The purpose of this essay is to discuss the importance of health promotion in relation to the delivery of holistic care. A patient from a recent practice placement will be the focus of this assignment. In accordance with The Nursing and Midwifery Council’s code of conduct which states that “You must respect peoples rights to confidentiality” (NMC, 2008 ) the names and locations of people involved have been changed and for the purpose of this essay the patient will be referred to as Rachel.
Health promotion is a process ‘of enabling people to increase control over and to improve their health. To reach a state of complete physical, mental and social well-being, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment’ (WHO 1986, p. 1).
Rachel was chosen as the subject of this essay because of her complex needs in relation to her diagnosis, alcohol problems and social situation. Furthermore because of the therapeutic relationship the nurse had built with Rachel.
Rachel is a 23 year old woman who has a mental health diagnosis of borderline personality disorder and schizoaffective disorder.
Borderline Personality Disorder (BPD) is defined as ‘a serious and often life-threatening disorder that is characterized by severe emotional pain and difficulties managing emotions’ (The National Educational Alliance for Borderline Personality Disorder, 2010). According to Emmelkamp and Vedel (2006, p.162) BPD has several characteristics which include ‘marked impulsivity, chronic feelings of emptiness, identity disturbance, lack of anger control, intense and frequent mood changes, life threatening behaviours (e.g. self injury and suicidal gestures), disturbed interpersonal functioning (e.g. chaotic relationships), and frantic efforts to avoid abandonment when separation is anticipated’.
Schizoaffective disorder is a combination of mood, thought and anxiety disorder, so that symptoms of mania or depression and psychotic symptoms of schizophrenia may be present at the same time or within days of each other (Rethink, 2010).
Rachel was admitted to the acute psychiatric admissions ward following a suicide attempt. She had been under the influence of alcohol which may have contributed to the attempt to commit suicide. Harkavy-Friedman et al (2001) suggest that substance use may increase impulsivity and reduce behavioural control. Furthermore they state that ‘an assessment of past and current substance use and its relationship to suicidal behaviour and depression is an important part of risk intervention’.
Rachel had attempted suicide on several occasions before and on each occasion had been under the influence of alcohol and or illicit substances. Additionally she was admitted to the acute ward and subsequently spent a number of months being assessed and treated under a section 2 and a section 3 of the Mental Health Act 1983. It was clear after consideration of Rachel’s history of self harm and circumstances surrounding such that she would benefit from some education around substance and alcohol misuse and the effect this was having on her physical and mental health.
During the assessment it was evident that Rachel’s alcohol use was increasing. She had stated that she was drinking alcohol most days and her drinking habits were changing in that she was drinking earlier in the day. She had disclosed that she was drinking a half litre bottle of vodka a day as well as lager. Although she denied this was a problem it was felt however that she did have a level of dependence on alcohol. In a study of some 43,000 people by the National Epidemiologic Survey of Alcohol and Related Conditions (NESARC) in 2001, it was found that having any personality disorder based on DSM-IV diagnostic criteria increased the odds of meeting criteria for alcohol dependence more than sevenfold at an initial interview during wave 1 of the study. Furthermore it found that 28.6 percent of people with current alcohol dependence had at least one personality disorder (Bates, 2010). In consideration of this evidence and the previous history of the patient it could be argued that in the case of Rachel, health promotion in relation to a holistic approach is vitally important to ensure a better quality of life, to help prevent further attempts at suicide and to reduce re-admissions to hospital.
A biopsychosocial approach which considers the biological, psychological and social needs of a person was adopted to ensure holistic care was being delivered. Additionally the stages of change model developed by Prochashka and DiClemente would be utilised which research has shown can be effective for changing a range of health related behaviours including alcohol and drug abuse. It also ‘takes a holistic approach and integrates a number of elements for example personal responsibility and choices and social and environmental forces which can limit a persons potential for change’ Ewles and Simnett (1999, p.263).
Rachel was prescribed medication to help alleviate some of the symptoms of her schizoaffective disorder and personality disorder; however Rachel had indicated that she had stopped taking her medication before admission because she did not like the side effects. During weekly reviews with the consultant psychiatrist and following discussions with Rachel it was decided to try an alternative medication regime. At first Rachel did not want to try another medication but following 1-1 discussions whereby information was provided for her to read and questions were answered with regards to side effects Rachel agreed.
As well as the medical intervention a series of 1-1 discussions were arranged with Rachel in addition to the 1-1’s that she already had with her named nurse. During these sessions a Cognitive Behavioural Therapy (CBT) approach was utilised by the nurse. CBT is based on the notion that particular ways of thinking i.e. unhelpful or harmful thoughts can contribute to certain health problems e.g. anxiety. In addition harmful or unhelpful behaviours such as avoiding situations which make us anxious can affect our day to day living. The aim of CBT is to alter the unhelpful or harmful thought patterns and help the person have more realistic thoughts (Patient UK, 2007).
