Assessment of Health Issues in Gideon

1. The Patient

The purpose of this case study is to identify a current health issue and provide an assessment of a simulated case study using the Roper-Logan-Tierney Model 12 Activities of Living (AL’s) (Roper, Logan & Tierney 2000). The identified AL’s to be used for this simulated case study are sleeping, eating and drinking and breathing. Furthermore, there are five Biopsychosocial influence factors related to current health issues which are part of the 12 AL’s (Holland, Jenkins, Solomon, & Whittam, 2008), which will also inform subsequent discussion. In order to ensure the confidentiality of those involved (Nursing and Midwifery Council [NMC], 2018), the patient is referred to as ‘Gideon’, a pseudonym,. No personally identifiable information will be included in this case study. Gideon is a 69-year-old male and a retired painter, living on his own with his modest public pension. Gideon and his wife did not have children and they never maintained a close relationship with family members. The death of his wife had resulted in him suffering depression. He also doubled the number of cigarettes he smoked per day (from 10 to 20 cigarettes). During this time, he became more isolated from his community. He displays signs of lack of personal care, and appears frail and unkempt. He was an active man who enjoyed playing golf and singing in the local choir of his church. However, he had to give up these activities due to continuing breathlessness, exhaustion, anxiety, and drowsiness. He feels worthless because he cannot cope with normal daily activities as before. Gideon was diagnosed with chronic obstructive pulmonary disease (COPD) three year ago. He has not been using any prescribed inhalers or prescribed medication since his wife passed away last year. While determining current health condition of Gideon, it seen by local doctor that, he has a BMI rate (Body Mass Index) 17. As mentioned by Powell (2019), BMI is defined as value that can be calculated through dividing body mass (weight of a person in kg) of a person by square of height of that person. Gideon also suffers from respiratory abnormalities, breathing issues with breathing rate is 8-10 breaths per minute [normal is 12-20 breaths per minute] and continuous cough from the last few months. He has also sleep disturbances, high level of depression and anxiety. He had been taken by neighbor to the city hospital in which he was diagnosed with lung infection which is the potential, reason behind occurring COPD. The diagnosis also shown that his oxygen saturation level is lower with only 77%. while admitted into hospital he was provided nebulizer in terms of assisting him to get 100% oxygen which improve his breathing issues. in addition to this, while conducting National early Warning Score (NEWS) for detecting the clinical deterioration of Gideon, health professional has seen that Gideon has a NEWS score 2, that usually point out to the respiratory issues and lung abnormalities.

2. Body system

2.1 Normal Function of the Respiratory System

Gideon’s COPD impacts upon the respiratory system because the condition affects the normal functioning of the lungs. The respiratory system consists of a series of organs that facilitate the breathing process (Miles & Cook, 2017). Functioning normally, the respiratory system allows people to inhale oxygen through the nose and direct it to the sinuses that regulate the temperature of the air (Broaddus et al., 2016). From the sinus, air flows into the bronchial tubes via the trachea (Broaddus et al., 2016). The bronchi divide into smaller tubes that are known as bronchioles, and that forms tiny air sacs called alveoli. Each alveolus contains a fine network of capillaries that facilitates gaseous exchange, and the air sacs produce a thin film of moisture that dissolves oxygen molecules before releasing them to the bloodstream (Broaddus et al., 2016). Oxygenated blood then flows to the heart where it is pumped to the rest of the body through the circulatory system. The air sacs produce a thin film of moisture that dissolves carbon dioxide as it crosses from the capillaries (Broaddus et al., 2016). In this way, the respiratory system absorbs oxygen and releases carbon dioxide through the breathing process (Miles & Cook, 2017). A figure of the normal respiratory system can be found in Appendix 1.

