Care of Complex Physical and Mental Health Illness across the Lifespan

Consider the impact on an individual of living with a long term condition and critically analyse the wider implications for society and health care provision.

Consider a long term condition, such as ‘diabetes or hypertension’ and critically analyse how the disease/ illness affects physical and mental health. Develop reasoned and logical arguments which should be supported by appropriately researched literature. The pathophysiology of the disease/ illness should be identified and explained in relation to complex physical and mental health.

The author aims within this piece to examine their knowledge of and appraise the contemporary political health and social care agenda in relation to the evidence based management of long term conditions. Whilst examining the aforementioned, it is the writer’s intention to develop cognizance of the pathophysiology of post traumatic stress disorder (PTSD) and discuss the presentation of the same. In order to evidence this understanding the author will synthesise the physical, psychological and social aspects associated with long term conditions. Furthermore examine the nurses role in promoting self care for patients and families. In the meantime substantiating their ability to support people experiencing long term conditions and plan their care effectively; as part of the multidisciplinary team by reflecting on the medical and nursing management of a long term condition from practice. Further it is also the author’s objective to analyse the importance of inter-disciplinary, inter-professional and inter-agency communication and working amongst care providers and outline the role of key workers.

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The World Health Organisation (WHO) in defining health pursue complete wellness through physical, mental and social well being, and do not simply concentrate on the lack of presence of disease or malaise (2015). This provides some clarity but does not provide for people who are dealing with a long term condition but are generally well. So using this definition the WHO actively discriminates against large proportions of the population (author unknown, Kings Fund, 2013). The definition above could be seen to limit the mindset of practitioners, as to observe a patient in health crisis does not mean that they will be acutely unwell. In fact the opposite is more likely when considering care planning to patients with long term health management needs (author unknown, Kings Fund 2013).

Historically PTSD has been something that has not been readily recognised and instead the sufferer has been described as being ‘spent from battles’ (Dryden, 2010).

There is very little recent data to consider when looking at Post Traumatic Stress Disorder, it is often considered in the round with mental health generally. Mateos (2000) estimated the global burden of PTSD was 0.6% of a year lost due to the disease. This according to his research is extrapolated to estimate 3,230,000 lives per year (Mateos, 2000). When considering this research, it is important to note that the sample size was 32,946 and was not limited to one specific area/ country. This allows for a wide range of variables to be in place, and in turn for more consideration to be made of social determinants and causative effects.

In the United Kingdom specifically however, in consideration with regards to traumatic events and differing categories of the same, the differentiation between major trauma such as a road traffic accident or through witnessing the same and armed conflict bringing PTSD about, it is important to note that the data collected is generic limited to that key term and in fact far from accurate and that is insufficient information available to develop a differentiation between causes of PTSD (Barker, 2009). Therefore the efficacy of research is easily challenged and the lack of rigourous research detracts from the findings (Barker, 2009).

In America 44.68 million people develop PTSD as the result of one or more traumatic events in their lives with somewhat higher rates of this disorder in African Americans, Hispanics and Native Americans compared with Caucasions in the US (Heal my PTSD, 2018)

In analysing the data there is no up to date statistics relating to the prevalence of PTSD in the United Kingdom, this could be for a wide of reasons, from the lack of credence that governments pays to PTSD sufferers, to the lack of evidence from research into the disease. Where questions asked or symptoms examined do not get to the root of the problem then inconclusive evidence leads to inconclusive treatment.

Members and veterans of the British armed forces get support from their welfare officer and regiment/ corps for a limited amount of time (Ministry of Defence, 2018) but because it is not necessarily understood/ prioritised this support quickly dwindles away and therefore the PTSD patient is in a position whereby their benefits/ support and welfare is only available upon application (Department of Health, 2017). Whilst the armed forces of the United Kingdom offer support, it is very much a short term measure and only designed for acute aspects, it is not a management tool but a short measure prior to signposting to mental health services either on a private funded basis or through the National Health Service (Ministry of Defence, 2018). 

