The assignment focuses on the promotion of oral health in the immunocompromised adolescent receiving chemotherapy. The client groups particular health education/promotion needs will be identified, followed by a detailed action plan, using authoritative literature and a theoretical framework, and discussion and critical evaluation of the strengths and weaknesses of the proposed plan of action.
The aim is to promote good oral health practices and minimise the severity of mucositis post chemotherapy. Corbett, (1991), suggests 90% of children receiving chemotherapy develop oral complications with factors such as dental caries, poor existing oral hygiene, age, inadequate self-care abilities, and nutritional state influencing its severity. Oral health is important, the presence of dental disease and mucositis affecting the most basic of human functions; communication, eating, social interaction, taste and breathing. It can be a dose limiting toxicity of treatment, (Graham et al, 1993, Dodd et al, 1996), and an important source of bacteraemia, which can cause life-threatening infections. (Dando, 1995). Combined with severe pain and distress, the impact is devastating.
Health promotion is based on many different theories about what influences people’s health and what constitutes an effective intervention or strategy to improve health. Nursing knowledge and skills are invaluable in empowering, supporting and teaching adolescents to achieve the potential for health. A theoretical framework facilitates the organisation of an effective plan of action. (Ewles and Simnett,1999).
The Specialist Practitioner role involves examining wider implications of service provision when identifying health promotion strategies for this client group. Advances in the control of nausea and vomiting and the introduction of colony stimulating factors to decrease the severity of aplasia have led to intensifying chemotherapy, increasing the potential for oral cavity breakdown, which still causes significant morbidity. (Berger and Eilers, 1998). Patients are often readmitted with oral problems associated with side effects of chemotherapy, which negatively impacts on quality of life. (Kennedy and Diamond, 1997). A rise in consumerism in health matters (Maben and Macleod Clark, 1995), an increasing number of long-term survivors, (Kissen and Wallace, 1995), and epidemiological shifts in disease patterns from acute to chronic morbidity all demonstrate the need for life-long oral health promotion. The specialist practitioner needs to ensure staff are involved with primary prevention of dental caries, secondary prevention, in promoting early detection and treatment and tertiary prevention in minimising potential complications relating to treatment, to give the best life chance benefits from health care. National objectives are laid out to improve the management of children’s services, through a shared governance approach (DOH, 1998), putting the patient at the centre of the care process.
There are many different models of health promotion (Becker, 1974, Ajzen and Fishbein, 1980, Tones and Tilford, 1993), but Becker’s (1974) Health Belief Model, promotes an individualistic health promotion ideology, highlighting the function of beliefs and attitudes in decision making. This is important in understanding the needs and characteristics of chronically sick adolescents, expected to follow unpleasant and disruptive treatments. Benner and Wrubel, (1989), identify that each kind of illness and disability create different demands for nursing care, but Zelter, (1980), asserts that it is more important to know what type of child has the disease.
The Health Belief Model suggests when people are faced with pressure to change their lifestyles they weigh up the potential costs to themselves with the perceived benefits, and make a decision accordingly, assuming that if the risks are great enough, behaviour will be changed (Purandare, 1997, Obeid, 1996). Buckingham, (1997), proposes this will determine compliance, of which attitudes play a large part. A family’s attitude to health and health beliefs will influence adolescents attitudes towards health care, as will personal attitudes such as self-esteem, self-perception, health locus of control and self-confidence. Purandare, (1997), advocates negative attitudes must be identified and dealt with before effective communication can take place, which can be achieved through an accurate Health needs assessment, which includes physical, psychological, social, educational, religious and cultural needs. The negative aspects of mucositis, such as intense pain and life-threatening bacteraemia, can then be changed into there being a reward for positive health behaviour, such as preventing or minimising complications. The Health Belief Model suggests cues to action may help motivate or maintain behavioural changes. The triggers may come from external sources, like a periodic reminder for a dental appointment or advice from nursing staff, or an internal source, such as prior pain and suffering of severe mucositis, which may improve the likelyhood of taking recommended action.
