More often people here about circumcision as a religious rite among Jews and Muslims and less likely this procedure is discussed from a medical point of view. There is no consensus about its feasibility and even doctors can not determine whether this procedure needed or not. According to statistics, about 1/7 of the world male are circumcised and, in most cases it is for religious reasons. In Europe, male circumcision is not very popular, unlike the U.S., where more than 50% of boys are circumcised, mostly for reasons of hygiene (Rosen, 2010). There are vivid reasons for this procedure the same as effects which should be thought out thoroughly.

The tradition of circumcision appeared in a primitive society, when the transition of boys into the group of adult men was accompanied by a rite of initiation. During the initiation, young men were not just receiving the traditions and intimate knowledge of the tribe, but also subjected to physical tests, among which the circumcision was perhaps not the most painful.

European and American part of the population is very ambivalent about this process. For example, in the early ’60s in Western countries there was the so-called “the boom of circumcision.” Through the process of cutting off the foreskin were going almost all male – adult and newborn babies. However, in the 70ies-80ies the “boom” finished and there was a time to sum up the results (it should be noted that according to statistics, nowadays about 80% of American men are circumcised) (Joseph, 2010).

In the modern world circumcision is made in some peoples of Australia, Oceania, and Africa. The most widespread, circumcision is in the religious rites of Judaism and Islam. So in some religions, circumcision is an obligatory ritual; for example Muslims circumcise children when they are 8-13 years old, while Jews do it already on the 8th day after the birth (Anwar, 2010).

Circumcision is a minor surgery aimed to remove the foreskin of the penis. The result of the complete removal of the foreskin is an open glans penis; as a result of partial removal of the foreskin, an opening of glans penis is achieved (Castellsague, 2002).

The question of circumcision is very discussible and has a lot of proponents and opponents.

Doctors have sounded positive and negative effects of circumcision. Discussing the positive effects, the most vivid are: the reduce of probability of occurrence the reproductive system malignant tumors; increased duration of coitus – due to the absence of the foreskin, the glans penis becomes less sensitive during the frictions that contributes to delay of ejaculation (though this point may not always be considered as positive); improvement in the appearance of the penis.

It is also proved that there is a connection between inflammation in the area of ​​the foreskin and urinary tract infection. Thus, while examining of 100 children with urinary tract infection in age from 5 days to 8 months, it was noticed that 95% of them were boys and all of them were not circumcised (Ginsberg CM, 1982). The survey of U.S. military showed that the incidence of urinary tract infections is 10-20 times higher in men who haven’t been circumcised (Wiswell TE, 1987).

One more positive medical effect of circumcision is that penile cancer is found only in men who previously did not have circumcision. Mortality in cases of penile cancer in the U.S. is 25% (Castellsague, 2002). Circumcision significantly reduces the likelihood of developing penile cancer in men. Also the connection between circumcision and sexually transmitted diseases is also acknowledged (Rosen, 2010). These diseases, which typically include the integrity of the epithelium, or ulcers (genetalny herpes, syphilis, AIDS) are more common in men who were not circumcised (Waldeck, 2003).

In addition, Australian researchers have found out that circumcised men are much less likely to get AIDS and other infectious diseases of the reproductive system. Scientists have discovered that immunodeficiency virus penetrates the foreskin much easier than other tissues of the male organism (Ferris, 2010). Also, a group of U.S. researchers, working in India under the leadership of Dr. Stephen Reynolds, made this conclusion, surveying more than 2 thousand men. The report of the Surgeon General is published in the medical journal Lancet (D’Arcy, 2011).

The article says that the risk of getting the deadly virus for circumcised men is six times less than for those who did not pass this procedure. However, scientists announce that from other sexually transmitted infections, circumcision does not protect. The reason may lie in specific cells of the foreskin, which are very susceptible to HIV (D’Arcy, 2011).

