Effective leadership is essential in health care organisations as in other organisations. It is necessary for driving innovation, effective patient care, patient safety, improving working within clinical teams, sorting out issues within emergency context and other aspects necessary for effective and efficient running of healthcare organisations. Transformational leadership has often been prescribed as the ‘gold standard’ of healthcare leadership(Gopee and Galloway 2009).This essay sets out to:

briefly discuss the concept of leadership;

highlight why leadership is important in healthcare;

make a distinction between the closely-related concepts of leadership and management;

briefly highlight how power relates to leadership;

describe some leadership approaches applicable within the context of healthcare organisations;

describe leadership styles visible in healthcare;

present a case study set in a teaching hospital practice setting in Africa ;

critically assess the leadership approaches operating within the setting and its effect on organisational performance ;and

make recommendations on improving leadership practice within the specified setting.

What is leadership?

Leadership can be defined as “the ability of an individual to influence a group of people to achieve a goal(Bryman 1992).It is also noted that ‘leadership can have four possible meanings, namely: the activity of leading; the body of people who lead a group; the status of the leader; and the ability to lead'(Gopee and Galloway 2009).

Kouzes and Posner (2007) suggest some characteristics of an effective leader namely to:

be more effective in meeting job-related demands;

be more successful in representing their units in upper management;

create higher performing teams;

foster renewed loyalty and commitment;

increase motivational levels and willingness to work hard; and

possess high degree of personal integrity.

Why leadership in healthcare?

Effective leadership and management has been found to contribute to efficiency of health care services, performance (McColl-Kennedy and Anderson 2002) and satisfaction of staff employed within them.(Bradley and Alimo-Metcalfe 2008) researched the causal relationship between leadership behaviours and the performance and productivity of staff and found that ‘engaging leadership’ improved employee engagement and performance.

(Morrison, Jones et al. 1997) studied the relationship between leadership style, empowerment, and job satisfaction on nursing staff at a regional medical centre. They used Bass’s Multifactor Leadership Questionnaire to measure leadership style, items from Spreitzer’s Psychological Empowerment instrument to measure empowerment, and the Warr, Cook, and Wall’s job satisfaction questionnaire to measure job satisfaction. The authors found that both transformational and transactional leadership were positively associated with job satisfaction.

Some other researchers reported that good leadership skills impacted on patient safety and quality of care (Corrigan, Lickey et al. 2000; Firth-Cozens and Mowbray 2001; Mohr, Abelson et al. 2002).Furthermore, leadership skills are essential in the world of public health policy and leadership is one of the core competencies required of public health trainees(Faculty of Public Health 2010).

Leadership versus management

Relevant to this discourse is making a distinction between leadership and management. They are two similar but distinct concepts. Management is seen as seeking order and maintaining stability while leadership is seen as seeking adaptive and constructive change. Leadership in the healthcare context aims to influence practitioners towards the achievement of the common goal of quality patient care. On the other hand, management as a process coordinates and directs the activities of an organisation to ensure it achieves its set objectives. Management ensures healthcare resources (human such as doctors, nurses and clerical staff and non-human resources like medical devices and consumables) are utilised in an efficient way whilst delivering effective healthcare service(Gopee and Galloway 2009). However, leadership is known to be complementary to management (Kotter 1999; Zaleznik 2004).

Leadership theories and styles in healthcare

A number of theoretical leadership approaches can be applied within healthcare .However, not all aspects fit in perfectly into healthcare, and thus some adaptation may be required.

Transformational leadership

Transformational leadership is a widely advocated approach for healthcare. Transformational leadership is one of the contemporary leadership approaches that are concerned with how an individual influences others in a group in other to achieve a common goal .Transformational leaders seek to accomplish greater pursuits within an organisation by inspiring other members of the group to share their vision for the organisation. Transformational leaders motivate and raise the morality of their followers and help them reach their fullest potential. Mohandas Gandhi Nelson Mandela have been cited as transformational leaders(Northouse 2007).

In an organisational context, a transformational leader is one who attempts to change the organisations values in order to portray a standard of fairness and justice while in the process emerging with a better set of moral values. Transformational leadership is about the collective good of an organisation; it is expected to bring about organisational change .It aims to inspire commitment to the organisation’s vision and ideals .In healthcare, teams of health care professionals are inspired to achieve the highest quality of patient care irrespective of limiting situations (Gopee and Galloway 2009).

The concept of transformational approach of leadership was popularised by the political sociologist, leadership expert, and presidential biographer- James Macgregor Burns in his seminal work Leadership written in 1978. In this book, he described the leadership styles of some political leaders. Bernard Bass widely cited in leadership literature built on the work of Burns and argued that leadership is an influence process which motivates followers to perform above their expected output by ‘raising the follower’s level of consciousness about the importance and values of the shared goals, operating beyond their self-interests and addressing higher level needs'(Bass 1985). He also suggested that transformational and transactional leadership models where a continuum rather than mutually exclusive entities.

Four qualities or behavioural have been widely cited as the leadership factors which are an integral part of transformational leadership- the 4 I’S(Bass 1985; Avolio, Waldman et al. 1991) namely:

idealised influence-describes the ability of the leader to act as role model s whose followers emulate. This factor is sometimes mentioned as being the same as charisma;

inspirational motivation-the ability to inspire the members of the group to become integrated with the vision of the organisation while transcending their own self-interest ;

intellectual stimulation-the stimulation of creativity and innovation in the followers so that they are able to discover and develop new ways of sorting out issues within the organisation as they arise; and

individualised consideration-portrays the need for leaders to recognise the strength and weakness of each member of the group foster on the development of followers and help each in the achievement of goals through personal development.

Transactional leadership, on the other hand, is one based on reward for performance. A transactional leader is described by (Bass 1985)as one who prefers a leader-member exchange relationship, in which the leader meets the needs of the followers in exchange for meeting basic expectations. In essence, a transactional leader has a penchant for avoiding risks and is able to build confidence in subordinates to allow them to achieve goals. The transactional leadership construct has three components:

Contingent reward -clarifies what is expected from followers and what they will receive if they meet expectations.

Active management by exception- focuses on monitoring tasks and arising problems and correcting these to maintain current performance.

Passive -Avoidant Leadership-reacts only after problems become serious and often avoids decision-making(Avolio, Bass et al. 1999).

Connective leadership is a theory based on the premise that establishing alliance with other organisations via networking is essential to the success of an organisation. Collaboration between different clinical teams within a hospital and with other health care organisations and service industry exemplifies this.(Klakovich 1994) suggests that ’empowering staff at all levels facilitates the collaboration and synergism needed in the reformed health care environment of the future’.

Distributed leadership

Clinical leadership

Leading change in the University College Hospital Ibadan: a failed effort in transformation?

Healthcare in Nigeria is faced with enormous challenges. The University College Hospital Ibadan was established in 1948 is the foremost tertiary hospital in Nigeria. It is basically organised as a public sector organisation whose primary goal is to provide the best available healthcare service in the western region and the country as a whole. Funding is from the Federal Government and its activities are regulated by the Federal Ministry of Health which is also responsible for the implementing healthcare policies. However, a private section of the hospital was established recently modelling the prevalence of internal markets currently prevailing within healthcare. Currently, the University College Hospital produces 1 in every 5 physician in the nation. It was initially commissioned with 500 bed spaces but has now grown to a 850 bed hospital. The current average bed occupancy ranges from 60-70%. The hospital board of management comprises:

the Chairman

the Chief Medical Director;

the Chairman, Medical Advisory Committee;

the Secretary of the Board;

representatives of public interest;

representative of the Nigerian Medical Association;

representative of the State Government;

representative of the University of Ibadan Senate;

representative of the Vice Chancellor of the University of Ibadan; and

the Provost of the College of Medicine.