Rosenbaum and Carty, (1996), confirm the importance of peers, suggesting nursing interaction with young people be guided by issues related to the subculture of adolescence and the understanding that health and care have many meanings to adolescents. Whyte and Smith, (1997), support this view, stating adolescents report a therapeutic value from belonging to a peer group, which becomes increasingly important and influential in adolescence. Critics, however, suggest the Health Belief Model takes little account of the influence on an individual of the environment, family, friends and peer group, viewing health as a personal strength. (Buckingham, 1997). Environment is important, as the socio-economic status of the family appears to have the biggest negative effect on Health Beliefs, posing the greatest barriers to health care. (Buckingham, 1997). Glasper and Campbell, (1995), report a correlation between poverty and prevalence of illness, which makes it increasingly difficult to get patients out of the ill-health role.
Individual characteristics vary enormously, and in formulating an action plan factors need identifying that impact positive and negative patient education systems such as experience, knowledge, culture, language, attitude, literacy, motivation, age, level of ability, psychological mood, receptiveness, symptom distress and locus of control, which influence health promotion strategies. Hinds et al, (1992), indicate adolescents with cancer report higher symptom distress levels than children, possibly due to attaching a more negative meaning to the symptoms and having greater concern over their body image. Indeed, Enskar et al, (1997), identifies the adolescent’s own experience of areas of life situation affected by the disease, highlighting that physical side effects experienced during the treatment period, were seen as the worst aspect of the disease, influencing the ability to live the life they wanted. This relates to the Health Belief Model’s locus of control, the loss of which can lead to non-compliance. Psychological mood can also affect compliance, Borkoswka et al, (1998), suggesting that intermediate levels of anxiety may be optimal in predicting compliance. Low levels may mean the adolescent is not concerned enough to follow advice, whilst high levels indicate they may be unable to correctly interpret advice. The specialist practitioner is in a unique position to foster a supportive environment whereby nurses can provide appropriate counselling and psychological support.
A major goal of education is to gain patient compliance with oral health and self-care measures. Factors affecting compliance include the adolescent’s estimation of the seriousness of the problem, relating to perceived susceptibility. Adolescents who underestimate the seriousness have a greater possibility of non-compliance. (Olson et al, 1986). The main objectives are raising health awareness, improving knowledge, self-empowering, changing attitudes and behaviour and environmental change.
Current health promotion ideology accepts empowerment as enabling and supporting clients to acquire the skills and confidence to take greater control of their own health status (Rodwell, 1996). The specialist practitioner needs to assist the health educator in raising awareness of the wider factors determining health choices, so adolescents feel that significant control resides with themselves. (Downie et al, 1998). Schulmeister, (1991), attributes symptom distress as a potential to affect patients learning abilities. Components of the process of patient teaching therefore include assessing learning needs and readiness to learn, setting learning goals, teaching and evaluating learning.
A Successful plan of action will depend on collating the evidence, effective communication, meeting the information needs of adolescents, education needs of staff, developing a strategy for shared governance, promoting “Partnerships” and effective management of the change process. Identifying what resources are already available is important to determine what additional resources will be required. Examining existing government policies, service provision, facilities, material resources and evidence-based practice will assist this process. A literature search and communication with other oncology centres, alongside identifying current practice throughout the trust, will determine existing service provision and an evidence base. There is undisputed evidence relating to the benefits of oral assessment and dental health promotion. (Kenny, 1990, Beck, 1992, Dose, 1995, Madeya, 1996, Clarkson and Eden,1998), but studies of specific oral care protocols over the last 20 years, have failed to identify a consistent preferred agent to reduce mucositis severity, (Dodd et al, 1996). Government initiatives such as the National Institute of Clinical Excellence will assist in providing guidance and support through clear consistent guidelines about which treatments work best. (DOH,1997). The Young Oncology Unit currently utilises prophylactic Nystatin, which, Buchanan et al, (1985), suggest is of no value. Epstein et al, (1992), supports this claim confirming that compliance with Nystatin is limited by an unpleasant taste, nausea and vomiting, which according to the Health Belief Model would be a perceived barrier in relation to cost-benefit analysis. Nystatin also conflicts with dental health advice as it is sugary and decays teeth. This could be an inhibiting factor in promoting health in relation to perceived benefit, as a sufficiently threatened adolescent may not accept recommended health action unless perceived as effective. (Obeid, 1996, Purandare, 1997).
