Optimal Care in Chronic Conditions Online Tutoring

Introduction:

According to McPhail, S. M. (2016), multimorbidity is an emerging concept mostly confined to older adults, and is currently lesser understood. The occurrence of multiple diseases either branches from a parent illness or has its own roots, and either way presents difficulties in devising a holistic treatment plan. Physicians are challenged by the heterogeneity of this age group, the complexity of multi-pharmacotherapies and fragmented health care systems. To overcome these challenges, we adopt a patient centered approach which as per Salisbury, C., Man, M. S., Bower, P., Guthrie, B., Chaplin, K., Gaunt, D. M., … & Lee, V. (2018), is widely recognized as a foundation to safe, high-quality healthcare. It is care that is respectful of, and responsive to the preferences, needs and values of the individual patient. Keeping this in mind, we shall discuss how health practitioners can adopt a targeted care plan.

In this case, we observe a 55-year-old patient with congestive heart failure and accompanied discomforts. Jean is a happily married mother and grandmother, who lived a fairly normal life until she was diagnosed with CHF and recently found her symptoms exacerbating. This chronic illness demands a complete lifestyle change and requires reassessing the daily choices to accommodate the illness.

As per, Conroy, T. (2018), “the key factors influencing optimal care for chronic illnesses include organizational factors, individual nurse or patient factors, and Interpersonal factors. Organizational factors include nursing leadership, the context of care delivery and the availability of time. Individual nurse and patient factors include the specific care needs of the patient and the individual nurse and patient characteristics. Interpersonal factors include the nurse-patient relationship; involving the patient in their care, ensuring understanding and respecting choices; communication; and setting care priorities.” In light of this, it can be seen that optimal care for chronic illnesses require a holistic person-centered plan, which would include careful assessment of not just the physical aspects of the illness but also the comorbidities that come with it, as well as the individual unique case scenarios.

Cardiac rehabilitation would require Jean to participate in therapeutic treatment regimens in order to ensure a considerably normal life even under strenuous circumstances. An effective treatment plan would involve multifactorial intervention from various health professionals with nurses at the epicenter. Typical priorities include physical and cognitive functions, symptom control, self-management, reduced burden of therapy, health-related quality of life, maintenance of independence, and overall well-being.

As per Dryer, D. E. (2007), patients who are enduring powerlessness may seem like they have no control over their situation and may act out with indifference, anger, violent behavior, or passivity. Also, patients who are suffering from chronic, debilitating, or terminal illnesses may have continuing perception of powerlessness because they are incapable of changing their inevitable outcomes.

According to Bos, L., Marsh, A., Carroll, D., Gupta, S., & Rees, M. (2008, July), patient empowerment on the other hand, in the health care context means to promote autonomous self-regulation so that the individual’s potential for health and wellness is maximized.

Patient empowerment entails supporting self-management, which as per McCorkle, R., Ercolano, E., Lazenby, M., Schulman‐Green, D., Schilling, L. S., Lorig, K., & Wagner, E. H. (2011) is defined as the tasks that patients must undertake to live well with one or more chronic conditions. These tasks include having the confidence to deal with medical management, role management and emotional management of their conditions.

According to McCormack, B., & McCance, T. (Eds.). (2016), person-centered care consists of five core components: consideration of the patient’s beliefs and values, engagement, shared decision making, a sympathetic presence, and provision of holistic care which forms the basis for self-management and empowerment. Based on this, the role of nurses in supporting patient’s self-management can go a long way in effective outcomes. This includes:

Davidson, P., Driscoll, A., Huang, N., Aho, Z., Atherton, J., Krum, H., … & Stewart, S. (2010), Assessment of the current self-management status:

According to Keene, L. (n.d), one of the pivotal points in patient centered care is inquiring about the patient habits, especially those that counter act with the treatment plan and makes their condition worse. In this case, Jean is an avid smoker, averaging on 10 cigarettes a day. What makes her habit worse is the codependency she potentially has with her husband who is also a chain smoker and hence makes abandoning the habit much harder. She also consumes soft drinks, about 6 cans a day and has a diet consisting mostly of takeaway with few vegetables and fruits.

