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Biopsychosocial: Vein and Compression Therapy

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This essay will examine the biopsychosocial issues that have influenced the perceptions of the health and well being of a patient I have nursed during a recent clinical placement. For the purpose of this essay the name of this patient has been changed to protect his anonymity as well as to be compliant with the Nursing Midwifery Council Professional Code of Conduct (NMC 2008) regarding confidentiality. The patient, who will be known as William, is 62 years of age and has a venous leg ulcer to his right leg which he has suffered for the past four years. This essay will also explore the biopsychosocial reasons for William’s initial non-compliance to compression therapy, and discuss various models and how they vary in their purpose.

The word biopsychosocial originates from three factors, biological, psychological, and sociological (Shorter 2005). Straub (2002) places these three factors together by suggesting that health and disease should be described in terms of multiple contexts which implies that in connection to biopsychosocial, the biological, psychological and social forces work together to establish a person’s health and vulnerability to disease. The word biology according to Naidoo and Wills (2008) is: “The science of life. It is the study of living organisms, what they are made of and how they function and how they interact with each other and the environment.” (p.23).

Biology has several branches, one of which is physiology (Naidoo and Wills 2008), and according to Marieb (2009) physiology “is the study of how the body and its parts work or function” (p.2). With regards to William and physiology this essay will explore the pathophysiology of leg ulcers, the symptoms, signs and treatment. Pathophysiology, according to Gould and Dyer (2011) is “the study of functional or physiologic changes in the body that result from disease processes” (p.2.). To use this approach requires basic knowledge of anatomy and physiology so as to explore the changes in the body and body function when it is altered by disease. These changes may be obvious or hidden, taking place from cellular level (Gould and Dyer 2011).

Psychology, according to Walker et al (2004) is “The study of human behaviour, thought, processes and emotions” (p.1). In this area this essay will examine William’s psychological influences, beliefs and behaviour towards his disease. It will explore his attitude to his leg ulcer and whether this has contributed to the time taken to healing, additionally how having his leg ulcer can affect his thoughts, feelings and daily performance (Straub 2002).

In relation to sociology, Smith and Natalier (2004) state:
“Sociologists try to understand the world in terms of the relationships between people’s choices . . . and the structures that constrain and create the decisions and opportunities available to them. Thus, sociology grounds the study of any particular issue in the empirical world, but moves beyond simple reportage. It examines and explains the regularities and differences that are evident in society . . . [and] offers the potential for a more nuanced and sophisticated understanding of the social world and our own life and others’ lives.” (p.2).

Clarke (2010) suggests that sociology is the study of social behaviour which is the core of the sociological enterprise, and that explanations regarding behaviour should not be limited to biological factors or psychological behaviours as we only get a partial understanding. Sociologists believe human beings are in effect social animals and consequently a full understanding of behaviour cannot be attained without considering aspects of the social setting where the behaviour takes place (Clarke 2010). In relation to William and sociology, this essay will explore how his illness had an affect on his social life and how his background might have affected his present behaviour to his illness. The biomedical model states that the causes of illness are outside the control of a person (Rana and Upton 2009).

According to Sarafino (2008) this model proposed that all diseases could be explained by disturbances in physiological processes that are a consequence of injury, bacterial infection and biochemical imbalances. The biomedical model presumes that disease is a suffering of the body and separate from the psychological and social processes. During the 19th and early 20th centuries this perspective of the biomedical model was widely accepted and still dominants outlook in today’s medicine (Sarafino 2008). As a consequence of this model there was a requirement for biomedical treatment such as vaccination, medication and surgery managed by medical professionals with no suggestion that psychology had any connection to physical illness (Rana and Upton 2009).

In the twentieth century it was recognised that a biomedical model alone was not sufficient and that lifestyle could impact on health, for example illness could be caused by stress, so the biopsychosocial model emerged (Rana and Upton 2009). This model was introduced by Engel (1977) who suggested that psychiatry would excel to emulate its sister medical rules by taking on the biomedical model. He felt that the biomedical model alone was no longer good enough to conquer illness and that there was a need for psychiatry input. According to Borrell-Carrio et al (2004): “The biopsychosocial model is both a philosophy of clinical care and practical clinical guide. Philosophically, it is a way of understanding how suffering, disease and illness are affected by multiple levels of organization, from the societal to the molecular. At the practical level, it is a way of understanding the patient’s subjective experience as an essential contributor to accurate diagnosis, health outcomes, and humane care.” (p. 576).

