This essay aims 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 Nursing and Midwifery Council (NMC, 2008). The pseudonym Mrs. Jones will be used. The essay will then define health and critically analyze the biomedical and biopsychosocial models approach individual health and social well-being. It will then be explained what has happened accurately to Mrs. Jones biologically regarding any pre dispositional disturbances in her physiological processes. This essay will then explore psychological and sociological factors that have impacted Mrs. Jones as an Individual, which include grief and perceived loneliness.
This essay will then summarize and formulate a conclusion based on the findings that have been established throughout the essay. Mrs. Jone’s individual patient profile is included foremost to give prospective readers an understanding of the biopsychosocial influences that have contributed to Mrs. Jone’s 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 biomedical model. Bury (2005) states the term “health” can be positively and negatively defined.
Prices start at $12
Prices start at $11
Prices start at $12
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 implore 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 that can be categorized 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). Thus, 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 their simplest forms are described as organizing complex phenomena simplified (Stockwell, 1985). McKenna (1997) suggests models guide an individual in understanding complex phenomena and putting them into perspective. Kenny (1993) criticizes nursing models for their complexity. The significant problem with models is the terminology used is inaccessible for laypeople; 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), the question that experience alone is not enough supports the position that nurses need models to guide practice. A depth of thought is required when following nursing models they develop the nursing practice by enhancing insight into patients’ 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 begun to expand due to the development of science and the advancement of technology (Rana and Upton, 2009). The conceptualization 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 model’s framework 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 (Wade and Halligan, 2004; Engel, 1977). When a breakdown in biological mechanisms occurs within the human body, the clinician’s priority, when practicing within the biomedical framework, is to assess and examine the patient, diagnostically label the disease, and treat it in terms of medication or surgery (Mckenna, 1997). Chapman (1985) criticizes the biomedical approach believing diagnostic labelling dehumanizes individuals. Wade and Halling (2004) argue that if there is no definite label for a patient’s illness, it may cause distress. This distress may create difficulty within a nursing environment when patients rely 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 accurately. Conversely, Engel did not dispute this fact, especially in medical research, the biomedical approach’s important advances 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) criticize how restrictive the biomedical approach is within nursing by focusing on disease and symptoms sequentially; 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 criticize the biomedical approach for not considering aspects of human life that may contribute to disease or illness.
Engel (1977) believed Individual lifestyles might impact health such as; psychological, behavioural, cultural and social influences and that illness could not be treated by just considering biological factors alone. Furthermore, individual health needs were not being met due to the clinician’s perceptions of illness and lack of interest in the 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 into 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 overall 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 illness’s influences on; behaviours, feelings and emotions play a major role in the etiology and advance of health problems, such as cancer and chronic illnesses. White and Grenyer (1999) investigated 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 harms patients and their family’s lives. They have indicated from this study that using a biopsychosocial approach; health professionals can acknowledge patients’ and families’ feelings when emotions such as sadness, anger and depression occur and give support.
This study has some limitations; participants were chosen, possibly outdated in 2011; conversely, open-ended questions were asked, and in-depth interviews give the study its strength. Smith (2002) believes that the aspect of the disease is still the defining factor within the biopsychosocial model’s framework. Sarafino and Smith (2010) argue that psychological and social influences are also definitive factors within the model’s framework, and all need to be incorporated together to give individualized 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. In today’s nursing, the NMC (2008) requires all students to be educated in delivering holistic care. Rana and Upton (2009) state that the biopsychosocial approach improves; patient satisfaction, quality of care, and enhances the nurse’s knowledge of individualized health issues. When on clinical placement, I was caring for Mrs. Jones 67-year-old woman. 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 no family support besides her husband; she conversely had a small social network of friends with whom she spent time. Mrs. Jone’s 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 consumes 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 takes a more than prescribed dose in one day.
Her beloved dog Millie, 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 who could 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 the 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 full orthopedic ward. Mrs. Jones had started physiotherapy and was mobilizing well, and her pain was being adequately controlled. Understanding 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) indicates that 70-75,000 thousand hip fractures occur annually in the United Kingdom (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, abbreviated as FX F or #, is described as a break in the bone’s continuity (McRae and Esser 2002; Martini and Nath 2009). Regardless of individual beliefs, there is no medical distinction between fracture and break (McRae and Esser 2002). Medically fractures are categorized 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 microorganisms entering the fractured location may cause infection (Whiteing 2008; Martini and Nath 2009). Whiteing (2008) states the mechanism of injury dictates fracture patterns and is 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 an unexpected event, 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) states a fractured hip has serious consequences for an elderly individual. The mortality rate within one month is 10% after the fall, rising to about 30% within the year (NHS, 2006). However, mortality rates are not just attributable to the fracture (NICE, 2009). Vestergaard et al. (2009) believe factors contributing to mortality rates post-fracture are; age, gender, smoking, alcoholism, physical and mental decline and pre-fracture status. Mortimore et al. (2008) argue 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 the femur, which disrupted normal physiological functioning of the bone. Bone is a biological dynamic tissue and the only tissue within the human body that can 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 a 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 an underlying disease has weakened the bone’s mineral strength, for example, tumours, osteomalacia, and osteoporosis (Whiteing, 2008).
Osteoporosis is a chronic degenerative bone disease that causes the 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 reached within women at about 30 years old (National osteoporosis society, 2007). Bones become thinner and weaker due to the natural ageing process after 30 years; 1% of bone mass in women is lost each year. In females, when the ovaries stop producing estrogen due to menopause, the lost bone mass increases (NOS, 2007). Genetic factors can determine if an individual is at an increased risk of osteoporosis. Individual lifestyles may influence the development of bone in children and factor in the rate of bone loss in adult life. Exercises, good nutritional intake, calcium and vitamin D are factors that determine bone health in later life. (Martini and Nath, 2008; Marieb, 2009).
