“Review the concept of family in contemporary society, describe family strengths as a framework and discuss how it can be applied as an approach to use in health care practice.”

When reviewing the concept of family in Australia a contemporary lens must be adopted. Australia has moved away from the traditional notion of family and as such the definition of family varies depending on the individual’s opinion and experiences. Regardless of an individual’s situation, a nurse must be responsive to these differences. Moreover, when adopting a Family Strengths approach a nurser is able to provide a care plan to promote positive health outcomes for the whole family. In practice the Family strength framework supports the inclusion of family members and assists nurses with empowering families to overcome the health care situations they are facing together.

To define family as a concrete term with contemporary society would unavoidably leave out a number of possible family configurations. The Australian Bureau of Statistics have attempted to define family and have included opinions such as: Two or more persons, over 15 years of age, relations of blood, marriage, adoption, step or fostering and household residential address (ABS, 2016). In contemporary society, these definitions do not remain relevant. For example, more children are living in out of home care arrangements such as residential care (Australian Institute of Family Studies 2018). A more contemporary understanding of family requires nurses to be aware of the bias and beliefs they hold when providing care to a patient (Mirlashari et al. 2018). When supporting children in these family models, it is important to remember their right to choose who they consider their family to be (United Nations 1989). This can include but is not limited to, friends, blood relatives, married/de facto relationships and foster care families (Smith & Ford, 2013). As a student nurse, reflecting on the concept of family, most significantly I have learned that family is a fluid concept. Patane and Forster (2017) support this thought when they discuss family developmental stages. Throughout a person’s life their definition of family or who they choose to include as family is subject to change based on the developmental stage of the family and nurses must be responsive to this (Patane & Forster 2017).

When working with families, it is important to work with their current strengths. One way of doing this is to work within the Family Strengths Framework. The Family Strengths Framework is a positive approach towards health care that focuses care plans on the whole family unit (Smith and Ford 2013). To support the implementation of the Family Strengths frameworks the Australian Family Strengths Nursing Assessment Guide (Assessment Guide) was developed. The Assessment guide describes nine family strengths – Communication, Togetherness, Sharing activities, Affection, Support, Acceptance, Commitment, Resilience and Spiritual Wellbeing and provides example questions for nurses to ask (Smith and Ford 2013). The Family Strengths Framework supports the identification of existing relationships and processes that have maintained the family unit in the past and which may be useful in the current situation (Well et al 2014; Smith and Ford 2013). While the aim of the Family Strengths Framework is to empower families by drawing on their existing strengths, the process also provides an opportunity for nurses to identify what a family may need in order to further support to each other (Smith and Ford 2013)

The Family Strengths Framework in practice allows Nurses the opportunity to work within a Family Partnership Model, to draw on the family’s strengths through family assessment (Smith and Ford 2013). Through genuine conversations and interactions, nurses are able to ascertain family strengths that build a ‘toolkit’ of relevant coping strategies for the family (Smith and Ford 2013). During this process nurses are working with families as partners to explore how their strengths can support each other. In practice, this assessment is not intended a clinical questionnaire (Patane & Forster 2017). The Assessment of a family is completed in a more conversational manner, over a period of time and may not be completed in one sitting (Smith and Ford 2013). At any time of change, it is important that nurses reflect on their assessment to ensure that the care plan they have developed still reflects the strengths of the patient and their family.

In conclusion, for nurses to implement a Family Partnership Model they must work within a Family strengths framework without bias or judgement. Each individual has their own concept of family and in contemporary Australia a one size fits all approach to health care is not conducive to positive induvial health outcomes.  By using each family’s strengths, nurses can work alongside families to build resilience and include the whole family in the care of a patient.

References.

