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Long Term Conditions

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HE0930A CASE STUDY | 1104964 |

Jane Smith aged 16 years, was diagnosed with diabetes aged 7. Last month, whilst attending the practice nurse’s diabetes review clinic Jane expresses concerns that over the past few weeks her blood sugar readings have been elevated. She does not want to increase the dosage of her twice daily insulin regime as she is worried that this will cause her to gain weight. 1. What is meant by the terms anticipatory care, self care and self management? (15%) 2. Critically discuss why current Scottish health policy is actively promoting the self care and self management of long-term conditions. (25%) 3. Critically discuss the practice nurse’s role in supporting Jane to self- manage her long term condition (60%).

A long term condition (LTC) can be defined as a prolonged health issue that never goes away and is very rarely cured (Magerson and Trenoweth 2010). These conditions require different degrees of on-going care and support tailored to the individual (Scottish Executive 2009). The government has realised that effective management of these LTC’s is one of the biggest challenges that healthcare faces (McVeigh 2009). This essay will focus on the above case study, defining anticipatory care, self-care and self-management, and analyse and explore current Scottish health policy in relation to self-management and self-care. A fundamental part of this essay will discuss the nurses’ role in supporting Jane to self-manage her diabetes.

Anticipatory care is a plan of the future that involves input from healthcare professionals, the individual and their families/carers to make a plan that sets out realistic goals (Scottish Executive 2010). Anticipatory care ensures that the best thing is being done for that individual so that the outcome is both positive and beneficial (Scottish Executive 2010). It sets out actions, interventions and responses that the individual wants following deterioration in their condition (Scottish Executive 2010). Most individuals with a LTC self- manage their own condition with help from family/carers and input from healthcare professionals (Department of Health [DOH] 2002). Self-management can be defined as the patient’s ability to handle the demands of a long-term condition (Carrier 2009), with the support of appropriate individuals and services (Scottish Executive 2008). Demands can include symptoms, treatment, physical and social issues and changes in lifestyle (Carrier 2009). Self-care includes activities tackled by an individual, their family and anyone else involved in their care, to help improve their quality of life, overall health, prevent disease, and limit their illness (Meerabeau and Wright 2011). Each of these definitions have a key component of person centered care, which is set out by the government (Scottish Executive 2007).

An evolving model of healthcare has been introduced within the NHS, which is geared towards self-management and self-care (Meerabeau and Wright 2011). Person centred care is recommended in the Better health, Better care action plan (Scottish Government 2009), which helped develop a ‘mutual’ NHS where staff and patients have a mutually exclusive relationship (Scottish Executive 2007). This relationship is also discussed in the Governments action plan ‘Improving the health and wellbeing of people with long-term conditions’ (2009). According to Hewitt-Taylor (2013), patients often talk of expertise of their own condition being valued and respected by healthcare professionals. Patients believe that partnership in their care and support and education from healthcare professionals empower them to self- manage their condition (Hewitt-Taylor 2013).
The idea of empowerment is reiterated in ‘Gaun yersel’ (2008), a strategy for LTC’s, in which the growing prevalence of LTC’s is recognised and calls for support (Scottish Executive 2008). The ageing population, and the premise that the ‘older you get, the more likely you are to suffer from ill health’ is a major contributory factor (Scottish Executive 2010). The Scottish Health survey (2012), report that approximately 46% are living with a LTC, and this is set to rise (Procter et al 2013). This obviously has a major financial and social implication for Scotland (Scottish Executive 2008). People with LTC’s are inconsistent users of the NHS (McVeigh 2009), with figures showing that 80% of G.P consultations and 60% of hospital bed days are accountable for this group (Scottish executive 2008).
With 78% of healthcare spending linked to managing LTC’s (McVeigh 2009), the high incidence of LTC’s is the driving force behind promoting self-care and self-management (Scottish Executive 2008). It is assumed that giving patients more control in their care will reduce ill health and unplanned hospital admissions (McVeigh 2009). Although care is aimed at being person centred, it can be proposed that the self-management policy agenda is being used to transfer costs and responsibilities onto patients and their families (Kirk et al 2012). The introduction of case management and ‘community matron’ policy that aims to ‘treat patient sooner, nearer to home and earlier in the course of disease’ (DoH 2005), implies this. Although it has worked well in areas, with patients describing themselves as having more ‘confidence’ and a reported reduction in ‘anxiety and worry’ (Sargeant et al 2007), there remains a difference in the quality of care Scotland wide (Carrier 2009).