This means that biological, psychological and social factors together are all important as they all affect a patients’ health, but just as significantly these three factors can be affected by the patients’ health (Rana and Upton 2009).

According to Shorter (2005) the biopsychosocial model has been reinforced in recent years since the provision of pharmacotherapy is visibly more inadequate in solving the majority of patients’ problems. However according to Herman (1989, as quoted in Muaksch 2005) there are three barriers that can affect the practice of biopsychosocial care. These are: applied biopsychosocial science is not easily taught, it is hard to apply selectively under conditions of stress, and, it lacks a nosological glossary that can help the ordinary doctor feel comfortable with it. It was suggested by Muaksch (2005) that maybe this model was too good for standards of today and was more a vision than a model and the emergence for models, policies, and research and possibly brings us closer to a biopsychosocial method of care.

William is the owner of a butcher shop that also sells groceries, home baked pies and cakes; he is married and has two daughters who are now grown up and have left home, both becoming teachers. William has been a butcher for all of his working life, as the shop was originally his parents. William was the eldest child of a large family, who inherited the business as the eldest son. He and his wife have spent all their married life living together in the house connected to the business where they work on average 70 hours a week. William’s leg ulcer transpired as a consequence of a trauma when he knocked his leg against the shop counter four years ago. The ulcer has not yet healed. He told me he has a tendency to lean on his right leg for long periods during his time behind the shop counter as standing still can get quite uncomfortable. He has accustomed himself to this posture over the past years and finds it difficult to stop the habit. He also stressed that his leg ulcer was extremely painful at times, and had been informed by the district nurse to elevate his leg for a few hours each day but he did not always get time due to work commitments.

William has a history of varicose veins of which he suffered for a long period without seeking medical help. He also has a high BMI due to a poor diet, ignoring dietary educational advice from health care professionals. William expressed to me how difficult it was to keep to a healthy diet when there was a lot of high fat and calorie food in his environment. His wife has expressed concerns regarding his diet and she supports the healthcare professional’s advice and endeavours to assist her husband with healthy eating. However Williams’ wife finds it difficult to regularly watch over his eating habits due to the demands of the business. Furthermore the couple do not socialise together anymore due to issues surrounding William’s ulcer which will be discussed further on in this essay.

According to Allen (2008) venous leg ulcers are “open, draining wounds, cyclical and chronic in their manifestation. They typically appear above the ankle and below the knee.” (p.17). They affect approximately 1-2% of the population (Graham et al 2003), and over 40% of patients will possibly suffer open ulceration for longer than a year (Nelzen et al 1994). Additionally 26-29% of leg ulcers reoccur within 12 months after healing; consequently a majority of patients may suffer a lifetime of leg ulceration (Nelson et al 2000, as quoted in Briggs and Flemming 2007).

Templeton and Telford (2010) say leg ulcers are a debilitating and chronic condition that can happen at any age but mainly strike older people. According to Negus et al (2005) elderly people have limited mobility due to degenerative diseases of joints, and poor healing which is most likely the reason why leg ulceration occurs. William is 62 and has suffered with his leg ulcer for 4 years; therefore he was only 58 when it developed which supports Callam et al (1987a) who stated the importance of not associating leg ulceration with old age. Callam et al (1987a) stressed that an investigation of the age of first onset of ulceration revealed that over one third of patients had ulcers before the age of fifty, furthermore, over two thirds before the age of sixty five.

Leg ulcers can be venous or arterial and according to Hampton and Collins (2004) “the principle aetiology of ulcers is chronic venous insufficiency” (p.162). One of the reasons for venous insufficiency is varicose veins which can develop from defect or weakness in the vein walls or valves (Gould and Dyer 2011). William suffered from varicose veins for a long period of time, which could have been a result from years of constantly standing still behind the shop counter as this causes the pressure within the vein to be greatly elevated (Gould and Dyer 2011). Varicose veins are one of many underlying causes of leg ulcers, other causes are arterial disease, underlying systemic disease, skin cancers and reactions from drugs (Templeton and Telford 2010). Venous insufficiency can affect 70% of individuals resulting with ulcers and 8-10% of them are arterial, however, since William’s leg ulcer is venous, the essay is focused on this. A further underlying reason of a venous leg ulcer is minor trauma which can be one of the immediate causes (Rainey 2002).