The organisation has three principal officers but the day -to -day running of the hospital falls on the Chief Medical Director who demonstrates some attributes of transformational leadership in order to bring about change .

Vision

‘To be the flagship tertiary health care institution in the West Africa sub-region, offering world-class training, research and services, and the first choice for seeking specialist health care in a conducive atmosphere, renowned for a culture of continuing and compassionate care'(University College Hospital Ibadan 2009).

Mission Statement

‘Rendering excellent, prompt, affordable, and accessible health care in an environment that promotes hope and dignity, irrespective of status, and developing high quality health personnel in an atmosphere that stimulates excellent and relevant research’. (University College Hospital Ibadan 2009).

The Chief Medical Director is an assigned leader-one whose leadership is based on formal position and legitimate authority .His appointment by the Federal Government in 2003 was proposed to be vital contribute to the improvement of the hospital. A trained obstetrician, he participates actively in the care of pregnant women.

With increasing satisfaction of healthcare staff, patient satisfaction rates began increase. A new magnetic resonance imaging ,centre, cancer treatment and research centre….new innovations…the bank to collect..Satellite pharmacies were established in order to reduce the time and effort spent by staff in getting patient medications. …staff development through exchange programmes, establishment of day care centres….shows his entrepreneurial qualities.

Despite it all, mortality rates remain high, medical errors are frequent, post operative patients developed infections frequently and physicians were verbally and physically abused by patient relatives. Private patients get more attention from the junior doctors and other specialist consultants. It has now been found wanting in serving the needs of the local population. Repeated nurses strike ,junior workers strike …..

SWOT analysis of the University College Hospital Ibadan

Strengths

Weaknesses

Fairly well-equipped operating theatres

Large newly renovated and well-built hospital blocks

Excellent medical microbiology services, including HIV testing

Residential accommodation for house officers and other specialist trainees

Strong alliance with international organisations for infectious diseases research

Expensive laboratory services

Relative shortage of medical staff

Politicisation of board of management appointments

Weak administrative set-up

Expensive pharmacy services

Inadequate funding

Delay in staff remuneration

Few opportunities for exchange programmes for students and residents

Inadequate supply of electricity

Opportunities

Threats

Federal Government’s commitment to the development of tertiary care

More research funding

Competition from existing private and missionary hospitals

Incessant industrial actions embarked upon by nursing staff, physicians and support staff

Critical analysis of the leadership approach in

Despite recognition that transformational leadership has some positive benefits, it is particularly difficult to act out within public services organizations Frederickson 1996 cited in (Currie 2005).Though with its own merits, the view that transformational leadership is the solution for healthcare leadership has been criticised. While there are advantages of using the transformational approach, it is not a universal panacea.

Transformational leadership alone cannot account for effective outcomes in this health care organisation. Other aspects like of organisational behaviour such as management practices, knowledge management, and organisational culture are also key determinants. A US study of 370 hospitals explored the relationship between leadership, quality and knowledge management and found that transformational leadership is fully mediated by knowledge responsiveness in its effect on organisational performance (Gowen, Henagan et al. 2009). Effective knowledge management is thus strong confounder in the relationship between leadership and organisational performance. In relation to organisational culture, there is also a link between hospital and ward culture with patient outcomes. Research has shown that hospitals with a strong hand-washing policy and practice recorded fewer infections.

Transformational leadership, while focusing on change, may not be in consonance with performance management needed for accountability in healthcare(Firth-Cozens and Mowbray 2001).

The context in which a leadership style operates is also a key determinant on outcome irrespective of leadership style. Studies have shown the relationship physician working hours, stress, and burnout on quality of care and patient outcomes (Firth-Cozens and Cording 2004; Landrigan, Rothschild et al. 2004).Tackling job stress is thus a key avenue for improving quality of care. The Chief Medical Director needs to understand the complexity within which healthcare is delivered and translate it to his practice setting rather than trying to adopt a prescribed process.

Conclusion

This essay has highlighted a number of leadership theories, skills, style leadership in healthcare has been assessed. There is no perfect style or approach to leadership and healthcare organisations pose a complex setting. Several approaches may operate simultaneously. Context, political environment and social factors will affect leadership styles and approach. Clarifying the situation of a practise and flexibility is very important.

Numerous challenges face healthcare organisations in Nigeria. The ability to deliver safe, effective, high quality care within organisations with the right cultures, the best systems, and the most highly skilled and motivated work forces will be the key to meeting this challenge. Conflicts still exist as to what constitutes good practice in leadership and there is no perfect set of prescriptions for effective leadership. All the existing theories merely provide a framework for which practise can be based. Healthcare organisations are a complex setting and to achieve efficiency and effectiveness, healthcare leaders need to be very flexible in their leadership .The University College Hospital should adopt an blend of different theories and styles in practice.

Recommendations

Leadership can be taught (Parks 2005)and improved through organising leadership development programme. It is also noted that leadership development programmes improved efficiency and quality in healthcare(McAlearney 2008). Top management and clinical staff can take these.(Kotter 1990) suggests that organisations can nurture and ‘grow’ their own leaders while adapting to constant changes(Parks 2005)

There appears a need for leadership approaches that are sensitive to a context in which there are significant professional and moral concerns graeme.

Antimicrobial resistance occurs when a microorganism such as bacteria, viruses or parasites acquire the ability to disable the effects of a drug designed to kill them or stop their growth (CDC, 2018). As a consequence the treatments to get rid of infections failed and the risk to spread to others increased (WHO, 2018).

Antibiotic Resistance is a global issue due to the fast and easy way of spreading. According to the CDC in 2013, around 2 million people were getting ill with bacteria that have the characteristic of being resistant to antibiotics. A minimum of 23,000 people dies every year because of this threat. In most of the cases, people cannot be treated correctly so the infections caused by these bacteria get worse (CDC, 2013).

The excessive use of antibiotics is one of the main causes of the evolution of antibiotic resistance. The antibiotics is one of the most used drugs in the world and in many cases are not prescribed in the right way when treating diseases in humans. They are also used to prevent and treat diseases in animals and in some countries to promote growth (CDC, 2013).

All people are exposed to this type of threat, however the population that is most at risk are those with chronic diseases (CDC, 2018). This includes people under cancer treatments, diabetes, asthma, rheumatoid arthritis, organ transplants and so on. These sorts of people depend on the effectiveness of antibiotics to treat possible complications caused by infections during their treatments (CDC, 2013). The cost of medical care provided to patients with antibiotic resistant infections is higher than in patients with common illnesses, this is because they can be prolonged and in many cases more expensive drugs are used (WHO, 2018). The total cost to treat infections related to antibiotic resistance in the United States is difficult to calculate and may vary, however by 2013 it was estimated that the cost could reach up to 20 billion dollars per year (CDC, 2013).

Genetic Basis of the Acquisition of Antibiotic Resistance

The bacteria use two main strategies to adapt to the attack of the antibiotics: Mutations in the gene and by the obtaining of DNA coding for resistance through the horizontal gene transfer (HGT). In the case of gene mutations, a group of bacteria susceptible to a certain antibiotic develops one or more resistance genes that make the effectiveness of the drug reduced or disappear. Once the resistance gene is expressed within the host, the antibiotic eliminates the susceptible community and resistant ones predominate. This type of mutations that result in antimicrobial resistance modifies the mode of action of the antibiotic using the following mechanisms: Reduction in the ability of absorption of the drug, activation of efflux mechanisms or overall changes in the metabolic pathways through the regulatory networks of the cell (Munita and Arias, 2016).