2.2 How COPD Alters the Normal Function of the Respiratory System

COPD affects the functioning of the respiratory system and causes difficulty in breathing (Popper, 2017; Brooker & Waugh, 2013). In this case, Gideon’s condition has led to the malfunctioning of the alveoli that allow oxygen to diffuse into his blood (Rabe &Watz, 2017). Gideon’s alveoli have formed large air pockets, bullae, that do not allow normal gaseous exchange in the lung (Popper, 2017). The large bullae hinder lung tissue from expanding properly when Gideon is breathing, thus limiting his lung function (Popper, 2017). The damage to the air sacs have decreased the level of oxygenated blood and resulted in increased carbon dioxide that has caused Gideon’s shortness of breath. Also, the patient shows signs of damaged bronchial tubes that further complicates his breathing process. Waugh and Grant (2014) state that the lung usually produces a small amount of fluid to support the respiratory system. However, in Gideon’s case, damaged bronchial tubes have altered the normal function of his lungs by causing an over-production of fluid that makes him frequently cough (Warchoł, 2018). Not only does this cough act as a clinical marker of COPD (Warchol, 2018), this common symptom of the condition seriously impinges on the quality of life of individuals with it (Deslee et al., 2016). A figure of the changes to the respiratory system caused by COPD can be found in Appendix 2.

3. Activities of Living

Psychological– relates to mental and intellectual activity

Sociocultural– relates to ideas, values, knowledge and beliefs

Environmental – housing, the atmosphere, noise and sound

Politico-economic – the impact of economy, law and politics on the individual

3.1 Sleeping

The first AL to be discussed is sleeping. Gideon’s sleep issues are as a result of COPD and smoking. Smoking cigarettes contributes to sleeping problems such as insomnia; for example, according to Brook et al. (2015), cigarette smokers are twice as likely to document inadequate rest and sleep, compared to non-smokers. Those who smoke display insomnia symptoms like rapid eye movement, higher sleep latency, shorter sleep duration, frequent leg movements, and episodes of sleep apnea (Liu et al., 2013). This is attributable to nicotine, a highly addictive substance (Liu et al., 2013). The substance acts as a stimulant to keep Gideon awake and alert (Brook, Zhang, Seltzer, &Brook, 2015). Obstructive sleep apnea is the most prevalent sleeping problem among smokers, and is triggered by the collapse of the throat muscles during sleep (Vries, Ravesloot& Van Maanen, 2014). COPD further impairs quality of sleep, further contributing to sleepiness, chronic fatigue, and poor quality of life (McNicholas, Verbraecken, & Marin, 2013; Stephanie et al., 2018). Patients with wheezing or nocturnal cough experience difficulties maintaining or initiating sleep, resulting in excessive sleepiness during the day (Celik&Ozkan, 2018). Spiegelhalder et al. (2013) confirm that adults suffering from insomnia tend to be depressed and anxious. Therefore, cigarette use, age progression, and the presence of chronic conditions are disrupting Gideon’s sleep. Addressing these issues is vital to improving Gideon’s quality of life

3.1.1 Biopsychosocial factors and sleep

3.1.1.1 Biological – Gideon’s current sleep pattern is poor, and consists of going to sleep late at night and waking throughout the night. The former issue is a likely result of nicotine acting as a stimulant on the body, whilst the latter is the result of the COPD-related cough. The lack of sleep is a concern on a biological level because if prolonged in nature, this can cause a number of further health issues (Tobaldini et al., 2017). This includes being less able to fight off infection, which considering his frailty, would be a concern. One approach to helping this would be for Gideon to receive support from community nurses regarding sleep hygiene techniques as per NICE (2019) guidelines.

3.1.1.2 Psychological – Gideon’s sleep can be seen to be negatively impacted by both his depression and his anxiety. Depression, which Gideon experienced following being widowed, is associated with difficulties sleeping (Cho et al., 2017). He is anxious about sleep as well, mainly due to his experiences of waking up in a coughing fit, which he finds very distressing. Whilst these factors are linked to poor sleep, poor sleep is known to further impact on depression and wellbeing (Lotfalianyet al., 2013), thus creating a cycle which needs to be addressed as a matter of priority.It is therefore important that Gideon’s mental health is closely monitored and supported by community mental health nurses, or via psychologists or assistant psychologists if he has access to an Improving Access to Psychological Therapies (IAPT) team.

