The bio-psycho-social perspectives
The aim of this essay is to critically evaluate the bio-psycho-social perspectives and influences on the health and well being of a patient, who has been nursed during an acute placement. In this essay names and places have been altered, to uphold the professional requirements, of the Nursing and Midwifery Council (NMC, 2008). The pseudonym Mrs Jones will be used.
The essay will then proceed to define what health is and then critical analyse the bio-medical and the biopsychosocial models approach, to individual health and social well being. It will then be explained what has happened accurately to Mrs Jones biologically, with regard to any pre dispositional disturbances in her physiological processes. This essay will then explore psychological and sociological factors that have had an impact on Mrs Jones as an Individual, which include grief and perceived loneliness. This essay will then summaries and formulate a conclusion based on the findings that have been established throughout the essay. Mrs Jones individual patient profile is included, foremost to give prospective readers an understanding of the biopsychosocial influences that have contributed to Mrs Jones ill-health.
The World Health Organization, (1948), defined health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity,” (p100). “Complete physical, mental, and social well-being” is complex to achieve and would leave most of us in today’s society as unhealthy, (Banyard, 2006). This definition though radical in its time, by stepping away from the empathies of health as the absence of disease, Its focus on the term disease is embedded in the heart of the bio medical model. Bury, (2005), states the term “health” can be positively and negatively defined.
Jadad and O` Grady, (2008), proposed a more positive definition of health as “the ability to adapt and self manage in the face of social, physical, and emotional challenges”.(p2). These two definitions conversely give an understanding of what health is, however the Jadad and O’ Grady (2008) definition implores a more holistic approach to health by using terms such as “adapt” and “self manage,” thus this proposed definition, seems to be based on concepts of the biopsychosocial model of health. Depp, (1999), suggested that many individuals understand that disease is “bad” and health is “good”, conversely an individual’s experiences and perception of disease and their health are subjective in nature.
The first to explore the concept of biological, psych, and social factors, to illness as separate identities were Greek philosophers Rana and Upton (2009). The term biopsychosocial refers to factors which can be categorised as; biological psychological and social, (Alder et al 2009). Roberts et al, (2000), defined biology as the “science of life and living organisms” (p1). Malin and Birch, (1998), define “psychology as the scientific study of behaviour and experience” (p3). Giddens, (2009), however provides the following description of sociology as the “study of human social life, groups and societies” (p6). When combining these three disciplines we are in theory exploring biological, psychological and social aspects of individual life.
Throughout the last century copious models have been devised and adapted by theorists in their own discipline. Models in there simplest forms are described as organizing complex phenomenon in a simplified way, (Stockwell, 1985). McKenna, (1997), suggests models guide an individual in understanding complex phenomenon and putting it into perspective. Kenny, (1993), criticises nursing models for their complexity. The significant problem with models is the terminology used is inaccessible for lay people; information about individual health could be lost in translation or misinterpreted (Kenny, 1993; Hodgson, 1992). Aggleton and Chalmers, (2000), disagree and believe in today’s society nurses are confident ‘to work creatively and questioningly.
Johns, (2002), believes that theoretical models may direct the nurse rather than allowing expertise and experience to guide them. Atkins and Murphy, (1994), question that experience alone is not enough, and support the position that nurses need models to guide practice. A depth of thought is required when following nursing models they develop nursing practice by enhancing insight into patents needs (Bulman ; Schutz, 2008; Hogston, and Simpson, 2002; Jasper, 2003).
The focus for analysis at this time is on the biomedical model and the Biopsychosocial model. In the late eighteenth century knowledge and perception of health and illness had began to expand due to development of science and advancement of technology (Rana and Upton, 2009). The conceptualisation that pathogens caused disease led to a progression of assessment, examination and diagnosis to treat diseases known as the biomedical approach (Freeth 2007).
The biomedical approach believes disease to be a breakdown within the biological mechanisms of the human body, consequential to age, genetics and pathogens the models frame work does not consider, social and psychological aspects, which contribute to ill health (Wade and Halligan, 2004; Banyard, 2006). This way of thinking has primarily dominated health care, in the last century (Wade and Halligan, 2004; Engel 1977).
When breakdown in biological mechanisms occur within the human body the clinician’s priority, when practicing within the bio medical framework is to assess and examine the patient and diagnostically label the disease, and treat in terms of medication or surgery (Mckenna, 1997). Chapman, (1985), criticises the biomedical approach believing diagnostic labelling dehumanises individuals. Wade and Halling, (2004), argue that if there is no definite label for a patients illness it may cause distress. This distress may create difficulty within a nursing environment when a patient relies on definite labelling to explain their ill health (Scott, 2010).
