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The aim of this case is to examine how a primary health care nurse develops a person-centred and culturally safe care plan for an Aboriginal person with chronic conditions particularly when transitioning from acute to primary care.    

Learning Outcomes

After working through this case, you will be able to:

  1. Create a concept map using a person-centred and culturally appropriate approach to identify health issues
  2. Develop a person-centred, culturally appropriate care plan resulting from the health issues identified in the concept map
  3. Describe the rationale for the care plan with reference to current literature and evidence based practice.

This case also relates to  Unit Learning Outcomes

1.discuss perspectives, and the physical, psychological and social aspects of ageing in the context of health and illness in older people in our community

  1. describe the impact of ageing and chronic illness on clients, families and carers and apply this to discharge planning bridging the transition from acute care to primary care and palliative care
  2. identify the primary care resources for people with issues related to ageing, chronic and life limiting illness in the community
  3. utilise health promotion, supportive and palliative approaches to care for people with chronic and life limiting illness in a range of health care settings

And links to The Aboriginal and Torres Strait Islander Health Framework (2014):

Intermediate: Respect

2.2 Examine Aboriginal and Torres Strait Islander key concepts of health and wellbeing and the influence of culture, family and connection to country in health practice

Intermediate: Communication 

5.2 Analyse the strengths and limitations of key terms and definitions in the context of culturally safe health practice

8.2 Analyse the contemporary role of Aboriginal and Torres Strait Islander health professionals, organisations and communities in delivering culturally safe health care to Aboriginal and Torres Strait Islander clients

Case Scenario

Paul is a Koori man in his fifties and lives in a rural area in Victoria with his partner Rodney. Paul has recently had cataract surgery and lives with diabetes, depression and Hepatitis C. In his younger years Paul liked to party but in his forties settled down as he became more mature and realised the impact partying was having on his health. Paul is passionate about being an Aboriginal community member, loves to attend local community events and often picks up friends and family on the way to events in his car. The day after having eye surgery in the city Paul receives a visit from an Aboriginal Health Worker, Eddie, from the local Aboriginal Health Service. 

Watch the interaction between Eddie and Paul in the video below.  


This case study highlights a number of issues for an Aboriginal person with chronic illness.  Using the case study, adopt the role of primary health care nurse to construct the following clinical action plan.  

Student response

In preparing your student response, please ensure that you address the following:

  • Develop a concept map identifying Paul’s life story, strength’s and concerns related to psychosocial factors, activities/ hobbies, physical environment and general health (750 words equivalent*)
  • Using the care plan templateprovided, develop a person-centred nursing care plan for Paul addressing physical, social, emotional and cultural well-being.  Ensure that the plan reflects Paul’s goals and uses his strengths. Your care plan should address two issues (at least one must be psychosocial), and identify one person-centred goal for each issue. (300 words equivalent*)
  • Provide your rationale for your care plan and with reference to current literature and evidence based practice. (750 words)

Please note: assignment should be referenced according to American Psychological Society (APA) 6th edition requirements. 

Learning Outcomes

Care plan for Paul:


Person-centred Goal

Interventions/ Actions

Who is responsible

Evaluation Criteria and date

Cataract surgery,  pain in the eyes and symptoms related to Hepatitis C (physical needs)

To empower Paul to understand the cause of Cataract surgery and teach strategies related to self-care of eyes after cataract surgery and identify symptoms of Hepatis C

1.Delivery of clear discharge instructions and personalized patient education related to reason for cataract and methods to protect the eye during the healing process.

2. Instructions need to be provided in both verbal and written format in the native language of the patient (Umfress and Brantley Jr, 2016)

3. To provide psycho-education to overcome barriers to treatment like depression, hallucination and psychosis caused by diagnosis of Hepatitis and empower client to take control of their health (Hong et al., 2011)

Health service staffs

Evaluation can be done based on Paul’s interest and knowledge in clearly articulating improvement in his symptoms and actively seeking information to self-manage issues related to care of the cataract.