William’s ulcer commenced with him knocking his leg against the shop counter, causing his skin to tare and bleed. This has not yet healed, and according to Gould and Dyer (2011) this a consequence of poor blood flow related to the signs and symptoms of varicose veins. William’s varicose veins were superficial, bulgy, and appeared purple in colour, he also had oedema in his feet. According to Gould and Dyer (2011) these are some of the typical signs and symptoms of varicose veins, in conjunction with fatigue and aching caused by increased interstitial fluid interfering with arterial flow and nutrient supply. Gould and Dyer (2011) also suggest that increased interstitial fluid leads to a shiny, pigmented, and hairless skin, which appeared on the area surrounding William’s ulcer. This can cause venous ulcers to develop because arterial blood flow continues to diminish and results in breakdown of skin. The healing is slow because of impaired blood flow (Gould and Dyer 2011).

According to Porth (2005):
“Veins are thin-walled, distensible vessels that collect blood from the tissues and return it to the heart. The venous system is a low-pressure system that relies on the pumping action of the skeletal muscles to move blood forward and the presence of venous valves to prevent retrograde flow.” (p.494.)

The venous valves stop the retrograde flow of blood and occupy a significant role in the function of the venous system. These valves appear to be unevenly located along the length of the veins; however they will be found at junctions where the communicating veins join with the larger, deeper ones, and the location of where the two veins meet (Porth 2005). The amount of venous valves vary in each individual, as does the structural competence and factors that possibly help to describe the familial predisposition towards growth of varicose veins (Porth 2005). According to Porth (2005): “Varicose veins are dilated and tortuous veins that result from sustained increased in pressure that causes the venous valves to become incompetent, allowing for reflux of blood and vein engorgement.” (p.494).

The action of numerous muscle pumps push blood from the lower extremes back up to the heart, one of which is the foot pump (Negus et al 2005). When an individual walks the deep venous channels return venous blood to the heart by the action of the leg muscles as they serve to increase flow in the deep venous channels (Porth 2005). William’s leg muscles did not achieve this action due to his standing still for long periods which caused his varicose veins. Bhutia et al (2008) say varicose veins are more common in people whose occupation involves prolonged periods of standing. An explanation of how these develop into ulcers has been explained previously.

Porth (2005) goes on to say the function of the muscle pump is situated in the gastrocnemius and soleus muscles of the lower extremities and is able to be checked through pumping action of the heart. While muscle is contracting, the valves in the communicating channels close, this is to stop backward flow of blood into the superficial system while deep venous blood is moved forward by the contracting muscles (Porth 2005). The communicating valves will then open during relaxation to allow blood from the superficial veins to progress to the deep veins (Porth 2005).

Varicose veins of the lower extremities, as defined earlier, are common, and frequently lead to secondary problems in relation to venous insufficiency and can be primary or secondary (Porth 2005). The primary varicose veins start off from the superficial saphenous veins while secondary varicose veins result from damaged flow in the deep venous channels. Eighty to ninety percent of venous blood from the lower extremities is transferred through the deep channels and progresses of secondary varicose veins become inevitable when flow in the deep venous channels become weak (Porth 2005). About 80% to 90% of venous blood is moved through the deep channels from the lower extremities and it is when they become impaired or blocked that secondary various veins can develop (Porth 2005). Porth also says the occurrence of varicose veins in Western populations is 25% in females and 30% in males and is more common in the over 50’s and obese people. The reason for being more common in the over 50’s was explained earlier.

According to Allen (2009) obese people are more at risk because of their increased body weight. This weight increases the workload of the heart and the amount of pressure on the arteries and veins. William is 62 and has a high BMI means he has these risk factors. Better Health Better Wales (1998) noted that levels of those overweight and obese in Wales were increasing with 51% of females and 53% of males in this category due to poor diet. It highlights that high levels of saturated fatty acids, and salt intake contribute to ill health. Heinen et al (2004) suggests that numerous studies show that patients who suffer with venous leg ulcers have deficiencies in vitamin A, zinc, and carotenes.

