A Case Study of Edna

Therapeutic communication, psychological and sociopolitical influences, health determinants and service provision barriers that impede the delivery of communication; Edna and the community Nurse

This essay is about a community nurse for a patient-client named Edna; it outlines barriers associated with therapeutic communication, psychological and sociopolitical factors, health determinants, and service provision aspects linked to the delivery of communication between Edna and the community nurse. The communication barriers focused on community nurses for Edna's case involve old age lifestyle disorders, social isolation, low self-esteem, stress, and depression. Other therapeutic communication barriers that will be considered in Edna's case involves her lonely living and depressed nature, her aging body leading to possible low hearing and visual sensitivity. Psychosocial aspects considered in Edna's case include her profound commitment to religion, stress, and anxiety due to her deteriorated church commitment. Socio-economic issues relating to her inability to afford quality meals and total dependence on families will also be outlined. The paper will then focus on effective communication strategies meant to overcome these strategies and other appropriate services the community nurse prefers to enable recovery in Edna's medical care.


Effective therapeutic communication between the nurse and Edna

Leg ulcers greatly impacts many aspects of the patients life and unless the community nurse or clinician has experienced them, they cannot imagine their full extent. It is therefore important for the nurse to build a therapeutic relationship with the person with leg ulcers in the aim of achieving healing. Many studies have shown that leg ulcers negatively impact a person’s quality of life and various aspects of daily living (Anderson, 2012). Such factors place a direct negative pressure on the emotional well-being of the individual which can lead to social embarrassment, depression, isolation, anxiety and anger. In the case, Edna has been feeling increasingly socially isolated. Her dependence on other people is increasing and she can only manage to do simple tasks like preparing simple meals but is dependent on others for various chores. She misses her independence and resents having to be dependent on friends and family. Due to the multifactorial aspects that both quality of life and leg ulcers have, it is important for the healthcare provider to understand the impact that the ulcer has on the individual in order to develop a therapeutic relationship (Anderson, 2012). In order to improve communication as well as treatment concordance, it is advised that the care provider develops a partnership with the patient which involves working on a one on one manner and building a relationship. Concordance refers to a negotiation between equals and therapeutic alliance which suggests a process of agreement instead of yielding to others. It is through such negotiation that healthy leg behaviors can be developed and sustained. One important component of therapeutic relationships involves the need to foster autonomy in the person with the leg ulcer. The community nurse must respect Edna’s autonomy by being understanding and showing a willingness to listen to them and compromise. In the case, Edna looks forward to the visits of the community nurse, especially those who appear to be communicative and interested in what she has to tell them.

A vital point to remember is that in many instances it is the person with the leg ulcer who is the expert in the care of their own limb since it is after all their leg and they may have tried many different treatments. Therefore, their assistance and opinion should be sought throughout the process of care and they should be actively involved in their leg care as much as is deemed appropriately possible. The community nurse should develop good communication skills as well as a confident knowledge base to ensure this occurs. The nurses need to keep in mind that the way they speak to Edna will affect concordance and it is important to consider the way they use particular phrases. Experts advise the use of mitigated directives like ‘let me say’ or ‘maybe you can’ with the aim of aiding concordance and presenting more of a joint action with the patient. Mahoney (2016) points out that it is important to empathize with the patient suffering from venous leg ulcers in order to understand their concerns instead of just labeling them as difficult when faced with challenges. Additionally, Edna’s old age may have contributed to lifestyle disorders that inhibit the delivery of communication between her and the community nurse. Old age causes sensory loss, memory deterioration, retarded information processing, reducing of intensity and impact over their own lives, retirement from work, and division from loved ones. When aged patients feel the dire need to speak with their doctors, impacts initiated within life and physiologic influences make it more impossible.

Psychosocial and socio-political influences

Edna’s feeling of being socially isolated might impede communication with her community nurse. Her social isolation is attributed to the fact she has not attended church regularly as she used to in the last 18 months due to venous leg ulcers in both legs. She also feels increasingly isolated and possible stress leading to depression; this is because she is unable to be independent as she used to, in terms of being sociable and preparing her own meals and undertaking her chores by herself. However, now it is becoming more dependent on family and friends for shopping and assistance. The dependence factor which Edna was not initially used to also has the ability to contribute to lowering her confidence and self-esteem, impacting her ability to communicate. Social isolation is mostly associated with older people and those suffering from leg ulcers as their movement abilities become limited. This isolation is characterized by reduced social contact and feelings of loneliness, making the patient despise the need for communication for their reduced quality of life (Chamanga et al., 2014). The absence of social interactions and behaviors have been shown to impede the delivery of vital communication by the patient, in that the socially isolated patients have lower subsequent recovery rates, and are more likely to be psychologically distressed eventually. Consequently, it impedes the health process due to inadequate relay of information (Robinson et al., 2006). Social disconnects have been correlatively linked to higher levels of stress. Anxiety and stress, which eventually lead to depression due to limited social interaction, damages not only the physiological body functionality but also that of the nervous system's support cells. The human need for social interaction has been demonstrated as vital to enhance information sharing and it can act as a “lifesaving factor.” Social interaction is, therefore, very essential, especially in venous leg ulcer cases like Edna’s.

