1. Competency 4 and 5: Chronic & Acute Illnesses and Client and Customer Service Developed by: Dede Carr, BS, LDA Karen Neu, MSN, CNE, CNP

2. U.S. Department of Labor Grant “This workforce solution was funded by a grant awarded by the U.S. Department of Labor’s Employment and Training Administration. The solution was created by the grantee and does not necessarily reflect the official position of the U.S. Department of Labor. The Department of Labor makes no guarantees, warranties, or assurances of any kind, express or implied, with respect to such information, including any information on linked sites and including but not limited to, accuracy of the information or its completeness, timeliness, usefulness, adequacy, continued availability, or ownership. This solution is copyrighted by the institution that created it. Internal use, by and organization and/or personal use by an individual or non-commercial purposes, is permissible. All other uses require the prior authorization of the copyright owner.” 2

3. Competency 4: Chronic & Acute Illness Competency: Explain how chronic & acute diseases can influence the functioning behaviors & attitudes of clients including dementia/Alzheimer’s Disease. Describe how chronic illness affects an individual’s coping & behaviors Describe how acute illness affects an individual’s coping & behaviors Review the Vocabulary List

4. Definitions Illness is a state in which a person’s physical, emotional, intellectual, social, developmental, or spiritual functioning is diminished or impaired compared with previous experience (Potter & Perry, p. 79) Illness may be defined as the highly individualized response a person has to disease (Ramon & Niedringhaus, p. 10) Restoring health means focusing on the ill client from early detection through the recovery period Wellness a state of well-being while engaging in attitudes & behavior that enhance quality of life & maximize personal potential (Ramon & Niedringhaus, p. 10)

5. Definitions Acute illness is a health problem of short duration in which the condition improves or resolves completely; symptoms appear abruptly, are intense, & often subside in a relatively short period (Potter & Perry, p. 79) Chronic illness persists usually longer than 6 months & can affect functioning in any dimension (Potter & Perry, p. 79)

6. Acute Illness Although acute illness is by nature, short-lived, it can be a crisis & stress families, especially if it involves hospitalization; it can impact families’ financial & time resources Many stressor that families experience in chronic illness can apply to acute illness It is important for the healthcare worker to realize that the person in crisis may act in ways that are not his/her normal behavior, because he/she feels a loss of control due to the illness Many times the person’s behavior in crisis is in the form of anger at the health care system

7. Chronic Illness Chronic illness has certain characteristics: It is caused by disease that produces signs & symptoms within a variable time period It develops slowly & runs a long course (usually 6 months & longer) It allows only a partial recovery It can impose an enormous financial burden on a family (Ramon & Niedringhaus, p. 305) Chronic illness affects a person’s ability to meet one’s basic needs for self-actualization Priority is given to meeting the alterations in physical or emotional health that the illness affects (Ramon & Niedringhaus, p. 305)

8. Chronic Illness Examples Some examples of chronic diseases are: Heart disease Diabetes Cancer Chronic obstructive lung disease Stroke Although the symptoms & general reactions caused by chronic disease may subside with proper treatment and care, the disease remains. This period during which the disease is controlled is called remission. Reactivation of the disease & increase in severity of symptoms is known as exacerbation. Exacerbation causes the client to seek medical attention & may lead to hospitalization (Ramon & Niedringhaus, p. 305)

9. Risk Factors for Illness & How Client’s & Family’s Behaviors Affect Illness

10. Risk Factors for Acute & Chronic Illness Predisposing risks: Age: Chronic illness can occur at any age, but the elderly are more likely to have long, drawn-out chronic diseases & there is an increase as people age Genetics: Sometimes an inherited trait or gene puts a person at a greater risk for certain diseases Race & Ethnicity : There is an association between disease occurrence & race; some diseases are more prevalent in certain groups (Ramon & Niedringhaus, p. 305)

11. Behavioral Risk Factors for Illness Behavioral risk factors are factors that people can control or change to prevent or delay chronic disease Behavioral Risk Factors Lifestyle: Way individuals live & work put one at risk Stress: Different types of stress can lead to chronic high blood pressure, chronic depression, & headaches; stress can be physical, psychological, or emotional Poor Nutrition: Can lead to high blood pressure, obesity, & high cholesterol Physical Inactivity: Insufficient or low physical activity can lead to obesity, heart disease, diabetes, & other chronic diseases (Ramon & Niedringhaus, p. 305)

