B. there is little doubt that her health would be improved if she lost weight. Ideally she could aim for a BMI in the region of 24-25, but as any experienced healthcare professional will tell you, this is seldom achieved in practice, but it is none the less a goal. (NICE 2000). The question for the health professional is how best to achieve this target? In general terms, the strategy of empowerment and education of the patient is considered to be amongst the most useful (Peile 2004). Mrs B is far more likely to comply with a treatment regime if she understands the regime, the reasoning behind it and is given the tools to achieve it. (McDonald et al 1999)
Identify the patient/client group with whom the strategy has been used.
Empowerment and education is an important concept in patient management and has been widely used over a huge range of clinical issues. (Fealy 1997). It will be particularly useful for Mrs B, not only with regard to the issue of weight loss, but also with the whole question of her diabetic control as well (Carter 1996). In terms of evidence based practice, the UKPDS trials have helped us to define the particular interventions which are likely to be helpful in any particular patient group in this clinical area. (UKPDS 13, 1995) (UKPDS 33, 1998)
Describe government initiatives that are linked with the strategy eg: NSFs.
The particular goals of Mrs B’s treatment have recently been both defined and, to an extent empowered, by a number of Government initiatives. In relation to this particular case, they were set out very concisely in a paper by Halligan, (et al 2001) which was written in conjunction with a statement to Parliament by Liam Donalson who outlined the government’s position. It should be read in association with the government strategy for the National Service Frameworks (Delivery Strategy 2003). The specific NSF for diabetes was published in 2001 (DOH 2001) and modified in 2002 (DOH 2002).
The significance of the National Service Frameworks are that they effectively set the “gold standard” of care provision for all patients Nationwide. (NICE 2000). For example Standard 11 of the National Service Framework details how AHA’s will monitor the provision of diabetic care and advice so that long term complications can be minimised and Standard 12 deals with the integration and provision of multi-agency support for both medical and social care. Both of these factors could, arguably, be very important to our Mrs B.
Explain the process of planning and implementing and evaluating the strategy.
Planning, implementation and evaluation of any health care intervention is important not only from the point of view of effective provision of a treatment plan, but with the advent of evidence-based medicine, evaluation is a vital ingredient to ensure that the proposed treatment is available for audit and subsequent analysis (Venning et al. 2000).
As Mrs B is seen in an A&E Department, it is probably not appropriate to fully plan her treatment, although it can (and should) be initiated. The task of full evaluation and implementation will probably fall to colleagues in primary care or the integrated diabetic clinic. An appropriate plan, in terms of her weight loss and diabetic control, would be a prompt referral to the dieticians who would be in the best position to give her specialist advice in terms of dietary manipulation. As a nurse in the A&E Department, it is entirely appropriate to begin this process with an explanation of how managed weight loss could reduce, and possibly remove, her diabetic tendency and therefore improve her long term life expectancy and indeed, her quality of life. (Adler et al 2000)
Mrs B will almost certainly have a large number of questions and concerns which she should be encouraged to raise as understanding is a vital ingredient of compliance. (Marinker M.1997)
Analyse the effectiveness of the strategy
To analyse just how effective this strategy would be in Mrs B’s case could only be done in retrospect with a review of her progress over a period of time. It is possible to make some generalisations however, as the UKPDS (UKPDS 13, 1995) (UKPDS 33, 1998) studies looked at the clinical outcomes of this type of patient and assessed the effectiveness of various treatment modalities in Type II diabetes mellitus, over a period of some years. They produced very good evidence that weight loss is directly associated with a reduction of the incidence of long term complications. It therefore follows that advice regarding weight loss would be a major component of the treatment strategy for Mrs B. at her initial presentation.
Explain which of the concepts of need your intervention is concerned with.
The concept of need in relation to Mrs B is an extremely complex issue. In order to discuss it further we will need to make a number of assumptions about Mrs B and why she put on weight in the first place. Obesity is a complex and incompletely understood phenomenon. (Nicholls et al 2005). In broad terms obesity can be either metabolic, or due to over- (or inappropriate) eating. The psychological ramifications of this issue have been discussed in a vast number of medical textbooks and are clearly beyond discussion here, but many authorities agree that a successful weight reduction programme must take account of the patient’s psychological needs and their implications (Edmunds et al 2001). One of the cornerstones in management of the obese patient is an understanding and recognition of just what their particular psychological needs are so that they can be specifically addressed.
Discuss the influence of locus of control in your chosen case.
The locus of control is a concept that has changed in both emphasis and definition in recent years. We have already quoted Marinker’s work on the subject in a different context. It is probably fair to comment that in the mid part of the last century, the emphasis of control was with a didactic approach from the healthcare professionals. The patients were given instructions and were expected to comply. (Martyn 1999).
Modern practice favours a concordance of agreement which is reached after a discussion which involves the patient as much as it involves the healthcare professional. (Richards 1999).
We have already touched on the concept of patient empowerment and education and we have described how this is seen to be vital to maximising patient compliance. Ultimately, the locus of control stays with the patient, as they will decide to what extent they will agree to comply with the treatment plan. Healthcare professionals are progressively seen as a resource of knowledge to allow the process of concordance to take place. (RPSGB 1997)
Describe health behaviour models that may influence how patients/clients receive health promotion advice.
There are many different models of health behaviour that can (and do) influence patient’s assimilation of health promotion advice. (Kawachi 2002). Perhaps one of the most persuasive in this context, is the ethnic/cultural model. (Ewles & Simnet 2003). In general terms, patients will tend to accept most readily those concepts and strategies that are broadly consistent with their own cultural background and beliefs. (Enright 1996). In some African cultures, obesity is perceived as being positively related to health, wealth and social status, whereas there is a trend in some sections of western society to regard thinness as a desirable quality.
One could invoke the behavioural models as being relevant to this case (Steptoe et al 1999) and describe Mrs B’s obesity solely in terms of her eating habits but this is unlikely to adequately cover all of the relevant aspects of her case.
The medicalisation model (Spice 2004) could equally well be described as being relevant to our patient, as it is likely that one strategy that might be adopted in her case is to appeal to her realisation that her weight is directly linked to the incidence of medical complications of diabetes.
Even before we can really consider how patients receive health promotion advice, we should probably consider their receptiveness and readiness to receive that advice. Prochaska and DiClemente’s model of readiness to change (Budd et al 1996) is a good example of this.
Mrs B is obese. It is hard to imagine that she has gone through life completely oblivious to the many messages that are generated by the medically related media that obesity is positively associated with a number of health risks. The fact is that she has presumably not wanted to change. Either through denial or apathy (or possibly other reasons) she has remained obese. This particular episode of chest pain and a diagnosis of Type II diabetes mellitus may well be the catalyst that Prochaska and DiClemente refer to in generating a perceived need to change. Realisation of this fact should be a useful tool for any healthcare professional to capitalise on when endeavouring to manage the change process. (Nickols 2004)
Learning theory
One of the critical aspects of this case, and indeed this essay, is the ability to learn from and reflect upon the various measures invoked (reflective practice). (Gibbs 1998). We have described Mrs B and her problems, but any experienced healthcare professional will tell us that this is only the beginning of a journey for this particular patient. We can outline any number of appropriate health related interventions in her case, but it is important not to loose sight of the fact that it is not simply the actual giving of appropriate advice that is important, but it is the professional imperative of understanding the background to that advice and the reasons why it is given (Kuhse et al 2001). The whole concept of concordance relies upon the fact that the healthcare professional is a knowledgeable resource, and this knowledge can only be realistically be obtained through learning and experience (Elwyn et al 2000)
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