The acquisition of the antibiotic resistance gene through horizontal gene transfer is one of the most important vehicles in the development and evolution of bacteria. In general, this method is the main responsible for the antimicrobial resistance. When the transfer of resistance genes occurs, in most cases it is due to the bacteria being in an environment where intrinsic resistance genetic factors are lodged (Munita and Arias, 2016).

Three main ways in which bacteria acquire genetic material from the environment are known:

1. Transformation, which consists of acquiring DNA from the environment in which it is located, it is also known as incorporation of naked DNA. In general, a donor microorganism releases DNA into the environment and is catch by host bacteria. This is the simplest method in how a bacterium can acquire resistance genes (Munita and Arias, 2016).
2. Conjugation or “bacterial sex”. Cell-to-cell contact is essential for the transfer process and it is presumed that it can occur at high rates within the digestive tract of humans who are in treatments that involve the ingestion of antibiotics. This method uses mobile genetic elements (MGE) as a vehicle for the distribution of genetic material, although it is also characterized by using direct transfer from chromosome to chromosome. Among the most important MGE are the plasmids and transposons, which play a key role in the distribution of microbial resistance in microorganisms of importance for human health (Munita and Arias, 2016).
3. Transduction, this mechanism involves genetic transfer through a virus particle (phage) to a host bacterium. The DNA is located in the phage and is responsible for the dissemination of the gene (Parkinson, 2016).

Mechanism for Antimicrobial Resistance

1. 
   Impermeability:
   
   Decrease in number of porin channels lead to decrease in the entry of antibiotics into the cell. The molecules of an antibiotic can enter the cell through porins that are found in the outer membrane of gram-negative bacteria. As the number of porins channels decrease the outer membrane becomes less permeable, preventing the passage of antibiotics such as β-lactams (Kapoor, 2017).
2. 
   Pumping out (efflux pumps):
   
   The efflux pumps are proteins of the membrane that are located in the cytoplasm and are responsible for exporting the antibiotics of the cell. When an antimicrobial agent tries to enter, it is expelled by the efflux mechanisms before they can reach their target. All classes of antibiotics are susceptible to this type of mechanism with the exception of polymyxin (Kapoor, 2017).
3. 
   Modification:
   
   Target site changes due to unexpected mutations of a bacterial gene located on the chromosome. These mutations prevent the binding of the antibiotic and the target site from taking place (Kapoor, 2017).
4. 
   Antibiotic inactivation:
   
   There are three main enzymes that are responsible for the inactivation of antibiotics: β-lactamases, aminoglycoside-modifying enzymes, and chloramphenicol acetyltransferases. These enzymes are responsible for completely inactivating the function of the antibiotic inside the cell (Kapoor, 2017).

How Antibiotic Resistance Spreads

In countries where people have high incomes, the use of antibiotics has increased in hospitals, the agricultural area and the community in general. Many antibiotics are used indiscriminately and this has resulted in a decrease in their effectiveness (Laxminarayan, 2013).

The increase in the use of antibiotics in the community has made the weaker bacteria disappear and only the strongest prevail. It is known that as the antimicrobial resistance increases, the consumption of antibiotics also increases. While bacteria have become champions of evolution, efforts in the development of new antibiotics have stalled, because the pharmaceutical industry has focused on the development of more lucrative drugs, used to treat diseases such as cancer or diabetes (Weckx, 2012)

The antibiotics are medicines that are used to eliminate bacteria that are causing some type of infection, however if this drug is given to people or animals that do not need it, the bacteria can develop resistance. One of the ways in which the microorganism can be prevented from developing resistance to antibiotics is through proper prescription. All people and animals have bacteria in the intestinal tract. When either of the two is treated with antibiotics, many of the bacteria will die, but those that are resistant will survive and multiply. Therefore, antibiotics should be used responsibly in humans and animals (CDC, 2018).

One of the critical points at the time of the dissemination of bacteria from animals is during slaughter and processing. At this point bacteria can contaminate meat and other products intended for human consumption. Another way in which bacteria can spread is through animal feces. These can contaminate the water and soil used to cultivated fruits and vegetables. People can acquire resistance infections through the manipulation or consumption of raw meat or products that have not been subjected to an adequate thermal process. It can also be contaminated by direct contact with animal feces or by drinking or swimming in pollutes water (CDC, 2018).

Some of the preventive actions taken by the CDC to prevent the transmission of antibiotic-resistant bacteria are: to track, study and analyze how the infection emerged and spread, identify and investigate as quickly as possible the outbreaks related to antimicrobial resistance, determine the source of contamination, educate people about preventive methods that include good hygiene practices when handling and consuming food, and promote the responsible use of antibiotics in humans and animals (CDC, 2018).

Regarding the preventive actions mention before, the CDC has established four main cores of actions to prevent antibiotic resistance, which includes: preventing infections and the spread of resistance, tracking, improving antibiotic prescribing and development of new drugs and tests. The main purpose of these cores is to control and prevent the spreading of resistance among the population (CDC, 2013).

The last report issued by the CDC on antibiotic resistance threat in 2013, reported the 18 principals threats (bacteria and fungi) of concern in human health. In each one, the minimum number of morbidity and mortality was evaluated, people who are at high risk for contracting resistant infections and actions that were being carried out to combat this threat. Among the microorganisms of greater relevance and that represented greater risks to health are:

Clostridium difficile

(

C. difficile

), Carbapenem-resistant Enterobacteriaceae (CRE), Drug-resistant

Neisseria gonorrhoeae

(cephalosporin resistance). The CDC is working in issuing a new report of antiotic threats by fall 2019 (CDC, 2018).

The National Antimicrobial Resistance Monitoring System (NARMS)

NARMS is a public health monitoring system in the United States established in association with the Food and Drug Administration (FDA), Center for Disease Control and Prevention (CDC) and the U.S. Department to track antibiotic resistance in foodborne and enteric bacteria from humans, retail meats and food animals.

• 
  
  https://www.cdc.gov/drugresistance/about.html
  
  
• 
  
  https://www.who.int/antimicrobial-resistance/en/
  
  
• 
  
  https://www.who.int/en/news-room/fact-sheets/detail/antimicrobial-resistance
  
  
• 
  
  https://www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf
  
  
• 
  
  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4888801/
  
  
• 
  https://jb.asm.org/content/198/21/2899
  
• 
  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5672523/
  
• 
  https://www.sciencedirect.com/science/article/pii/S1473309904011454
  
• 
  https://www.cdc.gov/features/antibiotic-resistance-food/index.html
  
• 
  https://www.cdc.gov/drugresistance/biggest_threats.html
  
• 
  https://www.fda.gov/animal-veterinary/national-antimicrobial-resistance-monitoring-system/about-narms
  

Introduction

All nurses have a duty of care to their patients (Brooker and Waugh, 2013). Nurses are expected to play a safeguarding role, recognising vulnerable patients and protecting them from harm, abuse and neglect. Elderly patients are at especial risk due to their poor health, disabilities and increased frailty (de Chesnay and Anderson, 2008). Of concern here, is the higher than average incidence of abuse in elderly people with dementia (Cooper et al., 2008). Nurses play an important role in recognising signs of abuse and acting as advocates for their dementia patients. Here, the principles of safeguarding and how they are applied in dementia nursing are presented.

