This essay is written as a case study referring to a patient from my practice area. As I will be reflecting on my practice in relation to the case study, use will be made of first person writing where appropriate. Hamill (1999) supports the use of first person writing in academic essays such as case studies and suggests it develops self-awareness, reflection, analysis and critique.
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As this essay is focused on a specific patient from my practice area it is important to consider issues of confidentiality. Therefore, throughout neither my practice area nor the patient name will be identified. However to be able to discuss key issues in relation to the patient I will refer to their age, gender and lifestyle, and use a false name to aid the flow of writing.
Asthma affects 5.2 million people in the UK: 1.1 million children and 4.1 million adults according to Asthma UK in their 2004 report. However, depending which report one reads, this number can almost double to 10.1 million (Masoli et al 2003). This wide variation of prevalence maybe explained by the different studies and reports used to gather the data and differing inclusion criteria used. There is nevertheless agreement on the fact that the numbers of cases of asthma are increasing. Asthma UK (2004) reports a 400,000 increase in the number of adults with asthma in the UK between 2001 and 2004. The rising patterns of asthma prevalence however are not explained by current knowledge of causes of asthma, but are paralleled by increases in other allergic conditions such as eczema and rhinitis (Masoli et al 2003).
There is currently no agreed definition of the disease. Widely documented in the literature however, is the National Heart, Lung and Blood Institute (1992) definition who describe it as, ‘a chronic inflammatory disorder of the airways causing widespread but variable airflow obstruction…Obstruction is often reversible, either spontaneously or with treatment.’ The severity of the condition varies significantly (Rees and Kanabar 2000) from mild intermittent asthma, to a distressing disabling condition which results in time off work or school, disturbed sleep, restriction of social and leisure activities and anxiety (Hyland 1998). The main aim of asthma management is to control symptoms, minimise asthma exacerbations and optimise quality of life (Scullion 2005).
As a student of the Acute Care Pathway Degree, one of the specific learning outcomes for my pathway is to be able to manage programmes of care for patients with chronic diseases (St Martins College 2006). Hyland (1998) states that the Advanced Nurse Practitioner has become a major provider of asthma care in the UK. Watkins, Edwards and Gastrell (2003) agree, and suggest that currently the management of long-term conditions, including asthma, are a core component of a Advanced Nurse Practitioner’s work. Therefore it is crucial that I have an understanding of this condition and be able to review patients effectively (Wiggins 1999) using evidence based guidelines, and to have the confidence to provide advice on the management of their condition.
I aim to improve my understanding and asthma management skills through critically reviewing key issues of patient care as a case study. The key issues I intend to focus on relating to a specific patient are:
- Treatment of Asthma in the Emergency Department
- Patient education
- Patient concordance
Initially this essay will examine my current practice in relation to asthma management through reflecting on my present level of knowledge and understanding, discussing the level of care I can provide for patients with asthma at the moment. I then intend to give a brief outline of the patient chosen for this study, explaining the reasons for that choice and the rationale behind the key issues highlighted for discussion. A critical review of the key issues will follow using up to date evidence based literature and considering relevant policies. The conclusion will summarise the main points, reflect on what I have learned from this module and consider ongoing learning requirements in relation to asthma management.
Reflection on current practice
At the time of writing I have so far completed 16 hours in practise, Therefore my first few days in practice were spent adjusting to this new and very different area of nursing. Nevertheless I have had the opportunity to observe my mentor assessing patients with asthma and recently have become more involved in the review of these patients, with supervision.
Prior to starting the course I did feel I had some understanding of the disease process of asthma from working in the Emergency Department, albeit very fundamental, and some basic knowledge of the management. Some of this understanding comes from personal experience but also through my previous experience working in dermatology. Often patients presenting with atopic eczema would also be asthmatic, there is a well known link between these conditions (Hyland 1998). Some of the advice given in eczema management, for example allergen avoidance, will also be relevant in asthma management (Rees and Kanabar 2000).
