This essay will address how to help a 20 year old asthma sufferer bring to an end his recurrent admissions to hospital because of acute exacerbations in his asthma. Asthma is a common and chronic inflammatory disorder of the airways, associated with marked health and economic consequences. It is estimated that approximately 5.2 million people in the United Kingdom (UK) suffer from asthma, making the condition the most common long term illness in this country. Asthma accounts for 1,400 deaths per annum, with a third of these being among individuals under 65 years of age. Similarly, asthma also accounts for about 69,000 hospital admissions a year. It is estimated that more than half of the 5.2 million people with asthma in the UK do not have adequate symptom control. While 500,000 of these have asthma that is difficult to control with available medication, and are thought to be resistant to corticosteroids, asthma is not well controlled in approximately 2.1 million people for reasons such as non-concordance with medication (Asthma UK, 2004, pp3-7).
As already mentioned asthma is a long-term chronic condition (LTC) and although chronic illness is not a newly-recognised phenomenon, the incidence and prevalence has significantly increased over the second half of the 20th century and continues to rise in the 21st century (Howie, 2005, p318). This is not least because of the aging population and advances in medical science diminishing the impact of infectious diseases. In addition, the emergence of unhealthy lifestyles is arguably the trigger for many non-communicable diseases such as chronic heart disease, type 2 diabetes mellitus, and chronic obstructive pulmonary disease to which asthma has similar pathophysiology. (Nissinen et al, 2001, p963). It is estimated that in the UK over 17.5 million people are affected by a LTC and 8.8 million have long term illness that severely limits their day to day ability to cope. It is proposed that those aged over 65 affected by a LTC are more likely to have multiple long term conditions, which makes care particularly complex. Debatably, unhealthy lifestyles and an aging population are the reasons for the high prevalence of LTCs contributing towards the large financial costs in caring for these patients who occupy up to 42 percent of all acute hospital bed days (Department of Health (DH), 2005b, p10). Arguably, these issues indicate that these patients are not receiving the care in ways that meet their needs or the needs of the health system. It is proposed that this is why management of LTCs is of specific importance to current Government health strategies. To this effect, numerous policy documents have been published that define the present philosophies for the management of LTCs.
One particular policy; The National Service Framework (NSF) for Long Term Conditions was published by the DH in March 2005 (DH, 2005b, p24). The NSF predominantly concentrates on individuals’ with long-term neurological conditions. However, it is anticipated that to a great extent the guidance presented could be relevant to all long-term conditions. The document has outlined 11 “quality requirements” and among others there are various ones that are particularly pertinent to Steven Williams’s case. These include the provision of person-centred care and choice, the offering of information and support for the safe and effective use of medicines, the supporting of self care and the consideration of health promotion needs.
It is suggested that in order to meet Steven’s needs he will require support and education so that he can make informed choices. Metcalf (2005, p60) suggests that informed choice for those with LTCs is the key to success and a means of examining issues pertaining to non-concordance, risk taking behaviours and patient choice. As already mentioned, Steven began to smoke when he started attending university. Cigarette smoking is implicated as a health-risk behaviour and there is evidence to suggest that active smoking in adults with asthma increases asthma severity. A study by Siroux et al, (2000, p470) on the relationships of active smoking to asthma and asthma severity, found that current smokers with asthma had more asthma symptoms, more frequent asthma attacks (? 1 attack per day) and scored higher on the asthma severity scores, compared to those asthma sufferers who had never smoked and ex-smokers. Other trigger factors that can exacerbate asthma symptoms include house dust mites, pet allergens, pollen, moulds and fungal spores, certain drugs such as asprin and beta blockers, occupational triggers and viral respiratory tract infections (Roberts, 2002, p46).
Arguably, in Steven’s case, alongside his lack of concordance with his asthma medication, it is suggested that his smoking habit is a key factor in his acute asthma exacerbations. Therefore, it is proposed that Steven needs help with smoking cessation and education on the side effects and concordance of his medication.
Numerous approaches are presently being utilised for smoking cessation. These approaches incorporate pharmacological methods, such as nicotine replacement therapy or antidepressants, hypnotherapy, and exercise supported interventions. Behavioural approaches include stage based interventions, which mainly use the transtheoretical model (Prochaska, DiClemente & Norcross, 1992, p1102-14) and this model divides people into five different stages. These are the precontemplation, contemplation, preparation, action, and maintenance stages. The justification behind “staging” people, as such, is to fit the therapy to a person’s need at his or her particular point in the change process. Succession through the stages is in order, although relapses to previous stages can happen. The model also recognises 10 processes of change, the theory being that the effectiveness of the different processes of change will vary according to the patient’s stage. Arguably, however, this has not repeatedly been defended in empirical research (Sutton, 2000, p31).
It is proposed that it would be necessary for health professionals to recognise precisely an individual’s stage of change, or readiness to change. This is so that an intervention based on “stage specific processes” of change can be employed. It is important that the stage of change is re-evaluated regularly, and that the intervention should reflect changes in the individual’s willingness to change. These elements of the intervention can be continual until the person accomplishes and sustains the change in behaviour. In this way, stage based interventions develop and adjust in answer to the individual’s progression through the stages of change. Therefore it is debated that stage based models recommend that interventions that take into account the existing stage of the individual will be much more successful and efficient than “one size fits all” interventions (Prochaska, DiClemente & Norcross, 1992, p1103). Having said this however, the stages of change theory does not take into account any outside influences that might have an impact on a person’s ability to change.