The fragility of bone due to Osteoporosis increases the risk of fractures, and Osteoporosis would not be uncommon in a female of Mrs. Jone’s age. The most common method of measuring the bone’s mineral density is a dual-energy x-ray absorptiometry (DEXA); this investigation conversely was not carried out on Mrs. Jones because she refused to contest the investigation. Mrs. Jones has been taking the synthetic drug levothyroxine for many years because of hypothyroidism. Thyroid hormone levels should be monitored regularly in all patients taken thyroxin therapy (Brown et al., 2005). Mrs. Jones, whilst in the hospital, had a thyroid function test (TFT) which came back normal. Mrs. Jones was advised not to double her prescribed dose of levothyroxine when she forgot. Weetman (1999) suggested over-supplementation of levothyroxine may increase the risk of Osteoporosis in postmenopausal females, leading to further research on the topic.
Schneider and Reiners (2003) conducted an objective, systematic review of the literature published from 1990 to 2001 identified by Medline search. The studies included in their review involved over 3279 patients in establishing the effects of levothyroxine therapy on bone mineral density. This study was designed to identify if patients had a reduction in bone mineral density due to thyroid replacement therapy. Schneider and Reiners (2003) identified from their study that critical debate between professionals still exists regarding the effects of synthetic levothyroxine on bone mineral density and its safety on skeletal integrity. As a result, Schneider and Reiners (2003) concluded that no tangible evidence exists regarding the effects of levothyroxine therapy and the extent of a double dose effect on reducing bone mineral density. In addition, the use of levothyroxine in post-menopausal females produced insufficient evidence to support the loss of bone density and the increased risk of Osteoporosis.
Fractures start healing from the time the fracture occurs, extensive bleeding and Inflammation frequently occur due to ruptured blood vessels, a fracture hematoma forms closing off the ruptured vessels (Martini and Nath, 2008). Blood loss can be very severe, often requiring a transfusion (Nice, 2009; Whitening, 2008). Osteocytes then, due to the disruption of circulation, began to die over several hours. The bone becomes necrotic along either direction of the shaft due to the fracture. Phagocytes then engulf, ingest alien particles, cell waste material, and bacteria (Whitening, 2008; Martini and Nath, 2008). The endosteum, a layer of single osteogenic cells, does not have any fibrous components; however, the periosteum is a tough vascular layer of fibrous dense tissue (Kalfas, 2001). Due to a fracture of the normal inactive endosteum and periosteum, biological trauma undergoes rapid cyclical cell division.
These cells, commonly known as daughter cells, migrate to the fracture site (Martini and Nath, 2008). An external callus then forms of bone and cartilage encompassing the bone at the point of fracture. Then the internal callus, which is extensive, forms within the medullary cavity and the broken ends of the bone shaft. The cells within the external callus differentiate into chondrocytes, and hyaline cartilage blocks are produced at each end of the callus; osteoblasts then construct a bridge-like structure that temporarily stabilizes the fracture. (Kalfas, 2001; Martini and Nath, 2008). Within terms of mobility, this temporary structure is very weak; however, due to the type of fracture or its severity, fortification may be required in the form of a plaster cast or internal fixation (Kalfas, 2001). The impacted neck of femur fractures occurs when a bone is forcefully driven into another. Whiteing (2008) states these fractures come adrift if internal fixation is not achieved.
The central cartilage of the external callus is replaced by spongy bone due to Osteoblasts activity; when this adaptation is finalized, both the internal and external callus form an extensive buttress at the site of the fracture uniting the struts of spongy bone and the fractured shaft ends (Martini and Nath, 2008). The adjacent area is progressively reshaped as the bones now held securely in situate can withstand everyday stresses. The remodelling of bone due to Osteoblasts and Osteoclasts activity continues for a time period of months to years (Kalfas, 2001). Complete Remodelling is finalized when bone callus has disappeared and only living compact bone, remains. The complete healing of a fracture restores bone to its unique and mechanical pre-fracture state. (Kalfas, 2001: Martini and Nath, 2008: Marieb, 2009). The remodelling of a fracture may take a long time in a patient such as Mrs. Jones due to her age and smoking (Whiteing, 2008).
Smoking cigarettes has detrimental effects on the body, contributing to chronic illnesses such as lung cancer, chronic obstructive pulmonary disease (COPD), and coronary artery disease (Warner, 2005). Cigarettes contain over 3000 injurious chemicals ranging from; arsenic, cadmium found in batteries, carbon monoxide (CO), nitrosamines (group of DNA damaging chemicals) and nicotine, the addictive component in cigarettes (Warner, 2005; Al-Mukhtar, 2010). Studies have shown that bone healing is delayed, and complications arise in fracture sites in individuals who smoke (Adams et al., 2001; Moller et al., 2002; W-Dahl and Toksvig-Larsen, 2004). There is considerable debate within the literature if nicotine directly affects metabolic bone activity, thus delaying fracture healing or due to the chemical components within cigarettes (Hollinger and Schmitt, 1999; W-Dahl and Toksvig-Larsen 2004; Warner, 2005).
Hollinger and Schmitt (1999) believed nicotine suppressed bone cell metabolic activity, thus delaying fracture healing. However, current research suggests that nicotine directly simulates bone metabolic cell activity and fractures heal quicker (W-Dahl and Toksvig-Larsen, 2007). Gullihorn et al. (2005) researched to test the hypothesis that components of cigarettes, rather than nicotine directly, were responsible for delayed skeletal healing. They concluded from their analysis that nicotine directly stimulates metabolic bone cell activity and suggests that absorption of the chemical components of cigarettes may delay bone healing. This research was, however, conducted using in vitro cultures of Osteoblasts cells. Thus, no individual participates included in this research.