The practice nurse (PN) needs to maintain his/her skills in order to provide proficient care, education and counselling to patients like Jane so that a positive outcome is achieved (Mikkonen and Hynynen 2011). Diabetes can effect physical, social and psychological functioning, amongst other aspects of life i.e. family life (Mikkonen and Hynynen 2011). Jane will require different aspects of intervention in order to maintain and manage her condition as effectively as possible (McVeigh, 2009). As Jane plays the biggest part in self-managing her condition, alongside family support, the PN should place an emphasis on health promotion and education of diabetes (Mikkinen and Hynynen, 2011). Self-management approaches in diabetes can improve knowledge and performance, self-efficacy, health status, and coping skills (McVeigh 2009). Listening skills are an important element for the PN in supporting Jane, especially in clinics where time constraints limit nurse-patient time (Meerabeau and Wright 2011). Listening allows Jane to express her feelings and concerns whilst forming part of the nurse-patient consultation. During consultation, the nurse can assess Jane’s condition (Meerabeau and Wright 2011).
The PN needs to address Jane’s needs holistically, as certain aspects can be overlooked (Magerson and Trenoweth 2010). Adolescents with diabetes are at risk of emotional and behavioural problems, and the psychological aspect of the disease can often be missed (Ashraff et al 2013). Jane may be reluctant to discuss issues such as depression, anxiety, and low self-esteem caused by her medical condition (Jaser et al 2013). It is important the PN enquires into psychological wellbeing during consultation as it may help Jane in disclosing issues (Randall and Ford 2011). This may be enough of an intervention, if not appropriate referral to others members of the Multi-disciplinary team (MDT) can be considered, and should be made routine nursing practice (Randall and Ford 2011).
It is important to note that at age 16, Jane will be going through rapid biological, social, and psychological changes (Newman, Steed and Mulligan 2009). Transition into adolescence with diabetes for Jane, can lead to poorer self-management and a deterioration in metabolic control (Jaser et al 2013), something the PN needs to address with person centred care. Management of diabetes is complicated, and requires Jane to monitor blood glucose levels, food intake, and exercise frequently, and to adjust insulin as needed (Jaser et al 2013). As Jane has had diabetes since childhood, initially her parents would have managed her condition, over time providing opportunities for her to become involved in aspects of managing her condition, and eventually becoming more responsible for self-management (Kirk et al 2012). Therefore it can be said that Jane will have/be in the process of transitioning from paediatric healthcare services to Adult services, placing Jane in control of self-management. The PN must adopt the role of educator, providing Jane with appropriate information, collaborate with her to set realistic goals, and offer support (Meerabeau and Wright 2011).
It can be implied that Jane should have knowledge of her LTC, and she has certainly recognised the elevation of her blood glucose levels and shows knowledge of weight gain being linked to increase in insulin. The PN should educate further, directing management of her diabetes through frequent blood glucose monitoring to accomplish normoglycaemia (Brooker and Nicol 2011). It should be explained that an intensive insulin regime is involved that may have to be altered in connection with dietary intake (Newman, Steed and Mulligan 2009). For Jane, insulin therapy is essential to maintain her life (Brooker and Nicol 2011). The importance of concordance is key, and understanding Jane’s need’s is vital (Carrier 2009). Jane is unwilling to increase her insulin regime as she is afraid that this will cause her to gain weight. This is a sensitive issue, but education regarding omission of insulin should be given including the threat of diabetic ketoacidosis and later life complications such as coronary heart disease if correct insulin doses are not taken (Wilson, 2012). A psychological assessment should be undertaken as to Jane’s reluctance to increased insulin, with a consideration of diabulimia or other eating disorders (Wilson 2012).
To achieve changes in Jane’s diet and lifestyle, what she wants should be considered (Carrier 2009). Appropriate dietary advice specific to Jane’s needs and culture is important to effectively manage her diabetes (Brooker and Nicol 2011). The PN’s aim is to give Jane information so that she can then make an informed decision regarding the type and quantity of food she eats (Brooker and Nicol 2011), placing emphasis on healthy eating and a balanced diet (Magerson, and trenoweth 2010). Weight management will be an important issue that’s needs encouragement and support from the nurse, but again needs to be handled sensitively (Brooker, and Nicol 2011). The PN can point Jane towards DAFNE (dose adjustment for normal eating) website which can help Jane lead as normal a life as possible while controlling blood glucose levels, encourage activities that will increase her exercise and help in managing her weight (Carrier 2009), as well as the above mentioned dietary advice. As Jane worries about her weight, the PN can use a multi-disciplinary approach (MDT) and make a referral to the dietician (Griffin 2010).