Porth (2005) says that prolonged standing and increased intraabdominal pressure is a significant causal factor in the progression of primary varicose veins as it increases venous pressure and causes the vessel wall to dilate and stretch. This was the case with William. A significant factor involved in the elevation of venous pressure is the hydrostatic effect connected to the standing position as the full weight of blood in the venous columns is transmitted to the veins in the leg (Porth 2005). The gravity effects of a person who stands for long periods and compounds problems as using their leg muscles means that they are not pumping blood back to the heart (Porth 2005). According to Hampton and Collins (2004) exercise is the most efficient way to return blood back to the heart, also, walking, as it activates the venous pump mechanism on the sole of the foot. Additionally, Ertl (1991) says the foot pump is significant in venous return and suggests it operates independently from muscular action.

With a person such as William who suffers venous insufficiency, when the calf muscle relaxes the superficial system attempts to refill but is unable to due to increased pressure in the vein which leads to venous hypertension and possible venous ulceration (Hampton and Collins 2004). Porth (2005) says that once the venous channels have been stretched repetitively and valves become damaged, normal venous tone and function cannot be restored. Porth (2005) goes on to suggest that certain measures should be considered to prevent the worsening of varicose veins, one of which is to avoid continued standing as is produces prolonged elevation of venous pressure.

William’s varicose veins were evidently the underlying cause of his venous leg ulcer due to standing for long periods behind the shop counter and leaning on his right leg. Measures of treatment are elastic support stockings or leggings which compress the superficial veins and prevent swelling. These stockings have to be correctly fitted and aim to improve venous flow and prevention of tissue injury (Porth 2005). William did not seek medical help for his varicose veins until they developed into an ulcer, therefore did not acquire these leggings or stockings.

Varicose veins lead to chronic venous insufficiency and venous ulcers, as the veins are not functioning adequately and poor blood flow leads to tissue transformation in the limb (Lampe 2004). Venous hypertension together with capillary hydrostatic pressure progresses to venous congestion and outflow of blood cells, protein, fibrin and fluid into interstitial space which causes oedema, pigment changes, poor tissue nutrition, lipodermatosclerosis and poor removal of cellular waste (Lampe 2004). These changes in tissue predispose the limb to ulcers due to a lack of arterial blood flow (Gould and Dyer 2011). A venous ulcer is moist and its appearance has a yellow fibrous film that covers its surface, the edges are irregular with firm fibrotic and indurated surrounding skin which may be a brown, rusty colour. (Baranoski and Ayello 2004). This is similar in appearance to William’s leg ulcer. The colour is due to the breakdown of the erythrocytes and deposition of hemosiderin (Baranoski and Ayello 2004).

An accurate diagnosis of a venous ulcer is important because it is the key to successful treatment, the main treatment being compression therapy (Dowsett 2005). Such treatment has to be applied accurately to improve venous return and is dangerous if it is applied to an arterial ulcer (Dowsett 2005). Tests such as a Doppler ultrasound can distinguish whether a leg ulcer is venous or arterial, and whether compression bandaging is to be used (Baranoski and Ayello 2004). Consequently, a full general and detailed clinical history of the patient should be carried out along with a physical examination and performed by a specialised trained healthcare professional in leg ulcer management (Downsett 2005).

According to Templeton and Telford (2010) diagnosing and deciding the correct aetiology regarding management of a leg ulcer is vital, as treatments for a venous leg ulcer are different to arterial leg ulcers. As stated above the most effective treatment for a venous leg ulcer is compression therapy yet it should not be used on an arterial ulcer because it can damage the leg and lead to an amputation (Templeton and Telford 2010). European Wound Management Association (EWMA 2003) recommends that assessment is the key to the most effective treatment for leg ulcers, as a patient’s history can provide clues to various diagnoses. A physical examination is also important to evaluate the size and characteristics of the wound and highlight any associated medical conditions (EWMA 2003).