Dementia: Cause of Vulnerability

Dementia is a group of symptoms that are associated with declining functionality and physical health of the brain (NHS Choices, 2015). This decline in mental function makes a person increasingly vulnerable (de Chesnay and Anderson, 2008). Dementia is typically seen in elderly people with one in every three people over 65 having dementia, and two-thirds of these will be women (Alzheimer’s Society, 2014). The signs and symptoms of dementia demonstrate how this condition makes someone vulnerable to harm, abuse or neglect (Hudson, 2003) as they include: memory loss, reduced thinking speed, reduced mental agility, language difficulties, lower levels of understanding and reduced judgement. Furthermore, as dementia develops people become more apathetic and isolated as they lose interest in socialising, putting them at increased risk.

Dementia can alter a person’s personality (Hudson, 2003). They may find it difficult to control their emotions and hard to empathise. They may appear more self-centred, suffer from hallucinations and even make false claims or statements. All of these factors make it difficult for relatives and carers to interact with the dementia patient especially when offering very personal care (Adams and Manthorpe, 2003). Dementia reduces a person’s ability to live independently and, as the condition progresses, they will increasingly need support and assistance. Their lack of mental capacity makes dementia patients vulnerable to the actions of others (Hudson, 2003). They will require assistance with decisions and gradually lose their autonomy as the dementia progresses, eventually relying on others for even the most simplistic decisions. Depending upon the stage and severity of their dementia, they may be living at home with support from relatives, or they may be in residential care.

Safeguarding: Duties and Expectations

Safeguarding adult patients means to protect those at risk of harm from suffering any abuse or neglect (Tidy, 2013). The CQC (2015) defines safeguarding people as “protecting people’s health, wellbeing and human rights, and enabling them to live free from harm, abuse and neglect”. Safeguarding is seen as an essential component of high quality health and social care. The healthcare provider is expected to minimise the risk of any abuse or neglect befalling a patient, identifying any potential causes and taking steps to mitigate them. A patient’s right to live safely and free from abuse or neglect must be protected, and their wellbeing promoted with ample consideration for their own views and beliefs.

The overall responsibility for safeguarding vulnerable adults lies with Adult Social Care (Dementia Partnerships, 2015). They receive and process and safeguarding issues from their partner agencies. However, each partner agency is expected to have its own procedures and practices to recognise and respond to any safeguarding alerts. This means that all staff employed by a health or social care provider has a duty to identify and report any safeguarding issues. Nurses caring for patients with dementia therefore have a duty to identify and report any signs of abuse or neglect (Hudson, 2003). Furthermore, they must have the knowledge and skills necessary to provide quality care to these patients with reduced mental capacity.

Abuse of a vulnerable adult can occur anywhere: at their home, in a hospital or a residential care setting (Tidy, 2013). Abuse can include physical actions, sexual abuse, mental or emotional abuse, neglect and also financial abuse. Often, the abuser is well known to the victim (de Chesnay and Anderson, 2008). They could be a neighbour, relative or friend, carer, nurse or social worker, a fellow resident or service user. The adults most at risk of abuse are the frail elderly people who either live alone, or live in residential care, but without any family support (Mandelstam, 2008). In terms of suffering physical harm, the most at risk are those adults with mental or physical disabilities.

Dementia Specific Issues

Dementia patients are vulnerable adults, their degree of vulnerability dependant on the stage and severity of their condition (Tidy, 2013). The Department of Health describes vulnerable adults as those who are unable to take care of themselves, or who are unable to protect themselves from harm (DH, 2000). People with care and support needs require help and assistance from both the nursing and social care disciplines. Part of the nurse’s duty is to safeguard their vulnerable patient from abuse and neglect (SCIE, 2015). The Care Act (HM Government, 2014) requires local authorities to perform safeguarding duties. This stipulates a multiagency approach where any safeguarding concerns are recognised, acknowledged and addressed. Dementia patients are especially vulnerable as they increasingly lack the mental capacity to participate in the decision-making process that will ultimately protect and promote their own interests (BMA, 2011). This means that any decisions made regarding their care or treatment are made on their behalf. This loss of autonomy disempowers them and makes them subject to others’ will. Coupled with the ageing process, declining physical health and increased frailty, this puts dementia patients in a highly vulnerable position.

Steps a Nurse Can Take: Identification

Safeguarding adults with dementia is a difficult task. It is widely acknowledged that it is difficult for the nurse to spot signs of abuse in dementia patients due to similarities between signs of abuse and symptoms of their underlying condition. General signs of abuse can include frequent arguments between the caregiver and the patient, and changes in the dementia patient’s personality or behaviour (Tidy, 2013). Yet, as noted above, these are also signs and symptoms of the progressive disease. Furthermore, spotting such trends requires the nurse to have good knowledge of both patient and carer. Recognised signs of emotional abuse such as rocking, sucking and/or mumbling to themselves are also dementia-like (Tidy, 2013). Often professionals can only detect the signs of physical abuse and neglect by way of a detailed physical examination. The nurse should look for signs of physical and sexual abuse such as physical injury, bruising and bleeding. These may seem more easily detectable, but can be concealed or explained away as accidents. Signs of neglect, including weight loss, dirty living conditions, poor personal hygiene and untreated physical problems, should be identified by the nurse. Again, factors associated with dementia such as increasing apathy, reduced taste / appetite may be the underlying cause and will need to be explored.

Effective safeguarding requires the nurse needs to get to know their patient, discussing all aspects of their well being with them and/or their carer. People with dementia are especially vulnerable to abuse being less able to remember or describe what has occurred (Alzheimer’s Society, 2014). Victims, whether they have dementia or not, find it difficult to tell anyone what has happened. Added to this general reluctance, are issues specific to dementia: patients may feel that they will not be believed, have difficulties recalling and communicating events. The distress caused by the abuse may exacerbate these difficulties. Dementia patient are often not believed, being discredited and thought of as confused and unreliable. Therefore, to protect their patients and best represent their interests it is essential that the nurse understands them and establishes a good trusting relationship.

Dementia patients are also at increased risk of financial abuse. This can include sales-people taking advantage of them, relatives or carers accessing their bank details or causing them to alter their will and/or gain power of attorney (Adams and Manthorpe, 2003). Yet, the nurse should remember that some of these actions may be necessary steps so as to provide care to elderly dementia sufferers. For example, a carer may need to pay for some goods or services for the patient, and, in cases of significant reductions in mental capacity, power of attorney has to be awarded to ensure that all aspects of the dementia patient’s life are managed. Nurses should be aware of the Mental Capacity Act (HM Government, 2005). This was introduced to help protect the rights and wellbeing of those who lack capacity. It governs the responsibilities and jurisdiction of those making decisions on another’s behalf. It aims to ensure that people’s autonomy is protected, but where they cannot make a decision, they are not ignored and any actions are in their best interest (Adams and Manthorpe, 2003).

The demanding care needs of dementia patients can result in high levels of ‘carer stress’ to be experienced by relatives and friends. This may cause that individual to do abusive things and behave out-of-character. Nurses should recognise that carers of dementia patients experience greater strain and distress compared to carers of other elderly people (Alzheimer’s Society, 2014). The enforced change of lifestyle resulting from caring full time can manifest as resentment and dislike. External pressures and stress can make people abuse others, as can a history of being abused themselves, previous violent or antisocial behaviour. Nurses should endeavour to develop a good relationship with both patient and carer(s). They should seek to establish trust and empathy and learn about the people behind the condition. This will enable the nurse to offer high quality care as described in the next section.