Nicotine dependence should be viewed as a chronic disease, with multiple possible comorbidities. For someone with CHF, this habit can be the last nail in the coffin, as it aggravates heart diseases. Lancaster, T., & Stead, L. F. (2017), stated in their systematic review that “there is high-quality evidence that individually-delivered smoking cessation counselling can assist smokers to quit”. Rice, V. H., & Stead, L. F. (2008), suggests that as a nurse, it is important to not only advice the patient to cease smoking but actually carve a practical path for them to do so. In order to provide a setting that would encourage Jean to quit, the nurse should also engage her husband in the smoking cessation program.

Furthermore, as per Paterna, S., Gaspare, P., Fasullo, S., Sarullo, F. M., & Di Pasquale, P. (2008), Jean and her family should be advised to make sure she cuts down on soft drinks as it can aggravate her condition. She should have a diet low in sodium and carbohydrates to avoid hypertension. Fruits and vegetable intake should be increased. A total of 30 minutes of physical activity every day should be encouraged.

Davidson, P., Driscoll, A., Huang, N., Aho, Z., Atherton, J., Krum, H., … & Stewart, S. (2010), Education and Counselling: Provide information and support for self-care, appropriate to patient’s circumstances:

Educating Jean regarding CHF is important in order to enable her to practice self-care at home. Regarding self-monitoring, she should be informed how CHF causes poor circulation, low oxygen levels and decreased cardiac output. As per Poppas, A., & Rounds, S. (2002), she is likely to experience symptoms of dizziness, light headedness, palpitations, shortness of breath and cold.

However, this education should not be limited to Jean. Molloy, G. J., Johnston, D. W., & Witham, M. D. (2005), it is just as important to keep the family up-to-date on the condition she is suffering from. For example, Jean has been known to have trouble keeping up with her medications. While in the hospital, the nurse has a direct responsibility to administer medications, at home it’s not that easy. Her husband should be coached to set timely reminders and a checklist for proper treatment regimens as she is not able to do so herself.

Davidson, P., Driscoll, A., Huang, N., Aho, Z., Atherton, J., Krum, H., … & Stewart, S. (2010), Assessment of psychosocial factors: Determine individual needs and develop a personalized care plan:

Jean feels weary of hospital visits and doesn’t feel heard by the healthcare staff. It is extremely important for a nurse to forge a meaningful relationship with her, which would make her feel heard. The nurse should keep a regular check on her mental health and encourage the patient to verbalize her concerns and make sure they are settled.

Moreover, Jean is concerned about the privacy of her condition when it is discussed freely among the clinical staff. The Nurse should make sure that the clinical details of her case are discussed behind closed doors which would make her feel less exposed, reducing anxiety and feelings of powerlessness.

Western NSW LHD has formulated programs aimed at improving provision of health services for the residents. This includes integrated care and building relationships and partnerships with other health providers. Some of the locally available sources include:

1. Hospital Facilities & Nursing Care:

Bathurst Base Hospital, Dubbo Base Hospital, Nepean Hospital and Orange Base Hospital provide cardiology care. Chronic Heart Failure Nurses are also available within the LHD who provide clinical services in the patient’s own homes, detect and treat exacerbation early, provide patient education, supportive counselling, facilitate self-management, and discharge planning including referral to outpatient rehabilitation. Blue, L., & McMurray, J. (2005).

2. Chronic Heart Failure Management Program:

The Chronic Disease Management Program (Connecting Care) is a high priority program that is being implemented in response to the Government’s Caring Together Strategy. Connecting Care is a free service intended to improve the health, wellbeing and independence of patients with complex chronic disease. The program focuses on the patient’s individual needs and links together the health services that look after the patient.

3.    Career Support Program

According to Western NSW Local Health District (n.d.), Western NSW Carer Support Program is committed to promoting carers as valued and respected partners in health care. This is achieved by educating health staff to identify and consult with carers, and to recognize carer expertise.