Depression and social isolation because of discrimination and poor satisfaction with health services (Psychosocial issue)

To provide effective health and social care support to client by addressing discrimination and providing holistic and culturally appropriate care  

1.To implement individualized interventions like coordinated care arrangement, social support and  holistic client-centred care plan (Brener et al., 2015)

 2.Include more Aboriginal  health workers to overcome language gap and  promote client engagement and satisfaction with care  (Brener et al., 2015). This strategy would also resolve the issue of racial discrimination faced by Paul when visiting health care services as Aboriginal staffs can easily related with social and culture issues affecting health of the client.

Health service and community support staff

Good mental health outcome, positive physical state and overall satisfaction with the service will indicate success of the care plan

 Rational for the care plan:

            As Mr. Paul has recently undergone cataract surgery and he has been experiencing pain in the eyes, the intervention of patient-education has been prioritized first so that Paul’s eye can heal and recover soon. Good recovery will promote psychosocial well-being of client and increase interest in self-management of other chronic conditions like Type 2 diabetes and participation in other meaningful activities too. As part of patient-centred care, personalized patient education has been chosen as it has the potential to improve outcome for older people and those with high racial risk factors.

Rosdahl et al. (2014) gave the evidence that educating patients about diagnosis and plan of care in the field of ophthalmology is essential to promote patient engagement and prevent adverse events like irreversible blindness. The study proved that providing patient education according to preferred learning practices can increase patient’s interest in cataracts. Newman-Casey et al. (2015) argues that counselling can improve patient’s knowledge related to cataract surgery and decisional aspect particularly for those patients who are illiterate or have limited access to care.   Older patient mostly prefer one-on-one interaction and as Mr. Paul is above 50, such interaction will also benefit him as he can also get information related to age related problems that influence his recovery and healing process.

            Hepatis C has also been included as a physical issues for Paul because the analysis of Paul’s video transcript revealed that Paul had poor conceptions related to knowledge about Hepatitis C and he was not sure whether certain symptoms experience by him were related to Hepatitis C or not. As he expressed interest in getting some resources related to Hepatitis C, the intervention of psycho-education has the potential to mitigate both barriers to treatment as well as treat depression and anxiety occurring due to poor management of the condition (Hong et al., 2011).

Evidence by Surjadi et al. (2011) has revealed the effectiveness of education for vulnerable population particularly injection drug users. As such population have limited knowledge about Hepatitis C, standardized patient education plays a role in reducing disparity in HCV prevalence and outcomes. As Paul is an aboriginal, he may also be vulnerable to poor outcome because of poor knowledge. Another advantage of education is that health care maintenance increase when people have good knowledge about HCV. Yang et al. (2017) argues that patient knowledge improves acceptance to antiviral therapy for Hepatitis C.

Case Scenario

This was proved by conducting research to evaluate the impact of HCV education on patient’s knowledge of HCV and acceptance of therapy in rural China. Knowledge about HCV significantly reduced risk of transmission and enable patients to make better decisions about their treatment. Hence, Paul will also be able to take best treatment decision when have good knowledge about the condition.

            Another problem or issue identified for Paul was diagnosis of depression. Both ageing related factors and social factors is the reason for diagnosis of depression. Age related factors include feeling of social isolation and poor self-esteem because of loss of independence and inability to engage in pleasing life activities like driving and social engagement. Evidence by Singh and Misra (2009) also supports this by stating that older people experience depression and social isolation because of physical and social role changes in life due to ageing.

Lack of contact with close families and gradual reduction in connections with the cultural origin also increase diagnosis of depression in elderly people (Theodore, 2017). As Paul came from Aboriginal background, he faced additional issues in society which increased the likelihood of depression. These included experiencing stigma and discrimination from health care staffs and other community members. This is consistent with study by Povey et al. (2016) which explained that 35% of Aboriginal people experience high level of distress because of challenges in accessing health services and stigma is one of the reasons for poor access to services. Being diagnosed with multiple disease condition and inability to engage in appropriate therapeutic communication process with health care staffs also increased the risk of depression for Paul.