William’s assessment confirmed his underlying reason was venous insufficiency, as his lower leg was swollen, and the surrounding skin to his ulcer was dry and brown in colour, which are symptoms of venous insufficiency (Allen 2008). The process of assessment as well as physical examination includes: understanding of the patients social factors, experience and concerns, the patients pain experience, clinical history, diet, and investigations such as peripheral vascular assessment, blood pressure, blood glucose, weight and urinalysis (Templeton and Telford 2010).

Since William’s assessment confirmed his ulcer to be venous, compression therapy was an option for him (EWMA 2003). The aim of this treatment is to exert external pressure on the veins in the lower leg and raise the efficiency of the calf muscle pump to force the blood back up the leg (Anderson 2006). When valves in the vein are patent but separated by extra blood volume, squeezing them together helps prevent back-flow of blood and also increases the blood velocity, therefore reducing congestion and chronic venous hypertension (Moffatt and Harper 1997). The compression on the outside will push fluid from the tissues back into circulation which will reduce oedema and allow access for nutrients to enter the skin and reduce eczema and dryness (Anderson 2006). Anderson also suggested that movement of the calf muscle, and leg elevation is important in addition to compression therapy along with control, skin care, and diet.

Elevation was not used by William as he said he did not always make time to do it, plus his diet was not healthy, as stated at the beginning of this essay. William’s diet contained too much saturated fats and salts (Better Health Better Wales 1998). William refused bandaging initially as he thought it would restrict his mobility, and had to be convinced by the district nurse to give them a try. He complained they were very tight, uncomfortable, and painful when they were first applied, and consequently he removed them. Annells et al (2008) noted studies showed that patients complained that compression therapy was uncomfortable and painful and led to the removal of bandaging. Additionally, in Persoon et al’s study (2004), patients stressed that dressing changes were painful.

According to Annells et al (2008) when a patient is undergoing compression therapy it is vital that they are willing and compliant, as this maintains positive results. Annells et al (2008) conducted a qualitative descriptive and exploratory study to research reasons for use or non-use of compression bandaging. The aim of this study was to explore the reasons why district nurses would or would not use compression bandaging despite being the most efficient treatment for venous leg ulcers (Annells et al 2008).

Twenty two district nurses were recruited for this study which was conducted over a four month period. These nurses were interviewed and questioned in relation to whether patients were willing or unwilling to wear compression bandaging and reasons for their decision. The outcome was that patients who were willing might not have been keen originally but after being correctly informed, educated and supported by the district nurse agreed to test the bandaging, and this led positive results. The reasons why some patients were unwilling were that they had suffered from leg ulceration for a long period and felt nothing had previously worked, so assumed compression bandaging was just another treatment (Annells et al 2008). Additionally the pain, discomfort and tightness of the bandaging were also a cause. When William was persuaded to tolerate the compression bandaging he experienced a slight positive outcome the result was a willingness to progress with the treatment.

Annells et al (2008) noted that compression bandaging cannot be applied and sustained unless the patient was willing to comply. Annells et al (2008) concluded that this study had several limitations; one being the sample was self-selecting, invitees who agreed to participate possibly because they felt more comfortable discussing commitment or concerns on this subject than other nurses.

Persoon et al (2004) stressed that nurses often focus too much on treatment, such as compression therapy, and should have an equal focus on the problems leg ulcers have on the impact of everyday life. Persoon et al (2004) conducted a review on these impacts and gathered information from previous qualitative and quantitative studies about how patients described these daily impacts. Physically the impacts were pain, impaired mobility, sleep disturbances, and problems related to wound characteristics. Psychologically and socially the impacts were mood and feelings, such as regret, depression, loss of will power, control, and helplessness. Additionally some patients felt unclean due to treatments like compression therapy because of not being able to have a bath or shower (Persoon et al 2004).

William demonstrated feelings of regret, as during his visits to clinic he spoke about his work and how his illness slowed him down. Consequently he had to rely on his wife to share a majority of the workload in the shop which seemed a matter of concern to him. He said he valued his work role and regretted not being able to meet his previous standards and was fearful of losing that role. According to Haralambos and Holborn (2000) performing a particular role involves social relationships; meaning that a person will play a role in relation to another role, for example the role of a husband in relation to the role of a wife, therefore interact in terms of roles. Social roles control and organise behaviour and can provide means of achieving certain tasks, for example teaching can be achieved more effectively if both teacher and student take on their appropriate roles. William could no longer achieve the tasks required for the role he took on in his shop due to his illness which means his wife had to take on some of his tasks.