Helman, (2001), states that the biomedical approach is still professionally respected due to rational and scientific approaches in treating diseases with accuracy. Conversely Engel did not dispute this fact, especially in the field of medical research the important advances the biomedical approach made into diseases such as measles (Borrell-Carrio et al, 2004). Freeth, (2007), argues by focusing on objectivity and science clinicians become subjectively detached from patients. Rana and Upton, (2009), criticise how restrictive the biomedical approach is within nursing by focusing on disease and symptoms sequentially, it is reductionist.
Wade and Halligan, (2004), declare the biomedical model is inadequate and outdated in today’s society. Potter and Perry, (2005) do not dispute this but criticise the biomedical approach for not considering aspects of human life that may contribute to disease or illness. Engel, (1977), believed Individual lifestyles may impact on health such as; psychological, behavioral, cultural and social influences and that illness could not be treated by just considering biological factors alone. Individual health needs were not being met, due to clinician’s perceptions of illness and lack of interest in patient’s individual health (Engel, 1977).
Due to these limitations in the biomedical approach a new model was proposed for explaining health and illness. Engel, (1977), integrated psychological and social factors to the biological aspect of the biomedical model. This new theory was called the biopsychosocial approach. Sarafino and Smith, (2008), proposed all three factors combined affect an individual’s health from molecular to societal, and contribute to ill health and over all social wellbeing of the individual.
Rana and Upton, (2009), suggest the biopsychosocial approach allows a better understanding of the determinants of disease. Sarafino and Smith, (2010), believe the influences illness has on; behaviours, feelings and emotions play a major role in the aetiology and advance of health problems, such as cancer and chronic illnesses.
White and Grenyer, (1999), conducted an investigation using the biopsychosocial approach, on patients with chronic end stage renal disease, and the impact of dialysis on their partners. Forty-four participants were chosen and interviewed; multiple themes were identified from the questions answered. White and Grenyer, (1999), concluded that chronic illness has a negative impact on patients and their family’s lives. They have indicated from this study that using a biopsychosocial approach, health professionals are able to acknowledge patients and families feelings, when emotions such as sadness anger and depression occur, and give support. This study has some limitations participates where chosen, and it is possibly out dated in 2011, conversely open ended questions were asked and in depth interviews give the study its strength.
Smith, (2002), believes that the aspect of disease is still the defining factor, within the biopsychosocial models framework. Sarafino and Smith, (2010), argue that psychological and social influences are also definitive factors within the models framework, and all need to be incorporated together to give individualised holistic care. Nursing a patient holistically and not just focusing on a disease aids individual recovery due to patient interaction (Rana and Upton, 2009).
Epstien and Borrell-Carrio, (2005), believed Engel excelled in his patient interactions, flexibility and observation. Engel believed all these qualities were needed within the medical profession not just diagnostic skills, holistic care should be taught, practiced and reinforced within the medical and nursing profession. In today’s nursing the NMC, (2008), requires all students to educated, in the process of delivering holistic care. Rana and Upton, (2009), state the biopsychosocial approach improves; patient satisfaction, quality of care given and enhances the nurse’s knowledge of individualised health issues.
When on a clinical placement I was caring for Mrs Jones 67 year old women. Mrs Jones has now retired from her position as a domestic cleaner. She lives alone with her beloved dog Millie in a two bedded bungalow by the sea. Her husband had been diagnosed with prostate cancer a couple of years ago and had unfortunately recently passed away. Mr and Mrs Jones had a son, who is living in Australia with his wife and children.
Mrs Jones had, had no family support besides her husband; she conversely had a small social network of friends who she spent time with. Mrs Jones lifestyle includes smoking approximately twenty cigarettes a day since the age of seventeen, and due to the stress of the passing of her husband she now consume a bottle of wine most evenings. Mrs Jones believes she has always eaten healthily but does not cook much for herself since her husband died, as she does not enjoy eating alone. She suffers from the chronic condition hypothyroidism and is currently on 150 micrograms of levothyroxine daily which she forgets to take and when she forgets takes a more than prescribed dose in one day.
Her beloved dog Millie who had been a family pet for many years had become a constant companion to her since her husband’s death. However due to old age Millie had become ill. Mrs Jones took Millie to the vet but due to Millie’s ill health was sadly euthanatized. Mrs Jones was devastated about this as Millie was her only family member left that was able to keep her company. She went to see her neighbour for support after visiting the vet with Millie. Mrs Jones was extremely upset and on the way back from visiting her neighbour had slipped on the pathway just outside her house. Mrs Jones was taken to hospital and was medically diagnosed with an impacted fracture of the right neck of femur, which required internal fixation.
