PPN201 - Weeks 5&6 Self management/care + Uncertainty/Social Isolation in Chronic Illness

Theoretical explaination of Self management

Milllet et Al. - chronic disease self management

Miller et Al (2015) - Chronic Disease self management (CDSM)

verb that refers to the behaviours that person use to manage the disease and its associated effects
Clients evaluate their own needs and necessary their HCPs evauluation of their needs

5 self managment behaviours

Problem solving
Decision making
Resource utilization
Forming relationship with provider
taking action

Self-care

Refers to daily activities individuals perform to maintain health and well-being

Self management

specifically involves the active management of chronic illness, including monitoring symptoms and adhering to treatment regimens.

Antecedents in Miller et al.

Chronic illness
Self efficacy
disease knowledge
social support
health beliefs
motivation/coping

Consequences in Miller et al.

disease status/severity
treatment adherence
HCP use
Q of Life, functional ability

CDSM working definition

Behaviours in which those with CD engage to achieve treatment adherence/manage symptoms
outcome= disease control & Increased Q of life

3 phases in Miller et al.

Theory - CDSM
Fieldwork
Analysis

Fieldwork in Miller et al.

Engaging in behaviours
going from exacerbation to chronicity
Using a system

System levels involved in CDSM

Intrapersonal systems - Assesing emotion, function, possibility, literacy
Interpersonal-selected support systems - Family/Support persons
Envriomental systems - HCPs/Resources to maximize daily ADLs, wellness and fucntional ability

CDSM changed definition

a fluid, iterative process during which Pt. incorporate multidimensional strats that meet self needs to cope with chronicity

Self care in Pt w chronic illness

Self management = dynamic as pt actively manages CD
Pt. actively involved in their care, problem solving, decision making

Disease management

Interventions by HCP based on standards of care
Disease-based approach

Self-management in CD Pt.

Clients with CD are motivated, empowered, and engaged in daily management in decision-making making about health, symptoms, and causes
Emphasizes client involvement, PCC

Self-Neglect

Inability to mee basic need
Opposite to self care

CDSM summary

CDSM targets individual characteristic
We need to include pt perspectives and the literature for a more comprehensive definition
Balancing act, Challenge to self-identity, Self-realization in Pts

Adaptation Strategies - Reigel and Carlson (2002)

Understand the various personal and environmental factors influencing these adaptation strategies and how they impact self-care in the context of chronic heart failure.

Common challenges to self-care with hear failure

Physical limitations
Coping with treatment regiment
Lack of knowledge
Negative emotions
Other health issues
Personal Struggles

Self care strategies with heart failure

Symptom recognition - Know when they are in trouble and should seek medical attention, Typical/Atypical symptoms
Follow treatment regimen - Watch diet, resting, exercising, medical aspects

Adaptation strategies to heart failure

Practical adaptations - Modifying environment
Learning about heart failure - Research/Books
Maintaining control - Desire to stay out of the hospital
Depending on others - Physicians, Family/friends
Ignoring, Withdrawing, Accepting - Ignoring problem

Nursing interventions - Role of the nurse Coates (2017)

Managing CI influecned by culutre of care, local service provisions, health policies
- need to examine power imbalance
- HCP moves from expert to enabler to support pt
- empowerment

Roles nurses play in helping Pts with chronic illness

Coach
Clinician
Gatekeeper
Educator

Coach

Guides and motivates patients in managing their health and making informed decisions.

Clinician

Provides expert medical care, monitoring, and treatment for chronic conditions.

Gatekeeper

Controls access to healthcare resources and services, coordinating care.

Educator

Teaches pt about their illness, treatment options, and self-care practices.

Motivational interviewing (MI) - Droppa & lee (2014)

Communication approach to guide/facilitate change in client behavior
Empower client to make decisions about health
- respect autonomy and integration of client needs
- self-efficacy, sensitivity to client needs, compassion

How MI is used

Client-centred to enhanced motivation to separate client goals
- Intent to guide pt to resolve ambivalence
- occurs thru evoking pts willingness, reason to change behavior
- relational context, empathy/acceptance
- help pt make a decision to change

MI - OARS communication style

Open questions for further explanation
Affrimations to promote positive feelings
Reflections to prove HCP's heard and understood Pt
Summaries, which build on reflections to generate change

Goals of Motivational Interviewing

Encourage Pt to set and achieve goals for health maintenance and disease management
Engage Pt in acitve (non-pharm) management of Chronic pain
Adressing frequent alcohol, opiate and drug use
Improving pt medication adherance

Outcomes of self managment programs

1. Conditon outcomes- Decrease in mobidity, Improvment in fucntional status
2. Individual outcomes- Health status, QofL, Wellbeing, connectedness to others
3. Family outcomes- depression in caregivers, family functioning, caregiver burden
4. Envriomental outcomes- Decrease in admin. rates, in cross infections, use of antibiotics due to HAI

Uncertainty

Chronic illness =
-prolonged stat of impending adversity
- Timing, duration and severity of symptoms are erratic
- Uncertainity impedes coping and adjustment to chronic illness, increasing distress, dminishing QofL

