Relevance of Psychology in Primary Health Care Delivery

Relevance of Psychology in Primary Health C ar lurchCritically discuss how an understanding of psychological science mickle enhance the sales prattle of firsthand health solicitude. (District Nursing) testifyThe creation of psychology as relevant to govern nursing and the primary health c atomic summate 18 group enkindle be examined on a list of divergent levels. An understanding of psychology is clearly valuable to the mother got when she interprets a affected roles opposeion to events in their personal illness trajectory. (Yura H et al. 1998). It is equally important as she casts her victor approach to the persevering role and the understanding of how a uncomplaining role forget react to the deli really and impact of health c atomic number 18, particularly in her stipulations of how to achieve maximum uncomplaining compliance in whatsoever habituated therapeutic regimen. (Dean A. 2002).T present are other, arguably less immediately obvious, ramificati ons of the impact of psychological implications in the deli genuinely of primary health care when genius overturns the interactions and dynamics of the primary health care team and the inter wanton in the midst of various members of the team.In this essay we shall consider all of these implications. We start with the general plan that the issuance of psychology in this background is potentially vast and for this reason we shall consider wizard-on-one illustrative episodes in some detail in ensnare to demonstrate an overall understanding of the celestial orbit.The experience of some(prenominal) disposed(p) detail and indeed, the evaluation of the probabilities that countermand from it, are generally bloodsucking on its presentation. This in turn gives rise to differences and variations in the number and ground of the possible outcomes from that situation. This is the so called surmisal of Rational Choice (De Martino B et al. 2006). The perception of a situation is d ep curioent on its inclose. It therefore follows that the outcome is also dependent on the same concept of figure of the presentation. This has swell relevance to our question, as the District Nurse can off endings that are influenced by the framing of the presentation by the patient, scarce to a great extent significantly, she can seek to modify the decisions that a patient at last makes by framing her presentation of the situation in a number of different ways. There is a substantial yard base in the literature which rallys examples of how decisions can be diversityd or even change if they are presented with different emphasis on different factors in the presentation (van Osch S M C et al. 2006).A full consideration of the implications of this statement will mention that these psychological concepts will have a direct bearing on other professional considerations much(prenominal) as autonomy and other honourable inconveniences. (Hendrick, J. 2000).How can a patient be considered to be making a truly autonomous decision if that decision is cosmos influenced by the abilities of a nurse to frame the presentation of the relevant factors in order to suggest that one outcome is better than some other? (Green J et al. 1998). How can a patient be considered to be empowered and amend intimately a course of preaching if the nurse has been selective in the way that treatment has been explained to the patient? (Sugarman J Sulmasy 2001).We do non presume to suggest that such concepts are necessarily wrong. It whitethorn be entirely reasonable for a nurse to use her professional achievement and judgement to suggest to a patient that one particular course of action is preferable to another by framing the presentation in such a way that the patient is guided towards a certain decision. In a plebeianly experienced clinical situation such as a frightened patient with an extensive skin wound to the leg which clearly requires suturing and who is saying that they arrogatet loss anything to be done, we could probably all agree that it would be quite appropriate for a nurse to suggest that the procedure of suturing is not very painful and will give a good cosmetic result whereas to leave the wound open will give rise to transmitting and other difficulties. From an analytical projectpoint, this approach could be viewed as detracting from the patients autonomy and ability to make their take in valid consent. (Gillon. R. 1997). A pragmatist might equally suggest that the nurse is operateing valid psychological principles in her professional desire to achieve what is probably the best outcome for the patient (Coulter A. 2002) mavin of the major areas that we shall consider in this appreciation of the significance of psychology in the delivery of health care, is that of military posture of those delivering the particular intervention to the patients concerned. This area is examined in commendable detail by the paper by Johansson (K et al. 2002) which peculiar(prenominal)ally considered the effectiveness of the delivery of alcohol awareness programmes in a group of problem drinkers. The reason that we have selected this paper for an initial consideration is that, unusually for a research paper, it does not simply consider the efficacy of a particular health care software, exclusively it reviews and critically analyses the attitudes of the health care professionals on the overall outcomes