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Empowerment is a multidimensional construct applicable to individuals, organizations, and neighbourhoods (Rappaport, 1987). It is viewed as a construct rather than a concept because it is not directly observable (Jacox, 1974).The case study indicates that Patrick lacks both self control and will power in his management of his diabetes. Individuals with long-term conditions are challenged by often persistent and disruptive health problems that have cognitive, social and emotional repercussions (Larsen & Lubkin, 2009). Established methods of treating people with long-term conditions are based on the assumption that prescriptive instruction by expert health professionals will guide the user’s behaviour, thereby effectively managing their condition. However, frequent non-adherence to health care advice (Zimmerer et al, 2009) and failure to achieve behaviour change through education programmes alone (Gibson et al, 2001) indicate that this approach is often unsuccessful. Self-management programmes typically incorporate development of action plans and training in the skills required to implement such action (Lorig & Holman, 2004). Collaboration between the professional and the person with the long-term condition is required to ensure that advice is not only provided but personalised in accordance with the individual’s needs and preferences (Bodenheimer et al, 2002). In April 2009 the Department of Health released a guide on Self Management.
It detailed the “Four Pillar” approach,firstly Information, a more informed patient can make better decisions about his or her treatment, secondly skills and training, providing the patient with the skills necessary to take care of their condition better, thirdly tools and devices aiming to equip the person with the means to control their condition, and finally the all important support networks, giving the person a sense of involvement in their care and the ability to communicate any fears around their disease.
Whilst on my community placement I was introduced to an initiative that is used within a local PCT in Birmingham. It is called the Diabetes Manual (Burden & Burden, Heart of Birmingham PCT). It is a booklet/log book which is given to every newly diagnosed diabetic. It aims to educate and inform patients on their diabetes and how best to control it. It details some/most of the complications/side effects that come with having a long time condition such as diabetes. Its main aim is to educate patients through simplified terms and pictures. The integrated log book is used by patients to write down how they manage their diabetes on a day to day basis. One key area of this booklet is the action planning page. The book also incorporates target/goal setting for Patrick. On initial interview with Patrick we would aim to introduce him to the booklet and discuss with him, firstly the benefit of using this book, allowing him to self manage his condition and to better understand the implications of a long term condition such as Diabetes. It is important to ensure that Patrick is literate as this plan will not succeed if this is not so. Goal-setting for the first few weeks would be to aim to maintain blood sugars at a mutually agreed safe level.
It would be unreasonable to expect too much of Patrick within the first few weeks and although it is important for his health that goals are reached we would aim to gradually introduce more aims as Patrick got used to effectively self managing his condition. This integrated logbook and information guide addresses at least two of the four pillars of Self Management (DoH 2009). Information contained in the book will allow Patrick to read and digest at his own leisure, bombarding a patient with information during an interview can often cause them to disregard and switch off from the information giver.
It also acts as a tool or device by which Patrick can write down his day to day life in the knowledge that it may be the key to controlling his blood sugar levels if he keeps an accurate food diary. This initiative relies heavily of the theory of Self Efficacy as detailed by Bandura (1977). He stated that people can be characterised primarily on the basis of their beliefs in their ability to control their lives, because those beliefs powerfully determine the effort they make to adapt to their surroundings. Self-efficacy theory predicts that the more an individual feels capable of predicting and controlling threatening events, the less vulnerable he or she will be to anxiety or stress disorders in response to traumatic experiences . Therefore if Patrick believes he holds the key to controlling his diabetes, he will endeavour to put plans into action to reduce his blood sugar levels, come to terms with his condition and prevent further complications associated with his Diabetes.
The self-management approach views the individual as an active agent in treatment. The purpose of self-management is to nurture skills such as behavioural management techniques and to support informed decision making and problem solving, thereby equipping the individual with the necessary expertise to manage their condition.
This person-centred approach focuses on personalisation of treatment and facilitation of independence, allowing Patrick to continue day to day routine as normal without any forbearance on his life. It has been described as a patient-centred approach based on respect and compassion and has an emphasis on collaboration with patients (including collaborative goal-setting), self-management skills and psychosocial issues. Nurses would play a pivotal role in providing advice, guidance, education and support to Patrick . Self-management is important as it not only benefits the patient, but also provides wider opportunities for community and specialist nurses to use and develop their clinical and interpersonal skills.