Using Benner’s (1984) novice to expert model I would classify myself at present as an advanced beginner. This is someone who has a marginally acceptable performance with some background experience but who still requires supervision. I feel this accurately describes my current ability in practice in relation to asthma management. With supervision I am able to undertake an assessment using a template for guidance, check medication usage, check symptoms and carry out peak flow assessment. However I still find the array of inhalers confusing and don’t feel confident in interpreting the information gleaned during assessment into planned care within the time constraints of the clinic. When I have the time to reflect on the information and review the guidelines away from the patient I feel more confident. I need however to be able to make the transition from an advanced beginner to a competent practitioner, increasing my level of proficiency to no longer requiring supervision but being aware of my own limitations. I feel with more experience in practice and by working through this case study I should be able to achieve this.
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Rationale for choice of patient and key issues
Rolfe, Freshwater and Jasper (2001) suggest that choosing an event or incident to reflect upon or analyse is concerned with anything that happens to us that we want to write about for some reason. It is the significance of the experience within our daily lives which helps us choose one experience over another. Having decided to focus on asthma as the topic for my case study, when I looked back at the patients I had seen with asthma, it was the above episode of care which held the most significance for me.
The aims of the pharmacological management of asthma are to control symptoms, prevent exacerbations and achieve the best possible lung function while minimising side-effects and long-term sequelae (Scullion 2005). National clinical guidelines developed in 2003 by the British Thoracic Society (BTS) and Scottish Intercollegiate Guidelines Network (SIGN) were produced in collaboration with, amongst others, Asthma UK and the Royal College of Physicians of London, and have more recently been updated in 2005. They are widely accepted as the ‘Gold Standard’ of evidence-based asthma care for health care professionals working in the UK (Levy and Pearce 2004).
Patient education and concordance
The issues of education and concordance will be discussed together as they are inextricably interlinked. It is difficult for the health professional to achieve concordance with the patient without providing education about their disease and its management (Levy and Pearce 2004). It is estimated that one quarter of asthma patients in the UK have a compliance rate of 30% or less (Das Gupta and Guest 2003). The term compliance in health care has become less fashionable recently due to it implying that a patient is perhaps ineffectual and hasn’t followed the health professionals’ instructions (Hyland 1998). Whereas in reality the reasons for non-compliance are complex (Holgate and Douglass 2006) and not necessarily the fault of the patient, for example, not being shown how to use their inhaler device properly (Carter et al 2005). Nevertheless non-compliance is thought to contribute to between 18% and 48% of asthma deaths (Asthma UK 2003). Concordance is the term used to describe a negotiated agreement between health professional and patient with regard to the management of their condition (BTS/SIGN 2005). However even when concordance seems to have been achieved a patient still may not adhere to the agreed plan of care for many reasons (Weller and Booker 2006).
Ensuring patients are well informed about how their medication works has been shown to improve adherence and control (Boulet 1998). They need to be aware of the risks of taking and of not taking their medication (Levy and Pearce 2004). The latter is of particular concern in asthma in that persistent inflammation of the airways may lead to irreversible obstruction (Rees and Kanabar 2000). Written personalised asthma action plans have been shown to improve outcomes of care (BTS/SIGN 2005). They reinforce verbal education and set out for patients what to do if their symptoms worsen (Roberts 2002).
Asthma is a frequently seen chronic condition in the Emergency Department and one that Advanced Nurse Practitioners are expected to be involved in the management of (Hampson 2002). Therefore as am Acute Care Pathway Degree Student, I need to develop my knowledge and skills in this condition to enable me to provide a high standard of evidence-based care for patients. Throughout this essay I have endeavoured to demonstrate my understanding of asthma especially in relation to the pharmacological management and issues of education and concordance. These issues have been discussed and have shown to be interrelated; without achieving concordance, adherence to prescribed medication cannot be achieved and without patient education concordance cannot be realised.
Although I have been unable to discuss all aspects of asthma management due to word limit constraints, my understanding of asthma medications and the use of the stepwise guidelines has increased significantly to the point where I now feel more confident in practice. More recently when seeing patients with asthma I have been able to visualise which ‘step’ they are on which has helped me to decide whether they are on the correct medication in relation to the severity of their disease. Reviewing the issues of concordance and education has made me realise how important these aspects of management are; however the time needed to address these issues in practice often doesn’t correlate to the time allowed for appointments.
To enable me to become a competent practitioner in asthma management I need to consolidate the increased knowledge I have gained from writing this essay with more experience in practice. I need to increase my knowledge in areas not discussed in this essay, such as non-pharmacological management through self-directed study and perhaps consider further education through an accredited asthma diploma course, on completion of my degree course.
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