with limited focus on their readiness to participate in such a venture. This is seminal to the major thrust of this essay and therefore merits a small examination.In essence, the entry cohort to this account was a collection of round 150 primary health care team workers who could potentially be involved in the delivery of an alcohol awareness programme. Each was asked to invade in a questionnaire which was designed to evaluate a personal profile of the respondent and covered areas such asexperiences with patients with alcohol- tie in health problems, knowledge and perceived capacity concerning early identification and intervention, attitudes towards the role of primary care staff in early identification and intervention and current intervention methods in use at the health centre.The results are interesting insofar as there was general agreement that the likelihood of a patient generating or triggering an enquiry into their alcohol usage was most believably to be when issues relating to the alcohol-related health-risks were perceived by the healthcare professionals. The relevance of the psychological aspects of such an enquiry became clear when it was found that nurses were more possible to ask than the sterilises in the sample and that on average, nurses tended to drink less alcohol than doctors. (Dihn-Zarr, T et al. 1999)Those who drank the least were more likely to be concerned about the health risks than those who drank more. Clearly the cause of alcohol in any individual patient are s pecific, still the willingness of a healthcare professional to instigate healthcare amount of moneys to minimise the health-related effects of alcohol appears to be dependent on their suffer attitudes towards alcohol and this whitethorn be reflected in their own levels of consumption.There is an old adage that the definition of an alcoholic is a patient who drinks more than their doctor. (Fleming, M et al. 1999). In the light of this study, this comment may not be as flippant as it initially appears. In alcohol-related problems, there is ofttimes an ingredient of self-renunciation, some(prenominal)(prenominal) in terms of alcohol intake and its effects. (Herbert, C et al. 1997). If the healthcare professional involved has a stop of denial of their own intake, clearly this will have repercussions on their presentation of the problem to the patient and their subsequent evaluation and willingness to invoke therapeutic or interventional measures for that patient. (Kaner, E. F. S et al. 1999) new(prenominal) significant factors that contributed to the likelihood of a healthcare professional instigating therapeutic measures were found to be their individual perception of their own degree of knowledge on the subject, both in terms of the effects of alcohol on the body and also in terms of the interventions that were available. (Aalto, M. et al. 2001)Many nurses expressed the fact that they were concerned that patients might react negatively to such enquiries and that this would affect the degree of patient empathy. Doctors appeared to be generally more confident about handling the orifice of a negative reaction. The same study pointed to the fact that it appears that such fears were unfounded in reality, as the same proportion of patients reacted in a negative way in both groups.From this drawing overview, it can be seen that psychology plays a role at many different levels in what is fundamentally a fairly straightforward healthcare professional / patient interchange, and the attitudes of both patient and healthcare professional can have a profound impact on the eventual outcome of the care package for the individual patient.The paper itself makes the comment thatNurses appear to be an unexploited resource, in need of training and support. Nurses may need to be convinced that an active role does not interfere with the nursepatient singingship. make teams of GPs and nurses in primary care might enhance the dissemination of alcohol prevention into regular practice.A raise psychological input that is relevant in this area is the perception of the healthcare professional of conscionable how effective the intervention that is proposed is likely to be. A previous paper on the same subject (Andrasson S et al. 2000), concluded that healthcare professionals were much more likely to recommend a healthcare intervention that they had personally experienced or witnessed as masteryful, with greater frequency than one which had been shown to have a se reanimate evidence base in published literature.The paper concludes with the suggestion that specific training in the subject require to be implemented and this training not only needs to address the knowledge gap that has been identified, but also the belief systems and attitudes of the healthcare professionals in the primary healthcare team in order that it can reach its maximum potential.Although this paper was tar worked and written in relation to a specific alcohol related intervention, it is reasonable to assume that the selected comments cited in this essay are sufficiently general to apply to most specific health related interventions and we will consider and explore other psychological rationales in specific relation to Health Promotion initiatives together with the inferences that can be drawn in relation to team building issues at greater length later in this essay.One of the major areas where