The Joint Services Needs Analysis (JSNA) shows national, local and regional in one table relating to the social determinants of health in a specific area for individual diseases or trouble areas, as not every area has the same issues to resolve. For example, Blackburn with Darwen has life expectancy at birth of 76.5 years for a male and 80.8 years for a female, this in comparison with Lancashire is 78.5 years for males and 82.1 years for females and England is 79.5 years and 83.1 years respectively (JSNA – Lancashire, 2018). There is no that the author could find in relation to mortality or indeed instances of crisis on a local level or nationally.

In Lancashire there are support groups available for sufferers of PTSD, but they are not designed with the intention to treat (PTSD UK, 2018). They are very much a signposting service provided by volunteers and fellow sufferers. Counselling on a private funded basis is available however, no government funded assistance is provided (PTSD UK, 2018).

The National Institute for Health and Care Excellence (NICE) set out a policy for PTSD. The policy is designed for the guidance of any care provider of people with a diagnosis of PTSD, as well as those with responsibility for services provision and care planning for people with a diagnosis of PTSD and their carers (2005). This policy is a small step to ensuring provision remains, however, it is vastly outdated and in need of updating because the care provision of long term mental health conditions does not stand still and constantly changes on a person by person basis (NICE, 2005).

National policy and trends are derived by Public Health England and also a safeguard but very much working hand in hand with the National Institute for Health and Care Excellence (NICE). There are few policies relating to PTSD and instead the mental health policies appear to be broad brush or blanket policy provision, this in one aspect ensures parity of provision, however, on the other it is a systematic failure to provide individualised person-centred care. The guidelines relating to PTSD are in the process of being updated and during 2016 multi agency contributions formed the initial development of update (NICE, 2017) To date, some two years later, such policy has not been updated.

The physiology of stress disorder relates to the hippocampi and the processing of a memory (Bailey et al, 2013). Bailey said that the psychological impact of experiencing a traumatic event, means that PTSD often leads to changes in the anatomy and neurophysiology of the brain (2013). Therefore the resulting reduced size of the hippocampus likely both a predisposing factor as well as being a  result of trauma (NHS, 2018).

The processing of emotions and modulating the fear response within the amygdala, could be argued to be overly reactive in patients with PTSD (Bailey et al, 2013). The inhibitory control of stress response and emotional reactivity of the amygdala by the medial prefrontal cortex (mPFC), is physically smaller and not as responsive or reactive in individuals with PTSD (Bailey et al, 2013). There is also commentary from experts such as the Royal College of Psychiatrists that alterations in neurohormonal and neurotransmitter functioning also occur (2016). Individuals with PTSD have been identified to have lower than normal circulating levels of the stress hormone cortisol, despite their ongoing stress and elevated levels of Corticotropin Releasing Factor (CRF) (Bailey et al, 2013). The lower levels of this hormone, leads to decreased production of CRF (RCP, 2016). Therefore, if cortisol is low it leads to CRF continuing to be high and stimulates a norepinephrine release and adrenal fatigue follows, this in turn has an impact upon the body’s homeostasis and a physical symptoms becomes more apparent (NHS, 2018).

Individuals with PTSD demonstrate hyperactivity of the sympathetic branch of the autonomic nervous system, as evidenced by changes in heart rate, blood pressure, skin conductance level, and other psychophysiological measures (NHS, 2018).

Further insight into the pathophysiology of PTSD may be found in the Dual Representational Theory (Brewin et al, 1996). This understanding highlights the presence of two separate systems for memory. Verbally accessible memory, first recorded in the hippocampus and later in general brain memory storage is able to be modified by reflection (Royal College of Psychiatrists, 2016). This is characteristic of most non-traumatic memories. Situationally accessible memory, on the other hand, is non-verbal and associated with very strong emotions and the amygdale (Royal College of Psychiatrists, 2016). 