Illness uncertainty

Affects CI person, as well as those within their social netowkr, including caregivers, family/friends
- members of social newtwork = own feelings/fears

Uncertainty Causes

Lack of medical information
Incomplete understanding of treatment choices/typical course of disease
difficulty coping with the precariousness of daily life

Uncertianty influces

Way pt responds to a Dx, symptoms, treatment regimens, social relationships
coping/adjustment
psych/emotion
QofL

Uncertainty defined - Mischel (1998)

Pyschological state in which pt initally percieve it and respond elative to how they believe it will impact them
Inability to determine the meaning of illness-related events and accurately anticipate or predict health outcomes

Uncertainty in illness theory - Mischel (1998)

4 components
1. Antecedents generating uncertainty
2. Apprasial of uncertainty
3. Coping w uncertainty
4. Adaptation to illness

1. Antecedents generating uncertainty

Stimuli frame
Cognitive Capabilities
Structure providers

Stimuli frame

Structure a cognitive schema to understand symptoms
- Symptom pattern (symptoms exists consistently); SOB w exercise
- Event familarity (when situation become habitual); Familiarity with HCPs
- Event congruency (consistency with expected/experience events); illness stability

Cognitive Capacity

Information processing capabilities
-e.g. reduced cognitive capacity results in difficulty perceiveing patterns

Structure Providers

Resources available to assist individuals interpret stimulus frame to decrease uncertainty

2. Appraisal of uncertanity

Clients appraisal of uncertanity can be in one of 2 ways
- Uncertainty = Opportunity (Positive)
- Uncertainty = Harm (Negative)

Uncertainty = Opportunity

Useful coping mechanism
Enables pt to reevaluate life, increased self acceptance/tolerance, and acceptance of others

Uncertainty = Harm

CD increases perception of harm and therfore, increase illness uncertainty
factors; stress, anxiety, loss of control, lack of information

3. Coping with Uncertainty

Coping is defined as the mental and physical ability to manage stressors
- based on individuals apprasial of uncertainty

4. Adaptation to uncertainty

Achieveing new balance and adjusting to new illness related experince triggered by uncertainty
accepting uncertainty = adaptive mech.
- (-)ive effects of uncertainty reduced by anticipating own needs
- Nurses work w CI pt to change negative and promote positive outcome

Reducing Uncertainty: Interventions

1. Cognitive Strategies
2. Emotional regulation
3. Behaviour strategies/self management
4. Social Networks/Support

1.Cognitive strategies

Designing and adapting routines
Education
Know the illness
Symptom management

2. Emotional strategies

Normalization
Control emotion
Reframing on uncertainty, problem solving, positive thinking
Building trust/confidence

3. Behavioural strategies

Managing ADLs
- Focus on daily routines decreases uncertainty
- Anticipatory guidance
- Enhance and prolong independence

Social Isolation

State where an individual lacks a sense of belonging socially, engagement with others, has minimal number of social contacts, and are deficient in fulfilling relationships
- Distancing of an individual, physically/psych. from their network of relationships

What is known abut social isolation

prevalent/growing problem in older adults
- leads to serious health problems
- defined inconsistenly, confused with similar concepts such as social networks

Considerations - Social Isolations

Its volunatry/involuntary
- characterized by boredom, marginality, exclusion
- Variety of illnesses across life

Social isolation and Chronic Illness

Major health problem for older adults in communities
- causes lonelieness
- diseases and social situations (moderate dementia)
- Clients experience with chronic illness is unique

Concept of Social Isolation - Nicholson 2009/2012

State in which the individual lacks a sense of belonging, lacks engagement with others, has a minimal number of social contacts.

Antecedents of social isolation - Nicholson (2009)

Psychological barriers - decline in cognition
Low financial and resource exchange - Money, transport, assistance
Physical barriers - health problems, decreased function
Prohibitive enviroment- geographicl location, housing type

Consequences of SI - Nicholson (2009)

Increased alcohol intake
Increased mortality/morbidity
Decreased QofL
Increased risks for falls, depression/depressive symptoms
cognitive decline
nutritional risk

Nicholson (2009) summary

Subjective/objective components need consideration when defining social isolation in older adults
Screening tools need to include several contacts, feeling of belongings
clinicians working with older adults should be familiar with antecedents of social isolation

Social isolation is..

What patient says it is
-The hierarchy of social needs exists on 4 levels
1. Self
2. Close confidants
3. Organization (schools/churches)
4. Community level, social structure, and the world
- Connections on all 4 levels satisfy a person's social needs

Assesment and Interventions for social isolation

Subjective/Objective data
Peer cosunselling, support groups, family networks, ehancing spirituality, internet support, therapeutic use of self
Active listening and presence
Assess SI by observing - negativity, involuntary/imposed solitude

Desired outcomes of interventions

Increase moral autonomy of client
Increase social interaction to meed the individuals needs
Use strategies that are client centered
Reduction of social isolation, maintainence of integrity of client