Steps a Nurse Can Take: Prevention

Nurses should recognise that abuse can take place in all settings and be performed by all people (Tidy, 2013). Abuse of dementia patients in formal residential or hospital care settings is usually a sign of an overall poor quality of care. It signifies that staff are not appropriately trained and skilled in dementia care. They do not understand the complex needs of these patients and therefore cannot adequately address them. Thus, where a nurse identifies abuse at an organisational level, the situation should be reported so the necessary systems and training can be put in place. Remedial action on this scale is outside the scope of this essay, but where a colleague or individual carer acts inappropriately, the nurse can intervene to educate and train them.

The communication difficulties posed by dementia patients does mean that it is more difficult to offer person-centred care. This results in an individual’s needs not being met. This is further exacerbated where the dementia patient exhibits behavioural and psychological symptoms such as restlessness, shouting and aggression. These can result in the patient being restrained or medicated inappropriately. Therefore, nurses should ensure that they have the knowledge and skill to work with dementia patients so as to act in their best interests. On occasion, the requirements of the Mental Capacity Act are not followed appropriately: Staff assume that all dementia patients lack capacity and therefore don’t involve them in decisions. Nurses should be aware of, and understand, the Act. They should know how to implement it and where to gain advice if necessary. Ideally, there should be continuity of care. The same nurse should work with the patient and their carer(s) throughout the progression of the condition. By knowing the patient well, they will be better able to facilitate person-centred care, upholding the patient’s interests and best representing their views.

The nurse also has safeguarding duties with regards to home-based care. Improving the emotional and practical support given to family carers of dementia patients is recognised as key to safeguarding patients. These carers have little or no training and often do not feel adequately prepared (Alzheimer’s Society, 2014). They often find the situation stressful and demanding: circumstances that could lead to abuse or neglect. The nurse should therefore ensure that they are approachable and inspire confidence in the patient and carer. They should provide education and advice to carers and ensure that back-up support and resources are available to those who need it at all times. Developing a good relationship between all parties is essential in preventing abuse from occurring, ensuring the patient’s needs are met and their interests respected.

Conclusion

Nurses play a key role in protecting dementia patients from abuse. In order to effectively safeguard their patients, it is essential for nurses to understand the types of abuse, how and why it may occur. Dementia patients are at especial risk due to their declining mental capacity and reliance on others. Nurses are well placed to identify and prevent abuse through establishing close, open and trusting relationships with both patient and carer. Nurses can act as advocates for their patients, representing their best interests and facilitating person-centred care. Through providing education and support for carers, nurses can ensure that all the dementia patient’s needs are met.

References

Adams, T., Manthorpe, J., (2003). Dementia Care: An evidence based textbook. Boston, CRC Press

Alzheimer’s Society, (2014). Dementia 2014 Infographic [on-line]. London, Alzheimer’s Society via:

http://www.alzheimers.org.uk/infographic

BMA, (2011). Safeguarding Vulnerable Adults – A toolkit for general practitioners. London, British Medical Association

Brooker, C., Waugh, A., (2013). Fundamentals of Nursing Practice: Fundamentals of Holistic Care. New York, Elsevier

Cooper, C., Selwood, A., Livingstone, G., (2008). The prevalence of elder abuse and neglect: A systematic review. Age and Ageing, 37(2): 151-160

CQC, (2015). Safeguarding People [on-line]. London, Care Quality Commission

http://www.cqc.org.uk/content/safeguarding-people

de Chesnay, M., Anderson, B.A., (2008). Caring for the Vulnerable: Perspectives in Nursing Theory, Practice and Research. London, Jones and Bartlett Learning

Dementia Partnerships, (2015). Safeguarding vulnerable adults [on-line]. Ashburton, Dementia Partnerships

http://www.dementiapartnershipd.org.uk/archive/primary-care/primarycaretoolkit/1-dementia-care/managing-a-long-term-condition/safeguarding/

DH, (2000). No Secrets: guidance on developing and implementing multi-agency policies and procedures to protect vulnerable adults from abuse. London, Department of Health

HM Government, (2014). The Care Act. London, The stationary office

HM Government, (2005). The Mental Capacity Act. London, The stationary office

Hudson, R., (2003). Dementia Nursing: A guide to practice. Oxford, Radcliffe Publishing

Mandelstam, M., (2008). Safeguarding Vulnerable Adults and the Law. London, Jessica Kingsley Publishers

NHS Choices, (2015). Dementia [on-line]. London, Department of Health

http://www.nhs.uk/Conditions/dementia-guide/Pages/about-dementia.aspx

SCIE, (2015). Adult Safeguarding [on-line]. London, Social Care Institute for Excellence

http://www.scie.org.uk/adults/safeguarding

Tidy, C., (2013). Safeguarding Adults. Leeds, Emergency Medical Information Service

This assignment will critically review recent public health policy developments in the field of Cancer in England also it will evaluate its effectiveness and implications for public health and health promotion practice. This assignment will first briefly review the recent public health policies of England starting from ‘Health of the Nation’ white paper (1992), ‘Saving lives’ white paper (1999), ‘Cancer Plan’ (2000) ‘Choosing health’ white paper (2004) and the most recent public health policy for Cancer ‘Cancer Reform Strategy’ (2007). After reviewing the recent public health policy developments for cancer in England, evaluation and implications of these policies will be discussed.

From 1992 to 1997, the Health of the Nation (HOTN) strategy was the central plank of health policy in England and formed the context for the planning of services provided by the National Health Services (NHS). The HOTN policy focused on five key areas: coronary heart disease and stroke; cancer; mental illness; HIV/AIDS and sexual health; and accidents. Each area had a statement of main objectives attached to it, together with twenty seven targets across the areas. Cancer targets of the HOTN policy were to, reduce death rate for breast cancer in women invited for screening by more than 25% by 2000, reduce incidence of invasive cervical cancer by 20% by 2000, reduce death rate for lung cancer in those aged less than 75 by 30% (men) and 15% (women) by 2010, halt year on year increase in incidence of skin cancer by 2005 (Department of Health 1992).

Health of the Nation white paper’s importance lay in the fact that it represented the first explicit attempt by government to provide a strategic approach to improve the overall health of the population. But according to the review of the HOTN’s policy commissioned by Department of Health 2000, HOTN’s policy failed over its five year lifespan to recognize its full potential and was handicapped from the outset by numerous flaws of both a conceptual and process type nature. Its impact on policy documents peaked as early as 1993; and, by 1997, its impact on local health policy making was negligible. The HOTN’s policy was regarded as a Department of Health initiative which lacked cross-departmental commitment and ownership. At local level, it was seen as principally a health service document and lacked local government ownership. (The Health of the Nation – a policy assessed 2000).