Furthermore during clinic William required assistance to remove and replace his shoes and socks and said he relied on his wife to assist with those tasks at home. He also said he was unable to bath or shower due to his compression therapy, so would have a top to tale wash but found it difficult to bend down and required help from his wife to wash his left foot, as that was the un-bandaged one. The limitations William endured are shared by other patients. Persoon’s (2004) study highlights that leg ulcers can have an impact on the daily activities of living, which according to Roper, Logan, and Tierney (2000) are twelve necessary daily activities that ensure our survival of life. William evidently could not achieve personal cleansing and dressing without assistance, additionally his illness restricted his work.

William may have prioritised his work over health, enduring varicose veins for years, and only requesting medical help when they developed into an ulcer and obstructed his daily activities. William evidently valued his work role, discussed previously, and his health only became an issue once it hindered his work. According to Denny and Earle (2009) health is a difficult subject to define and one of the most used definitions is ‘absence of disease’ (p.51). However Naidoo and Wills (2008) suggest health can be defined in several ways, one of these can be in subjective terms, and each can affect a person’s age, gender and social class. For example many young people will view health as eating healthy food and keeping fit, whereas older people will look at health as coping and being able to perform daily tasks and activities (Naidoo and Wills 2008). It is possible that William perceived his health this way, since he could manage to achieve a day’s work in his shop regardless of having a leg ulcer.

Psychologically, William’s attitude towards his leg ulcer seemed to be that he was in control of his health and knew what he had to do to recover, however he did not make time to achieve this, because of running a successful business. According to Rana and Upton (2009) when an individual behaves this way it is known as internal locus of control, which is when a person looks upon their health as though they are in control. Rana and Upton (2009) suggest “Locus of control is based on the attributions people hold about their health” (p.407). This was first noted by Rotter (1966) who supposed people had either internal or external locus of control (Rana and Upton 2009). According to Sarafino (2008) people who possess internal locus of control believe they have control over their success and failures, this means they are to blame for their own success or faults. External locus of control is when an individual believes his/her life is controlled by forces outside themselves such as luck or fate (Sarafino 2008).

The Health Belief Model (Becker 1974) supposes that action is based on a cognitive assessment of the result from a particular behaviour or change in behaviour (Walker et al 2004). It was developed with the aim to predict preventative health behaviours, and has been used to describe patient’s response to treatment in relation to both acute and chronic illnesses (Rana and Upton 2009). This model has proved to be a popular and resilient model in health education (Walker et al 2004). According to the health belief model an individuals probability of taking preventive action is determined by either, his/her perceived threat of the health problem or, the sum of pros and cons they perceive in taking action (Sarafino 2006). These actions are influenced by numerous factors, three of which influence an individuals perceived threat, and effect how much he/she are possibly worried about a particular health problem (Sarafino 2006).

These three factors are: Perceived seriousness, this is where a patient might only take preventive action if they feel the health problem is going to become more serious and become a threat to them, for example their social life. Perceived susceptibility is when an individual may assess the possibility of them developing the health problem and they are more likely to perceive a threat if they recognise the risks involved. Cues to action, this is when an individual is reminded or alerted by a possible health problem by means of a friend or relative becoming ill, newspaper articles, leaflets, posters, etc (Sarafino 2006).

In Williams case his relation to perceived seriousness, was possibly his presumption that his leg ulcer would heal in a few weeks just like a cut or graze and was unaware of the seriousness of having venous disease. However once he realised it was not healing but instead deteriorating and becoming a social problem, he was then convinced to take his condition seriously. His Perceived susceptibility was perhaps the risk of his ulcer not healing. Cues to action could have been related to a conversation he overheard in his shop.