psychology is relevant to the success (or otherwise) of a particul ar treatment is encapsulated in the concept of empowerment and education. (Howe and Anderson 2003). The patient who is both empowered and educated by the nurse will approach their illness trajectory in a arrestly different psychological frame of mind than one who is not. Time spent in explanation to a patient of the parameters and reasons for their treatment is seldom wasted. (Holzemer W et al. 1994). Marinkers concept of the differentiation of compliance and concordance. (Marinker M.1997) is particularly useful in this respect. Although his original paper was written with specific regard to the taking of medication, the principles that it expounds are sufficiently general that they are now commonly extrapolated to cover most aspects of the interaction between the healthcare professionals and the patient. The patient who understands wherefore he is being asked to undergo a particular therapeutic regimen is far more likely to accomplished is successfully than one who is simply tol d what to do. This can be encapsulated in the professional advice on the subject from the RCNPatients are as fully involved as practicable in the formulation and delivery of their care (e.g. by the use of self-care plans) Where appropriate, patients are offered treatments other than medication Treatment plans are individually tailored for each patient Patients are involved, unless impracticable, in any decisions about referral Where practicable, patients are informed of the reasons for referral to specialists or other professionals(cited in CSAG 1999)This element of compliance is frequently cited in many of the tools of quality indication that are used in ballock studies in this area. The degree to which a patient complies (or concords) with instructions can be viewed as a measure of success of the presentation of that treatment directly to the patient. (Campbell S M et al. 2000)As we have intimated in the introduction, the act of this essay can be interpreted at several differen t levels. In this piece we shall consider the impact of formal psychology services in primary health care. The rationale for our consideration of this topic specifically lies in the fact that an understanding of basic psychological principles is fundamental in allowing the nurse to hold the elements of treatment commonly undertaken in a psychology clinic. The excellent and informative article by Sobel (A B et al. 2001) provides a good starting point for this consideration. In practical terms, the average attendance at a psychology clinic is about five outpatient attendances. (Arndorfer, R. E et al. 1999). This means that the contact of a patient with the primary healthcare team is likely to outnumber the attendances at the clinic over a period of time. To give a specific example, it is clearly important for the nurse, who may come into contact with (for example) an anorexic adolescent, to understand the issues revolving around body dysmorphia, self-image sweetening and self-estee m (Lavigne, J. V. et al. 1999) if they have been under sack treatment, if the nurse is to consider giving any degree of holistic consideration to whatever problems are being presented to her at the time. It is clearly of little value, if requested to give advice on the subject of weight unit loss (which is a common enquiry at nurse-run clinics), (Hogston, R et al. 2002) . to attempt to give such advice without a background knowledge of the psychological principles that have been employed in trying to restore the patients eating habits to a more normal pattern. (La Greca, A. M. 1997). Equally the parents of a child who is undergoing treatment for enuresis may have questions that they have not felt able to ask at a busy clinic and these may be presented to the practice nurse. A background knowledge of current treatment (both interventional and behavioural) is clearly vital to being able to answer the questions with a degree of professional confidence.Another area where the nurses kn owledge of psychological issues may be important is that, granted the fact that a comparatively high number of patients default from follow up before being formally discharged, the nurse should know that psychological treatment is rarely successful if the less than optimum course of treatment is completed. (Sobel, A. B et al. 2001). Encouragement to return to complete the full course may be a useful postpone for the nurse demoed by a patient in this situation. It follows that a sensitive exploration of the reasons for default my also be helpful and a knowledge of the subject is clearly helpful here as well. The patient who has defaulted from follow up finished apathy needs completely different handling from the patient who has defaulted because of a resurgence of painful or difficult memories during a course of cognitive behavioural therapy. (Street, L. L.et al. 2000). In the latter case, empathetic handling is of great importance as the issues involved may have a deep significa nce for the patient and shutdown of the course may be fundamental to a complete resolution of the issues involved. (Mitchell M C et al. 2004). When traffic with the patient who has specific emotional or psychological issues, the professional nurse would commonly have to employ a degree of psychological understanding which may be deeper than in many other cases for both of the reasons