The national service framework Wales for older people (2007) states that 26% of adults in Wales smoke. Mrs. Jones smoked twenty a day; she understood the complications smoking could have on her health, such as chronic obstructive pulmonary disease (COPD), lung cancer and coronary artery disease. She was astonished that smoking could delay fracture healing; however, she refused to stop smoking as it was her only pleasure left in her life. Mrs. Jones had gone through severe physical trauma. However, she perceived her physical health as good, even though she had the chronic condition hypothyroidism and smoked heavily. Although Mrs. Jones understood that her activities of daily living would be restricted due to her mobility, this did not concern her for a period of time. Literature indicates that individuals are more resilient to physical trauma than indicated (Bonnona, 2004). Therefore, she was optimistic that she would return to her pre-fracture status and comply with her rehabilitation programme.
Fredman et al. (2006) conducted a longitudinal study to establish if elderly patients who had suffered a hip fracture and optimists had better post-fracture functional recovery. The study included four hundred and thirty-two participants aged sixty-five years and older. They concluded from their analysis that individual optimism has a beneficial effect on post-fracture recovery, and elderly patients that had suffered a hip fracture had better recovery. The limitations of this study were data was collected from individuals whilst hospitalized, and data samples collected included mainly women; this would limit results within the male population. Mrs. Jones spoke affectionately about her husband and the life they had together. She missed him deeply. However, she became extremely upset and cried a lot when talking about her beloved dog Millie. The death of Millie, who Mrs. Jones was emotionally attached to, was an intense loss for her. Durkin (2009) states the death of an animal is equivalent to that of a human depending on the attachment.
The death of Millie could have awoken feelings in Mrs. Jones regarding her own mortality and unresolved grief issues from the death of her husband (Sife, 2005). Buglass (2010) states grief is a human’s natural response to separation or loss, often the death of a loved one. Greenstreet (2004) explains grief as being individualized, as the individual experiencing the grief, due to its behavioural, physical, cultural, spiritual and social dimensions. Grief can refer to emotional reactions to other losses, loss of health due to disease, disability or injury and loss of social status. Bonanno (2010) is dubious that grief associated with these losses is comparable to the grief of a loved one and purposes further research on the topics. Bereavement is the state of losing someone significant through death. Bonanno (2010) explains it is a form of depression that may disappear over time. During this period, individuals may suffer anxiety, anger, guilt, or a feeling of helplessness due to the loss. Individuals are still classed as bereaved regardless of their behavioural reaction to the loss (Bonanno, 2010).
A bereavement response after a significant loss that an individual was attached to is a normal reaction. (Buglass, 2010). John Bowlby’s theory on attachment could be the answer in understanding the complexity of grief (Goldenburg et al. 2010). Bowlby (1980) explains all human beings form attachments or emotional bonds. Bowlby viewed attachment as an affectional bond resulting from a reciprocal relationship or relationships, which have occurred, from long-term interactions, starting from the early stages of childhood to later adult life. Individuals endeavour to keep attachment figures close with whom they have a strong emotional bond, too, as attachments are adaptive, they give; protection, comfort and strength to the individual (Goldenburg et al., 2010). When separation occurs, individuals may feel strong overpowering feelings of sadness and anxiety (Buglass, 2010). Separation sadly due to death is irreversible (Goldenburg, et al., 2010).
An individual such as Mrs. Jones is not predominantly grieving the loss of their companion animal. Baydock (2000) believes it is the loss of a particular individual with whom they have shared a mutual bond; it is the loss of the relationship that is being grieved. The Death of a companion animal such as Millie in an elderly person’s life may be their only emotional support and physical comfort and the very reason they get up in the morning (Walsh, 2009). Society discourages the display of grief regarding animal loss (Walsh 2009; Durkin 2009). It is often trivialized due to erroneous believes that the animal can be replaced (Sharkin and Knox, 2003). This discourages individuals from reaching out for support and complicate the grieving process (Durkin, 2009). Individuals are often overpowered and embarrassed by the intensity of grief they feel that precedes the death of an animal (Sharkin and Knox, 2003). Baydack (2000) believes individuals often start to question their own psychological stability.
Health professionals are often presented with patients experiencing an exacerbation of psychological symptoms in behavioural health settings following the loss of their companion animal (Durkin, 2009). Conversely, within community settings, nurses may nurse elderly individuals that have become depressed and lonely following the death of their animal (Sharkin and Knox 2003; Durkin, 2009). Nurses must understand the process of grief and the reactions and responses to grief those individuals may go through when a loss has occurred (Durkin 2009; Buglass, 2010). Within the literature, unfortunately, little has been published regarding the process of grief regarding the loss of a companion animal (Durkin 2009; Dunn et al., 2005)
Many theoretical frameworks are found within the literature to explain the physical, psychological and behavioural complexity of grief; all have common stages and themes ((Kubler-Ross, 1969; Parkes, 1975; Bowlby, 1980; Worden, 1991). The best known and widely cited seminal work is that of (Kubler-Ross) who developed a linear model originally applied to individuals suffering from a terminal illness. The model consists of five stages; denial, anger, bargaining, depression and acceptance. These stages identify the emotional aspects that an individual will pass through to resolve their grief and come to terms with death (Morgan and Thompson, 2002). Kubler-Ross expanded on her theoretical model later to apply the stages of grief to other significant life events when a loss has occurred. This model is universally adaptable and used within the professional practice (Rana and Upton, 2009). Therefore this model will be used to explore the complexity of grief about Mrs. Jones.
