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Transforming Nursing Practice

Introduction to Multimorbidity and Situational Complexity in Nursing

According to Zhou et al. (2016), medical complexity is defined as a condition in which due to chronic health conditions multiple organs are affected resulting in functional limitations, high resource need/use, and ongoing use of medical technology. The health professionals or nurses identify complexity based on the consequences of behavioral conditions or medical conditions, family/work stressors, the social context that influences health. If the patient is provided with patient-centered care then he/she can improve his/her health and such care support the providing of high-quality primary care with complex needs patients. Moreover, coordinated care and comprehensive care can help such medically complex patients (Howard et al., 2017). However, the barriers to serving such medically complex patients include lack of care continuity – patient involvement in unhealthy practices like alcohol consumption or no regular physiotherapy sessions. In some cases, the patient cannot manage with different health care sessions/appointments with different professionals or poor involvement of patient-family in health care (Foo et al., 2020).

The Elements Leading to Medical Complexity

In this case study, the elements of Ben’s medical history that contribute to him being classified as medically complex are his accident that resulted in a fusion of L4-L5 spinal vertebrae. This resulted in associated medical issues of chronic lower back pain and Ben also had a medical history of post-traumatic stress disorder PTSD. His long hours of sitting along with the vibration of the heavy earthmoving equipment aggravated his lower back and these act as a trigger for his PTSD. He is increasingly relying on pain medications like ibuprofen and panadeine forte, to get through the day and sleep at night. He is feeling increasingly depressed, has increased alcohol intake, regular psychiatrist appointments still facing increased depression as he has shifted to his parents where he cannot continue his gyms or health care sessions. All these elements combine to affect his health and make him medically complex. This is so because a patient with PTSD develops feelings of anger and anxiety, Ben is already suffering from increased depression and stress as he cannot live life and work normally like he used to do before.

Increased alcohol intake can take make the situation of the patient medically complex by worsening the conditions because more alcohol intake increases PTSD symptoms (Bradley & Martin, 2020). Physiotherapy sessions shows improvement in chronic lower back pain but if the patient do not continue with their sessions then it may have a negative impact on their health (Sullivan et al., 2019). Thereby, putting Ben in a more medically complex situation. It is also found that Ben’s family is also not interested in his medical condition as the mother does not want to talk about his condition and the father is not interested in medical therapies related knowledge. Family involvement in patient-centered care can result in providing effective care in improving the patient’s quality of life. Moreover, the impact of the workplace, peer, or family environment affects the depression or stress of the patient (Khamisa et al., 2017). In this case, Ben is feeling frustrated at his workplace and his health condition makes him more stressed and depressed ultimately complicating his medical situation.

The Conflicting Treatment or Management Elements

A nursing care management plan contains all of the relevant information about the patient’s goals of treatment, the patient’s diagnoses, an evaluation plan, and the specific nursing orders. According to Gonçalves et al. (2016), care plans can increase adherence to guideline recommendations, reduce or delay hospitalization, enhance self-management practices, and improve processes and clinical outcomes. In a nursing care management plan for patients with chronic pain and depression along with medical complexity, there are a few nursing interventions. These are cognitive-behavioral therapy (CBT), interpersonal psychotherapy, physical exercise, motivational interview, relaxation, physiotherapies, and medications. A multimodal treatment plan and should aim to increase self-efficacy, increase coping, and self-control skills regarding the illness (Gonçalves et al., 2016). However, there can be conflicting treatment or management elements in the care plan of the patient. 

In this case study, Ben is supposed to continue to engage in regular psychotherapy sessions and regular psychotherapy sessions for his PTSD. He is supposed to attend regular psychotherapy sessions for depression and physiotherapy and orthopedic sessions also. The conflicting treatment plans because he does not have to take separate psychotherapy sessions for depression and PTSD as a psychotherapist can assist with both health issues. This saves the patient’s time that was earlier divided due to attending two separate sessions. Moreover, he is recommended with three non-steroidal anti-inflammatory drugs like ibuprofen, panadeine fort, and oxycodone, these have side effects of depression in some cases (Kohler et al., 2016). Therefore, Ben who is already suffering from depression, the administration, or the use of these drugs can worsen his condition. So, regular tests should also be conducted for Ben to ensure that no such situation arises. According to Markowitz et al. (2016), the psychotherapy sessions can help in treating depression and PTSD as it relieves the symptoms. It helps to identify the factors that trigger to increase or evoke the symptoms. A regular assessment should also be done to track the progress report.

The Situational Complexity Act as Barriers to Nursing Management

The situational complexity can impact a great level on the health of a person/patient. The complexity resides in the social, medical, and personal management of a condition and it includes various factors like personal factors, environmental factors, and activities, and participation. In this case, Ben develops more pain due to his lower back issues so he took leave from his offices ended him with frustration as he had to work a desk job. Before his accident, Ben had a very active role as an infantry soldier and felt frustrated by the restricted duties due to his injuries. It is also seen that Ben did not like to discuss with others about his health issues. According to George et al. (2018), if proper communication occurs then effective care can be provided to the patient. After a patient tells about how he feels, his pain, or his feedback, only then an effective and comprehensive care plan can be made for him after assessing his feedback. Moreover, Ben has also started taking a high amount of alcohol because this helps him feel better and forget about his pain. Alcohol is taken by the patient as it acts as a depressant for their pain but it simultaneously impacts the health negatively (Gutmane et al., 2019). This alcohol intake affects his nursing management as alcohol addicts may show withdrawal symptoms, might get more aggressive or depressed, develop liver associated issues like liver damage or jaundice, and would then require to manage time to attend sessions for quitting alcohol and related medications. Moreover, living with his parents also acts as a barrier to his nursing management as he cannot attend his sessions or gyms regularly resulting in poor quality of care as he will not be assessed regularly as before.