set out above.Let us now consider a different aspect of psychology and its relevance to nursing practice in primary care. A large proportion of the work of the territory nurses can be taken up with the care of the dying patient. The dying, or terminally ill patient typically has a psychological profile that is quite different to the average patient. This was explored in the fascinating and very well written paper by The (The et al. 2000) who considered the elements of denial and cognitive distortion exhibited by a patient when being given news that they do not want to hear. The diversity of psycholog y shown by these patients is intimately unique to this group and a firm grasp of the essential elements is vital if the district nurse is going to handle the situation both professionally and well. The concept of a good death (Seale C et al. 2003) is one that is frequently cited in the modern literature and a fundamental prerequisite to a good death is that the patient is surrounded and treated by healthcare professionals who have broad understanding of the psychological issues that are relevant to this spectrum of patient. (Wilkerson, S. A et al. 1996)There are many patients who confront the inevitability of death with a stoic inevitability that makes their management a relatively straightforward matter (Wadensten et al. 2003). The patients that we shall specifically consider in this segment however, are those who have a positivist diagnosis of a life threatening condition but employ a number of coping mechanisms so that they do not have to directly confront the possibility of i mminent death. These mechanisms can range from false optimism right by to frank and abject denial (Weeks et al 1998).We have already considered some of the ethical implications of autonomy and consent earlier in this essay, but they also are of great relevance in this section. It follows that if a patient is to have any degree of meaningful input into their treatment plans and consideration of the various options that are open to them, they must be both fully aware of, and quite prepared to confront, the implications of the situation that they find themselves in. If they chose to distort some or any of the relevant facts of the case, it equally follows that they cannot make a reasoned and rational decision about the options and choices that they have in front of them. Once again we return to the issue and concept of framing the presentation, the only difference here is that it is generally the patient who deliberately distorts the frame rather than it being distorted or manipulated by the healthcare professionals.This specifically is the issue that The and his colleagues considered in their paper (The et al. 2000). We should start a consideration of this issue however, with a reference point to an earlier paper by Jennings (1997) who described the emotional roller coaster experienced by patients who deal with a malignant diagnosis and that this evolution of emotional landscapes can be predicted with a degree of certainty. This can be best examined with a verbatim extract from the The paper which refers to patients with small cell carcinoma of the lungFalse optimism about convalescence is usually developed during the (first) course of chemotherapy and was most prevalent when the cancer could no longer be seen in the x ray pictures. This optimism tended to vanish when the tumour recurred, but it could develop again, though to a lesser extent, during further courses of chemotherapy. Patients gradually found out the facts about their poor prognosis, partly beca use of physical deterioration and partly through contact with fellow patients who were in a more advanced stage of the illness and were dying. False optimism about recovery was the result an association between doctors activism and patients adherence to the treatment calendar and to the recovery plot, which allowed them not to notice explicitly what they should and could know. The doctor did and did not want to pronounce a death judgment of conviction and the patient did and did not want to hear it.Clearly an understanding of the psychology of what colours the patients reactions is vital to the district nurse if she is to handle this fictional character of situation both professionally and empathetically.If we take a completely gratis(p) and dispassionate consideration of this situation the healthcare professional can say with almost complete certainty, that the patient with a positive diagnosis of small cell carcinoma of the lung is going to die. Statistically we know that over 90% of patients are dead within two years of diagnosis and the overall five year choice figures are nil. (Seale C et al. 2003)The practicality of the situation is therefore that it clearly makes sense to discuss options in terms of treatment, moderation and support as soon as a positive diagnosis is made. In real terms, this is rarely done because healthcare professionals frequently find it difficult to effectively pronounce a death sentence on patients. In this respect the psychology of the situation is as much a reflection of the attitudes and feelings of the healthcare professionals as it is of the patient.On a fictional level one can cite the classic literary example of A J Cronins Dr Findlay (Cronin A J 1934) who disagreed with his partner Dr Cameron. Dr Findlay felt strongly that the eponymic Mrs McIver should be