Mrs Jones consented to the operation.it was however explained to Mrs Jones that if any compilations occurred during surgery she would be nursed in the intensive care unit (ITU). Mrs Jones spent two days in ITU due to post recovery difficulties. Mrs Jones was transferred eight days post operatively, later than was predicted, due to the orthopaedic ward being full to capacity. Mrs Jones had started physiotherapy and was mobilising well and her pain was being adequately controlled.
To understand how biological influences may affect an individual psychologically and socially, will be now be explored in more depth. The National Institute for Health and Clinical excellence, (2009), indicate 70-75,000 thousand hip fractures occur within the United Kingdom annually (NICE, 2009). The social and medical cost annually for all hip fractures amounts to a staggering ï¿½ 2, billion pounds. (NICE, 2009). Within the United Kingdom demographic projections signify the annual occurrence of hip fractures will increase to 91,500 thousand by the year 2015 (NICE 2009).
A bone fracture medically abbreviated as FX F or # is described as a break in the bones continuity (McRae and Esser 2002; Martini and Nath 2009). Regardless of individual belief there is no medically distinction between the term fracture and break (McRae and Esser 2002). Medically fractures are categorised as closed or open; closed fractures are internal only visible by x- rays. Open fractures conversely present with a break in the epidermis, uncontrolled bleeding can occur and exertion due to micro organisms, entering the fractured location may cause infection (Whiteing 2008; Martini and Nath 2009). Whiteing, (2008), states the mechanism of injury, dictates fracture patterns, and are therefore further classified according to; type, location and complexity.
Hip fractures NICE, (2009), state are the ubiquitous cause for admission to accident and emergency, caused by a fall normally affecting an older person. A fall is described as an event that is unexpected, resulting in the individual landing at ground level from a height (Agostini et al, 2001). Independent active elderly individuals are more prone to falling outside their home, resulting in a higher risk of sustaining a more severe fracture, than an inactive person who has fallen at home. (Sirkka and Branholm, 2003; Coote and Halsem, 2004).
The NHS Institute for Innovation and Improvement, (2006), state a fractured hip has serious consequences for an elderly individual as the mortality rate within one month is 10% after the fall, rising to about 30% within the year (NHS, 2006). Mortality rates are not just attributable to the fracture (NICE, 2009). Vestergaard et al, (2009), believe factors that contribute to mortality rates post fracture are; age, gender, smoking, alcoholism, physical and mental decline and pre-fracture status. Mortimore et al, (2008), argues fracture mortality, remains high in individuals with no overt co-morbidities or physical decline.
Mrs Jones fell outside; she sustained a fracture of the right neck of femur, which disrupted normal physiological functioning of the bone. Bone is a biological dynamic tissue and the only tissue within the human body that that is able to replace itself (Whitening, 2008). As a dynamic tissue bone forms several imperative functions within the human body; the protection of organs, structural support, aid of movement, the formation of blood cells, but conversely acts as a mineral reservoir for calcium and phosphorus, these minerals are essential for cellular activity throughout the human body (Marieb 2009; Martini and Nath, 2008).
Within the human body on a cellular level bone constantly remodels itself. The main cells active within bone are; Osteoclasts and Osteoblasts found present within the connective dense tissue of the bone matrix (Martini and Nath, 2008). Active Osteoclasts re absorb bone tissue whereas Osteoblasts put down new bone tissue, and then Osteoblasts revert to Bone Cells, that sit within the bone Matrix. The ability for a bone to constantly regenerate itself, due to cellular activity means a bone can normally heal fully following a fracture (Kalfas, 2001).
Regardless of bones mineral strength or individual co morbidities fractures can transpire when significant force acts on the bone, often due to road traffic accidents, falls and sports injuries (Whiteing, 2008). Stress fractures conversely present when repetitive trauma occurs, the body eventually does not handle the mechanical force acting on the bone (Martini and Nath 2008). Pathological fractures occur when there is underlying disease that has weakened the bones mineral strength for example; tumours, oesteomalica and osteoporosis (Whiteing, 2008).
Osteoporosis is a chronic degenerative bone disease that causes bone to lose its mineral density. The loss of bone density “silently” and progressively occurs; there are often no symptoms until the first fracture occurs (Nice, 2009). Peak bone mass as strong as the bone will become literature suggests is reached within women at about 30 years old (National osteoporosis society, 2007).
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