• Australian Bureau of Statistics (ABS) 2016,
  
  2901.0 – Census of population and housing: census dictionary
  
  , viewed 8 August 2019, ABS, https://www.abs.gov.au/ausstats/abs@.nsf/Lookup/2901.0Chapter32102016
• Australian Institute of Family Studies (AIFS): Child Family Community Australia 2018,
  
  Children in care,
  
  AIFS, viewed 11 August 2019, https://aifs.gov.au/cfca/publications/children-care.
• Patane, I and Forster, E 2017, ‘Family and community’, in J Fraser, D Waters, E Forster and N Brown (eds.),
  
  Paediatric nursing in Australia principles for practice,
  
  Cambridge university Press, Victoria Australia, pp. 38-54.
• Smith, L and Ford, K 2013, ‘Communication with children, young people and families – a family strengths-based approach’, in M Barnes and J Rowe (eds),
  
  Child, youth and family health: strengthening communities
  
  , Elsevier, Australia, pp. 91-110.
• United Nations 1989,
  
  Convention on the rights of the child
  
  , United Nations General Assembly, viewed 10 August 2019, https://www.ohchr.org/EN/ProfessionalInterest/Pages/CRC.aspx
• Mirlashari, J, Brown, H, Fomani, F K, de Salaberry, J, Zadeh, T K & Khoshkhou, F 2019, ‘The challenges of implementing family-centered care in NICU from the perspectives of physicians and nurses’ Australian Journal of Child and Family Health Nursing, doi: 10.1016/j.pedn.2019.06.013.
• Wells, G, Hauck, Y, Bennett, E, Shields, L, & Johnson, K 2014, ‘Nurses’ experience of using a strengths-based framework to facilitate change with families’
  
  Australian Journal of Child and Family Health Nursing
  
  , vol. 11, no. 1, pp. 17–24, viewed 11 August 2019, https://search-informit-com-au.ezproxy.usc.edu.au/fullText;dn=658083409312839;res=IELHEA

Introduction

It is becoming more widely recognized that in order to effectively prevent and treat any health condition a systems biology approach needs to be adopted (Carini et al., 2016). The focus of systems biology is to analyze the complex relationships between the components of biological systems in response to molecular to environmental influences. A systems biology approach embraces the complexity of human physiological and pathological processes and helps prevent any critical information from being left out of analyses (Carini et al., 2016).

A better understanding of the complex relationships within biological systems will provide higher quality data that can be translated more effectively into clinical practice. Personalized/precision medicine takes into account a patient’s genetic variability, lifestyle factors, and environment when determining a course of treatment (NIH, 2019).  Instead of a “one-size-fits-all” approach when it comes to treating a patient with a particular condition, these factors can be used to determine which treatment will be most effective for the individual patient, and which will likely not be effective or harmful. These variables will also allow for identification of those at risk for a disease who have not yet been diagnosed and in turn put more of a focus on prevention and early detection rather than a reactive approach (Landeck et al., 2016).

Biomarkers are a key component in the development of personalized/precision medicine. A biomarker was defined by the National Institutes of Health Biomarkers Definitions Working Group in 1998 as “a characteristic that can be objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacological responses to a therapeutic intervention” (Biomarkers Definitions Working Group, 2001). Identifying valid biomarkers will allow for more precise determination of what disease a patient is suffering from, their prognosis, and what treatment and dose they will respond best to (Landeck et al., 2016).

This topic is extremely important to explore because it holds potential for greatly improving the lives of those that are at risk of developing a disease and those that are already suffering from disease. As well, it will greatly increase knowledge about living systems. In this mini-review, the current state of knowledge on the role of biomarkers in personalized medicine will be evaluated and what resources are available to the public and privately will be explored. As well, the legal implications in precision medicine will be discussed.

Current State of Knowledge

In the last decades, advances in “omics” technologies have led to the discovery of many molecular biomarkers that can be used to identify a disease state or the ability to respond to a particular treatment. As well it has led to a greater understanding about the pathogenesis of many important diseases (Seyhan et al., 2019). Omics technologies are part of a systems biology approach and include high throughput techniques that make it possible to gather large amounts of data about specific molecules in a single experiment (Quezada et al., 2017). Examples of omics fields include: genomics, the study of the whole genome of an organism or a subset of it; transcriptomics, a field of study that looks at the full set of transcripts derived from a cell, tissue type or organism; and proteomics, the study of the universe of proteins in a cell or tissue type (Quezada et al., 2017). As mentioned, omics technologies are critical to first identify possible biomarkers by gathering large amounts of data on a particular molecule (e.g. DNA, mRNA, and proteins) in an individual with a particular disease. This plethora of data can then be further analyzed to determine if certain molecules/biomarkers are associated with a disease state, prognosis or response to therapeutic intervention. Upon discovery, these biomarkers are analytically and clinically validated in trials usually using techniques like PCR and ELISA (Quezada et al., 2017).