Evidence suggests normal toothbrushing with a soft brush twice a day, alongside professional dental care promotes good oral hygiene, (Beck, 1992, Gibson et al, 1997, Dose, 1995) which could be a motivating factor in conforming to peer group actions. Prophylactic Chlorhexidine mouthwashes may, in addition, benefit the severely immunocompromised patient, because of its proven prophylactic anti-fungal effect against candida. (Ferretti et al, 1990, De Beule et al, 1991, Dose, 1995).
The literature recommends all cancer patients have oral assessment and treatment of pre-existing disease prior to commencing chemotherapy, indicating the need to integrate medical and dental care.(Dose,1995, Madeya, 1996, Clarkson and Eden, 1998). This is a huge task considering the NorthWest has the worst child dental health record in England (Ashton, 1995), with only 65% of children in England even being registered with a dentist. (The Health Committee, 1996-1997). The Government is however, committed to improving the health of the population and existing policies will be a useful resource. (DOH,1998, NHSE,1998).
It is important to plan evaluation methods as evaluation is an integral part of the overall plan, and ensure effective documentation processes are in place. A detailed action plan can then be initiated which meets the needs and characteristics of the client group using the resources identified, whilst continually reviewing and monitoring the process to achieve the desired objectives.
Successful health promotion requires multi-collaborative working, networking, liaising, managing change and developing effective partnerships. (NHSE, 1998). The Health Committee Report, (1996-1997), repeatedly emphasises the importance of integrating services, whilst Casey et al, (1997), discuss the present fragmentation and lack of communication. The “UK Children’s Charter”, (NHSE, 1996), expressly states that all parents should have appropriate help and support from the community. Adopting a shared governance approach with the Doctors, Nursing staff, Pharmacist, Managers, School teacher, Dentist, Social worker, School nurse and Community team, will assist in integrating services, (DOH, 1998), and improving communication processes. This will help to establish clear lines of accountability and empower staff to take ownership of their own roles.
The specific information needs of adolescents’ need identifying as imparting appropriate, meaningful information may enhance self-care measures, increase self-esteem and decrease anxiety. The locus of control is then more likely to stay with the adolescent, facilitating the development of positive health beliefs, which may improve oral health promotion. In self-regulation theory, people form schemata of impending experiences. When people are faced with cancer, excessive amounts of new information must be incorporated into their schema. (Fieler, 1996). Health promotion and education may be difficult where the desired behaviour is unpleasant or doesn’t fit into their particular schema. Kanneh, (1991), advocates that failure to understand health education literature, or being denied access to it, can disempower young people. The psychological and social impact of cancer also makes information more difficult to absorb. Consideration needs to be given to user-friendly material in a suitable format and language and appropriate teaching strategies for individual needs, which will facilitate participation in the decision-making process. Working with Health Promotion units and Information forums may assist this process.
There is good evidence on which to promote oral health and immense organisation is required in preparing teaching and information packages, an oral assessment criteria and standards. The draft guidelines produced require dissemination to relevant personnel, which can also be fed through to local and national initiatives.
The benefits on a macro level are seen in terms of improved quality of care and patient satisfaction. Cost-benefit advantages may also emerge; a reduction in the incidence of preventable disease or morbidity, a lower re-admission rate, earlier recovery, less absenteeism from school, work or college and the acquisition of positive health related behaviours. (Palmer, 1994). There may also be reduced medication costs, particularly in relation to antibiotics where a decrease in usage is also of major importance in terms of resistance.