Hence, in such circumstances, individualized interventions like social support has been proposed because it would provide Paul the opportunity to establish reconnection with community life and gain sense of control over their life. Social support programs can help to engage in cultural activities that is an indicator of positive cultural identity as well as better mental health outcomes in Aboriginal people (Dudgeon et al., 2014). Organizational level interventions like cultural competence training and inclusion of aboriginal workforce can significantly improve the provision of providing equitable, respectful and culturally responsive care to patients like Paul (Browne et al., 2016).


Brener, L., Wilson, H., Jackson, L. C., Johnson, P., Saunders, V., & Treloar, C. (2015). The role of Aboriginal community attachment in promoting lifestyle changes after hepatitis C diagnosis. Health Psychology Open, 2(2), 

Browne, A. J., Varcoe, C., Lavoie, J., Smye, V., Wong, S. T., Krause, M., … Fridkin, A. (2016). Enhancing health care equity with Indigenous populations: evidence-based strategies from an ethnographic study. BMC Health Services Research, 16, 

Dudgeon, P., Walker, R., Scrine, C., Shepherd, C., Calma, T., & Ring, I. (2014). Effective strategies to strengthen the mental health and wellbeing of Aboriginal and Torres Strait Islander people. Issues paper, 12. 

Hong, B. A., North, C. S., Pollio, D. E., Abbacchi, A., Debold, C., Adewuyi, S. A., & Lisker-Melman, M. (2011). The use of psychoeducation for a patient with hepatitis C and psychiatric illness in preparation for antiviral therapy: a case report and discussion. Journal of clinical psychology in medical settings, 18(1), 99-107, doi: 10.1007/s10880-011-9227-6.

Newman-Casey, P. A., Ravilla, S., Haripriya, A., Palanichamy, V., Pillai, M., Balakrishnan, V., & Robin, A. L. (2015). The Effect of Counseling on Cataract Patient Knowledge, Decisional Conflict, and Satisfaction. Ophthalmic Epidemiology, 22(6), 387–393

Povey, J., Mills, P. P. J. R., Dingwall, K. M., Lowell, A., Singer, J., Rotumah, D., … Nagel, T. (2016). Acceptability of Mental Health Apps for Aboriginal and Torres Strait Islander Australians: A Qualitative Study. Journal of Medical Internet Research, 18(3), e65. 

Resnick, I., & Brener, L. (2010). Hepatitis C and the Aboriginal population. National Centre in HIV Social Research, the University of New South Wales. 

Rosdahl, J. A., Swamy, L., Stinnett, S., & Muir, K. W. (2014). Patient education preferences in ophthalmic care. Patient Preference and Adherence, 8, 565–574

Singh, A., & Misra, N. (2009). Loneliness, depression and sociability in old age. Industrial Psychiatry Journal, 18(1), 51–55.

Surjadi, M., Torruellas, C., Ayala, C., Yee, H. F., & Khalili, M. (2011). Formal Patient Education Improves Patient Knowledge of Hepatitis C in Vulnerable Populations. Digestive Diseases and Sciences, 56(1), 213–219. 

Theodore I., (2017). Aging In Grace and the Effects of Social Isolation on the Elderly Population. OAJ Gerontol & Geriatric Med. Vol. 1, No. 4, DOI: 10.19080/OAJGGM.2017.01.555566

Umfress, A.C. & Brantley Jr, M.A., (2016), July. Eye care disparities and health-related consequences in elderly patients with age-related eye disease. In Seminars in ophthalmology(Vol. 31, No. 4, pp. 432-438). Taylor & Francis, 

Yang, M., Rao, H.-Y., Feng, B., Wu, E., Wei, L., & Lok, A. S. (2017). Patient Education Improves Patient Knowledge and Acceptance on Antiviral Therapy of Hepatitis C in Rural China. Chinese Medical Journal, 130(22), 2750–2751. 

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