Dr. Reynolds says that circumcision can be a serious tool in the fight against AIDS – especially in developing countries, where condoms are not equally shared (D’Arcy, 2011). Previously, scientists believed that circumcised men were less susceptible to AIDS due to the special patterns of sexual behavior – their upbringing did not permit to have casual sexual acts. However, it is clear now that the reason is just physiological and has nothing to do with ethics or religion (Brooks, 2010).

The effects of circumcision have not only positive points, but negative also. One of the main effects is a severe pain. Previously, infants were circumcised without anesthesia, which in turn led to a painful shock, but nowadays local anesthesia is used almost always during such procedures. One more strong negative effect is unnecessary intervention in human anatomy. There is nothing superfluous in humans; in fact the foreskin performs the same role for the glans penis as the eyelid to the eye. It protects the glans penis. The opponents of circumcision believe that it is far from inconsistency to ethical standards. Since the infant can not decide himself whether he needs circumcision or not, human rights advocates say that decisions made by parents, are inhuman.

Like most surgeries, the procedure of circumcision has a number of postoperative complications, the most common of which are the following: hematoma (bleeding in the tissue, or a bruise) and wound infection. To eliminate these negative effects, in most cases is possible through the most thorough dressing and postoperative area care. There are also possible such negative effects as contagious infection, the formation of excessive scar tissue, mechanical damage to the urethra during surgery, various strains of penis, swelling and inflammation of the urethra. Never the less such problems happen rather rare. A more serious consequence, requiring repeated surgical intervention is painful erections that are also considered as possible medical effects of circumcision.

It is important to mention that the presence of the foreskin makes the surface of the glans penis moist corresponding humidity of woman’s vagina and that physiological. Penis after circumcision does not have such natural advantages, and circumcised men often have to use special lubricants during sex. Medical practice shows that children whose foreskin was cut are affected by infectious disease of the penis during the first years of life five times more often then children who were not circumcised. This is explained by the fact that smegma contains lysozyme, which reduces the risk of urinary tract infection.

The infant is not asked whether he wants to have such surgery or not. Adults decide everything for him. However, any surgery is a trauma, the psychological consequences of which can persist for life. Americans, carefully, even reverently care about their mental health, combined into society under the slogan of opponents of circumcision: “Circumcision – mutilation and violence against child’s personality.” At the same time, the surgeons quite successfully develop techniques that allow pulling the skin of penis to form a new foreskin.

Many people believe that circumcised foreskin impoverishes sexual feelings, and this view has the right for existence. Foreskin moves during the frictions, making the experience richer be the most natural way, without using any appliances from the store of intimate accessories. There is no doubt that circumcision is sometimes a necessary therapeutic measure during frequent inflammatory diseases of the foreskin, phimosis and paraphimosis. However, as a preventive operation, it is hardly justified, although not so long ago people practiced across-tonsillectomy as a preventive measure of angina, and cutting the appendix to avoid possible appendicitis.

Here’s what a well-known pediatrician, Dr. Hugh Jolly says: “There is no doubt that the best thing you can do with the foreskin of your infant son, is to leave it, you just need to give it time to separate itself from the glans, and it will easily pull back. It happens at the age of 4. It is best to try to move the foreskin during bathing. However, if the glans is exposed difficultly, do not hurry, there is no need… If you try to pull the foreskin before it happens naturally, you can damage skin and cause bleeding. The scar occurs at the place of injury. In cases where the foreskin is fused with the glans, circumcision can not be longer avoided” (Morris, 2010).

Until the natural separation of the foreskin, it protects the glans from infection. In infancy the cleansing of the glans penis in boys, as well as the clitoris in girls occurs itself, naturally. The irony is that it is after the cutoff there is an urgent need for careful care of the glans penis. Deepening and skin folds in the bridle and the corolla are ideal for bacterial growth.

The glans penis which is not circumcised has a smooth, slippery and wet surface. After the cutoff, it becomes matte and dry. The modern mentality often equates dryness and purity that is why from this point of view the untouched by the circumcision glans seen as dirty. That is a fallacy. Young people in the United States regularly go to the doctor for circumcision. Their decision, they often motivate by partner’s insistence, which is usually due to three factors: hygiene, aesthetics and traditions. The woman is afraid of dirt that can accumulate under a fold of skin, wrinkling her unpleasant appearance of the foreskin and, finally, she wants her partner looked like the rest men in her family.