Freud used the term denial, which is the first stage of the model in psychoanalytical theory, describing denial as the refusal to acknowledge the reality of a unbearable situation or the feelings connected with it (Telford et al., 2005; Chandra and Desai 2007). In the sense of loss, denial is viewed as necessary for individuals to self-preserve during a crisis. It is a coping mechanism when faced with psychological trauma (Burgess, 1994; Telford et al., 2005). Denial can be viewed as a healthy coping mechanism when serving a protective function (Kubler-Ross, 1980; Rana and Upton, 2009). When faced with physical or psychological trauma, denial buys individuals time to adjust and mobilize thoughts to cope with the situation (Stephenson, 2004). If denial is prolonged, it results in pathological or complicated grief (Telford et al., 2005).
Anger is the next stage next of the grief process. Kim (2009) states anger is a basic human emotional response to loss and separation, resulting in frustration and insecurity. Anger Hayes (2000) states develop when an individual feels they are losing control over their life. Mrs. Jones perceived she was losing control of her life and felt very insecure, as everyone she was attached to had died. The intensity and form of anger, Archer (1999), states are subject to the attribution process that individuals seek to make sense of loss. The intensity of anger can vary individually when a loss has occurred, dependent on unambiguous factors such as; was the loss was expected, the extent of individual attachment and the circumstances surrounding the loss. (McCutchen and Fleming, 2001: Walsh and McGoldrick, 2004). Theorists believe anger is an essential response in seeking an outlet when suffering emotional pain during the time of bereavement (Cerney and Buskirk, 1991; Miles, 1998)
The individual’s experience of anger is often associated with feelings that death is an unjust punishment (Parks, 1996). The anger an individual feels is often directed towards; health care professionals, family members and often directed at themselves (Kubler- Ross 2008). Literature indicates that individuals at this stage, such as Mrs. Jones, need good communicational relationships, especially between family, friends and health professionals (Kubler- Ross, 2008; Rana and Upton 2009; Sarafino and Smith 2010). How a nurse communicates with a patient during this stage is fundamental, effectual communication skills are needed to establish and maintain a therapeutic relationship. (Kubler- Ross, 2008). However, persistent anger alienates health professionals and damages social support and interpersonal relationships (Keltener et al., 1993; Lane and Hobfoll, 1992).
The third stage of the grief process is bargaining. Kulber-Ross, (2008) states this is a natural reaction to postpone what is inevitable. When faced with death or impending death, individuals may bargain with God or a higher being they religiously believe in (Sarafino, 1998; Kulber-Ross 2008). Mrs. Jones was not, however, a religious individual. The fourth stage of the model is depression when the individual can experience overwhelming self-pity, sadness, and blame. The griever may blame themselves for their losses during this stage. Kulber-Ross, (2008) states it is natural to experience these emotions; it shows the individual has begun to accept the reality of their situation. Acceptance, the final stage of the model, is where reality is realized; the loss has happened and cannot be reversed. Individuals begin to focus again on personal growth and daily life (Rana and Upton, 2009). Although individual acceptance may not be achieved, acceptance does not mean forgetting the loss entails coming to terms with a new reality. (Rana and Upton, 2009; Kulber-Ross, 2008).
Bonanno (2009) states there is little evidence in today’s literature supporting linear models due to the belief that bereaved individuals who don’t emotionally progress through the stages could be viewed as abnormal within the society they live in and judge. Many individuals, in reality, may not ever accept death; Cors (1993) argues identifying emotions and stages to explain the manifestation of grief leads to grief being viewed as simplistic in nature when in reality, it is complex. Buglass (2010) believes models of grief find similarities and patterns in human behaviour and individuals, who grieve take comfort knowing their experiences are normal. For example, it was explained to Mrs. Jones that the grief she was experiencing was a perfectly normal emotional reaction to any loss. Mrs. Jones believed that health care professionals did not understand how she was feeling, and she had never felt so angry and alone. It was difficult to predict what stage Mrs. Jones was at within the grieving process; she seemed to oscillate between anger and denial when using this model.
Kent and McDowell (2004) believe individuals who are bereaved experience more intense anger than individuals who have expected the death. Rana and Upton (2009) state that without the understanding and support of health professionals, individuals may feel isolated and lonely during the grieving process. The support and care gave immediately after death or any signified loss that initiates a grief response, Kent and McDowell, (2004), belief is central to the success of an individual working through their individual grief experience. An individualized care programme had been put into place for Mrs. Jones. The physiotherapist carried out a mobility assessment on Mrs. Jones, who was now mobilizing well with a stick. The occupational therapists had done home assessments. Social support had been arranged until Mrs. Jones was back to her pre-fracture status. Mrs. Jones was happy to go home but was anxious that without Millie, she would be lonely.
Fitzsimons (2010) states one defining concept associated with the growing number of elderly individuals due to longevity is loneliness. The Office for National Statistics (2009) states there are 9.9 million individuals living in the United Kingdom aged over 65 and above, with 1.3 million in this group aged 85 years and over. The probability of loss of a spouse, multiple losses, or ill health renders the elderly more vulnerable to loneliness, which can negatively affect individual health. Weiss (1973) introduced an interaction theory of loneliness and believed that loneliness has two social and emotional dimensions. Social loneliness occurs when there is deficient social integration on a personal or societal level and can be characterized by feelings of boredom and exclusion (Weiss, 1973; de Jong Gierveld, 1999). Emotional loneliness refers to an absence of a reliable attachment figure that an Individual has a bond with, thus characterized by feelings of insecurity, hopelessness and anxiety (Weiss 1973; Pettigrew and Roberts, 2008).