3.1.1.3. Socio-cultural: In case of Gideon, his sleep pattern is influenced by different socio-cultural factors such as his beliefs, perception, values and assumption regarding healthy living and maintain safe activities in improving eth quality of daily living. Gideon has negative beliefs, values and perception reading his health and wellbeing that impact adversely ion his sleep pattern. This is the reason why he does not sleep and walk through the night. As mentioned by Stephanie et al. (2018), social perception, values and beliefs impact on eth behavior, cognition and activities off living for individuals. I, case Gideon, he is full of negative beliefs and superstitions that adverse impact on this sleep. On the other hand, the social perception and cultural norms play important roles in influencing the activities of living of people. In case of Gideon, as he is social excluded due to his anxious and depressive behaviour, thus social isolation as well as cultural unsupportiveness pose harmful impact on his overall biological system that control eth sleep pattern in human being. In addition to that, cultural context such as traditional approach of people onwards depressive individuals pose negative impact on brain functioning and biological system of Gideon, who leads to unorganized as well as poor sleeping habit.

3.1.1.4. Environmental: Environment is one of the most important biopsychosocial factors which impact on the sleeping pattern on individual (Scoditti et al. 2019). The environment that bis maintained in the ward in which Gideon is admitted pose important impact on his sleep. Although, Gideon has poo health condition with COPD, lung infections and breathing difficulties, he has proper senses regarding the hazardous environment that can dangerous for his health and wellbeing. Gideon ‘s sleep pattern is associated with his concern about whether the hospital environment is safe for his health and wellbeing. Gideon needs hygiene and safe environment in hospital ward in which he is admitted. As Gideon faces sleeping difficulties it can be connected to the fact that, may be there is lack of safe and positive environment in hospital ward that make the mental and physical disturbances in him which is associated with devolvement of unorganised sleeping pattern. On the hand, the chances of environmental hazards in the hospital such as fire hazards, procedural hazards and technical hazards are linked to the poor sleeping process and unorganized sleeping pattern in Gideon

3.1.1.5. Politico-economic: The unorganized sleeping pattern and short duration of the sleep in Gideon can be linked to the politico-economic factors such as lack of proper resources in providing proper technique and clinical intervention in terms of assisting Gideon to get rid of poor sleeping pattern. As mentioned by Sánchez-Valle et al. (2017), lack of proper infrastructure in the healthcare is associated with inability to provide the quality care service that is linked to the unorganised sleeping patter in patients. in case of Gideon, sleeping disorder can be linked with lack of resources, lack of proper healthcare staffs, poor infrastructure and lack of modern techniques as well as innovative clinical intervention process needed for improving the functionating of mental and physical heath aspects that are associated with proper sleeping system in human being.

3.2 Eating and Drinking

The second AL to be discussed is eating and drinking. Gideon is 69 years old, and eating healthy and drinking liquid is paramount to avoid dehydration and malnutrition. Dehydration and malnutrition result in poor health outcomes, along with increasing hospital stays, failed discharges, and high mortality rates (COPD British Lung Foundation, 2017). Physical frailty and health complications make older people at risk of dehydration (British Nutrition Foundation, 2015). Gideon avoids drinking to minimise the need for toilet visits, which he finds hard to reach in time due to his breathlessness. Undernourishment is caused by poor appetite, inadequate dietary intake, weight loss, and muscle wasting (Rasheed &Woods, 2013). Gideon’s undernourishment is due to his low socioeconomic status, smoking, and inadequate dietary intake, issues that are threatening his quality of life.Gideon’s diet is unhealthy and imbalanced due to consisting mainly of toast and butter. He feels that he cannot eat properly because of his shortness in breath. Gideon is at risk of becoming malnourished and dehydrated. People with COPD are advised to limit their consumption of foods containing saturated and trans fats like butter (Lewthwaite et al., 2018). However, it is evident that Gideon lacks this knowledge because his meal comprises of butter and toasts, a situation that will worsen his condition. Gideon requires social support interventions to improve his health outcomes and prevent his condition from deteriorating further.