Multimorbidity Impact Diagnosis and Treatment

The condition of multimorbidity can impact diagnosis and treatment for complex patients (McPhail, 2016). If a patient had a history of PTSD and presently suffering from severe depression or stress then he should be diagnosed with alcohol or drug addictions as such patients develop an addiction to relieve their pain (McPhail, 2016). A patient with multimorbidity affects his/her treatments as well because for different health issues like depression or chronic pain is to be treated by different professional health care sessions that might not correlate with each other. Like for lower back pain, depressant, and pain killers are provided to enable the patient with good sleep but these medications can elevate the depression levels in the same patient as well. A multimorbidity patient receives health care services from a variety of health care providers like physiotherapists, psychologists, or nurses and they also attend different group sessions or therapies for getting improved health care results (McPhail, 2016).

Conclusion on Multimorbidity and Situational Complexity in Nursing

The health professionals or nurses identify complexity based on the consequences of behavioral conditions or medical conditions, family/work stressors, the social context that influences health. Many factors like social, biological and psychological can contribute to making a patient medically complex. The nursing management plan can also provide complicating treatments. The situational complexity can impact a great level on the health of a person/patient. The complexity resides in the social, medical, and personal management of a condition and it includes various factors like personal factors, environmental factors, and activities, and participation. Moreover, the condition of multimorbidity can impact diagnosis and treatment for complex patients.

References for Multimorbidity and Situational Complexity in Nursing

Bradley, A., & Martin, A. (2020).Reviewing the burden of comorbidity in patients receiving specialist in-patient treatment for drug and alcohol problems. BJS Sych Bulletin, 1-6. https://doi.org/10.1192/bjb.2020.4

Zhou, H., Roberts, P., Dhaliwal, S., & Della, P. (2016).Transitioning adolescent and young adults with chronic disease and/or disabilities from paediatric to adult care services - An integrative review. Journal of Clinical Nursing25(21-22), 3113–3130. https://doi.org/10.1111/jocn.13326

Foo, K. M., Sundram, M., &Legido-Quigley, H. (2020). Facilitators and barriers of managing patients with multiple chronic conditions in the community: A qualitative study. BMC Public Health20(1), 273. https://doi.org/10.1186/s12889-020-8375-8

George, S., Rahmatinick, S., & Ramos, J. (2018). Commit to sit to improve nurse communication. Critical Care Nurse38(2), 83-85. https://doi.org/10.4037/ccn2018846

Gonçalves, P., Pereira, N., Ribeiro, A., & Santos, C. (2016). Nursing interventions in patients with chronic pain and depression: A systematic review. The European Proceedings of Social & Behavioral Sciences. http://dx.doi.org/10.15405/epsbs.2016.07.02.2

Gutmane, E., Suna, N., Tomilova, A., Liepina, L., Folkmanis, V., & Karelis, G. (2019). Alcohol-related seizures may be associated with more severe depression, alcohol dependence syndrome, and more pronounced alcohol-related problems. Epilepsy & Behavior91, 81-85. https://doi.org/10.1016/j.yebeh.2018.10.023

Howard, S. W., Zhang, Z., Buchanan, P., Armbrecht, E., Williams, C., Wilson, G. & Loux, T. (2017).The effect of a comprehensive care transition model on cost and utilization for medically complex children with cerebral palsy. Journal of Pediatric Health Care31(6), 634-647. https://doi.org/10.1016/j.pedhc.2017.04.017

Khamisa, N., Peltzer, K., Ilic, D., & Oldenburg, B. (2017). Effect of personal and work stress on burnout, job satisfaction and general health of hospital nurses in South Africa. Health SA Gesondheid22(1), 252-258. DOI:10.1001/jama.2019.9058

Kohler, O., Krogh, J., Mors, O., &Benros, M. E. (2016).Inflammation in depression and the potential for anti-inflammatory treatment. Current Neuropharmacology14(7), 732–742. https://doi.org/10.2174/1570159x14666151208113700

Markowitz JC, Meehan KB, Petkova E, &Nazai, Y. (2016).Treatment preferences of psychotherapy patients with chronic PTSD. Journal of Clinical Psychiatry, 77(3), 363-370. DOI:10.4088/JCP.14m09640

McPhail S. M. (2016). Multimorbidity in chronic disease: Impact on health care resources and costs. Risk Management and Healthcare Policy9, 143–156. https://doi.org/10.2147/RMHP.S97248

Sullivan, N., Hebron, C., & Vuoskoski, P. (2019).“Selling” chronic pain: Physiotherapists’ lived experiences of communicating the diagnosis of chronic nonspecific lower back pain to their patients. Physiotherapy Theory and Practice, 1-20. https://doi.org/10.1080/09593985.2019.1672227

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