The essence of the problem is that the excision of the foreskin causes severe pain. In most cases, operations are done without anesthesia, as it is commonly believed that in the first week of child’s life it is risky. It looks awful when a small, helpless creature is tied to a special table for cutting. The child lies on it; crucified and abandoned by all … He reacts with horror at the bright light of surgical lights, ringing metal tools, masks of doctors, shining knives and the terrible physical pain. None knows how long his continues continue. The psychological effects of such procedure are not studied yet, so none can tell how it affects a child.

Journalist Philip Baffle wrote in The New York Times: “Newborns experience pain. There is no need to explain it to parents; it’s not a mystery to many pediatricians. Unfortunately among doctors, who are operating babies without anesthetic or with minimal use, opposite opinion is dominated” (Gilliam, 2010).

Philip Baffle states that according to one of scientific researched, 77% of all infants who had surgery because of serious defects of the cardiovascular system in 1954-1983, were given only local anesthesia, and very rare with the interrupted supply of nitrous oxide (Gilliam, 2010). Meanwhile, really effective painkillers, which are suitable for children, have already passed into the category of available. Such a rare use of analgesics while operating newborn proves that medical practice is sometimes based on incomplete knowledge and false beliefs and that criticism contributes the truth.

The situation is changing. In most U.S. medical institutions doctors use painkillers during major surgery. However, some anesthesiologists stubbornly adhere to old beliefs and there are still surgical units where little children are operated without anesthesia in the case of simple operations, such as circumcision.

Considerations which make the routine practice of circumcision doubtful include pain and risk associated with small surgical interventions. Circumcision is a surgical procedure, and the pain that is brought to the baby is also real. Pain is manifested in grimace, cry, heart palpitations and lack of saturation blood with oxygen (Kaufman, 2001). Studies indicate that circumcision in the neonatal period is a stress, which causes behavioral and psychological pain reactions (Malnory, 2003). American Academy of Pediatrics (AAP) recognizes that there is a significant painful reaction during neonatal circumcision and recommends the use of analgesics (Gatrad, 2002).

One of researchers believes that the most important argument against circumcision is a permanent violation of anatomy, histology and functions of the penis, which are fraught with potential complications (Atikeler, 2001). The same study reports about complications including bleeding, stenosis, incomplete circumcision, penile edema, damage of the glands, adhesion, hypospadias and damage of urethra (Atikeler, 2001). The overall incidence of complications of circumcision according to the medical literature is 1.6% (El-Bhnasawy, 2002).

Adhesion of the penis is the most preventable and non-binding complications of circumcision. Among all the complications, an adhesion is observed in 71% of cases (Kebaabetswe, 2003). After neonatal circumcision, the majority of adhesions resolve sponatanno (Kebaabetswe, 2003).

Another risk associated with circumcision, is the lack or excess of skin that can cause problems such as recurrent phimosis (Gatrad, 2002). Phimosis happens in approximately 2.9% of cases (Blalock, 2003). In the UK, the circumcision is not practiced routinely, as the procedure has limited medical benefits. As a result, circumcision is a medical event, which is paid by insurance only in case of medical necessity (Shah, 1999).

Summarizing everything that was written above, it is worth repeating that circumcision is a surgically removal of the foreskin. It is dome more due to cultural traditions, than medical prescriptions. Circumcision is a kind of intervention in the very intimate area associated with family and religious traditions. Typically, the feasibility of circumcision causes active debates. Modern parents, before deciding to cut off their son, must carefully think about pros and cons of this procedure and related to this operation danger. Circumcision causes medical and psychological effects on children and they are worth consideration while taking decision.