A myriad of biomarkers has been discovered over the years for many different diseases. Of high interest has been investigating genomic, epigenomic alterations and miRNA expression as biomarkers for diseases like cancer, diabetes, and inflammatory diseases. For example, a study by Rica et al. (2013), performed molecular profiling for DNA methylation and miRNA expression in Rheumatoid Arthritis (RA) synovial fibroblasts and compared the results with those of osteoarthritis patients who have a normal phenotype. The researchers found changes in key genes involved in RA pathogenesis, such as ILR6, CAPN8, DPP4, and several HOX genes. As well, the majority of genes modified by DNA methylation were inversely correlated with miRNA expression. The study concluded that genes that are regulated by DNA methylation and controlled by miRNAs, and miRNAs that are controlled by DNA methylation have the potential to be used as clinical biomarkers (Rico et al., 2013). However, it should be noted that although there is a surge in biomarker discovery, very few biomarkers are making it to clinical practice. Reasons for this include discovery of biomarkers from archived samples that do not properly represent the population in which the biomarker is intended to be used, poor study design and confounding control, and not following standardized protocols when it comes to sample collection, processing, and storage. Validated and properly calibrated techniques are crucial for correct and reproducible analyses (Quezada et al., 2017).

Furthermore, valid biomarkers have the potential to lead to an easier and shorter drug development process for the subset of patients who will benefit from the treatment. Traditionally, patients are randomly selected for studies under the assumption that they are fairly homogenous. Many inclusion and exclusion criteria are normally in place to help ensure homogeneity in the patient population, however despite these efforts the patients often end up being quite heterogeneous in regards to lifestyle factors, drug metabolizing abilities, previous exposure to medications and genetic make-up (Seyhan et al., 2019). Prospective use of patient stratification based on the presence of absence of particular biomarkers will for the separation of probable responders from non-responders and speeding up the drug approval process for patients that will benefit while further study can then be done for the greater population. Without patient stratification, a drug that is beneficial for a subset of patients could just be disregarded and lost in the noise caused by non-responders. As well, patient stratification based on biomarkers and understanding underlying molecular mechanisms responsible for disease and drug response will allow for safer and more efficacious matching of patients to a suitable therapy. Additionally, patient stratification will reduce drug development costs by preventing non-responders by being improperly treated (Seyhan et al., 2019).

Next, advancements in technology over the years have led to the development of digital biomarkers. Digital biomarkers can be defined as physiological or behavioural data that is objective and quantifiable and can be measured via digital devices such as wearable’s or embedded environmental sensors (Piau et al., 2019). Digital biomarkers make it possible for easier and continuous data collection that then can be analyzed and used to explain and/or predict health outcomes. A variety of smartphone apps have already been created to monitor users’ health. Besides giving consumers the ability to monitor their health characteristics on a daily basis, digital biomarkers may also be potentially useful for clinical trials and physicians by providing large amounts of data on an individual patient’s health status over time (Seyhan et al., 2019). Limitations of digital biomarkers include having to retrain health care workers and the risks of interfering with individual privacy and handling data securely, which will be discussed in this paper further later on.

Personalized Medicine and Biomarkers in Universal and Private Health Care

Due to the

Canada Health Act of 1984

health care in Canada is publicly funded by provincial and territorial governments and is universal (Begin, 1988). Almost all hospital and physician services are provided without user charges. For examples, there are limitations when it comes to psychiatric care and sex reassignment surgeries based on province (Lewis et al., 2001). However, about 30% of Canadian health care is privately funded. This includes services that are not covered, or only partially covered by the public sector, such as prescription drugs, dentistry and optometry (Hutchinson et al., 2011).