• Carer information booklet
• TOP 5 Program – Using Carer Knowledge
• Carers NSW

4.    Chronic Care Rehabilitation Service

According to Western NSW Local Health District (n.d.), the Chronic Care Rehabilitation Service is a multi-disciplinary service providing programs which run over 8 to 12 weeks and include individually tailored exercises and health education, self-management support, behavior modification strategies, risk factor identification and modification.

5. Quit Smoking:

As per Freund, M. A., Campbell, E. M., Paul, C. L., Wiggers, J. H., Knight, J. J., & Mitchell, E. N. (2008), a network of trained smoking cessation champions is available to provide intensive counselling and support to heavily addicted patients who wish to quit. Patients can visit their local pharmacist, GP or contact the NSW Quitline for enrolment.

In light of the local resources available to help manage patients with CHF, the recommended model of care for Jean would include:

• Education and Counselling:

Jean and her husband would be educated about her condition in an empathetic manner, keeping in view her unique psychosocial dynamics.

• Dedicated treatment plan:Jean along with her husband would be motivated in following her treatment regimen. As per Paterna, S., Gaspare, P., Fasullo, S., Sarullo, F. M., & Di Pasquale, P. (2008), taking medication on time, making healthy lifestyle changes, abstaining smoking, restricting sodium, cholesterol and fluid intake, keeping up with the required physical activity and being regular in medical appointments are some of the effective tailor-made interventions for Jean’s condition.
• Knowing when to seek help: Jean and her husband would be assisted and counselled in monitoring her condition and knowing when to seek help.
• Enroll in chronic care rehabilitation program: Advise Jean to enroll in the program for extra medical support where she would be able to see a dedicated community heart failure nurse.

The challenges in implementing the recommended optimal care plan in light of the available local resources in Jean’s case include:

National Health Priority Action Council (Australia). (2006), providing integrated and continuous care across time, different stages of the illness, co-morbid conditions and different services and providers.

Supporting self-management and counseling Jean and her husband since they are old and have unique psychosocial dynamics.

According to Busse, R., & Blümel, M. (2010), the frequent presence of co-morbidities including Jean’s dietary habits and lack of adherence to the prescribed treatment plan is likely to complicate the treatment. Furthermore, adoption of numerous practices, follow-up with caregivers and emotional management may be difficult for Jean as they may be hard to understand, seen as inacceptable intrusion in daily life and may interfere with recommendations given related to co-morbidities.

As per Schoen, C., Osborn, R., Squires, D., Doty, M., Pierson, R., & Applebaum, S. (2011), taking a multidisciplinary approach is imperative in addressing the multiple and complex medical, behavioral, psychosocial, environmental and financial issues that complicate the care of patients with heart failure.

Martinussen, P. E. (2013), integrated management of co-morbidities should be taken into account. Interaction and communication between patients, relatives and caregivers is equally important in assuring a sufficient care plan for Jean.

Conclusion:

Being a nursing student, I have come to understand the importance of patient centered care in the mitigation of severity of chronic illnesses. I would integrate this approach in my profession, and following are the actions I aspire to fulfill in every patient care I encounter.

I would schedule multiple follow-up visits with my patients, extended over a long term, planning individualized interventions. These interventions would encompass lifestyle modifications after carefully analyzing the existing routine and habits of the patient. Chronic illnesses demand uttermost attention to details, so I would focus on eliminating any detrimental factors like smoking, alcohol consumption, inactivity, and devising a health care plan that includes suitable diet, medications and psychiatric panel if needed.

To ensure that the emotional needs of my patient are met, I will spend a substantial amount of time with them. Having a lifelong ailment is scary, especially when you don’t understand the mechanics of it or feel any control over it. I would offer well rounded counseling and educate the patients and their carers on how to come in terms with the disease and listen to their concerns, resolving them to the best of my abilities.

The outcome of nursing care of these patients should be the achievement of a normal life to the maximum extent. My duty in these cases is to affirm self-management in patients. This entails the ability of the diseased in conjunction with their families to monitor illness, manage symptoms, treatments and the various psychosocial consequences of health conditions. I would encourage the patient to improve self-efficacy by being active in healthcare decisions, practice self-evaluation and goal congruence so that they take control of their life again.