There are many strengths and several weaknesses to the proposed plan of action. The specialist practitioner needs to be proactive in facilitating learning of all members of the multi-disciplinary team in current oral health issues, to develop service provision. One strength is a shared governance approach helps staff to learn rather than teaching them, which will unlock their potential to maximise their own performance. The Specialist Practitioner can then act as facilitator and coach, bringing staff together and motivating them to achieve change. The patients needs also drive the system, important in the effective management of change. Multi-collaborative working utilising a shared governance approach will assist in the integration of services, particularly important in the increasing provision of community support, and provide an environment in which nurses feel valued, supported and empowered, which will enable nurses to support and empower their patients.
Becker’s (1974) Model is useful in developing an understanding of individual needs and characteristics, but can be criticised for taking little account of the influence on an individual of the environment, family, friends and peer group. It is an excellent model for addressing compliance issues, and promotes choice and control, an important aspect of our nursing philosophy.
On the macro level, the specialist practitioner needs to ensure nurses are fully aware of their role as health educators. It may be necessary to change the beliefs and attitudes of staff, which hasn’t specifically been addressed within the action plan. This is important as patients and staff don’t always consider the health-within-illness concept, which can provide the opportunity for positive change. (Moch, 1998). Wallace et al, (1997), found staff working in areas where stomatitis was most severe scored low on attitude compared with general medical units, believing they had little impact on the problem. Thoughts and actions of staff have not been well explored by the Health Belief Model, (Obeid, 1996), yet, in order to motivate staff, they too need to believe the patient is susceptible, see the perceived benefits to the patient, have some locus of control and perceive that the process for making the change will work.
Another weakness is that the Health Belief Model assumes all people are able to process information rationally. Some studies appear to support the hypothesis that giving patients more information reduces anxiety levels and promotes recovery. (Hagopian, 1991; Poroch, 1995), but there is evidence of contradictory results. (Miller et al, 1988, Wells et al, 1990, Ohanian, 1990). Indeed, Ohanian (1990) demonstrated that information needs of parents and adolescents are quite different, with parents more concerned with prognostic indicators, whilst adolescents highlighted the need for information relating to personal bodily concerns. Hinds et al, (1995), suggest not everyone desires information. Malin and Teasdale, (1991), advocate this theory would predict a nurse with an ideological commitment to empowerment could make some patient’s unnecessarily anxious if a blanket information giving strategy was employed without regard to individual differences.
Cultural attitudes haven’t been specifically addressed but are important so staff don’t transmit negative non-verbal cues whilst trying to impart positive verbal messages, resulting in mistrust and confusion. (Purandare, 1997). It is sometimes difficult to be non-judgemental and objective in working with families whose behaviours and attitudes differ from or conflict with our own. Whilst empowerment, information and communication is emphasised, in the wider context of other significant factors, the adolescent may induce a compromise in respect of care. What the health care professional may see as irresponsible may be what the adolescent sees as the most responsible action in the circumstances, and this poses ethical dilemmas in allowing the individual to control their own lives and still trying to facilitate what’s best.
Other weaknesses of the action plan are that in taking a behavioural individualistic approach, using the Health Belief Model, it assumes that each individual has the genuine freedom to choose a healthier life-style, but this may be limited by economic and social factors. Indeed, a study of a lower socio-economic status, predominantly black sample of adolescents, found no relationship between variables from the Health Belief Model and dental appointment compliance. (West et al, 1993). The specialist practitioner must therefore assist staff in working within the socio-economic framework of the family. (Glasper and Campbell, 1995). Also, where the proposed behaviour is accepted, it may induce feelings of guilt if the action taken does not work, which, in relation to mucositis cannot be guaranteed.
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