In Ontario, the use of precision medicine and biomarkers in the public health sector is related to medically necessary diagnostic and laboratory tests, and prescribed medicine for hospital patients. For example, standard of care biomarker testing in Canada for those diagnosed with advanced lung cancer is now used to determine whether patients have particular gene mutations and are eligible for targeted therapy (Melosky et al., 2018). This includes, testing for epidermal growth factor receptor (EGFR) gene mutations usually using polymerase chain reaction (PCR) with the patient’s biopsy sample. The EGFR gene encodes a receptor tyrosine kinase and these mutations are of the first targetable mutations to be discovered in lung cancer. They have a prevalence of about 20% in patients diagnosed with non-small cell lung cancer. Some, but not all EGFR gene mutations are sensitive to EGFR tyrosine kinase inhibitors (Melsky et al., 2018). Determining whether a patient has these mutations is considered standard of care because patients that have EGFR-sensitive mutations respond well to EGFR inhibitors like erlotinib, which is a Health-Canada approved treatment (Melosky et al., 2018).

The use of precision medicine and biomarkers in the private health sector is related to prescription drugs provided in a non-hospital setting. An example of a prescription medication that targets a particular biomarker is ivacaftor for treating children with cystic fibrosis. This drug was approved by the FDA in 2012 and is designed to target alterations to chloride channels caused by a rare G551D mutation. The G551D mutation in cystic fibrosis causes chloride channels to be locked close, which prevents the flow of chloride and fluid. Ivacaftor prolongs the open state of chloride channels and in doing so increases BMI, quality of life and decreases sweat chloride concentration (Rafeeq et al., 2017). G551D mutation is only present in 2.3% of patients with cystic fibrosis and highlights the importance of biomarkers as therapeutic targets because without biomarker understanding and testing, ivacaftor would likely get dismissed since it is not very effective for those with more common cystic fibrosis mutations (Rafeeq et al., 2017).

Ethical Implications of Precision Medicine and Biomarkers

Before a new approach in precision medicine can be implemented, it needs to be established that the benefits of the intervention outweigh the risks and that strategies are in place to ensure effective use in the clinical setting. One specific ethical challenge is determining when evidence surrounding a new treatment or intervention is sufficient to warrant introduction into clinical practice and trials (Korngiebel et al., 2016). The extent of the estimated benefit, the existence of alternative treatments, extent of estimated harm and the overall quality of the evidence are all important factors that are considered in this process. When judging the existing evidence needs to also consider whether they align with the views and preferences of all stakeholders and whether the intervention follows established trustworthy clinical guidelines (Korngiebel et al., 2016). In another aspect of precision medicine, ethical challenges of digital biomarkers need to be considered. Just as new drugs need to be critically evaluated for safety and effectiveness, digital health tools do as well. One of the biggest concerns with self-managed digital biomarkers is ensuring privacy and autonomy since when patients directly interact with the devices themselves it is not protected under the Health Insurance Portability and Accountability Act (Coravos et al., 2019). Clear informed consent and transparency surrounding data-sharing rights and privacy policies is essential. An approach to tracking privacy vulnerabilities and performance transparently is potentially having software manufacturers provide the FDA with a “Software Bill of Materials” before marketing the device. The challenge however is that many of these algorithms are patented or trade secrets, making the possibility of this level of transparency difficult (Coravos et al., 2019).

Concluding Remarks

In conclusion, biomarkers in personalized medicine have the potential to drastically improve the quality and cost effectiveness of health care for many patients by shifting treatment strategies from a “one size fits all” to being more considerate of heterogeneity in the population.

Developments in “omics” technologies has led to the discovery of many novel biomarkers, and although few biomarkers are used in both the private and public health sectors, more rigorous analytical and clinical trials are still needed in order to implement many more potential biomarkers into clinical practice. Additionally, the surge of digital biomarkers is beginning to automate the way patients are monitored and generate large amounts of data on a single patient continuously. However, through this process device validation and data security need to be of high priority.

Future Directions

In order to more efficiently identify and validate biomarkers so that they can be integrated into clinical practice research needs to be done more rigorously upfront and take a top-down approach. If research heads in this direction there should be an increase seen in the amount of biomarkers entering the Canadian Public Health System in the future. Validating and integrating biomarkers has been a slow process so it may not be likely that very many biomarkers will make it into the clinic over the next 5 years. It seems more practical that this may take 10-20 years.

References

• Bégin, M. (1988).
  
  Medicare: Canada’s Right to Health.
  
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• Biomarker Definitions Working Group (2001). Biomarkers and surrogate endpoints: preferred definitions and conceptual framework.
  