It can be perceived from this definition of loneliness that Mrs. Jones could suffer from negative feelings of emotional loneliness. Pettigrew and Roberts, (2008) believe social loneliness should not be perceived as a negative experience; individuals may value productive time on their own. Loneliness Forbes (1996) describes is an unwelcome feeling due to loss or lack of companionship. Loneliness by description or definition conversely is an objectionable feeling in which an individual feels a sense of emptiness and a loss of belonging. Victor et al., (2000) argues loneliness is a perception that can’t be objectively observed. Many individuals experience loneliness at some time in their lives. Still, the negative stigma associated with loneliness is often overlooked or dismissed, so many individuals with deficient social relationships often won’t admit loneliness (de Jong Gierveld, 1999). Riddick and Keller (1992) identified loneliness as a major inciting factor for mental health problems within the ageing population.
A copious amount of studies have confirmed that there is a clear relationship between loneliness and depression. The studies also identified loneliness to be a feeling more frequently expressed by elderly women. (Tiikkainen and Heikkinen, 2005; Cacioppo et al, 2006). Many life events are conversely attributed to the feeling of loneliness (Edelbrock et al., 2001; Pettigrew and Roberts, 2006). Victor et al., (2005) conducted a study investigating risk factors of becoming lonely in later life in Great Britain; using a self-rating scale, individual loneliness was measured. Interviews with 999 participate over the age of 65 were conducted who lived at home. They identified various vulnerability factors constituted to loneliness in later life; poor health and current ill-health, basic education, marital status and living alone. They came to the conclusion that interventions and British government policies need to reflect the variables of loneliness in older people’s lives. Additional factors such as geographic location, low mobility levels and low socioeconomic status further increase the risk of loneliness (de Jong Gierveld, 1999; Edelbrock et al., 2001).
Research, however, indicates that loneliness may be hereditary (Boomsma et al., 2005: Cacioppo et al, 2007). These studies were carried out on adolescent and adult twins to establish if there was a hereditary characteristic in the way in which people process social relations. The research concluded that some individuals are more prone to the predisposition of loneliness due to their hereditary genetic makeup but propose to conduct further research on the topic (Boomsma et al. 2005: Cacioppo et al 2007). This study has been included as Mrs. Jone’s father had been an identical twin, and because of her genetic makeup, this may make Mrs. Jones more prone to experiencing loneliness. Individuals need relationships for companionship to belong and feel connected to their society (Larsen and Lubkin, 2009). Individuals all require different interpersonal needs from their relationships; if a relationship is lost, the loss an individual will feel depends on the social provision that the relationship gave (Larsen and Lubkin, 2009).
The social provision Millie gave Mrs. Jones was ineffable to her after the death of her husband. Millie was her only real emotional and physical support when the curtains closed at night. Mrs. Jones enjoyed taking Millie for a walk to her local park; it was her only source of exercise. During these walks, she would meet other dog owners with who she had something in common, they would chat about their dogs. This was Mrs. Jone’s only real source of social participation she had since her husband died. Weisman (1991) states that a relationship involving love, respect, and affinity despite interspecies is as authentic as any other. Cacioppo and Patrick (2008) believe Individuals are more likely to engage in behaviours that damage their health when loneliness is experienced. Mrs. Jones, as established from the profile, had been consuming a bottle of wine at night since her husband’s death and had never really drunk before, as her husband had been teetotal, but it had helped her sleep.
When she was drinking her wine, she established that she was smoking more. de Jong Gierveld (1999) believes that the pathological consequences of the individualized experience of loneliness are established in those who can’t adapt or develop personality disorders and excessive intake of alcohol. The experience of loneliness is not just a social aspect. It is correlated to physiological and psychological conditions that; included dietary inadequacies, overt alcohol consumption and depression (Pettigrew and Roberts, 2006). Since her husband had passed away, Mrs. Jones had not cooked much for herself. Instead, she would share a small sandwich in the evening with Millie. Individuals such as Mrs. Jones that have experienced and are experiencing loneliness have more problems sleeping. (Cacioppo and Patrick, 2008). Sleep deprivation is acknowledged to have equivalent hormonal and metabolic regulation effects as ageing (Cacioppo and Patrick, 2008; Pettigrew and Roberts, 2006).
The British Columbia Ministry of Health (2004) states social participation and integration of older adults are positive indicators of productive and healthy ageing. It is widely cited throughout the literature that social support has a strong positive effect on individual health (Umberson and Montez, 2010). It could be argued that it is, therefore of even greater importance than Mrs. Jone’s social connectedness maintained when she returned home since her husband and Millie (BMCH, 2004). To conclude, the biopsychosocial model of health and illness was used to explore Mrs. Jone’s perception of her overall health and social well-being. The biomedical model and the biopsychosocial model of health and illness were analyzed to give the reader a better understanding of how the biological, psychological, and social factors combined have influenced Mrs. Jone’s overall health. Mrs. Jones had suffered a fractured neck of femur; it was imperative to explore mortally rates associated with this type of fracture in women her age and examine other factors that could have contributed to her fracture.
The psychosocial factors were then explored in regard to Mrs. Jone’s overall health. Mrs. Jones had recently lost her husband, and her only comfort was her beloved dog Millie, who was put down due to ill health. Mrs. Jones was grieving the loss of Millie. Mrs. Jone’s grief led her to feel very lonely, and she perceived that she would be very lonely when she returned home. The biopsychosocial model of health and illness has proven to be a very productive nursing patient such as Mrs. Jones. Therefore, this model has an important place in nursing practice. It helps nurses develop their skills and knowledge to nurse a patient holistically, despite literature arguing that models in nursing practice are not always helpful.
- ADAMS, C. KEATING, J. COURT, F. BROWN, C.M., 2001. Cigarette smoking and open tibia fracture. Journal of injury and trauma; 32(1), 65-5.
- AGGLETON, P. CHALMERS, H. 2000. Nursing Models and Nursing Practice, 2nd ed. Macmillan Press: Basingstoke, Hampshire.
- AGOSTINI, J.V. BAKER, DI. BOGARDUS, ST. 2001 Prevention of falls in hospitalized and institutionalized older people. The Agency for Healthcare Research and Quality.