12. Risk Factors for Chronic Illness Behavioral Risk Factors Tobacco, Alcohol, & Substance Use: Use of these is a risk for cardiovascular disease & other multiple chronic illnesses Physiologic Factors: May include high blood pressure, high blood cholesterol, & obesity Environmental Factors: Pollution or exposure to chemicals, pesticides, etc. put one at a greater risk for cancer Socioeconomic Status: Those at a lower socioeconomic level have increased chronic disease (Ramon & Niedringhaus, p. 305)

13. Illness Behavior People who are ill generally act in a way known as “illness behavior” Illness behavior involves how people monitor their bodies, define & interpret symptoms, take remedial actions, & use the health care system (Mechanic, 1982, as cited in Potter & Perry, p. 79) Personal history, social situations, social norms, & opportunities & constraints of community institutions can affect health behavior (Mechanic, 1995, as cited in Potter & Perry, p. 79) If people perceive themselves to be ill, illness behavior can be a coping mechanism because as a result the client can be released from roles, social expectations, or responsibilities (Potter & Perry, pp. 79-80)

14. Influencing Variables on Illness What influences illness & illness behavior? Just as health & health behaviors are affected by internal & external variables (factors) so are illness and illness behaviors Influences of these variables & the stage of illness behavior the client is in will affect: The likelihood of the client seeking health care, Complying with therapy (following recommended treatment) Health outcomes

15. Influencing Variables on Illness Internal Variables (Within person) The client’s perception of symptoms & the nature of illness (what kind of illness does the client have & how serious is it?) If a person believes that the symptoms of the illness disrupt normal routine, he/she will more likely seek healthcare assistance than if the symptoms are not disruptive Example: if one is awakes with crushing chest pain in the middle of the night, one would perceive this to be serious & life-threatening & are more likely to see healthcare or if client fears serious illness the client may react by denying it & not seek healthcare assistance (Potter & Perry, p. 80)

16. Influencing Variables on Illness Internal Variables Nature of illness, either acute or chronic, affects client’s illness behavior Clients with acute illness are more likely to seek healthcare & readily comply with therapy Clients with chronic illness in which symptoms cannot be cured, but only partially relieved, may not be motivated to comply with therapy Chronically ill clients may become less active in their care, may experience greater frustration, & may comply less with care Client’s coping skills & locus of control affect the way the client behaves when ill (Potter & Perry, p. 80)

17. Influencing Variables on Illness Locus of Control A locus of control orientation is a belief about whether the outcomes of our actions are contingent on what we do (internal control orientation) or on events outside our personal control (external control orientation)" (Zimbardo, 1985, p. 275 as cited by Neill) Internal Locus of Control Individual believes that his/her behavior is guided by his/her personal decisions and efforts. External Locus of Control Individual believes that his/her behavior is guided by fate, luck, or other external circumstances

18. Influencing Variables on Illness External Variables External variables influencing a client’s illness behavior include the visibility of symptoms, social group, cultural background, economic variables, accessibility of the health care system, & social support (Potter & Perry, p. 80) Visibility of symptoms affect body image & illness behavior & thus the client is more likely to seek health care assistance Client’s social group (family, friends, & coworkers) may assist client in recognizing the threat of illness or support the denial of potential illness & influence the client’s illness behavior

19. Influencing Variables on Illness External Variables Cultural & ethnic background teaches a person how to be healthy, how to recognize illness, & how to be ill Effects of disease & its interpretations vary according to cultural circumstances Ethnic differences can influence decisions about healthcare & the use of diagnostic & health services Dietary practices among ethnic groups, occupations held by certain cultural groups, & cultural beliefs are factors that contribute to illness & the distribution of disease

20. Influencing Variables on Illness Economic Variables Economic variables influence the way a client reacts to illness Because of economic constraints a client may delay treatment & in many causes continue to carry out daily activities Access to health care system is closely related to economic factors Healthcare system is a socioeconomic system that clients must enter, react with, & exit For many clients the healthcare system may be complex & confusing & some clients may see non-emergency medical care in an emergency department, because they do not know how to obtain health services How close one is to a health care agency often influences how soon clients enter the system after deciding to seek health care (Potter & Perry, p. 80)

21. Illness Factors that Affect Clients & Families

22. Illness Factors Impacting Family Dynamics How does illness impact the family dynamics? The nature of the illness, whether acute or chronic, can range from minor to life threatening The duration of illness, ranges from short-term to long-term The residual effects of the illness, including none to permanent disability The meaning of illness to the family & its significance to family systems The financial impact of the illness, which is influenced by factors such as insurance & the ability of ill member to return to work The effect of the illness on future family functioning (for instance, previous patterns may be restored or new patterns may be established) (Berman et al., p. 437)