Therapeutic communication involves face-to-face interaction with the patient. This aims to improve physical and emotional patient well-being (Laffan, 2011). This method is used by nurses to deliver health care services and information to patients. Effective communication forms the basis of good nursing care. Conventional forms of nurse-patient communication are such as verbal and non-verbal communication, including body language, facial expression, gestures, and proximity between the nurse and the patients. Effective nurse-patient communication can overcome barriers. However, effective nurse-patient communication poses a major challenge for nurses and needs a lot of skills. Research studies have shown how social support is effective in controlling the effects of social isolation, such as stress, anxiety, and depression. By receiving social assistance, studies show that elderly people have challenges coping with high levels of stress as compared to young people (Robertson, 2005). Social support is strongly associated with feelings of mastery and the ability to deal with stressful situations, as well as strongly associated with increased quality of life. Thus, by increasing the amount of social interaction, support, and contact they receive, older people who experience social isolation can avoid the potential harm of physiological illness, cognitive impairment, and isolation emotions. To overcome the problem of possible neurological disorders such as loss of hearing and vision, the nurse should practice active listening. This is an important part of communication and requires listening for the content, intent, and feeling of the speaker. Active listening involves paying attention to what the patients say and allowing them to finish without judgment and interruption. Paraphrasing or echoing back to them what they have just said, and maintaining eye contact are also key elements of active listening (Robertson, 2005). The nurse should also consider paying attention to their non-verbal cues, such as facial expression, gestures, and eye contact. These skills can improve patient satisfaction and build trust over time.

The psychosocial and socio-economic issues in Edna’s case are inclusive of her dependence on family and friends for shopping and assistance and inability to afford quality meals. Edna's daily relationships with her family and friends have been impacted in that she only relies on them for support on shopping and assistance on chores. Her communication with them is affected as she already resents the fact that she has to depend on them, contrary to when she was independent. Social and economic factors such as income, employment, and social relationships significantly impact patient’s health and their lives (Kulkarni et al., 2008). The ability to select appropriate health services, afford quality medical care and housing, manage stress is dependent on these factors. The social and economic sectors in society, such as employment, schools, and strong social networks, are essential to achieving long and healthy lives. For example, employment provides income that determines decisions about health care, food, medical care, and other essential needs in the patient’s life. In contrast, unemployment limits these choices and the ability to accumulate savings and assets that can help cushion the health of the patient in times of economic distress. Edna's social status as a profound Christian may have affected her health and her way of life as a Christian impacted. She only looks forward to the community nurse visits and assistance from her family and friends. However, despite her being a regular church attendant and a sociable person, she does not anticipate any help from any of her fellow church believers whom she parted with 18 months ago. This might have caused depression affecting her health as these people had deserted her as their fellow believer triggering desperation as she even tries to communicate to the nurses, but they may not be interested in what she tells them.

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Health and social care services for support

In order to deal with the lifestyle issues that Edna is facing as well as possible comorbidity and non-adherence issues, the community nurse can introduce her to the Commissioning for Quality and Innovation Framework (CQUIN). The framework involves improving assessment of wounds as a national indicator in the UK and it includes tools that can be embedded in practice. It also incorporates standardized assessments, and lower-limb assessment algorithms based on best practice statements in the management of venous leg ulcers (Wounds UK, 2016). In addition, it incorporates assessment documentation which includes a quality of life consultation template which would be appropriate in addressing Edna’s quality of life issues. A 24 week venous leg ulcer treatment pathway can be introduced for Edna where the community nurse assesses her every four weeks to check the progression of the ulcers as per the healing trajectory. In case of discrepancies, a tissue viability team can be contacted for support and if referral to other specialties is necessary, the tissue viability team can liaise with general practitioners. Evidence has shown that the framework is effective and successful. Between January and August 2018, among 50 patients who entered the CQUIN pathway, 48 had been healed by the end of 24 weeks with the mean healing time of all patients being 2 months (Clarke, Felgate and Webb, 2019). Surveys, quality of life tools as well as thank you cards showed that the satisfaction as well as the quality of life of the patients had significantly improved.

Social care services that can be rendered to Edna's situation can be associated with her profound religious church faith. The church can provide hope and comfort through prayer and special services like sacraments, which are usually given in times of sickness or end of life. The church acts as an organization to provide spiritual support, a point of hope, and Holy Communion to enhance healing and recovery.

This paper observes Community nurse for Edna's medical situation, it has outlined social isolation, old age lifestyle conditions and socio-economic factors and how they impede communication between the nurse and the patient, and also how the issues impact the healthy daily life of the patient. The nurse's ability to overcome these barriers by active listening and ensuring concordance by forming a therapeutic relationship with Edna and taking into consideration her opinions can be effective in enhancing communication. To support the health of the patient, their recovery from the ulcers and improved quality of life, the community based CQUIN framework is highlighted as well as evidence of its effectiveness among leg ulcer patients.


ANDERSON, I. (2012). Encouraging compliance and concordance in leg ulcer patients. Wounds UK, 8(1).

Chamanga, E., Christie, J., & McKeown, E. (2014). Community nurses' experiences of treating patients with leg ulcers. Journal of community nursing, 28(6), 27-34.

Clarke, C., Felgate, C., & Webb, A. (2019). Improving venous leg ulcer care in community services. Nursing Times, 115(9), 24-25.

Kulkarni, A. V., Cochrane, D. D., McNeely, P. D., & Shams, I. (2008). Medical, social, and economic factors associated with health-related quality of life in Canadian children with hydrocephalus. The Journal of pediatrics, 153(5), 689-695.

Laffan, S. (2011). Therapeutic Communication and Behavioral Management.

Mahoney, K. (2016). A simple and effective solution to preventing recurrent venous leg ulcers. Journal of community nursing, 30(4), 24-28.

Robertson, K. (2005). Active listening: more than just paying attention. Australian family physician, 34(12), 1053.

Robinson, T. E., White Jr, G., & Houchins, J. C. (2006). Improving communication with older patients: tips from the literature. Family practice management, 13(8), 73.

Wounds, U. K. (2016). Best Practice Statement: Holistic management of venous leg ulceration. London: Wounds UK.

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