The White Paper ‘Saving Lives’ Our Healthier Nation was published on 6 July 1999 together with Reducing Health Inequalities: an Action Report. These two documents set out the Government’s strategy for health for the next 10 years. They brought a new and important focus to the promotion of health and the prevention of ill-health. The health strategy set out in the White Paper was centred on four priority areas (cancer, coronary heart disease and stroke, accidents and mental health). Action to tackle these important areas of ill-health was set in the context of both a Government-wide agenda to address the underlying causes (through, for example, measures to combat poverty, to improve education and work opportunities, and to improve the environment including the quality of the housing stock); also through the wider public health agenda, specifically action to tackle smoking (DH 2000)

The NHS Cancer Plan (2000) was the first comprehensive National cancer programme for England. It had four aims: to save more lives, to ensure people with cancer get the right professional support and care as well as the best treatments, to tackle the inequalities in health that mean unskilled workers are, twice as likely to die from cancer as professionals, to build for the future through investment in the cancer workforce, through strong research and through preparation for the genetics, revolution, so that the NHS never falls behind in cancer care again (NHS Cancer Plan 2000) . According to Department of Health (2000), for the first time this plan provided a comprehensive strategy for bringing together prevention, screening, diagnosis, treatment and care for cancer and the investment needed to deliver these services in terms of improved staffing, equipment, drugs, treatments and information systems. At the heart of the Plan there were three new commitments. 1) In addition to the existing (‘Smoking Kills’ white paper 1998) target of reducing smoking in adults from 28% to 24% by 2010, new national and local targets to address the gap between socio-economic groups in smoking rates and the resulting risks of cancer and heart disease. 2) New goals and targets was set to reduce waiting times for diagnosis and treatment of cancer so that no one should wait longer than one month from an urgent referral for suspected cancer to the beginning of treatment except for a good clinical reason or through patient choice. 3) An extra £50 million NHS investment a year by 2004 in hospices and specialist palliative care, to improve access to these services across the country. For the first time ever, NHS investment in specialist palliative care services will match that of the voluntary sector (Cancer Plan DH 2000).

There were enormous achievements since the NHS Cancer Plan 2000, like action on tobacco and the smoking ban had led to a fall in smoking rates (from 28% of the population in 1998 to 24% in 2005), amounting to 1.6 million fewer smokers.

More cancers were detected through screening by National Cancer Screening Programmes for breast, bowel and cervical cancers. New screening programmes were introduced as and when they were proven to be both clinically and cost effective. Waiting times for cancer care have reduced dramatically. There had been a major increase in the use of drugs approved by the National Institute for Health and Clinical Excellence (NICE), to treat cancer with less variation between cancer networks. Since April 1 2009, patients undergoing treatment for cancer, including the effects of past cancer treatment, have been able to apply for a medical exemption certificate. It is expected that the new scheme will benefit up to 150,000 people already diagnosed with cancer, who might pay £100 or more each year in prescription charges (NHS Cancer Plan DH, 2010)

Although there are tremendous improvements of ‘NHS Cancer Plan’ according to Department of health but according to the ‘The Lancet Oncology’ editorial 2009 the NHS cancer plan for England was set up, at least in part, in reaction to data from the EUROCARE project, which showed that England cancer survival rates was lagging behind the rest of the Europe. The stated aim of the plan was: “By 2010, England’s five year survival rates for cancer will compare with the best in Europe.” Despite all the caveats that must be borne in mind when extrapolating from available data, and when comparing across European countries, the evidence available suggests that England is at best keeping track with improvements elsewhere, rather than closing the gap, and that the 2010 cancer target looks optimistic. Solutions to the problems of cancer are not easy, but perhaps the time has come to consider rather more fundamental changes to the NHS than are offered in the cancer plan if England is to truly offer world class healthcare (The Lancet Oncology 2009). According to Bosanquet et al (2008) huge amounts of money have been thrown at cancer in NHS cancer plan. The exact sum is opaque but the investment in cancer care has more than tripled over the past decade and now have approached European levels but improvements in cancer survival rates is not comparable with other European countries (Bosanquet et al, 2008).

The Choosing Health White Paper was published in November 2004.  Choosing Health identified six key priority areas: – tackling health inequalities, reducing the numbers of people who smoke, tackling obesity, improving sexual health, improving mental health and well-being, reducing harm and encouraging sensible drinking (Choosing Health, Department of Health 2004). Choosing health policy was particularly successful in banning the smoking in public places (Department of Health 2010).

Before reviewing the most recent public health policy development for Cancer in England it is important to look at the current and past statistics of Cancer in the England. Also according to the Parkin (2006) accurate statistics on cancer occurrence and outcome are essential both for the purposes of research (into causes, prevention and treatment of cancer) and for the planning and evaluation of programmes for cancer control. According to the Office for National Statistics (ONS) 2010 UK the four most common cancers, breast, lung, colorectal and prostate accounted for more than half of the 245,300 new cases of malignant cancer (excluding non-melanoma skin cancer) registered in England in 2007. Of the total number of new cases in 2007 in England, 123,100 were in males and 122,200 in females, breast cancer accounted for 31 per cent of all cases of cancers in England among women and prostate cancer accounted for 25 per cent of all cases of cancers in England among men. Cancer is predominantly a disease of older people as only 0.5 per cent of cases registered in 2007 in England were in children (age under 15) and 25 per cent were in people aged under 60. Between 1971 and 2007, the age-standardised incidence of cancer increased by around 21 per cent in males and 45 per cent in females in England. In each year in England over one in four people die from cancer. In England cancer accounts for 30 per cent of all deaths in males and 25 per cent of all deaths in females (ONS UK, 2010). Survival rates of cancer patients in England varies by type of cancer and, for each cancer, by a number of factors including sex, age and socio-economic status. Five-year relative survival is very low (in the range 3-16 per cent) for cancers of the pancreas, lung, oesophagus, stomach and brain for patients diagnosed in England in 2001-06, compared with ovarian cancer (39 per cent), cancers of the bladder, colon and cervix (47-64 per cent), and cancers of the prostate and breast (77-82 per cent). In England for the majority of cancers, a higher proportion of women than men usually survives for at least five years after diagnosis. Among adults, the younger the age at diagnosis, the higher the survival for almost every cancer. In England five year survival rates for patients diagnosed between 2001-06 have improved slightly or stayed stable for 16 of the 21 most common cancers compared to the period 2000-04 (Cancer Research UK, ONS UK 2010).

The most recent public health policy for cancer in England is the Cancer Reform Strategy (DH 2010). The Cancer Reform Strategy published in December 2007, builds on progress made since publication of the NHS Cancer Plan in 2000 and sets out a clear direction for cancer services. According to the document of Cancer Reform Strategy published by Department of Health (2007), it shows how by 2012 cancer services in England can be among the best in the world. It also launched three new initiatives: 1) The National Awareness and Early Diagnosis Initiative, aimed to raise awareness of cancer symptoms among the public and health professionals and encourage those who may have symptoms to seek early attention. Almost £5 million was allocated to the NHS to support cancer networks and primary care trusts in improving awareness of cancers and promoting early diagnosis. 2) The National Cancer Survivorship Initiative is working to improve support for the 1.63 million people currently living with and beyond cancer in England. 3) The National Equality Initiative is working to reduce inequalities in cancer care. According to the Department of health (2010) the aims of the Cancer Reform Strategy is to build on progress already made and meet remaining challenges, the government has developed this strategy to set out the next steps for delivering cancer services in England, by saving more lives through prevention of cancer whenever possible and through earlier detection and better treatment, by improving patients’ quality of life by ensuring services patient centred and well-coordinated and by offering choice where appropriate, increase public awareness of cancer, reduce inequalities in access to services and in service quality – thereby reducing inequalities in cancer outcomes, build for the future, through education, research and workforce development, and enable cancer care to be delivered in the best place, at the right time.

Prevention of cancer by screening is a most important aspect to tackle cancer. NHS Screening programmes are part of the Cancer reform strategy 2007. According to NHS Screening Programme (2010), over half of all cancers in the past could be prevented if people adopted healthy lifestyles such as: by stopping smoking, avoiding obesity, eating a healthy diet, undertaking a moderate level of physical activity, avoiding too much alcohol, and excessive exposure to sunlight. According to the NHS Cervical Screening Programme (2010), it saves up to 4,500 lives in England every year. Within the NHS Cervical Screening Programme in England, women aged 25 to 49 are invited for free cervical screening every three years, and women aged 50 to 64 are invited every five years. Women over the age of 65 are invited if their previous three tests were not clear or if they have never been screened.