The Health Belief Model highlights that the pros and cons of carrying out health behaviour, which include the benefits and barriers of taking action can affect action taken (Sarafino 2006). The benefits being for instance becoming healthier or reducing the health risks, and the barriers the costs a person perceives in taking action (Sarafino 2006). To enable a person to take action, the benefits have to outweigh the barriers. For example a person might not attend an appointment for a physical check up due to not being able to afford bus fare to get there, however the benefit will be peace of mind from the threat of illness (Sarafino 2006). William’s barriers might have been having time out of work, but the benefits were requiring answers as to why his ulcer was not healing. Consequently the benefits outweighed the barriers.

William never took much time out of work due to the demands of running a business. He and his wife had mentioned they no longer attended social events together due to William being too tired from working, in too much pain, or afraid his leg ulcer might smell or weep. As a result his wife went to social events with her friends and acquaintances alone. William’s main socialising occurred only with customers when he was behind the shop counter. This may have been since he possibly felt more secure in this environment as the customers were unaware of his leg ulcer. The only other interaction was at the leg ulcer clinic he attended.

Brown’s (2005) two part study looked into the effects that leg ulcers have on a patient’s social life. The issues explored were whether the presence of a chronic venous leg ulcer impacts negatively on a patient’s social life, and to determine whether the ‘knitting needle syndrome’ exists. This was a qualitative study where eight participants were recruited and interviewed. The findings of this study showed three main subjects which were pain, social disconnectedness and coping, although the study focused on just two of these, being disconnectedness and coping, since they were closely linked. Many of the participants said they did not socialize anymore due to poor mobility because of the ulcer and compression bandages. Several participants came across as being lonely but disguised their feelings by comparing themselves to others who may be worse off. William may have felt lonely, since he did not socialise with anyone other than his wife and customers, due to his leg ulcer, consequently his wife attended social events without him.

Some of the participants removed their bandaging because they were too tight and uncomfortable, despite knowing it would delay the healing process. William removed his bandages initially because they were too tight and uncomfortable which did delay his healing. However at that time he did not fully understand the underlying reasons for compression therapy. According to this study, when patients behaved this way, it caused frustration for many nurses, and could have contributed to the highlighted issue of ‘knitting needle syndrome’. This, according to Snyder (2006) is evidence of patients tampering with their bandages and dressings to purposely delay healing, which may provide benefits such as continued nursing care. However this study showed there was no literature found to support the syndrome.

The study showed that the impact of having leg ulcers can be restriction of a patient’s social life which causes them to feel isolated and lonely, even with patients who have a partner and close family living nearby. Patients are thought to value the company of friends rather than family, as family are more duty bound. Consequently patients value the company of nurses more for the time spent with them to talk than the given treatment (Brown 2005). In William’s case he was always keen to chat and was sociable during his visits to clinic, even though he never seemed too keen with compression therapy. Maybe he felt more at ease socialising in clinic as other patients had a similar condition, thus removing the feeling of embarrassment about his ulcer.

Limitations of this study were that it contained only a small sample which means further research would be required to support it. Brown’s (2005) study also suggested that participants felt a sense of social disconnectedness. Lindsay (2001) supposes that this was due to a lack of peer support and empathy, which can be combated through the formation of groups containing fellow sufferers. Yet Brown (2005) notes that this type of intervention was not suitable for all patients. Furthermore Brown did not discuss pain in this study, which according to McMullen (2004) who conducted a critical review on the relationship between pain and leg ulcers, pain is a significant issue for venous leg ulcers. This was also an issue for William since he said his ulcer was extremely painful at times. According to Byrne and Kelly (2010) pain is recognized as the worst attribute of leg ulcers and is possibly one of the initial causes of social isolation.

William’s persistence to carry on working in his shop regardless of his ulcer might have been for social reasons, as other than family and clinic he did not socialise. Therefore if it wasn’t for his work he may have felt isolated. Another reason for his determination to work could be that he values his gender role. According to Haralambos and Holborn (2008) gender roles are culturally produced rather than biologically, regardless of the biological tendencies for men and women to behave differently, cultural factors can override these behaviours.

Culture is the whole way of life that a person lives, a society that they have been brought up in and the set of ideas and habits they are taught which are passed on to each generation (Linton 1945). Cultures can form a person’s identity, as it determines how people of society think and feel, and directs their behaviours and defines their attitude towards life and becomes so much of a part of the person that they are blind to its existence (Haralambos and Holborn 2008). As with William, he was perhaps groomed to be the breadwinner. Haralabos and Holborn (2008) suggest the breadwinner role originates from the nuclear family, which is defined by Bilton et al (2002) as “a household unit composed of a man and a woman in a stable marital relationship, and their dependent children” (p.230).

