Adjustment to Health Change or Crisis

The following essay will describe the understanding that I have gained regarding a person who is adjusting to their health change. Throughout the essay I will be referring to the patient as John, and his wife as Sally, therefore adhering to the Nursing and Midwifery Council (2008) guidelines upholding confidentiality. John’s background will be summarised and key terminology being used throughout the essay clarified. I will underpin my essay with theory relevant to adjustment and coping, linking the theory to the interventions that were implemented while John was on the ward. Demonstration on how these interventions were effective and significance in supporting John with his adjustment will be shown, concluding with my own professional development.

John is 68 years old; I met him while on placement. John was admitted to the ward after deterioration in his mental state at home. John has a diagnosis of Alzheimer’s Dementia (AD) and has recently become confused and was becoming aggressive, both verbally and physically with his family and friends. According to Jacoby,Oppenheimer (2003) reported aggression towards carers from people with AD is high and is generally the reason for the person to have a hospital admission. Sally was finding it increasingly difficult to manage his needs and her own health was suffering. John was also unsafe to be left at home alone due to his tendency to wander and his inability to recognise his limitations, and was therefore at serious risk of accidents. His presentation on admission showed lack of hygiene and he appeared under nourished. Sally explained that up to a few weeks previous John had been coping moderately well with his diagnosis of AD with support from his family, but had become anxious and depressed when he started to become more confused and disorientated. A common symptom of dementia is the persons change in mood with depression being most prominent. Jacoby,Oppenheimer,(2003). He had been refusing his medication and had little or no sleep. John had voiced wishes to end his life and had attempted to walk in front of traffic. His doctor had felt that due to his depressed state of mind and the non-concordance with his medication that an informal admission to the assessment ward would be of benefit to him and Sally. Hammen makes the point that “Depression is one of the few psychological disorders that can be said to be fatal. Indeed, suicidal thoughts are a symptom of the syndrome of depression” (2002, p 41). People, who suffer from severe depression, present with a greater risk of suicide which should be treated with the correct treatment as soon as possible Guthrie and Lewis, (2002). To underpin my interventions I will be using the Transactional Model of Stress/Adaptation developed by Lazarus and Folkman (1984). This model offers a framework which helps to describe the adjustment to John’s health crisis using the concepts of ‘stress’ and ‘coping’ and supports the idea of ‘cognitive appraisal,’ which is basically a person’s awareness of their situation. The Transactional Model Lazarus and Folkman, (1984), describes the cognitive appraisal as being in two parts, firstly, ‘primary appraisal’, which for John was being scared, anxious and angry, and ‘secondary appraisal’ which is where John evaluated his situation and felt depressed and a burden to his family coming to the conclusion that they would be better off without him, ultimately leading him to attempting to walk in front of traffic. Primary and secondary appraisal processes work in conjunction with each other Power and Dalgleish, (2008). Folkman and Lazarus (1984) give their opinion that “the secondary appraisal coping stage can be seen as being divided into two sections, emotion-focused and problem-focused coping.” (Cited in Power and Dalgleish 2008,p:89). Lazarus and Folkman define coping as “constantly changing cognitive and behavioural efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person” (1984, p:178).

Cognitive appraisal is defined into two parts; the first part is where a person assesses the danger/risk and how significant is the threat from the stressor. If the stressor is deemed real, the second stage is triggered where we look at our options to deal with the situation effectively. After the threat is analysed if it is seen as severe, depending on if we have the means to deal with the threat, controls the amount of stress experienced. Martin, Carlson, and Buskist (2010). By using cognitive appraisal it can be useful to establish John’s responses to both his external event (his change in his health ) and his internal processes ( the feelings he had about his diagnosis and the behaviours he was exhibiting ) Research done by Folkman & Lazarus (1984) surrounding depression and anxiety explores the theory that “people suffering from depression are more likely to use the emotional –focused coping strategies than the problem-focused” (cited in Power and Dalgleish 2008, p. 89). Problem-focused coping involves confronting the problem and reconstructing it to be manageable. This way of coping involves seeking information and support. Taking problem-solving action e.g. taking medication and identifying events and goals that provide short term satisfaction Ogden (2007).The appropriate nursing interventions would hopefully support him to adapt to the problem –coping strategies.