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  The Milbank Quarterly, 89
  
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• Korngiebel, D. M., Thummel, K. E., & Burke, W. (2017). Implementing precision medicine: the ethical challenges.
  
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• Landeck, L., Kneip, C., Reischl, J., Asadullah, K. (2016). Biomarkers and personalized medicine: current status and further perspectives with special focus on dermatology.
  
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  , 114.

For this assignment I have chosen to use the diabetes case study. I will abide by NMC code of conduct at all times and remain professional in my approach.

Empowerment is a multidimensional construct applicable to individuals, organizations, and neighbourhoods (Rappaport, 1987). It is viewed as a construct rather than a concept because it is not directly observable (Jacox, 1974).The case study indicates that Patrick lacks both self control and will power in his management of his diabetes. Individuals with long-term conditions are challenged by often persistent and disruptive health problems that have cognitive, social and emotional repercussions (Larsen & Lubkin, 2009). Established methods of treating people with long-term conditions are based on the assumption that prescriptive instruction by expert health professionals will guide the user’s behaviour, thereby effectively managing their condition. However, frequent non-adherence to health care advice (Zimmerer et al, 2009) and failure to achieve behaviour change through education programmes alone (Gibson et al, 2001) indicate that this approach is often unsuccessful. Self-management programmes typically incorporate development of action plans and training in the skills required to implement such action (Lorig & Holman, 2004). Collaboration between the professional and the person with the long-term condition is required to ensure that advice is not only provided but personalised in accordance with the individual’s needs and preferences (Bodenheimer et al, 2002). In April 2009 the Department of Health released a guide on Self Management.

It detailed the “Four Pillar” approach,firstly Information, a more informed patient can make better decisions about his or her treatment, secondly skills and training, providing the patient with the skills necessary to take care of their condition better, thirdly tools and devices aiming to equip the person with the means to control their condition, and finally the all important support networks, giving the person a sense of involvement in their care and the ability to communicate any fears around their disease.

Whilst on my community placement I was introduced to an initiative that is used within a local PCT in Birmingham. It is called the Diabetes Manual (Burden & Burden, Heart of Birmingham PCT). It is a booklet/log book which is given to every newly diagnosed diabetic. It aims to educate and inform patients on their diabetes and how best to control it. It details some/most of the complications/side effects that come with having a long time condition such as diabetes. Its main aim is to educate patients through simplified terms and pictures. The integrated log book is used by patients to write down how they manage their diabetes on a day to day basis. One key area of this booklet is the action planning page. The book also incorporates target/goal setting for Patrick. On initial interview with Patrick we would aim to introduce him to the booklet and discuss with him, firstly the benefit of using this book, allowing him to self manage his condition and to better understand the implications of a long term condition such as Diabetes. It is important to ensure that Patrick is literate as this plan will not succeed if this is not so. Goal-setting for the first few weeks would be to aim to maintain blood sugars at a mutually agreed safe level.

It would be unreasonable to expect too much of Patrick within the first few weeks and although it is important for his health that goals are reached we would aim to gradually introduce more aims as Patrick got used to effectively self managing his condition. This integrated logbook and information guide addresses at least two of the four pillars of Self Management (DoH 2009). Information contained in the book will allow Patrick to read and digest at his own leisure, bombarding a patient with information during an interview can often cause them to disregard and switch off from the information giver.

It also acts as a tool or device by which Patrick can write down his day to day life in the knowledge that it may be the key to controlling his blood sugar levels if he keeps an accurate food diary. This initiative relies heavily of the theory of Self Efficacy as detailed by Bandura (1977). He stated that people can be characterised primarily on the basis of their beliefs in their ability to control their lives, because those beliefs powerfully determine the effort they make to adapt to their surroundings. Self-efficacy theory predicts that the more an individual feels capable of predicting and controlling threatening events, the less vulnerable he or she will be to anxiety or stress disorders in response to traumatic experiences . Therefore if Patrick believes he holds the key to controlling his diabetes, he will endeavour to put plans into action to reduce his blood sugar levels, come to terms with his condition and prevent further complications associated with his Diabetes.

The self-management approach views the individual as an active agent in treatment. The purpose of self-management is to nurture skills such as behavioural management techniques and to support informed decision making and problem solving, thereby equipping the individual with the necessary expertise to manage their condition.

