Long Term Conditions

The aim of this essay is to define a long term condition (LTC) and explain why this is important for nurses. Common symptoms may accompany many LTC’s and how these are treated, along with the impact on patient and carer will be considered. The patient chosen for this case study shall be referred to as John to conform to the Nursing and Midwifery Council’s (NMC) (2008) guide concerning confidentiality. John has Type 2 Diabetes and after a road traffic accident has an injury to his foot which is slow to heal. As a student nurse, being involved in the care of many patients with diabetes, this patient was chosen to improve my awareness of the condition and to improve care given in the future. This essay will explore depression and its effects on people with diabetes and its prevalence within other LTC’s. In the past, LTC’s have been treated medically; however, empowering patients can contribute to a healthier life and an introduction into how Type 2 Diabetes is currently managed will be discussed. Finally, the essay will explore educational programmes and policies relating to care for people with diabetes and other LTC’s.

The Department of Health (DOH) (2005a) state that a long term condition is one that cannot be cured but can be managed through medication and/or therapy. It usually affects older people more than those of younger years and also people in lower socio-economic groups. Additionally, the DOH National Service Framework (NSF)(2005b) although refer to long term neurological conditions, expand on this definition by adding that all LTC’s will affect families and the individual in some way for the rest of their life. According to the DOH (2008) there are approximately 17.5 million people in England with at least one LTC, the most common being cardiovascular diseases, diabetes, chronic obstructive pulmonary disease, asthma and depression. Caring for these patients costs the National Health Service 70% of their primary and acute budgets (DOH 2008).

This is a significant consideration to the future of nursing as it is important to realise that the majority of people we will be caring for will have at least one LTC. Indeed, Plews (2005) notes that 60% of hospital beds are occupied by people suffering a LTC. Additionally, Margereson et al (2010) suggests that as life expectancy increases, so will the number of people living with LTC’s, thus presenting nurses with increasing numbers of patients with complex needs.

Ascott et al (2011) suggest that people with LTC’s may often share common symptoms such as fatigue, pain, depression, stress and breathlessness. As nurses, the ability to offer quality care requires knowledge of LTC’s and the common symptoms that can accompany them. The treatment of these symptoms not only affects patient’s quality of life, but also their ability to manage their condition. Additionally, Margereson et al (2010) suggest that holistic care will consider the psychological, social, emotional, physical and spiritual needs of the patient which in turn may improve the quality of their life overall.

Type 2 Diabetes is classed as a LTC as it cannot be cured but can be managed through medication. National Institute of Health and Clinical Excellence (NICE) (2009) define Type 2 Diabetes as the inability of the pancreas to produce enough insulin, or when the cells in the body do not react to the insulin that is produced. This results in elevated blood glucose levels, which can lead to complications such as heart disease, stroke, renal failure, blindness and amputation. On first diagnosis, healthier eating and exercise may be sufficient to control glucose levels; however, as it is a progressive disease, medication may later be prescribed. The DOH (2001) suggests that approximately 90% of adults in the UK that have Diabetes have Type 2, and that this condition can have a significant effect on the psychological well-being of these people and their families.

John is in his early forties and has had Type 2 Diabetes for 8 years. When he was first diagnosed, he was offered a diet sheet and advice from his doctor to introduce physical exercise into his life. John is a manual worker and feels he doesn’t need to exercise as he keeps active most of the day. He gave up smoking and drinking alcohol, but after 3 months his blood glucose level was still above normal and was prescribed medication. Eight years later, he now uses insulin to control his blood glucose levels and is a non-smoker. He was admitted to hospital following a road traffic accident which resulted in an operation on his foot which had sustained multiple injuries. The wound was very slow healing and intravenous antibiotics were prescribed.

John was diagnosed with depression shortly after being prescribed insulin to control his diabetes. Although depression is considered to be a long term condition itself, it is often noted to accompany other LTC’s suggests Carrier (2009). John has a wife and a daughter of 20 months and often feels unable to enjoy a normal relationship with them due to his low mood and feelings of anxiety. Before John’s diagnosis of depression, he enjoyed playing darts for his local pub which included lots of social events. He doesn’t play anymore as he doesn’t have the motivation. As a result, his wife feels guilty as she plays for the women’s darts team and still enjoys the social activities. NICE (2004) suggest that depression can range from tearfulness and low self esteem to self-harm and suicide. John also feels anxious when he thinks of his father as he had Type 2 Diabetes, he had a below the knee amputation due to diabetic neuropathy and died aged 72.

Lloyd and Skinner (2009) suggest that people with diabetes are more likely to have a higher prevalence of depression or anxiety due to the ongoing demands of the self-care required of managing an LTC. In addition, increased levels of cortisol which is linked to anxiety, can also lead to raised blood glucose levels. Poor dietary management, lack of physical activity and increased smoking and alcohol intake are factors of self care that can be affected when depressed (Lloyd and Skinner 2009). Contrary to this, although John is taking medication for depression, he has managed to stop smoking and drinking.