When referring to stress it can be used in different ways but the most common understanding and the way stress presented with John was as “a critical condition that places such a heavy demand on our resources that we cannot cope adequately with it through our usual modes of adjustment”(Coan 1983, p. 38). Each person has a different perception of stress and as Lazarus and Folkman (1984), states, it is their “cognitive appraisal [..] of the stressful situation that will define the measurement of stress experienced”( cited in Martin, Carlson and Buskist., 2010 p.753 ). John’s perception was that he was becoming a burden to his family and that he was aware that he was slowly losing the ability to carry out normal daily living activities. By John attempting to walk into traffic demonstrated his critical condition. People who suffer from severe depression, present with a greater risk of suicide which should be treated with the correct treatment as soon as possible .Guthrie and Lewis, (2002). It is also generally considered that disruption in sleep pattern, having little appetite (often resulting in weight loss) and a general lowering in mood are common symptoms of depression. Guthrie and Lewis, (2002). These symptoms were all present on John’s admission. An assessment had been carried out on admission; by assessing someone’s mental health it enables the professionals to gain a history and base line observations, both physical and psychological that can help determine future care. By carrying out this assessment collaboratively it enables the patient to be part of the care planning process. From the client history the nursing staff can assess the areas such as severity of mood swings, cognitive changes, language difficulties. If the patient is unable to give all the necessary information Townsend (2006) recommends that family members can fill in the gaps, Sally was happy to assist the staff with this information. It was clear to the nursing team that John was having trouble adjusting to his diagnosis of AD which had contributed to his depressed state of mind.

Sally informed staff of John’s background; Previous to his diagnosis he had been a very active member of society while at work and when he had retired. John was a manager at a large company and had a lot of responsibility. When he had been told about his AD he had taken early retirement so that he could enjoy travelling with Sally while he was still able. It became clear in the conversation that both Sally and John did not expect the illness to affect his cognitive abilities at such a rapid pace and neither of them had had the time to adjust. Adjustment is normally classified as an individual’s connection with themselves and their environment and is associated with the fact that a person is able to adapt to any situation with ease (Coan, 1983). Adjustment is defined by Townsend as “the process of modifying one’s behaviour in changed circumstances or an altered environment in order to fulfil psychological, physiological, and social needs.”(2006, p.674).John had attempted to obtain adjustment by retiring early as he recognised that he could no longer maintain the managerial role he held to his previous ability. As the disease progressed it appeared that adjustment to the new situation was increasingly more difficult for them both. I questioned Sally on what support they were offered and if she had felt it was adequate. She explained that she gained the best support from the Alzheimer’s group she attended as there were other carers there that gave her advice on ways to adjust to her new role, as a career and as the one in charge of the finances. I reassured her that I would enquire for her about support both financially and with other services, to help her to adjust to John’s condition so she could therefore give him the appropriate assistance.

The Nursing Interventions used were focused predominantly on developing and sustaining positive coping strategies, to enable John to come to terms with his situation therefore allowing him to adjust to his illness and function within it, and for Sally to ultimately give him the best care she could.

My mentor and I spoke to John about his non concordance with the medication that he had been prescribed to determine his reasons .Concordance means conformity with medication Norman and Ryrie (2009), in order for concordance to take place it is recommended that the patient views on taking medication are considered first and then the healthcare professional gives theirs. The final decision to take medication should belong to the patient, Bond (2004).John explained that he found it hard to adjust to taking medication as historically he was in good health and avoided medication, and “what was the point, as I won’t get better”. John was still at the stage that he had the capacity to comprehend what was being explained to him. I showed him literature about the medication he was prescribed reading through it with him and Sally, informing them of the importance for his health and mental stability. I explained to John how the medication prescribed would help to elevate his mood and manage his symptoms of AD therefore allowing him to adjust to his circumstances and gain a better quality of life. NICE guidelines (2011) recommend “donepezil, Galantamine and Rivastigmine for options for the management of mild to moderate AD disease.”