This project is based on the nursing care provided to a patient with Chronic Obstructive Pulmonary Disease (COPD), with specific focus on holistic assessment and identification of patient care needs. A patient profile will be provided, along with a description of COPD, including epidemiological data on incidence and prevalence and information on the causes and prognosis of the condition. Two key issues, as identified by the patient, will be analysed and a patient-centred approach to helping the patient with these issues will be demonstrated.

Patient Profile

The patient will be referred to as ‘George’ within this project, but his real identity will remain anonymous in line with the Nursing and Midwifery Code of Conduct on patient confidentiality (NMC, 2008).

George is a 66-year old gentleman who was diagnosed with COPD approximately 1-year previously. His wife recently passed away and George is now living on his own. Adjusting to this change has been difficult for him and he has found his health deteriorating rapidly. On enquiring about George’s lifestyle, it is established that he is a heavy smoker, sometimes having over a packet of cigarettes in one day. He also mainly consumes a diet of convenience food, sharing that his wife always used to do the cooking. At 5ft 5inches and weighing 17 stones (238 pounds), George is clinically obese; his body mass index (BMI) is 39.6. Along with the smoking, his excess weight is exacerbating the COPD and reducing his mobility. He is easily out of breath and sounds wheezy. This is his fourth self-initiated medical visit in the last month, all of which have been due to, in George’s own words, “phlegm at the back of my mouth.”

Chronic Obstructive Pulmonary Disease (COPD)

COPD is a long-term, progressive respiratory disease affecting approximately 900,000 people in England and Wales (NICE, 2004). It is the umbrella term to describe both chronic bronchitis and emphysema, both of which are characterised by “chronic obstruction of lung airflow that interferes with normal breathing and is not fully reversible” (WHO, 2008, p. 1). COPD is the fifth most common cause of death in the UK, taking over 30,000 lives each year (National Statistics, 2006). By 2020, it is predicted to be the third most common cause of death worldwide (Lopez et al., 2006).

The primary cause of COPD is smoking (NICE, 2004), however, other risk factors include family history, airway hyper-responsiveness, and living in a polluted environment (Holt, 2004). The symptoms of COPD include (O’Donnell et al., 2006):

shortness of breath

chest tightness

wheezing

chronic coughing

excessive sputum

fatigue

loss of appetite and weight

Weight loss has not been a problem for George due to his unhealthy lifestyle. However, he reports all other symptoms, which are likely get worse as the disease progresses. Furthermore, if left unmanaged, COPD can lead to pulmonary hypertension and right heart failure.

Holistic Assessment

‘Holism’ in healthcare is “the belief that in the treatment of medical conditions, all of one’s physical, mental, emotional and social conditions – not just physical symptoms – should be taken into account” (American Holistic Nursing Association, 2010, p.1). Holistic nursing is defined as “all nursing that has healing the whole person as its goal” (American Holistic Nursing Association, 1998). Florence Nightingale is believed to be one of the first nurses to practice holism, focusing care on the person as a whole including consideration of their relationships and environment.

Holistic nursing is patient-centred and utilises nursing knowledge, theory, and evidence to build a therapeutic relationship with patents. Indeed, in many ways holistic nursing supports current government efforts to place the patient at the centre of their own health care, recognising the unique and subjective experience of each patient. In turn, holism also supports the increasing emphasis on self-management of long-term chronic conditions since it includes the integration of self-care and self-responsibility (Department of Health, 2008). In many ways, holistic nursing is not merely about the practice of providing nursing care, but also about attitude, philosophy and a way of ‘being’ (Thornton, 2008).

Traditionally, before a recent call for a holistic approach to COPD assessment (NICE, 2010), the care of people with COPD adhered primarily to the medical model of health and well-being. Assessment focused on spirometry readings, which are a measure of airflow and lung volume. The severity of COPD is based on the patients’ forced expiratory volume in one second (FEV1); this is the volume of air that can be exhaled in the first second of a forced expiratory manoeuvre. FEV1 readings indicate the following levels of disease severity:

FEV1 80 – 100%: Normal

FEV1 60 – 79%: Mild

FEV1 40 – 59%: Moderate

FEV1 35 – 40%: Severe

FEV1 <35%: Very Severe

George’s spirometry reading was 40%, thus moderate to severe.