John’s experience of Type 2 Diabetes is individual to him and by comparing his experience to that of Ken who was highlighted by Morris (2006) may show that people who share the same LTC, do not necessarily share the same experience. Ken was in his fifties with Type 2 Diabetes and his blood glucose levels were not managed well. He had little concern for this; however, his main worry was erectile dysfunction. Until this was successfully treated, Ken’s self esteem was low and his relationship with his wife was suffering. This illustrates that although the experiences differ, key features of low self esteem and the effects of these on family can be similar.

In John’s case, successful treatment of his depression may improve the quality of life for him and his family. Lewin (2007) suggest that practice nurses with training and good communication skills can offer support and monitor the management of milder forms of depression. Sin and Trenoweth (2010) note that when a patient is diagnosed with a LTC it can impact many aspects of their life from relationships, employment and finances to self esteem and mood. John is a manual worker and is self employed. Until now, he has always been able to provide for his family; however he is worried over when he will be able to return to work.

Carrier (2009) notes that in previous years, LTC’s have been managed by the medical model of care, however in contrast to this, Holman and Lorig (2000) suggests that empowering patients with the skills and knowledge to manage their condition will ultimately lead to better health outcomes and quality of life. The initial stages of managing Type 2 Diabetes are to control blood glucose levels initially through diet and lifestyle changes. Berry and Robson (2010) suggest that people with diabetes should be involved in decisions concerning their care and treatment. However, as it is a progressive condition, medication and referrals to additional health care professionals may be required.

According to the DOH (2007) Social Care Long Term Conditions Model, to deliver the most appropriate care to patients with LTC’s, it may be beneficial to use the three tier triangle approach which is based on the Kaiser Permanente triangle of care management (DOH 2005c). Level one is supported self care which helps patients and their carers to develop their knowledge and confidence to care for themselves effectively. This is the level of care John currently receives for his diabetes. With the help of the practice nurse, Carrier (2009) suggests that patients can be reviewed and referred to other members of the multi-disciplinary team such as nutritionists and podiatrists as required. Indeed, maintaining a sense of well-being and leading an independent life is high on the list of priorities for these people. The DOH (2001) suggests that effective care of diabetes is predominantly self-management which would be included in level one.

Level two and three are involved in more complex care which at this stage John does not require.

Health and social care policies are in place to guide nurses in their management of care. The aim of these policies is to develop and improve services available to patients and carers with LTC’s (DOH 2007). For John to be able to manage his diabetes successfully he has to have knowledge, confidence and support. The Expert Patient Programme (DOH 2001) is designed to empower patients to manage some of the self care of their condition together with their health and social care providers. Since its inception, the programme has developed into many condition specific sessions, indeed John has been invited to the X-Pert Insulin Programme – although he is yet to attend. The programme runs for six weeks and each session is two and a half hours. The NMC (2004) states that as professionals we must ensure patients have access to information and support that is relevant to their needs so referring patients and by increasing investment in the Expert Patient Programme, it is hoped that patients will have a clear plan of how to manage their condition better. For John, this could be advice on diet, information on insulin, self-monitoring blood glucose and care planning. The DOH National Service Framework (NSF) (2001) for Diabetes emphasises the approach to patient focussed services set out in the Expert Patient.

The DOH (2005) published a `Supporting People with Long Term Conditions: An NHS Social Care Model to Support Local Innovation and Integration. This was a basic strategy to help local services enhance the care provided for people with LTC’s. To develop this, the DOH (2008) published `Raising the Profile of Long Term Conditions Care’ which was to improve care by putting in place initiatives based on the 2005 strategy. For John, this means being registered on a clinical information system which recalls him for regular reviews Carrier (2009). It also allows him access to regular diabetic nurse specialists, podiatrist services and retinopathy screening.

In addition, the DOH (2006) published Our Health, Our Care, Our Say: A New Direction for Community Services, which was to offer more support for people with LTC’s, as it was noted that half the people with long term conditions were not aware of the support or treatment options that were available to them.

In conclusion, it is noted that people with LTC’s place high demands on the limited NHS resources. An LTC cannot be cured, so successful management by the individual and holistic care given by health professionals is essential for a better life and well being. Due to the increase in life expectancy, the prevalence of people with LTC’s is expected to rise. Therefore, nurses should have knowledge of LTC’s and the common symptoms that may accompany them as these can impact the lives of both patients and carers. It is shown that empowering patients to manage their condition can sometimes lead to better health outcomes and quality of life. The development of the Expert Patient Programme is a valued tool which strives towards empowerment, resulting in patients having more confidence to manage their care. If John’s depression can be managed successfully, I feel that he would benefit from the Expert Patient Programme which may result in better blood glucose management and a better quality of life overall for John and his family.

The knowledge I have gained from researching type 2 diabetes and long term conditions will be of great value and most useful in future practise.

References.

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