To help John adjust to his environment on the ward, I spent time with him showing him how to get to his room, I put his name on the door of his room, and the toilet has a sign on to prompt all patients. I spent time with John and Sally and together we compiled his Life book, which gives insight for the staff on John’s life and is an aid to help John remember his life and shows him that his life is important although in a new context. To add to the sense of normality for John while on the ward we facilitated visiting for Sally and family. When John was first on the ward he was not keen on engaging with the staff or other patients and spent most of his time in his bed and had to be prompted to have his meals and attend to his personal hygiene. When I tried to initiate conversation with him he would not give eye contact and only grunted or replied with one word answers. It was decided amongst the nursing team that there was a need to encourage John out of his bedroom and onto the ward, which would hopefully establish a therapeutic relationship, enabling him to engage in the nursing interventions that had been decided upon. The importance of a therapeutic relationship cannot be overestimated: if the patient feels the relationship is good it could provide the foundation of the success of other interventions. The main responsibilities of a mental health nurse tends to be not as clear as other members of the multi-disciplinary team, it is essential though, that the nurse is able to drawn from her personal qualities to be able to gain a therapeutic relationship, which will enable an approach which combines clinical techniques to achieve insight and behavioural changes for the patient. Norman and Ryrie,(2009). I found out from Sally that John enjoyed crossword puzzles, to encourage John to engage with the nursing staff I set up a board in the patients lounge and copied a crossword from the newspaper onto it. When John came down for his lunch I asked him about one of the questions, this initiated a positive engagement with him and he interacted with me and some of the other patients. It seemed that this activity helped him to adjust to his present environment and allowed the start of a therapeutic relationship between us.

The consultant prescribed Rivastigmine for AD and Citalopram to treat his low mood. John showed concordance with his medication and within a few weeks he was in a less confused and depressed state. Sally had been visiting regularly and taken John for walks and her health had improved due to having less stress at home and a proper sleep pattern. I researched ways to help Sally get support with her finances and relayed this information to her. I referred her for a carers assessment which would give her means to get support and respite. NICE guidelines CG042 states “health and social care managers should ensure that the rights of carers to receive an assessment of needs as set out in the Carers and Disabled Children Act 2000 and the Carers (Equal Opportunities) Act 2004, are upheld.”(2012) Sally was able to get support and had some adjustments made to their home which would benefit both of them. Due to these alterations, including door alarms, and bathroom modifications she stated that she felt able to manage John at home and it was decided that John could have home leave for an afternoon. During the weeks that I was on the ward John slowly extended the time he spent at home, progressing into staying overnight. Throughout my time on placement John attended the social group within the hospital and it became apparent that John was adjusting to his situation with his health and the limitations that were being enforced upon his life. Having been a manager in his working career John sometimes went back into “work mode” and came into the ward office and started picking up paperwork it was obvious that he was struggling to adjust to no longer working. I found some paperwork that was not confidential and when John came into the office I would hand it to him and he would quite happily sit there rearranging it. It appeared that this activity settled him.

When evaluating the effectiveness of these interventions it can be seen that becoming more in control of his present, he could cope with his situation. I learnt the importance of communication, Norman and Ryrie stress that communication is essential to person-centred care even though the person ability to communicate varies. Allowances are made for the amount of cognitive impairment but ensuring that the person is not disempowered. (2013)I had to adjust to allow communication to between us to be facilitated. I spoke slower and waited for his respone. He became aware that his family needed him and that he could continue with some normality the activities he was used to doing, therefore he was learning to ‘master’ his life. Mandler, acknowledges that “Mastery implies that we become the masters of the situation, that we can encounter its demands and by meeting them adequately render them manageable” (1984, p.123). Using psychosocial interventions John was able to develop problem-focused coping strategies and incorporate the knowledge he gained about mindfulness to enable him to improve his mental health. “Mindfulness is the awareness that emerges through paying attention on purpose, in the present moment, and non-judgementally to things as they are” Kabat-Zinn, J., Segal, Z.V., Teasdale, J.D. and Williams, J.M.G ,(2007, p.47 ). Barker states that “Mindfulness is also recognized as an effective approach to stress management”. (2009, p.383).