With being a healthcare professional comes a great responsibility. Especially as a nurse that acts as a mediator between physicians and patients and the closest link the patients have to compassion in hospitals, it is our duty to ascertain that instrumental care is being provided to these people while maintaining their individuality.

REFERENCES:

Blue, L., & McMurray, J. (2005). How much responsibility should heart failure nurses take?. European journal of heart failure, 7(3), 351-361.

Bos, L., Marsh, A., Carroll, D., Gupta, S., & Rees, M. (2008, July). Patient 2.0 Empowerment. In SWWS (pp. 164-168).

Busse, R., & Blümel, M. (2010). Tackling chronic disease in Europe: strategies, interventions and challenges (No. 20). WHO Regional Office Europe.

Conroy, T. (2018). Factors influencing the delivery of the fundamentals of care: Perceptions of nurses, nursing leaders and healthcare consumers. Journal of clinical nursing, 27(11-12), 2373-2386.

Davidson, P., Driscoll, A., Huang, N., Aho, Z., Atherton, J., Krum, H., … & Stewart, S. (2010). Multidisciplinary care for people with chronic heart failure: Principles and recommendations for best practice.

Dryer, D. E. (2007). The Phenomenon of Powerlessness in the Elderly. College of Nursing and Health Sciences. Saginaw Valley State University.

Freund, M. A., Campbell, E. M., Paul, C. L., Wiggers, J. H., Knight, J. J., & Mitchell, E. N. (2008). Provision of smoking care in NSW hospitals: opportunities for further enhancement. New South Wales public health bulletin, 19(4), 50-55.

Western NSW Local Health District (n.d.). Improving outcomes for people with chronic disease, Retrieved on May 16, 2020, from https://wnswlhd.health.nsw.gov.au/our-services/chronic-care

Keene, L. (n.d.). Patient Centred Care: Improving quality and safety.

Lancaster, T., & Stead, L. F. (2017). Individual behavioural counselling for smoking cessation. Cochrane database of systematic reviews, (3).

Martinussen, P. E. (2013). Referral quality and the cooperation between hospital physicians and general practice: the role of physician and primary care factors. Scandinavian journal of public health, 41(8), 874-882.

McCorkle, R., Ercolano, E., Lazenby, M., Schulman‐Green, D., Schilling, L. S., Lorig, K., & Wagner, E. H. (2011). Self‐management: Enabling and empowering patients living with cancer as a chronic illness. CA: a cancer journal for clinicians, 61(1), 50-62.

McCormack, B., & McCance, T. (Eds.). (2016). Person-centred practice in nursing and health care: theory and practice. John Wiley & Sons.

Molloy, G. J., Johnston, D. W., & Witham, M. D. (2005). Family caregiving and congestive heart failure. Review and analysis. European Journal of Heart Failure, 7(4), 592-603.

National Health Priority Action Council (Australia). (2006). National Chronic Disease Strategy and the Frameworks. Department of Health and Ageing.

Paterna, S., Gaspare, P., Fasullo, S., Sarullo, F. M., & Di Pasquale, P. (2008). Normal-sodium diet compared with low-sodium diet in compensated congestive heart failure: is sodium an old enemy or a new friend?. Clinical Science, 114(3), 221-230.

Poppas, A., & Rounds, S. (2002). Congestive heart failure. American journal of respiratory and critical care medicine, 165(1), 4-8.

Rice, V. H., & Stead, L. F. (2008). Nursing interventions for smoking cessation. Cochrane database of systematic reviews, (1).

Salisbury, C., Man, M. S., Bower, P., Guthrie, B., Chaplin, K., Gaunt, D. M., … & Lee, V. (2018). Management of multimorbidity using a patient-centred care model: a pragmatic cluster-randomised trial of the 3D approach. The Lancet, 392(10141), 41-50.

Schoen, C., Osborn, R., Squires, D., Doty, M., Pierson, R., & Applebaum, S. (2011). New 2011 survey of patients with complex care needs in eleven countries finds that care is often poorly coordinated. Health Affairs, 30(12), 2437-2448.

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