3.2.1 Biopsychosocial Factors: eating and drinking

3.2.1.1. Biological – Gideon’s intake of fluids is impacted upon by his physical state; he feels he cannot make it to the toilet in time if he needs to urinate, due to both weakness in movement and breathlessness caused by this exertion. Hence, he limits his fluid intake to a minimum. His frailty precludes him from going outside to the community to shop for groceries other than the bare essentials. This lack of adequate nutrition will only further exacerbate these problems, again creating a cycle which both maintains and increases the nature of these issues. His community nurse could give him so health promotion advice regarding this, as well as seek to provide him with a commode so that he can more easily perform toileting functions without fear of having an accident.

3.2.2.2. Psychological: In case of Gideon, his loss of appetite, poor nutritional intake, poor diet and undernourishment can be linked with his poor as well as unorganized mental condition. As mentioned by Viniol & Volgelmeier (2018), nutrition is one of the most important factors that is associated with having healthy mental health. Poor nutrition and poor diet leads to wight loss, lack of proper physical strength and poor muscle activities in Gideon. The poor physical strength impact on et overall thoughts, decision making process and self-confidence of Gideon. This is why Gideon often shows mood swing, unorganized behavior and poor problem-solving skill. In addition to this, the eating disorder in Gideon is strongly associated with poor assumption, analyzing skill, perception and interpretation which make Gideon unable to interact with people surrounding him in proper manner.

3.2.2.4. socio-cultural: The social perception, social beliefs, values can be linked to the behavior, menta condition and physiological condition of Gideon. As mentioned by Waugh & Grant (2018), socio-cultural aspects such as cultural trend, social values and beliefs are connected to the mentality and behavior of people. In case of Gideon, his eating disorder is associated with poor social perception, negative social thoughts and social isolation. After his wife’s death, who was the decider of his overall diet and nutrition, Gideon was unable to take care of his own health and wellbeing. His depression and odd behavior make him isolated from society which not only impacts on his mental and physical condition but also on his activities of living such as eating process. The social unsupportiveness, lack of positive culture and poor social values are linked with unorganized and poor nutritional intake by Gideon.

3.2.2.4 Environmental: Hospital environment is associated with poor eating behavior and eating disorder in Gideon. According to Stephanie et al. (2018), negative and unhealthy environment is associated with eating disorder in patients. Gideon resides in poor as well as unhealthy environment framework within hospital with full of safety and health risk. There is huge conflict between care managers and are staffs, which most of the times makes it difficult for Gideon, to get proper nutritional food at right time. On the other hand, the unhygienic environment in the ward often makes it impossible to take the food that is served to him without maintaining any safety and hygiene.

3.2.1.2. Politicoeconomic – Gideon's diet is unidimensional in nature and lacking in the nutritional intake to remain healthy. His wife used to do all of the cooking and food shopping and since her death he has not felt able to learn how to cook. He also does not have sufficient technical skills to conduct online grocery shopping - which would have prevented the physical exertion of going out shopping. Developing an enhanced knowledge both of food preparation and in using the internet would empower Gideon to improve his nutrition and health (Hollywood et al.,2017).An occupational therapist would provide such input and would be able to work with Gideon on functional adaptations as well as skills development.

3.3 Breathing

COPD obstructs bronchial airflow, the reason behind Gideon’s breathlessness. Maltais (2013) states that a person diagnosed with COPD condition displays symptoms like wheezing, breathlessness, and coughing. Others might experience nocturnal symptoms, such as sleep disturbance accompanied by airway constriction. In the elderly population, chronic obstructive pulmonary disease (COPD) is characterised by the deterioration in respiratory function. The situation is worsened by co-morbid conditions like muscular de-conditioning and cardiac disease (Jayadev& Gill, 2017). Gideon’s breathing difficulties are caused by COPD and worsened by his smoking habit. His respiratory function is also undermined by his physiological and anatomical changes triggered by the aging process (Waugh & Grant, 2018; Peate, Nair, &VLeBooks, 2016). Additionally, his smoking habit contributed to his development of COPD conditions. 50% of smokers develop COPD, and it is advisable to stop smoking once diagnosed with the condition (Eklund, Nilsson, Hedman, & Lindberg, 2012). If Gideon does not stop smoking, he might damage his respiratory health, which might be irreversible. Crisafulli, Barbeta, Lelp, & Torres(2018) posit that intermittent cessation or smoking cessation reduces the decline in lung functioning caused by tobacco smoke while reducing exacerbations risks. Additionally, Gideon must access behavioural support, pharmacological treatments, and counselling to manage his condition. However, because of his nicotine dependence, Gideon might find it challenging to quit smoking.