told of her hopeless prognosis on the grounds of being completely fairnessful with the patient and this was against the advice of the older, more experienced part ner, Dr Cameron who had been hitherto managing the situation by keeping the ladys spirits high by telling her how well she was looking at each occasion he had contact with her. Dr Findlay confronts the situation by telling Mrs McIver the truth and within a few days she has died. The relevance of the story is seen at the end where Dr Findlay is depicted talking to the dead ladys husband and Dr Findlay expresses his shock at the speed at which the old lady died and the husband concludes the episode by observing thatShe was doing really well until you took away from her the one thing that she had left and that was hope.In short, this episode highlights some of the difficulties and dilemmas that are frequently faced by healthcare professionals in general and district nurses in particular. The practicality of the situation could have been handled better with a more thorough understanding of the thought processes and psychological mechanisms employed by Mrs McIver in her last few weeks. One can see the point of view of Dr Findlay who took the view that the lady would not have been in any realistic position to make appropriate arrangements to confront her own death if she had never faced the possibility in the management plan that Dr Cameron had adopted. Dr Findlays approach could be argued to have allowed her to consider a number of timely treatment options if the truth was confronted. The fact of the matter was that she chose to actively cabal with the optimistic approach of Dr Cameron and she derived strong suit and the ability to cope from the transparent belief (a cognitive distortion) that her prognosis was not hopeless. Dr Cameron was clearly of the opinion that this was of greater benefit to her than confronting her imminent death.What the story does not tell us (and we can only surmise) is that Dr Cameron, in common with many other real healthcare professionals, also has psychological difficulties in dealing with the subject himself. A number of different mechanisms may be active in this situation. It is possible that, by telling a patient that they are soon to die, it may challenge the notion that medical science can recuperate everything and that healthcare professionals are infallible (sadly, a still all to common belief). Equally it could be that the healthcare professionals involved do not like to be vicariously reminded of their own mortality and therefore collude willingly with the patients false optimism. Others again may take a rational view that if the patient wants to know the truth and then they will ask, if they dont want to know then they wont ask and thereby actively avoid confronting the situation (Curtis J R. 2000)The The paper examines this issue in considerable depth with a commendable degree of scientific scrutiny. In the words of the paper, the authors suggest thatThe problem of patient / doctor collusion does rattling require an active, patient orientated approach from the doctor.A practical and novel soluti on to this problem is suggested in the form of the use of a treatment broker who is defined asa person who is trusted by both patient and doctor and who can help both parties to clarify and communicate their (otherwise implicit) assumptions and expectations.Thes analysis suggested that the majority of patients in the study did actively want to know if the illness that they had was terminal with over 85% stating that they would wish to be told the truth rather than be given false optimism in an unrealistic fashion. This is contrasted with the finding that, in the study, when a patient was given a terminal diagnosis, the next question was almost invariably a variation of what are the chances of a resume? (Meredith et al 1996).It is also the case that other studies on the psychology of this type of situation have shown that when patients ask about their condition (and this applies not specifically to terminal conditions) they do not want to hear anything other than good news (Costain et al 1999). This argument is extrapolated even further in a study by Leydon and his co-workers (Leydon et al 2000) who provide an excellent qualitative study into patients reactions and they cite examples of patients who were interviewed directly after a recorded conversation with a healthcare professional and who overtly denied that they had been given a terminal diagnosis even though this was demonstrably not true.An interesting twist in these discussions of the psychology of the situation is provided by Dean (Dean 2002), who offers a specific insight into the way patients perceive the differences between nurses and other healthcare professionals. He takes the arguments of false optimism and overt denial and examines them further. Again, this paper is specifically concerned with the patient with a terminal diagnosis, and it looked at the differences in the content and tone of the conversations that patients had with both doctors and nurses. A significant finding from this paper was that a patient may choose to overtly collude with the doctor during discussions of a cure but within a very short space of time may choose to talk in a much more open way with a nurse when pretences of a cure are actively dropped. Dean suggests that such a dichotomy of approach