This person-centred approach focuses on personalisation of treatment and facilitation of independence, allowing Patrick to continue day to day routine as normal without any forbearance on his life. It has been described as a patient-centred approach based on respect and compassion and has an emphasis on collaboration with patients (including collaborative goal-setting), self-management skills and psychosocial issues. Nurses would play a pivotal role in providing advice, guidance, education and support to Patrick . Self-management is important as it not only benefits the patient, but also provides wider opportunities for community and specialist nurses to use and develop their clinical and interpersonal skills.

It was highlighted in the case study that Patrick has started to develop Retinopathy. Diabetic Retinopathy is a vascular condition in which the retinal capillaries tend to degenerate after a number of years. The condition is characterised by ocular haemorrhages, lipid exudate and the growth of new blood vessels and connective tissue. This has resulted in poor eyesight which could prove problematic if not dealt with soon to prevent blindness. Patrick currently works as a bus driver so his eyesight is very important to him to be able to continue to work and provide financially for his family. Diabetes-related complications can have a major affect on the individual and family members, and are costly to the patient. There are a number of eye conditions specifically associated with diabetes. These include temporary disturbances in lens shape, related to hyperglycaemia and often seen at diagnosis, and cataracts, including the rare ‘sugar cataract’ only seen in people with diabetes. However, DR is likely to affect most people with diabetes as the duration of their condition increases (Williams and Pickup 1999). DR is one of the long-term micro vascular complications of diabetes mellitus and is the leading cause of blindness in the working population of the UK (BDA 1995).

Ninety per cent of people with type 1 diabetes have some degree of DR within 20 years of diagnosis and it has been suggested that it is present at diagnosis in 40 per cent of those with type 2 diabetes (Cummings 2002). A survey has found that blindness was the most well known complication of diabetes (Diabetes UK 2000). However the future for Patrick does not have to as bleak as it sounds. The National Service Framework for Diabetes (DoH 2001) recommends early and regular screening for all diabetics.

Developing a plan of action/care for Patrick should begin with a thorough nursing assessment which is essential to ensure that a correct diagnosis regarding diabetic Retinopathy is made. Patrick may complain initially of the signs of vitreous haemorrhage such as ‘floaters’, which look like small, black insects, or a lacy curtain across the field of vision. Macular involvement may be revealed by the patient’s description of a general deterioration in fine and colour vision that is not improved by wearing a range of spectacles. The main aim of screening for diabetic Retinopathy is to identify patients with sight-threatening Retinopathy who may require preventive treatment. Screening and treatment for diabetic Retinopathy will not eliminate all cases of sight loss, but can be important in minimising the number of patients with sight loss as a result of this condition. The aim of a retinal screening programme is to ensure that a yearly examination of all patients in a given area is performed (Walker and Rodgers 2002). This assessment should be done prior to a direct and rapid referral to an Ophthalmologist to screen and evaluate the degree of Retinopathy. As a preventive strategy, health education should include the best available research evidence to assist patients to make decisions about lifestyle changes and gain control over their condition (Watkinson and Chetram 2005).

Micro vascular complications may be prevented or onset delayed with good medical treatment (Kanski 2007). The nurse should involve Patrick and with permission the family to identify areas such as diet and alcohol consumption that can be modified to provide better and tighter glycaemic control. Levels of blood glucose are set at preferably below HbA1c 6.5-7.5% according to the individual’s target (NICE 2005). Patrick’s is 9.9% which puts him in the danger zone for developing complications and increasing his risk of irreversible damage. The target is based on the risk of macro vascular and micro vascular complications. Individuals with type 2 diabetes need to have an ongoing structured evaluation every two to six months, to assess the risk factor. A reduction in the prevalence of diabetic Retinopathy is associated with tighter blood glucose control (Younis et al 2002).

By involving the whole family in this change in lifestyle will prove to Patrick he is not on his own and offer him support. Using the initiative I discussed early in this assignment the log book/information guide offers helpful advice for diet and lifestyle change. Setting Patrick some SMART goals/challenges will allow him to maintain his control of his own body and increase compliance. The target is to reduce his HbA1c to within the acceptable target range discussed above. A significant lifestyle change is needed but must be done with concordance with Patrick and his family. It is noted that Patrick is overweight with a BMI of 29.5. This can increase his risk of hypertension, which itself is a factor in Retinopathy as it increases the pressure within the eye. Effective blood pressure management is as significant as blood glucose control in reducing the risk of progression of diabetic Retinopathy in those with type 2 diabetes (UK Prospective Diabetes Study Group 2004). Good blood pressure control is considered to be at or below 140/80mmHg (NICE 2005).