3.3.1 Biopsychosocial Factors:

3.3.1.1 Psychological - As noted above, smoking cessation should be considered a priority when COPD is diagnosed. However, Gideon does not have a strong sense of self-efficacy regarding his ability to do this, and displays low levels of motivation to do so. Any behavioural change such as smoking cessation relies upon both motivation and self-efficacy (Hughes &Naud, 2016). In order to help Gideon’s breathing, smoking cessation should be a priority, and work will need to be done to empower him in this process (Hughes &Naud, 2016).Specialist smoking cessation services should be accessed to support him with this, although some motivational work conducted by his community use may benefit the uptake of this.

3.3.1.2 Sociocultural - Gideon’s health beliefs related to smoking are very entrenched in linking it to his identity. He notes that smoking is 'what a man does' and that he has done it all his life. He also states that 'you can't teach an old dog new tricks’. When he was working, all of his colleagues and friends smoked, and looked down upon those who tried to quit smoking. These beliefs represent a significant barrier to Gideon's uptake of smoking cessation support. Whilst respecting everyone’s right to opinion, these views may be able to be challenged during initial motivational work with his nurse, and by the smoking cessation staff that may work with Gideon in the future.

3.3.1.3. Biological: As Gideon, is COPD patient he has poor respiratory activities due to lack of capacity of lungs to supply enough oxygen to the cells (Stephanie et al. 2018). Lung is infected with cough in Gideon, that reduces the diameter of the inner wall of the alveoli, which reduce the overall oxygen supply from lung to cells. In addition to this, respiratory issues also are associated with poor functioning of other organs, as poor oxygen supply makes all the organism unable to perform well. Reduced oxygen supply in cells not only associated with poor physical; activities but also with poor mental and brain functioning which leads to lack of proper decision-making skills and negative sills.

3.3.1.4. environmental: The poor hospital environment with lack of hygiene condition, poor infrastructure, lack of proper sanitization and lack of positive environment in the hospital is associated with breathing difficulties in Gideon. In addition to this, unhygienic condition in hospital generate dust that may infect the lung as well as alveoli’s which in turn can cause breathing difficulties and respiratory disorders.

3.3.1.5 Politico-economic: Lack of infrastructure and lack of proper healthcare staffs and poor mechanism as well as technique can rise the breathing difficulties and COPD issue in Gideon. The lack of proper ventilation system and nebulizer also can enhance the breathing risk for Gideon.

4. Health and Social Care Agenda 750 WORDS

4.1 Overview of the aims of the Health and Social Care Delivery Plan

The primary objective of the Health and Social Care Delivery Plan (2016) is to support self-management, early intervention, and prevention of various health conditions among the Scottish population. The plan is located upon pillars: Better care, Better health, and Better value.

Better Care: The plan ensures that every citizen access the right helps at the right time. The plan encourages healthcare providers to shift from just providing services to people to including them in their distinct aspects of support and care. Ideally, patients must be offered the control, dignity, freedom, and choice over their care. For people with complex and chronic conditions, they must be helped and supported in managing their health conditions over the course of their lives.

Better Health: The plan advocates for the shift from fix and treat strategy to one that is founded on self-management, prevention, and anticipation. Collaboration between healthcare providers is a must in creating a culture that embraces healthy behaviours from childhood through adulthood. The plan also acknowledges the importance of mental and physical health and tackling conditions undermining one’s health.

Better Value: The Health and Social Care Delivery Plan (2016) concentrates on delivering value using the available resources. Balancing healthcare delivery in community care settings, hospitals, and individual homes is crucial in improving the value of care accessed by individuals.

