Health Promotion College

The aim of this case study is to provide a detailed account of a patients holistic health care needs from a health promotion perspective utilising the Tannahill Model which will be described. In promoting the health of the patient maintaining individuality within a diverse community will also be discussed by the application of the model to the patient.

Mary, the patient the study focuses on (surname withheld to uphold confidentiality), was chosen due to the writers involvement throughout the duration of her stay in hospital. The writer met Mary prior to her operation in theatre and was present for the duration of her operation. When Mary was admitted to ward L4 the writer was directly involved in Mary’s care and discharge.

Mary is a 75 year old widowed lady. She is a devout Roman Catholic and attends church every Sunday. She is retired, during her working years used to work for a local catalogue company. She lives in a ground floor flat prior to admission she normally mobilised with a stick although she still enjoyed walking. She has one daughter who visits regularly on a weekly basis. She is a smoker and smokes twenty cigarettes per day for the past fifty years. Mary receives no home care input from social services and considered herself independent around the home prior to admission. She was admitted to hospital due to a fall at home, Mary had no previous history of falls. On investigation at hospital it was found that she had fractured her left Neck of Femur. Subsequently, this led to an operation in which a Thompson’s Hemiarthroplasty was performed which involves a replacement of the Neck of Femur with a prosthesis. Following the surgery Mary’s recovery was gradual, the members of the multi-disciplinary team, Mary and her family felt she would benefit from further rehabilitation consequently she was referred to ward L4.

The ward is an orthopaedic rehabilitation unit which endeavours to promote a patients recovery, restore confidence and maximise their independence. The rehabilitation programme is achieved through a multi-disciplinary approach. The core members of this multi-disciplinary team undertake an assessment with each patient and then together they plan and implement an individual rehabilitation programme that will meet each patients individual health needs. When Mary was transferred to ward L4 she was introduced to her primary nurse and the members of the team to which she was allocated as the ward operates on a team nursing basis to deliver care. Consistency in staffing encourages a development of trust and the promotion of a ‘ surrogate family’ (Holloway 1988).

In 1946, the Constitution of the World Health Organisation defined health as:

‘ Health is a state of complete physical, mental and social well-being, and not merely the absence of disease of infirmity’ (WHO 1946)

This definition takes a holistic view of health which is to treat the patient as a whole including social and mental well-being, not just their symptoms. The initial assessment at the ward level allowed the identification of Mary’s holistic health needs. Spiritual needs identified were her religious beliefs and practice as a Roman Catholic. The expression of her religious beliefs was respected and appreciated by all the staff. As previously acknowledged Mary regularly attends church. To ensure that this aspect of her life was maintained she was advised of the hospital church and encouraged to attend mass. She declined initially saying that she did not feel physically capable of attending. The Roman Catholic priest visit’s the ward on a weekly basis every Friday, it was arranged that Mary would receive Holy Communion at her bed side. This was greatly appreciated by Mary as she felt she could still practice her religion. Sociocultural needs raised were: Mary’s wound was found to be infected with Methicillin-resistant Staphylococcus aureus (MRSA).

As per infection control policies in place in the trust Mary was transferred to a single side ward. Mary’s initial reaction was favourable enjoying the fact that she had her own room. Later in her stay she expressed feelings of isolation and loneliness in the side ward. Previously, she was situated in a four bedded bay of ladies in which she expressed no feelings of isolation. Following the expression of Mary’s anxieties she visited the day room on a daily basis but remained in her wheelchair and was advised not to have physical contact with the other patients for infection control purposes. This integration with the other patients also had a positive impact in her psychological well-being. Psychologically Mary was affected by many factors. Her husband died the previous year in hospital following surgery that led to deterioration in his health and Mary had to be constantly reassured of her progress and that hospital admissions did not ultimately lead to deterioration in health. Mary’s injury was a direct result of a fall in her home.

This combined with her lengthy stay in hospital had decreased confidence in her own capabilities when she was able to return home. It was stressed to Mary that she should not be apprehensive to voice her fears. Biological needs refer to the physiological and anatomical functioning of the body. This includes the actual medical condition of Mary. As previously mentioned the surgical wound had become infected which would delay the rate at which it healed. Following her surgery, mobilising was difficult for Mary. On sessions with physiotherapists, it was reported that she had often conveyed frustration with limited walking abilities.

Health promotion as defined by the World Health Organisation (1985) is the process of empowering individuals to exert an increased control over, and to improve their health. The ultimate goal of health promotion according to Downie et al 1990, is to achieve an equilibrium of the enhancement of the physical, mental and social components that contribute to positive health, in conjunction with the prevention of physical, mental and social ill health.

The Tannahill model of health promotion (Appendix 1) was developed to define, plan and implement health promotion to illustrate the linkages between health education, health protection and prevention (Tannahill 1985). This model was chosen primarily due to its extensive possibilities to which it can be successfully applied. The Tannahill model is composed of three overlapping spheres of activity. Including the overlapping areas, seven areas of health promotion measures are distinguished which are titled:

1. Prevention e.g. immunisation, screening for handicapping congenital disorders, self help groups, nicotine replacements therapies for smoking cessation, hypertension case finding.