Traumatic memories tend to be stored as situationally accessible memories, which are harder to process, are readily triggered by associations, and more likely to cause emotional distress when activated (Royal College of Psychiatrists, 2016). Individuals may struggle to integrate these traumatic experiences with the rest of their life narrative thereby resulting in the traumatic memory having a significant impact on their views of the world and themselves (Royal College of Psychiatrists, 2016).

In the case of pathophysiology when considering Post Traumatic Stress Disorder (PTSD) it is important to note that very little is observable in a person suffering with this (Bailey et al, 2013). Post Traumatic Stress Disorder (PTSD) is a chronic anxiety disorder causatively linked to very stressful, frightening or distressing events (NHS, 2017). Therefore the observable aspects are likely to be feelings of shame or guilt, difficulty controlling your emotions, periods of losing attention and concentration, this is known as dissociation, physical symptoms, such as headaches, dizziness, chest pains and stomach aches, cutting yourself off from friends and family, relationship difficulties, destructive or risky behaviour, such as self-harm, alcohol misuse or abuse and even suicidal thoughts (Royal College of Psychiatrists, 2016).

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PTSD is an insipid vacuous illness that saps hope, feelings of self worth and confidence of the individual (Barker, 2009). During the allied conflict with Germany of 1914-1918 soldiers were shot dead for deserting their post or for wandering around in a state of confusion, this we now know is PTSD, they were considered to be cowards or suffering from shell-shock, later when men came home to their pre war lives, they found talking about their experience daunting and embarrassing (Barker, 2009). There was huge stigma around being ill of mind or shell-shocked (Barker, 2009).

PTSD is on the face of it a mental health condition and therefore there is a certain amount of stigma around mental health. The aim of care provision for sufferers of PTSD should be to empower the patient to help themselves and to understand triggers to their crisis or flashbacks, this is heavily dependent upon the type of trauma that the person has experienced (NHS, 2017).

Within healthcare in a hospital, the role of the nurse is pivotal. Nurses are providing twenty four hour care to patients whereas other disciplines simply dip in and out depending upon the patient’s needs (Lubkin & Larsen, 2013).  They are often dealing with highly complicated and stressful issues whilst providing care to a vulnerable individual (Lubkin & Larsen, 2013). Whilst undertaking these important tasks for patient’s there should also be an opportunity to provide health promotion advice and promote the whole picture of health including prevention and steps that a patient can take to help themselves (Gerlich & Hegner, 2014).

Nurses have a responsibility to make every contact count, this is a government initiative to provide health education to every patient we encounter (Department of Health, 2017), whether that is providing direct information such as a leaflet on assistance to cut down their alcohol consumption or a general conversation about their diet and how this may contribute to their physical health, the role of the nurse and the funding for specialism and health promotion, ‘making every contact count’ (Department of Health, 2017).

When considering epidemiology which is the study of why people get sick and the determinants that influence that, promoting the holistic approach and not just treating the presenting condition. As part of the every contact counts, the NHS policy (2015) and five year forward view places strategies to identify and educate the population on mindfulness and self compassion (2017).

The NHS five year forward view provides for aims and objectives in which healthcare can actively become a positive aspect in peoples lives and not only a service to use when people become unwell (2014). By making every contact count nurses can actively contribute to effective prevention of acute symptoms and education of service users to enable them to help themselves prior to becoming unwell (NHS, 2014). This promotes a proactive approach to health care generally.

PTSD unlike many long term conditions does not have a specific specialist nurse within a health trust environment, instead a number of differing specialist nurses will have an input into the care of this person (major trauma clinical specialist and psychiatric nurses are just two examples). The key worker role for a patient with PTSD would be most suitably a social worker so as to adequately manage their care as the patient requires .

Both physical health and mental health nurses, Psychiatrists, Counsellors, Psychotherapists, Social Workers, Law Enforcement and Legislature, Councils, Occupational Therapists, Charities, Samaritans or similar, G.P.s, Carers, Employers and Pharmacists as well as others all contribute to the provision of care to people with PTSD. The key worker is likely to be a social worker/ mental health nurse who co-ordinating the care of the person.  