4.1.1 Gideon’s and Health and Social Care Delivery Plan

COPD, as a long term condition, COPD contributes to a significant burden on healthcare resources made scarce due to a decade of economic austerity (Powell, 2019). When treating long term conditions, one of the key priorities is enhancing the level of self-management the patient can engage with (Morgan et al., 2017). This is because self-management has been linked with reduced health resource usage and improved quality of life (Barker, Steventon,Williamson & Deeny, 2018). The Social Care Delivery Plan requires nurses and allied professionals to encourage self-management programs to enhance the sustainability of the healthcare system. Gideon’s condition has been deteriorating because he lacks information about managing COPD. He continuous to smoke, exposes himself to poor air quality, and has an unhealthy diet. The plan encourages healthcare providers to work with patients such as Gideon to support them in managing their complex health conditions. Using the Social Care Delivery Plan, clinician's must work with Gideon to design an intervention plan that meets his needs. The plan should revolve around smoking cessation and self-management approaches like adhering to a healthy diet, being physically active, and adhering to treatment regimen. Health professionals must incorporate the Roper-Logan-Tierney Model for nursing to assess Gideon’s response to their treatment intervention. The model assesses patient’s progress rather than concentrating on patient’s quality of life and independence (Rolland & Jenkins, 2019). The Roper-Logan-Tierney Model helps nurses identify areas that patients are unable to address on their own, such as quitting smoking, and helps design interventions to help them to do so (Roper, Logan, Tierney, 2000). Self-management provides Gideon with the skills and information needed to modify his behaviour and adhere to medical therapies to improve his health and well-being., and reduce the effect of chronic illness (Verbrugge, De Boer, & Georges, 2013; Brooker & Waugh, 2013). For example the National Institute for Health and Care Excellence (NICE) recommend that those with a condition such as Gideon be prescribed with long-acting bronchodilator inhalers (NICE, 2019). These may be either be a beta-2 agonist inhaler such as salmeterol, or an antimuscarinic inhaler such as tiotropium (NICE, 2019). Additionally, the use of Theophylline tablets - a type of bronchodilator - may be prescribed. The British National Formulary (NICE, 2020) notes that these come in the form of capsules that should be taken daily, and it would be necessary within the context of Gideon’s care that the importance of adhering to his medication regimen is highlighted to him. It would also be important to inform Gideon of the potential side effects of such medication. For example in the case of Theophylline, the BNF (NICE, 2020) notes that these may include feeling or being sick, as well as symptoms such as insomnia, palpitations of the heart, and persistent headaches. Informing Gideon of these in advance is important because if he were to experience any of these side effects, he should consult with his prescribing clinician to see if there was an alternative approach that could be taken. This should be encouraged early on with Gideon, rather than risk these side effects either being ignored by him, or erroneously being taken by him to be a sign that he should stop engaging with his medication regime. Although such side effects are written on the box of medications, it would be best practice to ensure discussion around this is conducted in a proactive manner. Therefore, the application of the plan to Gideon will focus on psychosocial and mental support, pulmonary rehabilitation, and smoking cessation. As someone with a long term condition, Gideon may also benefit from the Expert Patient Programme, which is a peer led support service which focusses on self-management principles and has been shown to be effective in engaging individuals such as Gideon (Mestre et al., 2016).

Healthcare providers can also educate Gideon with the effective utilisation of technology to monitor his condition. Technology-supported care initiatives provide patients with accessible coaching to promote an active lifestyle and address exacerbations (Fraser, Page, &Skingley, 2013). Supporting Gideon to develop the skills to carry out his grocery shopping online, and to expand his social network are also likely to improve his quality of life (Sánchez-Valle, Abad& Llorente-Barroso, 2017). The use of these approaches will instill confidence in Gideon because such self-management would be patient-oriented. Self-management is effective because it focuses on the preferences, interests, and strengths of Gideon (Mestre et al., 2016). Health professionals must ensure that they respond to psychological, social, and physical needs of Gideon. Special attention should be in promoting his well-being, meeting his care and health needs, and preventing his deteriorating condition (Nursing & Midwifery Council, 2015 & 2018).

5.Health Promotion Activities: Support Groups for People with COPD

Gideon’s would benefit from his enrolling in a local support group to provide him with developing insights regarding his condition. He will also learn from people with a similar condition but who are leading a healthy and fulfilling life. It is also of note that such groups can be effective in addressing aspects of social isolation (Baker &Fatoye, 2019). Two local or national health promotion services that relate to Gideon are Breathe Falmouth Club and Expert Patient Programme, which will be discussed in more detail below.