Recognising that the assessment should not merely focus on George’s physical condition if an appropriate care plan is to be devised (Shapiro et al., 2007), Roper, Logan and Tierney’s Activities of Living Model (Roper et al, 2000) was utilised (appendix 1). This is a holistic model based on the 12 activities of living (ALs) perceived to be essential components of health and well-being in humans.

The model comprises five components, all of which guided George’s assessment (Box 1):

1) A patients’ level of independence in each of the 12 ALs is assessed.

2) The level of nursing intervention required relates to the patient’s level of dependence or independence the patient has on the nurse regarding these ALs.

3) The patient’s position on a lifespan continuum from birth to death will have a bearing on the level of independence.

4) A range of factors influence ALs: biological, psychological, sociocultural, environmental and politico-economic.

5) The nursing needs to be individualised according to these ALs, level of dependence or independence in regard to ALs, age, and the influencing factors of ALs.

Box 1: Patient Assessment using the Roper, Logan and Tierney’s Activities of Living Model (Roper et al, 2000)

PATIENT ASSESSMENT

Date: 03/01/2012

Patient ID: 14573

Patients Name: George Deakins Height: 5ft 5in FEV1: 40%

Age: 62-years old Weight: 17st (238lbs) Blood Pressure: 116/79

Activities of Living (D=dependent; I=independent):

– Maintaining a safe environment D I

– Communication D I

– Breathing D I

– Eating and drinking D I

– Elimination D I

– Personal grooming D I

– Controlling body temperature D I

– Mobilising D I

– Working and playing D I

– Expressing sexuality D I

– Sleeping D I

– Dying D I

Comments: George indicates areas of dependency in terms of four ALs: breathing; eating and drinking; mobilizing; and working and playing.

Influencing Factors

Biological:

George is clinically obese.

George smokes excessively (often one packet of cigarettes per day). He has been a smoker most of his life, but this has increased over the last 3-4 months.

Diagnosed with COPD approximately 1-year ago. Increased sputum and coughing over the last month.

George is 65-years of age.

Reduced mobility due to worsening COPD symptoms.

Psychological: George’s wife passed away very recently (approx. 3-months ago). He is finding it difficult to adapt to ALs without her. They were married for over 30-years.

Socio-cultural: George’s wife cooked his meals for him. George does not know how to cook and is currently consuming an unhealthy diet of convenience foods.

Environmental: George says that his house is very untidy without his wife; she usually did the housework. He washes dishes and cutlery as he needs them, leaving dirty plates, etc. in the sink for days at a time.

Politico-economic: No current issues relating to ALs.

The model is particularly relevant to the problems and needs expressed by George, who was currently experiencing difficulties with breathing, eating, mobilising, and actively pursuing enjoyable social activities.

Aware that an important issue within the management of George’s COPD symptoms would be smoking cessation, a motivational interviewing approach was utilised within the assessment process. Motivational interviewing is a patient-centered style of counselling designed to help people explore and resolve ambivalence about behaviour change, such as smoking cessation (Miller and Rollnick, 2009). The technique has been found to facilitate smoking cessation, smoking reduction, and reduce rates of passive smoking (Karatay et al., 2010).

Ensuring that George remained in control of identifying his own healthcare support needs, he was asked if he had any ideas as to changes he could make that might reduce his symptoms. This open-ended questioning approach underlies motivational interviewing and has been found to be effective in motivating behaviour change (Miller and Rollnick, 2009). This was the case with George, as described next.

Issue 1: Smoking Cessation

The motivational interviewing approach adopted within the holistic assessment of George highlighted an issue for which George required support. When asked about any changes he could make to reduce his symptoms, his response was, “Smoking . . . I need to stop smoking. I have known this for a long time, but . . . it is very hard . . . there isn’t much else to do without my Jean

[

1

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around.”