The woman’s role was to give warmth, security and emotional support to the family, and the male being the breadwinner who spent his day competing in an achievement-oriented society (Parsons 1955, as quoted in Haralambos and Holborn 2008). William was perhaps brought up in a similar manner. According to Giddens (2006) society expects males and females to act their role appropriately. These gender roles are learned during childhood socialisation, and that society expects the male role to take the lead and females to be more passive, consequently the male being the main provider.

Socialisation, according to Bilton et al (2002) is “the ongoing process whereby individuals learn to conform to society’s prevailing norms and values” (p.58). The most important aspect of this process is the primary socialisation which occurs during infancy, where a child will learn the language and basic behaviour patterns of his/her society (Haralambos and Holborn (2000). Within these societies there are certain guidelines which are norms and values. According to Haralambos and Holborn (2000) “a norm is a specific guide to action which defines acceptable and appropriate behaviour in particular situati

ons” (p.4). For example, most societies expect individuals to dress appropriately, males in trousers and females in a skirt, or for particular occasions such as work, a social night out or a funeral. A value is defined by Haralambos and Holborn (2000) as “a belief that something is good and desirable” (p.5), and is important to an individual, worthwhile and worth striving for. For example a person might believe it is important to come first in a race, or be top of the class. William was possibly socialised in a similar way to the nuclear family (Parsons 1955, as quoted in Haralambos and Holborn 2008), consequently his norms and values might relate to being a good husband, father, and successful in business.

William was the eldest child of a large family brought up in a working environment, with his mother fulfilling her female role (Parsons 1955, as quoted in Haralambos and Holborn 2008) doing the household chores and bringing up the children while his father worked in the shop taking care of the business. William being the eldest had to also take on a working role at a young age to help run the business, and he has told me he was taught everything he needed to know about running a business by his father. It seemed education was not an important issue for William during his upbringing as he left school early to work in the shop. During his era the Education Act of 1944 permitted free secondary education for all children to remain in school up to the age of fifteen (Giddens 2006). However William’s two daughters have clearly had a good education, both being school teachers, which probably means neither one had intentions of taking over the family business. In turn this has put further pressure on William to continue working, as he will undoubtedly not want to renounce his family business.

It is evident that William was brought up in a working class environment yet he wanted his daughters to move up in class, something which in today’s society does not have to be determined from birth or land ownership (Bilton et al 2002). Presently in society the working class are recognized as skilled manual, partly skilled and unskilled manual, and middle class are professional, intermediate and skilled non-manual. These skill recognitions place his two daughters in the middle class (Bilton et al 2002). Acherson (1998) states that although occupation is the main form of determining socioeconomic groups, education, and access to ownership of assets can also be indicators. William has then achieved his working goal as a father by raising the status of his daughters. Still he believes he has to continue his role of a husband, in the way he was cultured.

Following examination of William’s health from a biopsychosocial view, this essay shows how physiologically disease can alter the function of the human body, and how William’s varicose veins developed into a leg ulcer that ended up being long term. The fact that it was long term may have been caused by his psychological perceptions and behaviour towards health. Furthermore his social background in terms of education would also have had an influence. Acherson (1998) notes that poor educational achievement can lead to poor adult health, as the skills and knowledge necessary for a healthy lifestyle are not acquired. In the lower socioeconomic groups there was a higher rate of obesity, and fewer intakes of fruit and vegetables, which lead to a deficiency of vitamins, minerals and dietary fibre (Acherson 1998). The disease was clearly an influence on William’s present lifestyle, as stated above.

This essay has also examined how research studies can provide evidence base information to help healthcare professionals understand certain biopsychosocial issues that can contribute to an individual’s perception towards health, and reasons why people behave differently. This essay has brought to my attention, that to determine a patient’s health and illness, a holistic approach is necessary, as this way, all dimensions such as physical, social, and psychological needs are dealt with equally (McSherry 2007).

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