- ALDER, B. CHARLES, S. PORTER, M. VAN TEIJLINGER, E., 2009. Psychology and sociology applied to medicine 3rd ed. Churchill Livingston.
- AL-MUKHTAR, S.A., 2010. The effects of cigarette smoking on bone healing in the elderly with a Colles fracture. Tobacco use insights; 10(3), 17-22.
- ARCHER, J. 1999. The nature of grief; the evolution and psychology of reactions to loss. London: Rutledge.
- ATKINS, S. MURPHY, K., 1993. Reflection: a review of the literature. Journal of Advanced Nursing. 18(8), 1188-1192.
- BANYNAR, D., 2006. Applying psychology to health. Oxon: Bookpoint LTD.
- BAYDAK, M. A., 2000. Human grief on the death of a pet. A Practicum
- Submitted to the Faculty of Graduate Studies in the Degree of master of social work: National Library of Canada.
- BEKOFF, M., 2007. The emotional lives of animals. Novato Ca: New world library.
- BONANNO, G.A., 2004. Loss and trauma and human resilience have we underestimated the human capacity to thrive after extremely adverse events? American Psychological Association; 59(1), 20-28.
- BONANNO, G.A., 2010. The other side of sadness, what the new science of bereavement tells us about life after loss. New York: Basic books.
- BOOMSMA, D. I. WILLEMSEN, G. DOLAN, C.V. HAWKLEY, L.C. CACIOPPO, J.T., 2005. Genetic and Environmental Contributions to Loneliness in Adults: The Netherlands Twin Register Study; 35(6), 745 -752.
- BORREL-CARRIO, F. SUCHMAN, A.L. EPSTEIN, R.M., 2004. The biopsychosocial model 25 years later: Principles, practice, and scientific inquiry. Annals of Family Medicine; 2(6), 576-582.
- BOWLBY, J., 1969. Attachment and loss: vol. 1. New York: Basic books.
- BOWLBY, J., 1980. Loss: sadness & depression. Attachment and Loss (vol. 3); London: Hogarth Press.
- BRITISH COLUMBIA MINISTRY OF HEALTH 2004. Social isolation among seniors an emerging issue, an investigation by children’s women’s and senior branches. BCMH 2004.
- BROWN, B.T. BONELLO, R. POLLARD, H., 2005. The Biopsychosocial model and hypothyroidism Chiropractic and osteopathy; 13(5), 1-9.
- BUGLASS, E., 2010. Grief and Bereavement Theories. Nursing standard; 24(41), 44-77.
- BULMAN, C. SCHUTZ, S., 2008. Reflective practice in nursing, 4th edition. Oxford: Blackwell Scientific Publications.
- BURGESS, D., 1994. Denial and terminal illness. American Journal of hospice and palliative care; 11(2), 46-48.
- BURY, M., 2005. Health and illness. Cambridge: Polity Press.
- CACIOPPO,J. T.,HUGHES, M.E., WAITE, L.J., HAWLEY, L.C., THISTED, R.A, 2006 Loneliness as a specific risk factor for depressive symptoms; Cross-sectional and longitudinal analyses. Psychology and ageing,21(1),140-151.
- CACIOPPO, J.T. BOOMSMA, D.I. TIHOMIR, B.M.A. CLARK., 2007. Longitudinal Genetic Analysis for Loneliness in Dutch Twins Twin Research and Human Genetics; 10 (2), 267-273.
- CACIOPPO, J. T. AND PATRICK, W. 2008. Loneliness: Human Nature and the Need for Social Connection New York: W. W. Norton and Company.
- CERNEY, MS. BUSKIRK, JR., 1991 Anger: the hidden part of grief. Bulletin of the Menninger clinic 55 228-238.
- CHANDRA, P.S. DESAI, G., 2007. Denial as an experiential phenomenon in serious illness. Journal of palliative care; 13(1), 8-14.
- CHAPMAN, C.M., 1985. Theory of nursing; practical application. London: Harper and row.
- CORR, C. A., 1993. Coping with dying lessons, we should and should not learn from the work of Elizabeth Kubler-Ross. Death studies; 17(1), 69- 83.
- COTE, A. HASLEM, P., 2004. Rheumatology and orthopedics. Edinburgh; Mosby.
- COWLES, K.V., 1985. The death of a pet: Human responses to the breaking of the bond. Mamagey Review; 8(34), 135-148.
- DEEP, P., 1999. Biological and Biopsychosocial models of health and disease in dentistry. Journal of the Canadian Dental Association; 65(9), 469-497.
- DE JONG GIERVELD, J. 1998. A review of loneliness, Concepts and definitions, causes and consequences. Reviews in Clinical Gerontology; 8, 73-80.
- DUNN, K.L. MEHLER, S.J. GREENBURG, H.S., 2005. Social work with a pet loss support group in a university veterinary hospital. Social work in health care; 41(2), 59-70.
- DURKIN, A., 2009. Loss of a companion animal understands and helping the bereaved Journal of psychosocial nursing; 47(7), 26-31.
- DWELL, A., 2005. Our inner ape New York penguin.
- EDELBROCK, D. BUYS, L. CREASEY, H. BROE, G.A., 2001. Social support, social networks and social isolation: the Sydney older persons’ study. Australasian Journal on Ageing; 20(4), 173-8.
- ENGEL, G. L., 1977. The need for a new medical model: A challenge for biomedicine. Science, 196, 129-136.
- EPSTEIN, R.M. BORELL-CARRIOï¿½, F., 2005. The biopsychosocial model exploring six things families systems and health; 23(4), 426-431.
- FITZSIMONS, P., 2010. Dialling up social care for older people. working with older people; 14(3), 10-14.
