PPN201 - Weeks 3&4 Chronicity/Chronic Illness

Social/Enviromental determinants of chronic illness

Education
Income
Childhood poverty
Employment
Community belonging

Behavioural risks for chronic illness

24h movement
physical/sedentary acitvity
sleep
nutrition
chronic stress
alcohol/drug use

Chronic illness effect on everybody

either Directly or indirectly
threatens quality of life and accounts for 1/3rd of life lost below the age of 65
affects familly/friends/caregivers, 1/4 report caring for somebody w a chronic illness
impacts healthcare system

Emergence of medicare

1966, the federal government passed the Medical Care Act to support universal healthcare
1984, the Canadian Health Act was introduced, said that health care was a right not a privilege; established 5 principles for hospital/physician care

5 Principles of the Canada Health Act

1. Public Administration
2. Comprehensiveness
3. Universality
4. Portability
5. Accessibility

1. Public administration

Health insurance system must be administered by a public authority on a non-profit basis

2. Comprehensiveness

Health insurance system must cover all necessary health services, including hospitals, physicians, surgical dentists.

3. Universality

Health insurance system must provide the same level of health care to all insured residents

4. Portability

Health insurance system must allow insured residents to move and travel within canada without losing their coverage

5. Accessibility

Health insurance system mustensure reasonable access to health care without financial or other barriers

Challenges to living with Chronic illness

Canada Health care provisions do not apply to health promotion, health education, extended health care services (LTC, Adult residential care), supplementary care services (Chiro, PT, Dental)

Where are individuals with chronic conditions mostly managed?

Those living with chronic conditions are mostly managed outside of acute care facilities. The non-acute sector not meeting the needs of many Canadians who have chronic illness

What is disease?

Pathophysiology of a condition

What is illness?

human experience of symptoms/suffering and how disease is seen

Acute illness

Sudden onset, resolved quickly; recovery and resumption of pre-illness activites

Chronic Illness

Continues, slow/insidious/sudden onset, patterns of flareups/exacerbations/remissions, staying well takes work, illness becomes identity, never completely cured

Symptoms/Diagnosis do NOT equal clients exp. of chronicity - Ironside et al (2003)

1. focus on functional status doesn't account for experience of chronic illness
2. shifting away from the treatment of symptoms, allows for equally important discussions of meaning-making in chronic illness
3. Objectified language of healthcare covers over how chronic illness is experienced

Imporant framework #1 - Patterson's Shifting Perspective model

Chronic illness is an ongoing and continually shifting process and involves ever-changing perspectives about the disease that enable persons to make sense of their experience.

Factors influence the illness and wellness perspective in Patterson's model?

It is based upon one's beliefs, perception, expectations, attitudes, and experiences about the meaning of living with chronic illness.

2 key points of shifting perspective model

Illness in the foreground
Wellness in the foreground

Illness in the foreground

Focus on the sickness, suffering, loss, and burden
Dx of a chronic disease or new symptoms forces one to attend to illness
Illness viewed as destructive to self and others
Absorbed in their illness; may have difficulty attending to needs of others
Protective, maintenence, utilitarian function

Wellness in the foreground

Chronic illness viewed as an opportunity for change
Attempt to create consonance between self-identity and identity shaped by disease
Describes health as good/excellent despite poor physical fucntion, not a distorted but a revsioning
Body objectified; placed at a distance, developed by learning more about diesease, creating supportive enviroments.

Shifting from Wellness to Illness in the foreground

Major factor is the threat to control
- personally defined, may not be seen by observers- signs of disease progression, disease-related stigma, dependence and hopelessness, the cumulative effect of disease-related losses (lifestyle, body image)
- Wellness strats may actually shift to illness (support groups, hiding one's illness at work)

Shifiting from Illness to Wellness in the foreground

"Boucing back" with hope and optimisim
- Req. person to undestand that shift to illness occured, identify a need to return to wellness, and strats to resolve the illness in the foreground POV

Paradoxes of living with chronic illness

Although one may live with wellness in the foreground, and sickness is distant, the illness req. attention in order NOT to pay attention
People who find meaning, hope and quality of life may have to assume illness to maintain healthcare services
Illness in foreground is self-absorbing, may alienate others

Important framework #2 - Reed & Corner's Illness Trajectory Model (2015)

Applied Corbin and Strauss' Chronic Illness Trajectory Model, to show that patients experience cycles of symptom reprieve and decline, highlighting the need to shift care from end-of-life to managing the ongoing disease trajectory.