It was highlighted in the case study that Patrick has started to develop Retinopathy. Diabetic Retinopathy is a vascular condition in which the retinal capillaries tend to degenerate after a number of years. The condition is characterised by ocular haemorrhages, lipid exudate and the growth of new blood vessels and connective tissue. This has resulted in poor eyesight which could prove problematic if not dealt with soon to prevent blindness. Patrick currently works as a bus driver so his eyesight is very important to him to be able to continue to work and provide financially for his family. Diabetes-related complications can have a major affect on the individual and family members, and are costly to the patient. There are a number of eye conditions specifically associated with diabetes. These include temporary disturbances in lens shape, related to hyperglycaemia and often seen at diagnosis, and cataracts, including the rare ‘sugar cataract’ only seen in people with diabetes. However, DR is likely to affect most people with diabetes as the duration of their condition increases (Williams and Pickup 1999). DR is one of the long-term micro vascular complications of diabetes mellitus and is the leading cause of blindness in the working population of the UK (BDA 1995).
Ninety per cent of people with type 1 diabetes have some degree of DR within 20 years of diagnosis and it has been suggested that it is present at diagnosis in 40 per cent of those with type 2 diabetes (Cummings 2002). A survey has found that blindness was the most well known complication of diabetes (Diabetes UK 2000). However the future for Patrick does not have to as bleak as it sounds. The National Service Framework for Diabetes (DoH 2001) recommends early and regular screening for all diabetics.
Developing a plan of action/care for Patrick should begin with a thorough nursing assessment which is essential to ensure that a correct diagnosis regarding diabetic Retinopathy is made. Patrick may complain initially of the signs of vitreous haemorrhage such as ‘floaters’, which look like small, black insects, or a lacy curtain across the field of vision. Macular involvement may be revealed by the patient’s description of a general deterioration in fine and colour vision that is not improved by wearing a range of spectacles. The main aim of screening for diabetic Retinopathy is to identify patients with sight-threatening Retinopathy who may require preventive treatment. Screening and treatment for diabetic Retinopathy will not eliminate all cases of sight loss, but can be important in minimising the number of patients with sight loss as a result of this condition. The aim of a retinal screening programme is to ensure that a yearly examination of all patients in a given area is performed (Walker and Rodgers 2002). This assessment should be done prior to a direct and rapid referral to an Ophthalmologist to screen and evaluate the degree of Retinopathy. As a preventive strategy, health education should include the best available research evidence to assist patients to make decisions about lifestyle changes and gain control over their condition (Watkinson and Chetram 2005).
Micro vascular complications may be prevented or onset delayed with good medical treatment (Kanski 2007). The nurse should involve Patrick and with permission the family to identify areas such as diet and alcohol consumption that can be modified to provide better and tighter glycaemic control. Levels of blood glucose are set at preferably below HbA1c 6.5-7.5% according to the individual’s target (NICE 2005). Patrick’s is 9.9% which puts him in the danger zone for developing complications and increasing his risk of irreversible damage. The target is based on the risk of macro vascular and micro vascular complications. Individuals with type 2 diabetes need to have an ongoing structured evaluation every two to six months, to assess the risk factor. A reduction in the prevalence of diabetic Retinopathy is associated with tighter blood glucose control (Younis et al 2002).
By involving the whole family in this change in lifestyle will prove to Patrick he is not on his own and offer him support. Using the initiative I discussed early in this assignment the log book/information guide offers helpful advice for diet and lifestyle change. Setting Patrick some SMART goals/challenges will allow him to maintain his control of his own body and increase compliance. The target is to reduce his HbA1c to within the acceptable target range discussed above. A significant lifestyle change is needed but must be done with concordance with Patrick and his family. It is noted that Patrick is overweight with a BMI of 29.5. This can increase his risk of hypertension, which itself is a factor in Retinopathy as it increases the pressure within the eye. Effective blood pressure management is as significant as blood glucose control in reducing the risk of progression of diabetic Retinopathy in those with type 2 diabetes (UK Prospective Diabetes Study Group 2004). Good blood pressure control is considered to be at or below 140/80mmHg (NICE 2005).