Anticipatory care, self-care and self-management are very much the centre of healthcare today, and are a key focus of Scotland’s health agenda. Each incorporate person centred care and an anticipatory approach with the patient becoming an expert. The case study of Jane utilises an anticipatory care approach to self-managing her diabetes with support through patient education and promotion being facilitated through the PN. This should ‘empower’ Jane to take responsibility for her LTC management, through a collaboration individual to Jane’s needs.

References:
Brooker, B., and Nicol, M. 2011. Alexander’s Nursing practice. 4th edition. Elsevier: Churchill Livingstone.
Carrier, J. 2010. Managing long-term conditions and chronic illness in primary care: A guide to good practice. London: Routledge.
Dafne. 2013. [online]. Available from: http://www.dafneonline.co.uk/ [accessed 13/11/13].
Department of Health. 2002. National service Framework for Diabetes: Standards. London: DoH.
Department of Health. 2005. Supporting people with long-term conditions. London: DoH.
Hewitt- Taylor, J. et al. 2013. The experiences of older people who live with long term conditions. Nursing Older People. 25(6). pp. 21- 25.
Jaser, S., Faulkner, M., Whittemore, R., Jeon, S., Murphy, K., Delamater, A., and Grey, M. 2012. Coping, Self-Management, and adaptation in Adolsecents with type 1 Diabetes. National Institute of Health.43(3): pp.311-319.
Kirk, S., Beatty, S., Callery, P., Milnes, L., Pryjmachuk, S. 2012. Perceptions of effective self-care support for children and young people with long-term conditions. Journal of Clinical Nursing. 21(1):pp. 1974-1987.
Macveigh, H. (ed). 2009. Fundamental aspects of long-term conditions. Cambridge: Quay books.
Margerson, S., and Trenoweth, S. 2009. Developing holistic care for long-term conditions. London: Routledge.
Meerabeau, E., and Wright, K. 2011. Long-term conditions: nursing care and management. Oxford: Wiley-Blackwell.
Mikkonen, I., and Hynynen, M.A. 2012. Healthcare professionals’ views about supporting patients’ self-management. Health Education.112(5):pp. 396-405.
Newman, Steed and Mulligan. 2009. Chronic physical illness: Self-management and behavioural interventions. Maidenhead: Open University Press.
Proctor, S., Wilson, M.P., Brooks, F., and Kendall, S. 2013. Success and failure in integrated models of nursing for long-term conditions: multiple case studies of whole systems. International Journal of Nursing Studies.50(1):pp632-643.
Randall S., and Ford, H. 2011. Long-term conditions: a guide for nurses and healthcare professionals. Chichester: Wiley-Blackwell.
Sarent, P., Pickard,S.,Sheaff,R., and Boaden,R. 2007. Patient and carer perceptions of case management for long-term conditions. Health and social care in the community. 15(6):pp.511-519.
Scottish Executive. 2005. Delivering for Health. Edinburgh: Scottish Executive.
Scottish Executive. 2007. Better Health, Better care: A discussion document. Edinburgh: Scottish Executive.
Scottish Executive. 2008. ‘Gaun Yersel’: the self-management strategy for long-term conditions in Scotland. Edinburgh: Scottish Executive.
Scottish Intercollegiate Guidelines Network. 2010. Management of Diabetes: A National Clinical Guideline. [online]. Available from: http://www.sign.ac.uk/pdf/sign116.pdf [Accessed 15 Ocotber 2013].
Scottish Executive. 2011. Improving the health and wellbeing of people with long-term conditions: a national action plan. Edinburgh: Scottish executive.
Scottish Government. 2012. The Scottish health survey [online]. Available from http://www.scotland.gov.uk/Topics/Statistics/Browse/Health/scottish-health-survey [accessed 12/11/13].
Wilson, V. 2012. Reflections on reducing insulin to reduce weight. Nursing Practice. 108(43):pp. 21-25.