According to the NHS Breast Screening Programme (2010), its breast screening awareness programme regarded as one of the best screening programmes in the world, saving an estimated 1,400 lives each year. 96.4 per cent of women who have had invasive breast cancer detected by screening are alive five years later. Under the NHS Breast Screening Programme, breast screening is provided every three years for all women in England aged 50 and over. Currently, women aged between 50 to 69 years are invited routinely and women over the age of 70 can request free three-yearly screening. The eligible age range for routine breast screening will be extended further to provide nine screening rounds between 47 and 73 years. According to the NHS Bowel Cancer Screening Programme (2010), it is one of the first National bowel screening programmes in the world and the first cancer screening programme in England to include men as well as women. All men and women aged 60 to 69 are expected to be included by December 2010, meaning around 2 million men and women will be screened and an estimated 3,000 cancers detected every year. The programme will be extended from 2010 to include men and women aged 70-75 years.

According to the Lancet Oncology editorial (2009), although the Government’s Cancer Plan and Cancer Reform Strategy has had some impact on how long sufferers survive after diagnosis, it is still struggling to close the gap between England and other European countries. A study by Bernard Rachet et al, (2007) published in the Lancet Oncology journal also suggested that some of the improvements in cancer in England merely reflect ongoing trends in cancer cure rather than real change. There are also large variations in cancer cure and survival rates across the country, with patients in the North West of England still more likely to die earlier from the same cancer as those in the South of England. An editorial in the journal also warns that the time has come to consider more fundamental change in the NHS than the Cancer Plan and Cancer Reform Strategy offers. The study by Bernard Rachet et al, (2007) in The Lancet Oncology journal looked at survival rates for 21 common cancers, comparing the rates in England and Wales, ( in Wales a similar scheme like Cancer Plan was introduced only in 2006) most cancers showed a rise in survival rates in England compared to Wales after 2001, but there was a fall in the survival rates in England compared to Wales for bladder cancer, Hodgkin’s lymphoma and leukaemia (blood cancer).

According to the Professor Karol Sikora, medical director of Cancer Partners UK, (Lancet Oncology 2009) that there is no striking improvement in the cancer cure rates and survival rates in England, despite the huge resources involved in the NHS cancer Plan and Cancer reform strategy, also there is still wide regional variation in survival, with deprivation still being linked to poor outcome, a factor which the plan was meant to address. Also according to Karol Sikora, access to new cancer drugs in England is also poor, the latest EU comparator (2008) shows that the use of six cancer drugs approved in the past three years is fivefold less in the UK than the EU average.

According to Ciaran Devane Macmillan Cancer Support (Telegraph UK April 2010), although there are more cancer survivors in England because of both the improvements in treatment and an ageing population, but this does not show the whole picture of cancer policy of England. After once the treatment of cancer ends, many patients feel abandoned by the NHS and struggle to cope with the long-term effects of cancer, and cancer treatment. The NHS cancer policy needs to ensure all cancer patients have the support they need to manage the long term effects of cancer treatment.

A recent report by National Radiotherapy Advisory Group (2007) suggests that England need a massive 90% expansion in radiotherapy provision for cancer patients. According to Crump (2009) that in England radiotherapy for cancer patients is at the same level as it was in the 1980s, with only 7% of eligible patients getting precisely targeted intensity-modulated radiotherapy.

In conclusion of this assignment, although the recent public health policy developments in field of cancer have shown some success in England but there are certain areas where significant improvement is require like early detection of cancers to reduce higher incidence rates of cancer by decreasing the waiting times for patients and cancer survival rates especially when comparing to other top European countries. There is a need to change cancer policy of England to meet the real requirements of current and future cancer patients.

Write an essay explaining how and to what extent a particular life course stage can add to the understandings of health and illness provided by sociology, biology and psychology. This can be done either in relation to a single area of health and illness chosen from the subjects covered in Block 3 or across the range of those subjects. Follow the instructions below and use no more than 1500 words:

Explain how your chosen life course stage, working alongside the perspectives of biology, psychology and sociology, shapes our understanding of health and illness; how does it help us to understand experiences of health and illness?

The focus of this essay is to explain how my chosen life stage Menopause contributes to understanding of health and illness.  I have chosen to explore Menopause by explaining the life course perspective and how the five principles relate to menopause.  Focus will be placed on the biological, psychological and social health needs and what physical and emotional symptoms the changes menopause brings. I will discuss with evidence any changes in strategies or legislation and how these can help facilitate the health professional meet the needs of the individual across their mid-life span.  I will evaluate how to obtain optimum health and wellbeing by focusing on Health Promotion as my criteria.

Evidence and explanation



(750 words)

Explain both your choice of life course stage and how that stage, working alongside the perspectives of biology, psychology and sociology, shapes our understanding of health and illness. How does it help us understand experiences of health and illness?

I have chosen for this essay “Menopause” the middle age life course to understand the stages of menopause as it proceeds through changes of woman’s emotions such as a sense of loss due reproductive years ending, loss of identity and feeling of uselessness to their family or society and explore how the menopause is related to the changes often known as “the change of life” and how women feel about these changes and their opinion on “body image” by their experiences and whether or not it is a positive or negative experience (Watson, 2019c).

The life course perspective defines age categories as people progress from birth to death.  It is broken down into life course stages and it is important to highlight women’s course varies and are shaped by the society and culture they habitat.  Similarly, this shapes the role, responsibility and experiences for women giving a better understanding of any factors that contribute to their health and wellbeing during this stage of their life (Rogers, 2019).

The Life Course Theory consists of five principles and is defined as a theory developed in the 1960’s to focus on a person from birth, middle age and adulthood and further on to ascertain the historic, social and cultural surroundings in an individual’s life.  Bengtson et al. (2005) highlights the importance of the cultural and historical context, the importance of kinship and friendship in that family or friends may influences a person which ultimately changes a person’s attitude or  behaviour which can make our health care job more difficult to treat. He explains historical time and place will interact with age and geographical location such as economy which can disrupt family life (Rogers, 2019a).  It is important to recognise that menopause is a stage of life woman pass through with five live course principles to consider, linked lives such as “health before birth”, historical time and place, transitions and their timings, agency and planfulness and biographical process and the role of the individual which are important in the reporting and preventing any illness menopause may present by considering the life course principles (Rogers, 2019b).

Having established menopause as a life course perspective it happens as a natural biological event in which the ovaries do not producing eggs and the hormones oestrogen and progesterone which usual occurs normally in woman in their early 50’s but can happen at an earlier age.  Menopause is when the function of the ovary’s ceases, the ovary (female gonad), is one of a pair of reproductive glands in women and produce eggs (ova) and female hormones such as oestrogen.  Subsequently during menopause, the low and changing degrees of ovarian hormones especially oestrogen is the reason for menopausal events and health outcomes and menopause experiences can be different depending on how each individual coping mechanism depending on their physical, emotional and mental health (Melissa Conrad Stöppler, 2019).  Some women may be induced by medical intervention known as bilateral oophorectomy, undergo a hysterectomy or receive chemotherapy for breast cancer or pelvic radiation therapy which causes ovarian damage resulting in loss of fertility and the end of menstrual periods and very much depend on sex and age, hormones are pertinent with behaviour and fitting to the social aspect (Anon, 2019).  Change in menstrual cycle causes women to have hot flushes, night sweats, headaches or dizziness, vaginal dryness, difficulty sleeping, mood swings, memory problems, loss of interest in sex and weight gain being symptoms experienced (Healthtalk.org, 2019).