Adherence to prescribed anti hypertensive treatment is vital as diabetic patients with hypertension have a poor visual prognosis (NICE 2005). A consultation with Patrick’s GP should be arranged to ascertain if there is any hypertension and if found it has been shown that ACE inhibitors prove very effective in the reduction of high blood pressure in Diabetics.(NICE 2005).There are new schemes devised by the Department of Health to reduce the use of medication in weight loss and to increase exercise in the population. Free weigh loss classes are offered to patients who meet the criteria. Patrick would benefit from these schemes. Medication management and strict concordance with the regime is incredibly important to ensure Patrick maintains a level of the drugs in his body. If it is adhered to it may be that he will not have to take insulin.
By providing ongoing psychological support to Patrick and to his family the nurse can help the patient to maintain his or her self-esteem and improve self-management of the condition. Visual impairment in patients with diabetes is often compounded by the loss of self-management skills, which may have psychosocial implications (Hall and Waterman 1997). Reactions to visual loss can also lead to psychological distress such as depression, suicidal thoughts and anxiety (Hall and Waterman 1997). It is therefore the nurse’s duty to discuss these issues with the patient and relatives and provide appropriate support (Nursing and Midwifery Council (NMC) 2004). Organisations such as Diabetes UK and the Royal National Institute of Blind People (RNIB) can also provide ongoing help and support. Regular screening and repeat follow ups should ensure Patrick’s Retinopathy does not continue to worsen.
Nearly two decades ago Fielding and Llewellyn (1987) pointed out that effective nurse-patient communication was central to the quality of care that patients received, stating rather poignantly that: ‘Communication is both one of the most demanding and difficult aspects of a nurse’s job, and one which is frequently avoided or done badly although central to the quality of patient care.’Encouraging people to change their attitude towards a health issue is an important part of any health education programme, but people’s values can be particularly resistant to change. Even when clients are persuaded to change their attitude (for example towards diet, smoking, safer sex) it is often frustrating for nurses to realise that this may not lead to a change in their behaviour. An understanding of the complex relationship between a person’s knowledge, attitude and behaviour can assist health professionals in realising why clients may continue to behave in a certain way, despite health advice to the contrary. Persuasive communication theory offers specific techniques that can be used successfully within health promotion. It is important for the nurse to listen to Patrick’s concerns and endeavour to offer counsel or help.
I have attempted to prove in this assignment that communication with Patrick and his family is of the utmost importance to ensure concordance and thus improve his control of his condition. By educating both parties it shows Patrick that he is not alone and he can gain support from his family and other networks accessible to him such as local support groups.
It has been mentioned in the case study that Patrick drives a bus and as a result of his poor control of his Diabetes, he has been falling asleep at the wheel. This provides the nurse with a significant ethical dilemma. Bound by the NMC professional code of conduct means nurses are restricted to what information they can release.
A disconcerting feature of ethics can be its association with apparently complex theories such as utilitarianism (the moral value of an action is determined by its overall benefit) and de-ontologyy (concerned with adhering to moral rules or moral duty rather than with the consequences of actions) (Beauchamp and Childress 2001). These established theories are important components of ethics and can help to guide decisions. The general principles of Ethics are that of Avoiding Harm and moral obligations and duties. As a nurse we have a moral obligation to notify the DVLA as it is in the public best interest to prevent harm coming to others if Patrick falls asleep at the wheel, thus avoiding harm to others.
In this assignment I have endeavoured to show that the key to controlling Patrick’s Diabetes is through effective communication, self-efficacy/self management and family involvement. By encouraging Patrick to look at his life and analyse his lifestyle he is on the road to effective self management. Change is only possible if Patrick’s attitude towards his condition alters. By offering him the option of utilising the logbook he can challenge his attitudes with the main aims/challenges of keeping further complications at bay, maintaining tighter glycaemic control and thus lowering his HbA1c.
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