- FORBES, A., 1996. Caring for Older People: Loneliness. British Medical Journal. 313, (4) 352-354.
- FREDMAN , L ., HAWKES, W.G., BLACK ,S., BERTRAND, R., MAGAZINER, J., 2006. Elderly patients with hip fractures with positive effects have better functional recovery over 2 years. The American Geriatrics society. 54(7),1074-81.
- FREETH, R., 2007. Working within the medical model. Therapy today; 18(9), 31-4.
- GIDDENS, A., 2009. Sociology 6th ed. Cambridge: Polity Press.
- GOLDENBURG, M. BIGGS, Q. FLYNN, B. MCCARROL, J., 2010. The CSTS trauma group at the centre for the study of traumatic stress; 73(4), 38-92.
- GREENHALAH, T., HURWTIZ, B., 1999 Education and debate. Narrative-based medicine, why study narrative. British medical journal. 318-48-50
- GREENSTREET, W., 2004. Why nurses need to understand the principles of bereavement theories. British Journal of Nursing; 13(10), 590-593.
- GUILLIHORN, L. KARTPMAN, R. LIPPIELLO, L., 2005 Differential effects of nicotine and smoke condensate on bone cell metabolic activity. Journal of orthopaedic trauma; 19(1), 17-22.
- HELMAN, C., 2001. Culture, Health and Illness 4th ed. London: Arnold.
- HODGSON, R., 1992. A nursing muse. British Journal of Nursing; 1(7), 330-333.
- HOGSTON, R., 2006. Managing nursing care. London; Palgrave.
- HOGSTON, R. SIMPSON, P., 2002. Foundations of nursing practice, 2nd ed. Basingstoke: Palgrave MacMillan.
- HOLLINGER, J. SCHMITT, O., 1999. Impact of nicotine on bone healing. Journal of Biomedicine; 45(4), 294 -301.
- JADAD, A. O GRADY, L., 2008. What is health? British Medical Journal BMJ www.bmj.com/highwire/filestream/389121/field_highwire_article_pdf/0.pdf Accessed November 2011.
- JASPER, M., 2003. Beginning reflective practise foundations in nursing health care. Cheltenham: Nelson Thornes.
- JOHNS, C., 2000. Becoming a Reflective Practitioner: a reflective and holistic approach to clinical nursing, practice development and clinical supervision. Oxford: Blackwell Science.
- KALFAS, I.H., 2001. Principles of bone healing. Journal of neurosurgery; 10(4), 7-10.
- KELTNER, D. ELLSWORTH, P.C. EDWARDS, K., 1993. Beyond the simple pessimism; Effects of sadness and anger on social perception .journal of personality and social Psychology; 64, 740-752.
- KENNY, T., 1993 Nursing models fail in practice. British Journal of Nursing; 2, 133-136.
- KENT, H. MCDOWELL, J. Sudden bereavement in acute care settings. Nursing standard; 19(6), 384-42.
- KIM, S., 2009. The influence of finding meaning and worldview of accepting death on anger among bereaved older spouses Ageing and mental health; 13(1), 38-45.
- KUBLER-ROSS, E., 1969. On death and dying. New York; McMillan
- KUBLER-ROSS, E., 2008. On death and dying. New York; McMillan.
- LANE, C. HOBFOLL, S.E., 1992. How loss effects anger and alienates potential supporters. Journal of consulting and clinical psychology; 60, 935-942.
- LARSEN P LUBKIN M 2009 Chronic illness impact and interventions 7th ed London: Jones Bartlett publishers.
- MALIN, T. BIRCH, A., 1998. Introductory psychology. New York: Palgrave.
- MARIEB, E.N., 2009. Essentials of human anatomy and physiology, 9th edition. San Francisco: Pearson Education.
- MARTINI, F.H. NATH, J.L., 2008. Fundamentals of anatomy and physiology 8th edition London: Benjamin Cummings.
- MAY, T., 2009. Death art of living. London; acumen publishing
- MCKENNA, A., 1997. Nursing theories and models. London: Press Ltd.
- MCRAE, R. ESSER, M., 2002. Practical fracture treatment 4th edition Edinburgh: Churchill Livingston.
- MCCUTCHEON, K.A. FLEMMING, S.T., 2001. Grief resulting from euthanasia and natural death of complaining animals. Journal of death and dying; 44(2), 169 -185.
- MILES, A.R., 1998. Anger at god after a loved one dies. American journal of nursing; 9, 864-66.
- MOLLER, A.M. PEDERSONT, MUNKSGAARD, A., 2003. Effects of smoking on early complication after elative orthopaedic surgery. Journal of bone and joint surgery; 85, 178-81.
- MORGAN, J.D. THOMPSONN., 2002. Loss and grief. A guide for human service practitioners. Hampshire: Palgrave.
- MORTIMORE, E. HASLOW, D. DOLAN, M. HAWICES, W.G. LANGENBERG, P ZIMMERMANS, MAGAZINER, J., 2008. Amount of social contact and hip fracture mortality. Journal of American geriatrics society; 56(6), 1069-74.
- NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE 2009. The guidelines manual, clinical guideline on the management of fractured neck of femur’ (www.nice.org.uk/guidelinesmanual). Information on the progress of the guideline will also be available from the NICE website (www.nice.org.uk). Accessed January 2012.
- NATIONAL SERVICE FRAMEWORK FOR OLDER PEOPLE WALES 2007. Dignity for older people. http://www.wales.nhs.uk/sites. Accessed December 2011.
- NATIONAL OSTEOPOROSIS SOCIETY 2007.http://www.nos.org.uk/page Accessed December 2011.
- NHS INSTITUTE FOR INNOVATION AND IMPROVEMENT 2006. Delivering quality and value focus on fracture neck of femur. http://www.institute.nhs.uk/. Accessed November 2011.