Phases of the illness trajectory model

1) Pre-trajectory
2) Trajectory onset
3) Stable
4) Unstable
5) Acute
6) Crisis
7) Comeback
8) Downward
9) Dying

1) Pre-trajectory

Genetic factors/lifestyle behaviours that place and individual/community at risk for development of chronic illness

2) Trajectory onset

Appearance of noticable symptoms, includes periods of diagnostic workup as person begins to discover/cope with implications of dx

3) Stable

Illness course and symptoms are under control. everyday life activites are being managed within limitations of illness

4) Unstable

Periods of inability to keep symptoms under control or reactivation of illness. Biographical disruption/Difficulty carrying out everyday life activites. Adjustments being made

5) Acute

Severe and unrelieved symptoms or development of illness complicates hospitalization or bed rest to bring course under control. ADLs placed on hold, cut back

6) Crisis

Critical/Life-threatning situation requiring emergency treatment or care. ADLs suspended until crisis passes

7) Comeback

Gradual return to acceptable way of life within limits imposed by illness.
Physical healing, rehabilitative procedures, adjustment/re-engagment in everyday life

8) Downward

Illness course characterised by rapid or gradual physical decline accompanied by increasing difficulty in controlling symptoms

9) Dying

Finals days before death. Gradual/rapid shutting down of bodily processes, biographical disengagement and relinquishment of ADLs/ Life

3 typical illness trajectories of Reed and Corner

1."ticking over nicely"
2."is there no end to it"
3. "its a rollercoaster"

Important framework #3 - Positive Living Ambrosiso (2015)

Living w chronic illness is complex, dynamic and multi-dimensional process whose final goal is Positive Living
Identifies 4 typologies of living with chronic illness in adults

4 typologies of living with chronic illness

1) disavowal (denial/refusal to accept)
2) False normality (experiential knowledge w/o acknowledgment)
3) The new normal (positive living)
4) Disruption (relapse/distressing factors occur)

1) Disavowel

Lack of control/balance in ones life

2) False normality

Partial control/balance
vulnerable to disruption

3) The New Normal

Achieved attribute of acceptance/developed the other attributes to reach positive living
total control/balance = long-lasting and less vulnerable to disruption

4) Disruption

Exposed to distress/experiences a stressfull situation
loss of stability/balance previously achieved, returns to inital attributes

Nursing implication and Typologies

Nursing can work w Pt towards a common goal of Positive Living
Identification of the attributes, antecedents and consequences of living with chronic illness can serve as points of assessment

Framework #4 - Families living well: Robinson (2017)

explored how families manage chronic illness, focusing on primary caregivers. In a study of 43 participants from 17 families, most caregivers were women who also had chronic illness, highlighting the dual role of patient and caregiver in managing long-term illness at home.

Healing process of Moving On - Robinson (2017)

Managing chronic illness is about 2 relationships that change over time:
1. Relationship w chronic illness itself
2. Relationship among family members
proposed 5 interconnected phases that are revised as chronic illness changes

Phases of Healing Process of Moving On

1) The fight - Denial of illness
2) Accepting - Coming to terms with illness
3) Living w Chronic illness - how to integrate illness in to family
4) Sharing the experience- maitining social relationships
5) Reconstructing life: How to live beyond ilness

Important framework #5 - Personal Strengths; Kristiandottir (2018)

Historically living with illness, focused on pathology
shift towards a focus on strength/resilience, self mgmt, empowerment, PCC
The author states that "an essential process to learning to live well with chronic illness is to find one's own strengths/weakness
3 strengths identified in living w chronic illness

3 strengths in living with chronic illness

1) Internal strengths - being kind/caring, having a positive outlook, positive emotions, kindness towards self
2) External Strengths
3) Self-managemtn strategies

Salutogensis & Personal Strengths

Study of the origins of health and focuses on factors that support human health and well-being, rather than on factors that cause disease (pathogenesis)
General Resistance Factors (GRR, e.g. biology, material/psychosocial factors, knowledge) interface w personal strengths to determine health def.
Subjective experiences can be salutary psychosocial factors

Positive Psychology & Personal Strengths

Positve psych. has identified positive character strengths:
Perseeverance, kindness, braver, humour, and gratitude in the general pop.