5.1 How the Services Offered are Beneficial to Gideon

Whilst a specialist NHS stop smoking programme would be an obvious choice to refer Gideon too, at this point he has expressed little motivation to engage with this and demonstrated a high level of resistance to the idea of stopping smoking. This resistance is likely to be grounded in the psychological and sociocultural factors discussed in Section 3.3.1. As a result, it would not be considered person-centred or empowering to simply attempt to force Gideon to access this service, and would not be ethical to do so. Instead, the expert patient programme (EPP) would be an important first step in developing Gideon's motivation to change. EPPs were founded within the framework of person centred care, and are designed to provide individuals such as Gideon - i.e. those with long term conditions - to develop the necessary skills for effective self-management of their condition, whilst also helping to develop more positive relationships with their healthcare clinician (Amro, 2013). These are delivered over a six week period and seeks to improve the self-management skills of patients by identifying solutions to common problems, addressing issues such as a lack of motivation to change, and by providing techniques to manage stress, to engage with a healthy eating programme, and to deal with poor sleep, pain, and fatigue (Knowles, Mason, McNarry& Peters, 2017).These are all areas that Gideon has needs identified within, and the fact that this is a peer led patient programme draws upon the positive impacts of social learning theory on health behaviours (Chen, Wang & Hung, 2015). Seeing others in a similar situation making positive changes to their health behaviours may be effective in helping Gideon to shift his motivation towards feeling able to do so himself. It is also of note that EPPs are person-centred and strength based, which will enable Gideon’s sense of empowerment and self-efficacy to grow. By providing him with the opportunity to better understand his condition - and the things he can do to improve it - the EPP represents a positive first step towards engaging Gideon in a subsequent smoking cessation programme. The second service is registering with Breathe Falmouth Club. The club is suitable for individuals diagnosed with Chronic Obstructive Pulmonary Diseases and breathing problems. It is purely an exercise club and requires its members to adhere to their Pulmonary Rehabilitation Program from their local medical facility (Kernow Clinical Commissioning Group, 2020). The club regularly invites a private chartered physiotherapist to monitor the appropriateness of its exercise sessions. Gideon was greatly affected by the loss of his wife. He became depressed and isolated himself from the world. However, enrolling in this club will alleviate Gideon’s presenting symptoms. Exercise will boost his energy levels, address depression, anxiety, and stress, improve sleep and self-esteem,as well as improve his breathlessness(Tabak et al., 2014;Ettema&Smajic, 2015;Emtner&Wadell, 2016 ). The club and the support group will be instrumental in transforming Gideon’s deteriorating condition. It is of note that both of the identified interventions are representative of peer support groups; this is a planned strategy to address the social isolation that Gideon has been experiencing since his wife's death. This is important not just within the context of role modelling and social learning theory, which may improve Gideon’s motivation to change, but is also important considering his depressive symptoms. Becoming more socially active and forging new relationships - a by product of such groups - depressive symptoms can be eased (Tomasino, Lattie, Ho, Palac, Kaiser &Mohr, 2017). This is an important consideration for not only is depression a serious illness in itself, it can contribute to a lack of motivation to engage in new behaviours or to change health behaviours. As a result, it can be concluded that the two interventions discussed above meet criteria of being person centred, of promoting empowerment, and of enhancing motivation to change. These are all highly important areas to consider then working with those with a long term condition, particularly when motivation to change may be low (Knowles et al., 2017). It is important to note that whilst the EPP and the Breathe Falmouth Club are run by service users and volunteers respectively, the role of healthcare professionals will be vital to ensure progress made within these interventions is built upon. For example, one of the aims of the EPP is to actually encourage a better relationship between service users and clinical staff; this is because nursing staff are vital to ensuring not only that the symptoms of COPD are regularly monitored, but also in providing support for health behaviour changes made by the service user. The support may involve helping them initiate such change, or helping them maintain it (Fletcher & Dahl, 2013). The initial groups listed above may provide the impetus to such change, but it will be via the support of nursing staff that these further change and development will likely occur (Zakrisson&Hägglund, 2010).

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