2. Preventative health education. Educational measures for individuals to alter their lifestyles accordingly to prevent occurrences of ill health encouraging individuals to utilise preventative services e.g. smoking cessation services.

3. Preventative health protection e.g. Fluoride in water to prevent dental cavities, legislation regarding the sale of alcohol and tobacco products to minors, the control of communicable diseases such as tuberculosis patients who are non compliant with their medication being admitted to hospital to receive their medication.

4. Health education for preventative health protection e.g. successful campaigning for seat belts and the ban on advertising of tobacco products.

5. Positive health education. Two categories: Firstly, Health educational aimed at influencing behaviour in order to promote health gains, such as encouraging a proactive approach to enhancing physical fitness and or adopting a healthier eating regime. Secondly, to empower individuals, communities and groups to develop positive health characteristics to achieve true well-being (e.g. by increasing their self esteem).

6. Positive health protection e.g. the development of workplace no-smoking policies to provide clean air.

7. Health education aimed at positive health protection. Raising awareness to public health issues for instance the lobbying to prohibit alcohol consumption in public achieved by both the government and the public in order to promote positive health (Tannahill et al 1990).

In utilising the Tannahill model, Mary’s health can be promoted in several approaches which are individual to her specific requirements. Preventative measures would be to firstly, ensure that Mary is fully aware and understands the possibility of dislocation of her hip replacement if she does not adhere to the safety precautions an example being not to flex the hip over 90°. Secondly, Mary would benefit from a bone density assessment to determine whether she has osteoporosis which is characterised by a gradual deterioration in bone mass leading to an increased risk of fractures due to the fragile state of the bony tissue (WHO 1999). Mary is considered to be at risk as she is a post menopausal female, a smoker and she has suffered a fractured Neck of Femur (DoH 1998). Preventative health education measures are to educated Mary in the special precautions to avoid displacing the joint and incorporate these precautions into her lifestyle (Appendix 2). Additionally, to Mary advise of the positive implications of her health and services available to her with regards to smoking cessation.

Mary was referred to the Minerva Day hospital, which provides ‘falls group’ teaching sessions to those who have a history of falls or are at risk of falls. These sessions aim to educate the patient in ways to minimise the risk of falls and in the event of a fall ways they can minimise the damage that occurs. This includes educating the patient on the correct technique of using their walking aids, in the case of Mary a Zimmer frame. Preventative health protection for Mary’s future is encompassed in the National Service Framework for Older People (DoH 2001) which aims to reduce incidence of falls resulting in serious injury and to ensure effective treatment and rehabilitation for those who have fallen through partnership between the government and the NHS. This is required as individuals who have fallen are at risk of falling again (DoH 2001), the goal of this domain is to identify risk factors that could result in Mary having another fall and to intend to reduce these risks by providing support mechanisms.

On discharge a domiciliary visit by the physiotherapists at Mary’s home would be arranged to ensure Mary is managing to mobilise at home safely. Health education for preventative health protection would involve educating Mary of the preventative services that are available to her. This includes encouraging Mary to attend the ‘falls group’ teaching sessions at the Minerva Day hospital. Attending the falls group teaching sessions is also promoting health by means of positive health education as it influences health positively by developing positive health attributes. As well encouraging Mary to attend the day room on a daily basis, interacting with other patients both act to promote her social and mental well-being. As Mary’s wound is infected with MRSA the infection control trust policy requires the appropriate nursing intervention to reduce the risk of the infection spreading. Mary’s wound is to be redressed under aseptic technique and for staff to ensure that Mary’s immune system is not further compromised by cross contamination from other patients by effective hand washing prior to contact with Mary.

Adequate discharge planning for Mary is significant since she might require the installation of equipment at home for instance raised toilet seat, to protect her prosthesis as assessed by the occupational therapist on a assessment of Mary’s home. The infection control policy and the discharge planning act as means of positive health protection. Therefore, health education aimed at positive health protection involves educating Mary on the subject of MRSA , providing the support and medication (if applicable) to prevent subsequent contaminations and to eradicate the infection. Preparing Mary for discharge requires the education of Mary in relation to the equipment installed.

In conclusion, the Tannahill model was developed with the intention to define, plan and implement health promotion to illustrate the linkages between health education, health protection and prevention (Tannahill 1985). It dismisses the previous ‘primary’, ‘secondary’ and ‘tertiary’ classifications of health promotion focusing on four elements of prevention and three elements of promoting positive health which incorporate health protection. This provides a additional definition to what is health promotion is being:

‘ health promotion comprises efforts to enhance positive health and prevent ill health, through the overlapping spheres of health education, prevention and protection’ (Tannahill et al 1990 p 59)

The model if used correctly, encourages considerations to health promotion that are individualised and relevant to the specific patient. It has provided several important actions that could be implemented with Mary to promote her health. The focal point of the model is to educate. By providing the patient with sufficient information, preventative measures can be adopted by the patient to prevent of the occurrence of ill health and to enhance positive social, physical and mental well-being.