According to the stages of change model, there are five stages to lifestyle-related behaviour change (Prochaska, DiClemente, and Norcross 1992; Figure 1): 1) the pre-contemplation stage, where the individual is unaware of a problem and does not intend to change their behaviour in the near future; 2) the contemplation stage, when the individual is aware of the health risks of smoking and is considering change; 3) the preparation stage, when the individual is displaying serious resolve towards behavioural change; 4) the action stage, which is the first few weeks and months of actively taking positive steps towards smoking cessation; and, 5) the maintenance stage, which is typically about 6-months to 5-years after initiation of the smoking cessation decision, when the individual is aware of the danger of relapse and takes action to avoid it.

Description: http://www.recoverfromheroin.co.uk/img/spiral-diagram.jpg

Figure 1: Spiral Model of Stages of Change (Prochaska, DiClemente, and Norcross 1992)

George was clearly at the contemplation stage. He was aware of the problem (i.e. smoking exacerbating his COPD symptoms) and the solution (i.e. smoking cessation), but was finding it difficult to overcome some challenging barriers (i.e. the loss of his wife, loneliness, etc.). These concerns were recognised and dealt with in a constructive manner in order to remove any perceived barriers and help George move towards the action stage (Nicol et al., 2004).

On being asked what might help him to overcome these barriers, George expressed that, “I need to occupy my time . . . keep my hands busy.” Through discussion and collaborative decision-making, George was provided with information about his local NHS Stop Smoking programme. There is evidence that NHS intensive smoking cessation interventions are effective in both the short-term and long-term, with 13-23% of short-term quitters remaining abstinent at 52-weeks (NICE, 2007). Group interventions are reported to be particularly effective for smoking cessation (Stead and Lancaster, 2005), and thus focus was placed on the option of group behaviour therapy via scheduled meetings.

In addition, since the literature suggests that implementation intentions (i.e. the development of a plan to engage in behaviour change) facilitate the achievement of behavioural change goals (Gollwitzer and Sheeran, 2006), George was asked to specify cues in the environment that might tempt him to smoke. These were then linked to distracting behaviours that would assist him if he encountered such cues. As found within research on the concept of implementation intentions, George appeared to find this a motivating activity (van Osch et al., 2010).

Issue 2: Activities of Daily Living

A second issue identified by George when asked what he perceived to be his greatest support need was, “The cooking . . . I need to learn to cook or something . . . I am not too worried about my weight at the moment, but don’t want to get any bigger.”

This issue was confronted by more barriers than the smoking cessation, since the latter is currently well supported within the NHS. The possibility of ‘meals on wheels’ was discussed, but this was not George’s preferred course of action, as indicated by his comment that, “Meals on wheels would make me feel old. No, no . . . I’m not at that stage yet.”

After spending some time with George, looking over patient information and investigating local resources, the possibility of cooking lessons was introduced by George. He felt that it would help with the smoking cessation because it would keep him busy and give him something else to do (i.e. experiment in the kitchen). Information on a local resource that George could utilise for such purposes was provided to him (see Resource Profile for more details).

George raised some concerns about grocery shopping when preparing to cook meals. He had only entered the supermarket once since his wife passed away, and found it “overwhelming” and “confusing.” On being asked if he had a computer and could do online shopping over the internet, George confirmed that he did have a computer, but found it difficult to use. He was, however, interested in the idea of ordering his groceries to be delivered to his home. Computer training was thus added to George’s care plan, offering another route of social integration and opportunities for George to occupy himself whilst trying to quit smoking. In turn, being more active and learning cooking skills would likely help with weight management.

Resource Profile

Fortunately, Norfolk offers a range of services to assist George in his efforts towards better self-management of COPD, smoking cessation, social integration, and activities of daily living. As one example, the national campaign ‘Right Tools for the Job’, advertises that people who are serious about quitting smoking can get information and advice by ordering a free ‘Quit Kit’ from the NHS (NHS, 2010). There is also ‘Smokefree Norfolk,’ which provides free, confidential advice and support to people trying to quit smoking. George is also made aware that his GP surgery offers advice and might be a useful resource if he wishes to discuss the possibility of nicotine patches. Many practices also have Stop Smoking Advisors, as do many of the pharmacies in Norfolk. Advisors can offer one-to-one advice and support at a convenient time.