Rachel was given the opportunity to explore her emotions, thoughts and feelings. She talked about events leading up to her hospital admission and from those discussions it became evident that Rachel’s relationship with her mother was becoming increasingly strained. She expressed that her feelings towards her mother were very negative and that most of the time they could not talk without screaming at one another. This inevitably resulted in Rachel leaving the property and consuming alcohol to alleviate the emotional pain she was experiencing. Rachel’s mother Joan was invited to her review, with her consent, and during the review Joan took an active part. The National Institute for Clinical Excellence (NICE) states ‘If the service user agrees, carers (who may include family and friends) should have the opportunity to be involved in decisions about treatment and care. Families and carers should also be given the information and support they need’ (NICE, 2009).
At times the animosity between mother and daughter was very evident, but what was obvious was Joan’s desire to help Rachel in which ever way she could. It was suggested that family therapy may be an option to discuss issues with their relationship and both Rachel and Joan agreed this would be helpful. In addition discussions with Joan revealed her limited understanding of Rachel’s diagnosis. Informational leaflets were offered to Joan as well as informational material printed from the internet which gave guidance for family members.
An educational approach was used with regards to Rachel’s use of alcohol. During 1-1 sessions she was encouraged to talk about her alcohol use and how this affected her both mentally and physically. Information was provided in the form of leaflets, and discussions were formulated around them. It could be said that Rachel was in the pre-contemplation stage of the Stages of Change model as she did not see her alcohol use as a risk to her health and well being. Ewles and Simnett (1999, p. 265) suggest that education and awareness-raising is appropriate for someone in the ‘pre-contemplation’ stage. Prochashka and DiClemente state that ‘The stage which precedes entry into the change cycle is referred to as pre-contemplation’ ‘At this stage a person has no awareness of a need to change, or does not accept it, and no motivation to change habits or lifestyle’ Ewles and Simnett (1999, p.263); however following the provision of information Rachel did agree that her behaviour was risky and could see the link between her alcohol use and her suicide attempts. She did want to change but felt she wasn’t strong enough emotionally to do it.
It was suggested to Rachel that a Wellness Recovery Action Plan (WRAP) may help her on discharge from hospital. Time was spent with Rachel explaining the concept of WRAP and a copy was given to her to complete. She completed much of it herself, but asked for support to complete some of the sections. WRAP was developed initially by Mary Ellen Copeland and a group of people who experience mental health problems. It enables the person to identify what makes them well, develop an effective approach to overcoming distressing symptoms and develop best course of action in a crisis (Mental Health recovery and Wrap 2009). It is completed by the individual and reflects what works for them making it truly person centred.
In reflection of the health promotion and delivery of holistic care in the case of Rachel I suppose that there are some positive outcomes and some limitations. I feel that because of Rachel’s unwillingness or inability to change her behaviour at this stage that the only option was to provide up to date and relevant information. This would enable her to understand the consequences of her behaviour and help her to make informed choices. The fact that she said she wanted to change her behaviour was quite significant and I feel that when she felt able to deal with her emotional responses that she would benefit from further support from a more specialised service e.g. North East Council on Addictions (NECA).
I feel that the development of a therapeutic relationship between nurse and patient was paramount in the delivery of holistic care. Much of the care delivery was through communication, getting to know Rachel; her likes, dislikes, her triggers for relapse and what works for her when she is unwell. The completion of her WRAP would be invaluable on her discharge and would I believe either reduce the frequency of hospital admissions or help in reducing the distress of hospital admission as well as empower Rachel to have more control over her well being in turn could improve her quality of life. In my opinion the WRAP tool is an excellent way to empower people and give them more autonomy in making decisions about their lives.
NICE (2009) states ‘When discharging a person with borderline personality disorder from secondary care to primary care, discuss the process with them and, whenever possible, their family or carers beforehand. Agree a care plan that specifies the steps they can take to try to manage their distress, how to cope with future crises and how to re-engage with community mental health services if needed’. The development of WRAP would compliment the discharge care plan and enable Rachel to use strategies designed by her to employ in the event of crisis.
I still feel there is too much emphasis on the use of medication from the point of view of the Consultant Psychiatrist, however I do accept that it is necessary to help stabilise people especially in crisis situations. On the other hand it was positive in that the Consultant listened to Rachel when she said that she stopped taking the medication because of side effects and by offering her an alternative medication with a less sedative effect I feel she would have felt empowered by being given choices.
‘The recovery model aims to help people with mental health problems to move beyond mere survival and existence, encouraging them to move forward and carry out activities and develop relationships that give their lives meaning’ (Mental Health Foundation, 2011).
In consideration of this statement I feel that Rachel has, on the whole, experienced a holistic and person centred approach to her health needs, she has been able to make informed choices about her treatment, has been able to re-establish relationships with her significant others and developed her own WRAP based on what works best for her which should ultimately enhance her recovery process.