Long term conditions such as PTSD cannot practically be managed solely by the medical model, therefore the house of care was created to support the changing face of long term condition care (NHS England, 2013). This acknowledges the patient as an expert in their condition and enables a holistic approach to care bringing about the best outcomes for the patient (NHS England, 2013).

Patients in England with long term conditions have the most complex healthcare needs of the population with approximately half of all general practitioner appointments being taken by long term condition patients (NHS England, 2013). The impact of this is that treatment of these patients absorbs large amounts of acute and primary care budgets, the figure is approximately seventy percent of the respective budgets (NHS England, 2013). The sustainability of medical models dealing with single condition problems is becoming more strained and a more holistic approach is necessary as multiple conditions having effect on morbidity is more prevalent (NHS England, 2013).

There are inordinate barriers to appropriate care for long term condition sufferers, such as single condition care services adopting single condition guidelines, and failing to consider the specific dangers of multiple medication interactions, known as poly-pharmacy and further failing to include a holistic approach patients and care provision (Wagner, 1998 also NHS England, 2013).

Due to the failures in care coordination, patients and families are unaware of who to turn to when there is a problem and desperately needing a key worker to be in place to help with the signposting, having a wider more remote viewpoint and aiding the support of the patient this is especially prevalent in the gap in care provision for PTSD sufferers. (NHS England, 2013).

A key consideration of providing care for PTSD sufferers is a lack of attention to the physical health of people with mental disorder as their primary long term condition (NHS England, 2013). This in turn has lead to dangerous incidences and large scale gaps in care provision when a whole system approach with appropriate agencies such as social care and everyday functional support such as transport, benefits and housing (NHS England, 2013). This is known as fragmented care, which in turn when combined with lack of information sharing leads to potentially perilous situations for people with long term conditions (NHS England, 2013).

The health service provision of reactivity not proactivity and lack of consultation with the patient around their own care is isolating and brings about a two way condition of lack of trust between practitioner and patient, this can in turn lead to greater difficulties in managing the condition and surrounding factors (Coulter et al, 2013).

The house of care (2013) based upon the chronic model of Wagner (1998) centres around four mutually reliant parts, which must be present for person centred care and essential continuity to be achieved. These are: 1. commissioning which involves an ever improving process with the previous process informing the next. 2. engaged, informed individuals and carers which in turn leads to patients self managing self signposting through concordance and knowing what they need and when they need it. 3. Structure through organisational and clinical processes to assess the needs of patients and carers. 4. Shared partnership working between health and care professionals to develop continuity of care (2013).

Through consideration and shared practice the safeguarding of patients with PTSD, who are some of the most vulnerable owing to the lack of provision for their condition can be achieved (Office of the Public Guardian, 2015). The Care Act 2015, provides that where an adult who has care and support needs may be at risk of neglect, including self neglect that an independent advocate is appointed and speaks for the best interests of the adult. This includes where provision gaps are identified as in that of PTSD patients and their families.

The house of care model is suitable for all people with long term conditions (LTCs), not just those with single diseases or in high risk groups, and for frontline clinical practice, supported by local and national policy and strategy. 

There is very little information that can delve into the role of the nurse there is no clinical nurse specialist for post traumatic stress disorder. In this instance the key worker is likely a social worker (Gaebel et al, 2017).

Sadly, the conclusions and findings of gaps in health and social care provision for patients with long term conditions, specifically PTSD are systemic from government to the front line. Nurses, health and social care providers and other professionals are doing their best with limited resources however, without appropriate funding and a commitment to revise provision, the support and treatment of PTSD sufferers will remain in decline and ultimately service users and patients will suffer. This presents safeguarding concerns on a regular basis and therefore it is not too large a step to consider that diagnosis of PTSD may provide more questions of a health and social care system than it answers. 

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