Access to a Personal Health Plan, as provided by NHS Norfolk Patient Advice and Liaison, would enable George to have more control over his health and health care. It would also provide support in being able learn self-management skills. Anyone can have a plan; however, it is currently being offered to patients with COPD or heart failure.

There is a local COPD service at Queen Elizabeth Hospital, Kings Lynn (from Monday to Friday 9am – 4pm), which delivers specialist care to people in the community with a confirmed diagnosis of COPD. The service aims to avoid hospital admissions and provide general advice, among other things. The service is accessible to all patients with a Norfolk GP and is accessed via telephone or face-to-face.

In terms of learning how to cook, ‘The Joy of Food’ provides a place for George to learn some easy recipes, whilst also being taught about nutrition and how to read food labels. Combined with access to internet training, as offered by Age Concern in Norfolk, George will have access to resources productive of independent living.

In addition to the resources available for George’s condition and the two issues he identified, George was also supplied with the Age Concern (2008) information leaflet on ‘Bereavement: Coping with a death,’ which comprises useful information not only on dealing with the psychological implications of grief but also how to deal with practical concerns. Phone numbers for support are also provided.

Overall, all of the required resources to help George maintain his health and well-being are available within the local geographical area and no forthcoming removal of these services is evident. George even has access to wider geographical resources, such as Great Yarmouth and Waveny Community Services, who provide support in the community. If, in the future, George’s condition was to worsen, which is likely due to the progressive nature of COPD, he might be able to secure the help of a district nurse who could visit him in his home. Indeed, the Community Services have published a 5-year strategy covering 2009-2014, which outlines plans to improve the services available for people with COPD (Lippa, 2010). For example, efforts will be made to reduce the number of emergency admissions arising from patients with COPD by giving some the opportunity to self‐manage their condition via a telehealth pilot. This is a self‐management initiative which enables people with COPD to monitor their own vital signs (i.e. blood pressure, heart rate, oxygen levels, and weight), with support and interaction being undertaken by a remote clinical team. This team provide advice on lifestyle, self-management skills, and risk assessment, as well as ensuring appropriate referrals to the GP or hospital.

Conclusion

As part of this patient-centred project, insight has been gained into the experience of living with COPD, from the patient perspective. In particular, a greater understanding of the holistic implications of the disease has been gained, providing knowledge of assessment procedures and the utilisation of such procedures in care planning. A vast array of resources have been identified to assist older people like George, who are struggling with a long-term condition as well as age-related factors such as loss of loved ones and difficulties with activities of living. The process has been challenging, but has also demonstrated the huge beneficial impact nurses can have on a patient’s health and quality of life if they take a patient-centred, holistic approach to care. The process has also contributed to continued professional development and it is anticipated that the knowledge and skills acquired during this project will enhance future patient-centred practice.

Appendix 1: The Roper, Logan and Tierney Nursing Model (Roper et al., 2000)

Level of dependence (D) or independence (I) on 12 Activities of Living (ALs):

– Maintaining a safe environment D I

– Communication D I

– Breathing D I

– Eating and drinking D I

– Elimination D I

– Personal grooming D I

– Controlling body temperature D I

– Mobilising D I

– Working and playing D I

– Expressing sexuality D I

– Sleeping D I

– Dying D I

The patient’s position on a lifespan continuum from birth to death:

Birth Death

Influencing Factors:

Biological (e.g. overall health, current illness or injury, anatomy and physiology, age)

Psychological (e.g. emotion, cognition, spiritual belief, ability to understand)

Sociocultural (e.g. societal and cultural experience, expectations, values)

Environmental (e.g. damp in the home, air pollution)

Politico-economic (e.g. government, politics, economy)

Individualised care according to these ALs, level of dependence or independence in regard to ALs, position on the life continuum, and the influencing factors of ALs.