John was still on the ward when I finished my placement. I felt privileged to have been involved in John’s treatment and observed a remarkable change in his presentation by the end of my placement from when I first came into contact with him. I learnt about the bio-psychosocial impact that depression can have on a person. I was able to be included in the assessment, adjustment and interventions for John. I had the chance to develop an understanding of the significance of current nursing interventions in facilitating adjustment and including coping and stressors. I have expanded my awareness on the importance of medication, psychosocial inclusion, and problem-focused coping to support someone going through a crisis. I have expanded my knowledge to applying the theory of Lazarus and Folkman (1984) Stress/Adaptation and the role of cognitive appraisal in assisting someone to gain mastery of their life. The experience has enabled me to move forward towards the necessary competency required when working in this environment.

When reflecting on my professional development I believe that I need to keep up to date with recent developments in my field of nursing through courses, conferences and membership of professional bodies relevant to my profession. It is my understanding that due to new research that is always being undertaken that we are forever developing knowledge and I intend to take advantage of all resources available to me. By continuing professional development and working collaboratively with a Multidisciplinary Team , I feel that this is a way I can ensure that I can expand my education and hopefully follow a degree pathway once I have gained my diploma.

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References

• Barker, P. (2009) Psychiatric and Mental Health Nursing: The Craft of Caring (2nd Edition) London: Hodder Arnold

• Bond, C. (2004) Concordance. London: Pharmaceutical press.

• Coan, R.W. (1983) Psychology of Adjustment: Personal Experience and Development. USA: John Wiley & Sons, Inc.

• Guthrie, E., and Lewis, S. (2002). Psychiatry, A clinical core text with self-assessment: UK Elsevier Science Limited.

• Hammen, C (2002) Depression East Sussex: Psychology Press Ltd.

• Jacoby, R.,Oppenheimer ,C., (2003) Psychiatry in the Elderly 3rd Edition, New York :Oxford University Press.

• Kabat-Zinn, J., Segal, Z.V., Teasdale, J.D. and Williams, J.M.G. (2007) The Mindful Way through Depression: Freeing Yourself from Chronic Unhappiness New York: Guilford Press

• Lazarus, R., Folkman, S. (1984) Stress Appraisal, and Coping. New York: Springer Publishing Company Inc

• Mandler, G. (1984) Mind and Body. Canada: Stoddart Publishing

• Martin, G., Carlson,N., and Buskist, W. (2010) Psychology (4th Edition).Great Britain: Pearson Education Limited.
References

• National Institute of Clinical Excellence,(2012) Supporting people with dementia and their carers in health and social care . P.44,1.11.1.1 Retrieved 08/08/2013,from http://www.nice.org.uk/nicemedia/pdf/cg042niceguideline.pdf

• National Institute of Clinical Excellence (2011). Alzheimer's disease - donepezil, galantamine, rivastigmine and memantine (TA217).Retrieved 05/08/2013,from http://www.nice.org.uk/guidance/TA217

• Norman, I. & Ryrie, I. (2009) The art and science of mental health nursing, a textbook of principles and practice. 2nd edition, Maidenhead: Open university press.

• Norman, I. & Ryrie, I. (2013) The art and science of mental health nursing, principles and practice.3rd edition.New York

• Nursing and Midwifery Council (2008) retrieved 09/08/13 from http://www.nmc-uk.org/Nurses-and-midwives/The-code/The-code-in-full/

• Ogden, J (2007) Health psychology a textbook. 4th edition, Maidenhead: Open university press.

• Power, M and Dalgleish,T. (2008).Cognition and Emotion: From Order to Disorder. (2 nd Edition) New York: Psychology Press.

• Townsend, M.C., (2006) Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based Practice (5th Edition) Philadelphia: F.A. Davis