BIBLIOGRAPHY
Ashraff, S., and Siddiqui. M.A., and Carline. T.E. 2013. The psychosocial impact of diabetes in adolescents: A review. Oman Medical Journal. 28(3): pp. 159-162.
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Bowler, M. 2006. Use of community matrons for care of long-term conditions. Nursing Times. 102(33): pp.31-33.
Carrier, J. 2010. Managing long-term conditions and chronic illness in primary care: A guide to good practice. London: Routledge.
Dafne. 2013. [online]. Available from: http://www.dafneonline.co.uk/ [accessed 13/11/13].
Davies, NJ. 2010. Improving self-management for patients with long-term conditions. Nursing Standard. 24(25):pp.49-56.
Department of Health. 2002. National service Framework for Diabetes: Standards. London: DoH.
Department of Health. 2005. Supporting people with long-term conditions. London: DoH.
Department of Health. 2006. Caring for people with long-term conditions: An education framework for community matrons and case managers. London: DoH.
Funnell, M., Brown, T., Childs, B., Haas, L., and Hosey, G. 2012. National Standards for Diabetes Self-management Education. Diabetes Care. 35(5):pp. 101-108.
Hackworth, N.J., Hamilton, V.E., Northam, S.M., Bucalo, Z., and Cameron, F.J. 2013. Predictors of Diabetes self-care, metabolic control, and mental health in youth with type 1 Diabetes. Australian Psychologist. 48(5):pp. 360-368.
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Jaser, S., Faulkner, M., Whittemore, R., Jeon, S., Murphy, K., Delamater, A., and Grey, M. 2012. Coping, Self-Management, and adaptation in Adolsecents with type 1 Diabetes. National Institute of Health.43(3): pp.311-319.
Kennedy, C., Harbison, J., Mahoney, C., Jarvis, A., and Veitch, L. 2010. Investigating the contribution of community nurses to anticipatory care: a qualitative exploratory study. Journal of Advanced Nurisng. 67(7):pp. 1558-1567.
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Land, L.M., Jobanputra, P., Webber, J., and Ross, J.C. 2012. Patient Satisfaction in three clinics managing long-term conditions. British Journal of Nursing. 21(3):pp. 186-188.
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Scottish Executive. 2005. Delivering for Health. Edinburgh: Scottish Executive.
Scottish Executive. 2007. Better Health, Better care: A discussion document. Edinburgh: Scottish Executive.
Scottish Executive. 2008. ‘Gaun Yersel’: the self-management strategy for long-term conditions in Scotland. Edinburgh: Scottish Executive.
Scottish executive. 2009. Improving the health and wellbeing of people with long-term conditions: a national action plan. Edinburgh: Scottish Executive.
Scottish Intercollegiate Guidelines Network. 2010. Management of Diabetes: A National Clinical Guideline. [online]. Available from: http://www.sign.ac.uk/pdf/sign116.pdf [Accessed 15 Ocotber 2013].
Scottish Government. 2012. The Scottish health survey [online]. Available from http://www.scotland.gov.uk/Topics/Statistics/Browse/Health/scottish-health-survey [accessed 12/11/13].
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