Adherence to prescribed anti hypertensive treatment is vital as diabetic patients with hypertension have a poor visual prognosis (NICE 2005). A consultation with Patrick’s GP should be arranged to ascertain if there is any hypertension and if found it has been shown that ACE inhibitors prove very effective in the reduction of high blood pressure in Diabetics.(NICE 2005).There are new schemes devised by the Department of Health to reduce the use of medication in weight loss and to increase exercise in the population. Free weigh loss classes are offered to patients who meet the criteria. Patrick would benefit from these schemes. Medication management and strict concordance with the regime is incredibly important to ensure Patrick maintains a level of the drugs in his body. If it is adhered to it may be that he will not have to take insulin.

By providing ongoing psychological support to Patrick and to his family the nurse can help the patient to maintain his or her self-esteem and improve self-management of the condition. Visual impairment in patients with diabetes is often compounded by the loss of self-management skills, which may have psychosocial implications (Hall and Waterman 1997). Reactions to visual loss can also lead to psychological distress such as depression, suicidal thoughts and anxiety (Hall and Waterman 1997). It is therefore the nurse’s duty to discuss these issues with the patient and relatives and provide appropriate support (Nursing and Midwifery Council (NMC) 2004). Organisations such as Diabetes UK and the Royal National Institute of Blind People (RNIB) can also provide ongoing help and support. Regular screening and repeat follow ups should ensure Patrick’s Retinopathy does not continue to worsen.

Nearly two decades ago Fielding and Llewellyn (1987) pointed out that effective nurse-patient communication was central to the quality of care that patients received, stating rather poignantly that: ‘Communication is both one of the most demanding and difficult aspects of a nurse’s job, and one which is frequently avoided or done badly although central to the quality of patient care.’Encouraging people to change their attitude towards a health issue is an important part of any health education programme, but people’s values can be particularly resistant to change. Even when clients are persuaded to change their attitude (for example towards diet, smoking, safer sex) it is often frustrating for nurses to realise that this may not lead to a change in their behaviour. An understanding of the complex relationship between a person’s knowledge, attitude and behaviour can assist health professionals in realising why clients may continue to behave in a certain way, despite health advice to the contrary. Persuasive communication theory offers specific techniques that can be used successfully within health promotion. It is important for the nurse to listen to Patrick’s concerns and endeavour to offer counsel or help.

I have attempted to prove in this assignment that communication with Patrick and his family is of the utmost importance to ensure concordance and thus improve his control of his condition. By educating both parties it shows Patrick that he is not alone and he can gain support from his family and other networks accessible to him such as local support groups.

It has been mentioned in the case study that Patrick drives a bus and as a result of his poor control of his Diabetes, he has been falling asleep at the wheel. This provides the nurse with a significant ethical dilemma. Bound by the NMC professional code of conduct means nurses are restricted to what information they can release.

A disconcerting feature of ethics can be its association with apparently complex theories such as utilitarianism (the moral value of an action is determined by its overall benefit) and de-ontologyy (concerned with adhering to moral rules or moral duty rather than with the consequences of actions) (Beauchamp and Childress 2001). These established theories are important components of ethics and can help to guide decisions. The general principles of Ethics are that of Avoiding Harm and moral obligations and duties. As a nurse we have a moral obligation to notify the DVLA as it is in the public best interest to prevent harm coming to others if Patrick falls asleep at the wheel, thus avoiding harm to others.

In this assignment I have endeavoured to show that the key to controlling Patrick’s Diabetes is through effective communication, self-efficacy/self management and family involvement. By encouraging Patrick to look at his life and analyse his lifestyle he is on the road to effective self management. Change is only possible if Patrick’s attitude towards his condition alters. By offering him the option of utilising the logbook he can challenge his attitudes with the main aims/challenges of keeping further complications at bay, maintaining tighter glycaemic control and thus lowering his HbA1c.