is not unusual. He suggests thatPatients may well feel a need for a theatrical faade to bolster their own psychological states as well as to collude with the doctor and indicate that they are remaining positive and confident in the doctors ability to try to achieve a cure.And this suggestion is echoed and grow in the Curtis paper (Curtis 2000) with the observation that, in their more candid moments patients may well wish to get a more down to earth response, which they perceive that they will get from the nurse, who they think may not require a faade or even indulge in the sophisticated game play of the doctor. Lynn (Lynn 2001) adds a counter-intuitive note of caution for the nurse with the thought that this situation requires a great deal of sure handling by the nurse, as the psychological mechanism that underlies the nursing approach is that the patient may actually be looking for reassurance and (possibly unexpected) reinforcement of their own false optimism. This is an exemplification of the constant calls in the literature for a holistic and patient centred approach to patient care rather than a blanket approach to this type of clinical problem.The rest of Thes paper is concerned with the psychological theory behind the explanations of just why it is that patients do adopt these defensive positions and just why it is that healthcare professionals frequently collude with them on this issue. It is not particularly relevant to explore this in any further detail as the point is clearly made that a basic understanding of the mechanisms by which patients cope with their adversity and the psychological constructs that are frequently presented in these circumstances is of great impor tance to the nurse who has to deal with, interpret and empathise with the patients particular needs at any given time in their illness trajectory.Nurses are very much involved, both overtly and in their everyday work, in the business of Health Promotion. Psychology plays a very important part in the overall success and implementation of health promotion strategies on a both a population and an individual level. The theoretical basis of much recent work in the vault of heaven of Health Promotion is in the concept of the Attitude-Behaviour theory (A-B theory) (Rise J 2000). This theory suggests that the optimum change in behaviour patterns (at least in the field of health and self-interest) is achieved with the optimum change in attitude (or realignment in the jargon).We opened this essay with a reference to the Theory of Rational Choice. An offshoot of this theory (the Theory of Reasoned Action) modifies the A-B Theory to the extent that it provides a model framework by which one c an pass judgment the many divergent processes by which attitudes guide behaviour. The hypothesis states that if people can become highly actuate to make a correct decision and are in a position (because they have been given relevant information), then they are likely to spontaneously engage in a deliberate and serious-minded process in deciding how to behave (Rise J 2000). In the context of Health Education (which was the field that the theories were originally developed in) the theory suggests that if people are given sufficient and persuasive information in relation to their health, then a significant proportion will spontaneously indulge in life style changing activity which can be consistent with healthier living. The significance of these theories is that, if the nurse has a remit to promote a healthier life-style (which is arguably part of a professional remit), she is most likely to have the greatest success in providing significant amounts of information to patients rat her than simply dictating to them how they should alter their lifestyle without any significant explanation. This comment effectively brings us full circle to the concept of compliance and conformance as postulated by Marinker.Another issue that has deep seated psychological implications, is the current trend towards teambuilding in primary health care. The ramifications of this concept are huge, and therefore we intend to only discuss the issue by considering a number of the most relevant points. To a large extent, team building overlaps with the concept of multidisciplinary team working. This move has required a redistribution of both power and authority (and thereby a redistribution of responsibility) within the team. (Shortell S M et al. 1998).The psychological implications of this are that if one considers the NHS of more than about twenty years ago its mental synthesis was more isolationist and based on individual practice (DHSS 1988). Individual speciality teams and individ uals worked in a degree of comparative isolation and this also implied a greater degree of individual responsibility than they have at present. This change has brought about a number of major changes in areas such as ethical motive and work practices which are not particularly relevant to our topic in this essay (and therefore will not be discussed further), and also the psychology of working, which clearly is.The first consideration is the psychology behind the concept of lead. Leadership is clearly important if one is to have an effective team. In psychological terms styles of leading can be divided into several categories. The two most prominent being congruent leadership and transformational leadership. A full discus