It is proposed that Steven recognises that he has a problem and has asked for help. Therefore, it is suggested that this places him in the contemplation stage. It is suggested therefore, that Steven needs to be given help and advice that will lead him to the preparation for action stage. In doing this, debatably, it will be necessary for Steven to assess his feelings regarding his smoking behaviour. It is important therefore that health professionals who are using behavioural change models for smoking cessation are thoroughly trained in the procedure or at least are aware of the availability of a smoking cessation nurse. Ethically, it is argued that health professionals have a duty of care to help patients like Steven live healthier lifestyles. However, ethically Steven has the right to autonomy in his lifestyle choices (Tschudin, 2003, p151).
It is proposed that inhaled corticosteroids are still the most effective preventer drug for attaining treatment objectives (British Thoracic Society, Scottish Intercollegiate Guidelines Network (BTS, SIGN, 2004, Chapter 4, p2). Steven has voiced concerns about the effects of steroids and this has stopped him taking his preventative inhaler. Similarly, he only uses his reliever inhaler when he becomes extremely wheezy. This is in accordance with Bender’s (2002, p554) suggestion that one of the reasons people do not take their medication is because they are worried about side effects. It is argued that this could be because their initial concerns might have not been fully addressed by health professionals (Carter et al, 2003, p27). It is proposed that nurses are ideally placed to educate patients on the benefits of medication concordance. It is important that a nurse thoroughly explains the necessity of the treatment and any subsequent side effects. Inhaled corticosteroids are the main preventative treatment for asthma sufferers. When taken twice daily at a low dose, corticosteroids are highly effective in reducing asthmatic symptoms, improving lung function, and reducing cellular inflammation. Systemic effects are rare on a low dose and most asthma patients are extremely well controlled on a low dose inhaler. Adverse local effects can include dysphonia and oral candidiasis. These symptoms can be relieved by either gargling or rinsing the mouth with water after inhalation (Roberts, 2002, p48). It is proposed that if Steven regularly takes his preventative inhaler then his asthma will be better controlled and he is much less likely to need systemic corticosteroids that can have adverse side effects such as weight gain and thinning of the skin when taken long-term.
The NSF quality requirements of person-centred care and choice, and the offering of advice on the use of medication are relevant to the case mentioned, as is the consideration of health promotion needs. The patient will require help in giving up smoking as this is a major factor contributing to his repeat admissions to hospital. Help in the correct use of his medication is also required if he is to remain free from episodes of acute asthma. Nurses caring for patients like Steven will need to know what help is available with smoking cessation and the various options that can be offered to individuals who want to cease smoking. The Prochaska and DiClemente model of behaviour change is commonly used in smoking cessation; however, its effectiveness is questionable.
Asthma UK (2004) Where do we stand, http://www.asthma.org.uk/how_we_help/publishing_reports/index.html (last accessed: June 25th 2007)
Bender BG (2002) Overcoming barriers to nonadherence in asthma treatment, Journal of Allergy and Clinical Immunology, 109 Supplement 6, S554-559
British Thoracic Society, Scottish Intercollegiate Guidelines Network (BTS, SIGN) (2004) British Guideline on the Management of Asthma: A National Clinical Guideline, revised edition, Edinburgh, http://www.sign.ac.uk/guidelines/published/support/guideline63/download.html, chapter4, (last accessed: June 26th 2007)
Carter S, Taylor D & Levenson R (2003) A Question of Choice: Compliance in Medicine Taking, Medicines Partnership, London
Department of Health (2005b) The National Service Framework for Long-term Conditions, http://www.dh.gov.uk/en/Policyandguidance/Healthandsocialcaretopics/Longtermconditions/index.htm (last accessed: June 25th 2007)
Howie K (2005) Long-term conditions, Practice Nursing, 16, 7, 318
Metcalf J (2005) The management of patients with long-term conditions, Nursing Standard, 19, 45, 53-60
Nissinen A, Berrios X & Puska P (2001) Community-based noncommunicable disease intervention: lessons from developed countries for developing ones, Bulletin of the World Health Organisation, 79, 963-970, http://www.who.int/bulletin/archives/79(10)963.pdf (last accessed: June 25th 2007)
Prochaska JO, DiClemente CC & Norcross JC (1992) In search of how people change: Applications to addictive behaviors, American Psychologist, 47, 1102-14
Roberts J (2002) The management of poorly controlled asthma, Nursing Standard, 16, 21, 45-51
Tschudin V (2003) Ethics in Nursing: The Caring Relationship, Third edition, Butterworth Heinemann, London
Siroux V, Pin I, Oryszczyn MP, Le Moual N, & Kauffmann F (2000) Relationships of active smoking to asthma and asthma severity in the EGEA study, European Respiratory Journal, 15, 3, 470–477
Sutton S (2000) A critical review of the transtheoretical model applied to smoking cessation. In: Norman P, Abraham C, Conner M, eds. Understanding and changing health behaviour: from health beliefs to self-regulation. Amsterdam: Harwood Academic Press