The biological lens is particularly important and is highlighted in the biomedical model of healthcare and seen as a medical issue or disease, the medical profession see it as “a deficiency disease needing to be treated or cured with the use of hormone replacement therapy” focusing on diseases like bone density decreasing, risk of osteoarthritis increasing (Anon, 2019), hormone balances changing and the risk of cardiovascular diseases

(SAGE Journals, 2019).

Subsequently we need to consider the psychological aspect to understand the biology aspect better using theoretical models and expectation on normal day to day functioning of each woman experiencing menopause and what can alleviate these biological changes such as exercise and lifestyle changes (McFadden and Rawson Swan, 2012).  GP’s prescribe HRT treatment such as tablets or skin patches which replaces oestrogen to control symptoms taking into consideration bone protection to avoid osteoporosis (Menopausematters.co.uk, 2019) and vaginal oestrogen creams for vaginal dryness or alternative therapies such as Cognitive Behavioural Therapy (CBT) to help with low mood or feelings of anxiety.  Information can be given on nutrition and exercise to improve symptoms (nhs.uk. 2019).

Psychological and emotional symptoms occur during the menopause such as anxiety, depression, sadness, difficulty concentrating and anger and irritability as examples, positive mental health and wellbeing avoids deteriorating health however deteriorating health affects menopausal women psychologically as their thoughts, feelings and coping mechanisms are altered significantly due to life experiences and their ability to cope with same and how critical the role of family relationships can play in health and illness.  McFadden and Swann’s review of the research available identify and evidence that poor concentration, night sweats, disturbed sleep pattern equals poor daily performance at work or at home (McFadden and Rawson Swan, 2012).   The psychological lens is important in relation to how each woman embraces the menopause, for many women they can have very few symptoms and others experience very negative symptoms which affects their lives and health.  These can be characterised as psychosocial and environmental therefore society, family and how a woman perceives menopause will portray how they cope physically and mentally (Bhutani, Bhutani and Bhutani, 2019).   There is evidence in recent studies Campbell (2003) states that poor family relationships can be negative to health and illness impacting on depression, negative environments such as a smoking environment impacts on health however Campbell (2003) says family support is important and helps improve health, education and support (Rogers, 2019d).  Therefore, developing resilience and being happy is important qualities to good health and happiness, resilience is defined as ‘The ability of a substance or object to spring back into shape; elasticity’ (

Oxford Dictionaries

, 2014) therefore woman going through menopause need good psychological resilience to cope with stress and anxiety (Rogers, 2019e).

Another point to consider is the sociology lens of menopause.  Many women’s symptoms include, depression, forgetfulness, mood swings, stress, hot flushes and vaginal dryness.  Therefore, it is understandable that this would affect a women’s social life or work life.  Due to severe symptoms this creates poor overall health status for woman and will interfere with their day to day living.  Due to the drop in oestrogen levels during menopause this can lead to hot flushes that disturbs sleep that can lead to anxiety, fears and mood swings and will impact on woman’s concentration during the day which leads ultimately to poor work performance and in some cases women may have to leave their employment leading to financial difficulties which contributes to mood alterations such as depression  (Relationship-affairs.com, 2019).   The earlier the menopause due to induced menopause will socially affect a couple and impact on their sex life.  Woman feel they have lost their womanliness and sexual attraction perhaps due to vaginal dryness or feeling unattractive.  Others will suffer other health issues for example sore painful joints, headaches, anxiety or urinary incontinence and would have to be managed by HRT Treatments, support groups or CBT counselling (Bhutani, Bhutani and Bhutani, 2019.  Using a sociological lens aids understanding of the social aspect be it cultural, social and group influences women may choose to manage the menopause such as nutritional needs are important in alleviating several health problems like obesity or anorexia.  Woman now juggle full time employment with family life and therefore this pace of life is very different to a woman in the 1920’s.  Fast food and convenience foods are to hand and are convenient but high in fat and sugar content.  Nutrition is also seen as a customary behaviour in families which influences food choices which increases diseases such are obesity, heart disease or diabetes (Rogers, 2019f).

Evaluation of the perspectives



(550 words)

Evaluate how much effect your chosen life course stage has in shaping our understanding of health and illness; you will need to outline the criteria – for example, its ease of application to your own practice – that you have used to come to this judgement.

As a health care practitioner, we are trained to offer interventions that can improve health, education, information and support to provide personal centred care.  Applying a holistic and reductionist approach to menopausal woman incorporating all three lenses (biological, psychological and sociological) can be difficult and specialist information is required for the entire holistic picture and address menopausal woman as a whole identity that is physically, mentally, emotionally and socially.  The need to understand all the arguments in order to support women to make the right informed choices for them (Watson, 2019g).

Therefore, the criteria I am using to evaluate and has good potential to empower menopausal woman on the implications, symptoms and support available to them is “health promotion”. As a future nurse I need to provide informed care to service users if they need advice and guidance and what available evidence is there to assist.  NICE Guidelines are continually making recommendations to improve on the individuals care and gives advice and information too family members so menopausal women can feel supported in their symptoms, lifestyle choices, treatments available which ultimately eases their symptoms and manages their general health and wellbeing.   Considering HRT or CBT can alleviate low mood and educate women they are not “mad or abnormal”, they have voices and are being listened too helps with health-related illnesses (Nice.org.uk, 2019).  Health Promotion advertises and encourages menopausal woman to attend support groups for woman to feel connected, share their experiences and manage lifestyle changes such as dietary information, exercise, support on giving up smoking and reducing alcohol intake.   Menopausal women feel socially isolated which increases their levels of stress and anxiety, joining groups such as yoga, mediation or attending for acupuncture are among several resources available for women suffering from menopause (Mysecondspring.ie, 2019).

There are medications or remedies for menopausal women like antidepressants, HRT, CBT, Mindfulness or Counselling however it does come down to a person preferred choice (Menopausematters.co.uk, 2019) and researchers are continually promoting and researching what is best for each individual.  Feminist research will influence the menstrual cycle such as the randomised controlled trial Schierbeck and colleagues reported that woman who were given HRT showed a decline in cardiovascular activity therefore they believe HRT is a positive treatment in improving death rates.  Results also indicated that HRT did not increase the risk of breast cancer or stroke.  However, this was debated with Loppie and Keddy who argue menopause is not a medical condition rather a natural occurrence and they believe woman are misled with inconsistent information (Watson, 2019g).  Even though the topic is controversial we must understand that evidence and health promotion are key to understanding both sides of the arguments taking into consideration the three lenses and a holistic approach to support woman in their own decision making as health care professionals.

Conclusions



(100 words)

In summary combining medical research and all three perspectives will give a better focus on how the middle life stage of menopause evolves, from symptoms, illnesses and experiences.  By applying a holistic and reductionist approach and incorporating all three lenses can be difficult and specialist information is required for the entire holistic picture and address menopausal woman as a whole identity.  The need to understand all the arguments in order to support women to make the right informed choices.  As discussed the NMC Guidelines support not only the menopausal women but their family and carers also and advocate being more proactive in their recommendations so we all receive clearer guidelines to share and communicate accordingly, this in return encourages woman to be more proactive in their health care choices for example nutrition or medication (HRT).  Understanding health and illness during menopause is complex and it is evitable occurrence for all woman bringing with it health implications which in turn adds challenges for services.  Research tends to be focusing on factors that completely influence the physical and psychological aspects of menopause such as health lifestyle changes to support and improve a woman’s quality of life during and after menopause.

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