- NURSING AND MIDWIFERY COUNCIL. 2008. The code: Standards of conduct, performance and ethics for nurses and midwives. London: NMC.
- OFFICE FOR NATIONAL STATISTICS 2009 Population trends 138: Winter 2009 Newport Office for Nation statists ONS (2009).
- PARKS, C.M., 1975. Determinants of outcome following bereavement omega; 6(1), 303-323.
- PARKS, C.M., 1996. Bereavement studies of grief in adult life 3rd ed. London: Penguin books.
- PETTIGREW, S. ROBERTS, M., 2008. Addressing loneliness in later life. Aging and mental health; 12 (3), 302-309.
- POTTER, P.A. GRIFFIN-PERRY, A., 2005. Fundamentals of Nursing, 6th edition, London: Mosby. Check-in Google.
- RANA, D. UPTON, D., 2009. Psychology for nurses England Pearson education LTD.
- RIDDICK, C.C. KELLER, M.J., 1992. Efficacy of recreation on influencing the social-psychological health of elder’s parks recreation; 27(3), 20-24.
- ROBERTS, M. REISS, M. MONGER, G., 2000. Advanced Biology. United Kingdom: Nelson.
- ROPER, LOGAN & TIERNEY., 2008. Applying the Roper, Logan & Tierney Model in practice. 2nd edition. London: Churchill Livingstone Elsevier.
- SARAFINO, E.P. SMITH, E.P., 2010. Health Psychology: Biopsychosocial interactions 7th ed United States; Wiley.
- SCHNEIDER, R. REINERS, C., 2003. The effect of levothyroxine therapy on bone mineral density: a systematic review of the literature. Experience of Endocrine conditions; 111(8), 455-70.
- SCOTT H., 2010. The medical model; the right approach to service provision? Journal of mental health practice; 13(5), 27- 30.
- SHARKIN, B.S. KNOX, D., 2003. Pet loss; issues and implications for psychologist’s Professional psychology research and practice; 34, 414-421
- SIFE, W., 2005. The loss of a pet: A guide to coping with the grieving process when a pet dies. 3rd ed. New Jersey: Wiley publishing.
- SIRKKA, M. BRANHOLM, I., 2003. Consequences of a hip fracture in activity performance and life satisfaction in an elderly Swedish clientele. Journal of occupational therapy; 10 (1), 34-39.
- SMITH, R.C., 2002. The biopsychosocial revolution. Journal of general medicine; 17 (4), 309-310.
- STEPHENSON, P., 2004. Understanding denial oncology nursing forum; 31(5), 985-8.
- STOCKWELL, F., 1995. The nursing process in psychiatric Nursing. London: Cromm
- TELFORD, K. KRALIK, D. KOCH, T., 2005. Acceptance and denial, complications for people adapting to chronic illness, literature review. Journal of advanced nursing; 55(4), 457-64.
- TIIKKAINEN, P. HEIKKINEN, R.L., 2005. Associations between loneliness, depressive symptoms and perceived togetherness in older people. Ageing and mental health; 9(6), 526-534.
- UMBERSON D MONTEZ JK 2010 Social relationships and health, a flashpoint for health policy. Journal of health and social behaviour; 51(5), 54 66.
- VESTERGGARD, P. REJNMARK, L. MOSEKILCLE, L., 2009. Loss of life years after a hip fracture effects on ageing and sex. Acta orthopedic; 80 (5), 525-530.
- VICTOR, C. SCRAMBLER, S. BOND, J. AND BOWLING, A., (2000). Being alone in later life: loneliness, social isolation and living alone. Reviews in Clinical Gerontology: Vol.10, 407-417.
- VICTOR, C. SCRAMBLER, S. BOND, J. AND BOWLING, A., 2005 The prevalence of and risk factors of loneliness in later life: a survey of older people in Great Britain: 25, 357- 375.
- WADE, D.T. HALLIGAN, P.W., 2004. Do biomedical models of illness make for good health care systems? British Medical Journal; 32(9), 1398-1401.
- WALSH, F. MCGOLDRICK., 2004. Loss and the family, a systemic perspective in Walsh and McGoldrick. Living beyond loss. Death in the family 2nd ed New York: Norton.
- WALSH F 2009 Human-Animal bonds ll: The Role of pets in Family Systems and Family Therapy; 48(4), 481-499.
- WARNER, D.O, 2005. Helping surgical patients quit smoking: Why, When and How 101 481 -7.
- W- DAHL, A. TOKSVIG-LARSEN, S., 2004. Cigarette smoking delays bone healing: A prospective study of 200 patients operated on by the Hemi callotasis technique; Acta orthopedic. 75 (3), 347-51.
- W- DAHL A, TOKSVIG-LARSEN, S 2007; No delayed bone healing in Swedish male oral snuff-ers operated on by the Hemi-allostasis technique. Acta orthopedic; 78(6), 79 -794.
- WEETMAN, A.P., 1999. Hypothyroidism: screening and subclinical disease British medical journal; 314(7088), 1175-1179.
- Weisman, A. D. 1991. Bereavement and companion animals. (4), 24 1-248.
- WEISS, ROBERT S. 1973. Loneliness: The Experience of Emotional and Social Isolation. Cambridge: MIT Press.
- WHITE, Y. GRENYER, B.F.S., 1999.The biopsychosocial impact on end-stage renal disease, the experience of dialysis, patients and their partners. Journal of advance nursing; 30(6), 1312-1320.
- WHITEING, N.L., 2008. Fractures; pathophysiology, treatment and nursing care. Nursing standard; 23 (2), 49-57.
- WORDEN, J.W., 1991. Grief counselling and grief therapy, a handbook for mental health practitioners 2nd ed London: Routledge.
- WORLD HEALTH ORGANISATION (1946). The preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100).