23. Chronic Illness Stressors Chronic illness includes stressors that impact the client & family: Emotional stress over a period of time can lead to other chronic conditions such as depression, isolation Physical stress depends on the body systems affected by disease & can gravely impact family, as well as client (example: chronic pain or limited mobility) Social stress may result in isolation from friends & community activities Financial: Healthcare costs for the disease impacts the client’s financial resources or in some cases, the disease impacts the client’s ability to work to earn monies to pay for treatments needed (Biggest health problem affecting developed nations) (Duffy, p. 1213) Family dynamics may be affected by the type of illness or injury, its duration, & illnesses effects on client’s ability to fulfill a specific family role (Juliar)

24. Illness Factors Impacting Family Dynamics Illness impacts the family dynamics by causing stress & client & family react to those stressors, which may result in changes of behavior. Some areas that illness affects or impacts are Behavioral & emotional changes Body Image Self-Concept Family Roles (Potter & Perry, pp. 80-81) The following slides explain how illness may impact the client/family that may result in changes of behaviors.

25. Impact of Illness on Client & Family Behavioral & Emotional Changes People act differently to illness or the threat of illness & behavioral & emotional reactions depend on nature of illness, client’s attitude toward it, reactions of others to it, & variables of illness behavior Short-term, non-life-threatening illnesses evoke few behavioral changes in functioning of client & family Example if husband/father has a cold, he may lack energy & patience to spend time with family activities & may be irritable & prefer not to interact with family (normal response to illness) Severe illness can result in more extensive changes, such as anxiety, shock, denial, anger, & withdrawal (common responses to the stress of illness) (Potter & Perry, p. 80)

26. Impact of Illness on Client & Family Impact on Body Image (Subjective concept of physical appearance) as some illnesses result in physical changes & clients/families react differently to these changes Reactions depend on the type of changes (loss of limb or an organ), their adaptive capacity, the rate at which changes take place, & support services available When body image changes occur, as amputation for example, client generally adjusts in following phases: shock, withdrawal, acknowledgement, acceptance, & rehabilitation (natural process); client & family move through a period of grieving as they acknowledge the loss (Potter & Perry, p. 80-81)

27. Impact of Illness on Client & Family Impact on Self-Concept Self-concept is a mental self-image of strengths & weaknesses in all aspects of personality; self-concept depends on body image & roles, but also on aspects of psychology & spirituality Impact of illness on self-concepts of clients/family members may be more complex & less readily observed than role changes Client’s self-concept changes because of illness may no longer meet family expectations, leading to tension or conflict; as a result family members may change their interactions with the client (Potter & Perry, p. 81)

28. Impact of Illness on Client & Family Impact on Family Roles People have many roles in life, such as wage earner, decision- maker, professional, child, sibling, or parent When illness occurs, parents & children try to adapt to major changes resulting from a family members illness If a parent of an adult becomes ill & cannot carry out usual activities, the adult child often assumes many of parent’s responsibilities & in essence becomes a parent to the parent. Such a reversal of the usual situation can lead to stress, conflicting responsibilities for the adult child, or direct conflict over decision-making Change may be subtle & short-term or drastic & long-term Long-term changes require an adjustment process similar to the grieving process (Potter & Perry, p. 81)

29. Impact of Illness on Client & Family Impact on Family Dynamics Family dynamics is the process by which the family: functions, makes decisions, gives support to individual members, & copes with everyday changes & challenges If a parent becomes ill, family activities & decision making often come to a halt, as the other family members wait for the illness to pass. Or they delay action because they are reluctant to assume the ill person’s roles or responsibilities Illness often changes the family dynamics (Potter & Perry, p. 81)

30. Physical Illness Physical illness is any illness that affects the body Any illness that causes pain, physical discomfort, or mood problems, such as anxiety & depression, often result in sleep problems too (Potter & Perry, p. 1031)

31. Prevention of Chronic Illness Because chronic disease evolves over time & changes may become irreversible so the goal is to detect risk factors as early as possible Prevention: Interrupting or stopping the development of a disease before it occurs Primary Prevention: Health promotion & specific prevention against disease Secondary Prevention: Early detection of disease & prompt intervention to halt disease progression Tertiary Prevention: Rehabilitation (for those with disease) to prevent complications, & restoring independent functioning to the highest level (Ramon & Niedringhaus, p. 305)

32. Customer & Client Services & Satisfaction

33. Describe selected client service strategies, including customer service, their impact on quality client care and the importance of client participation in group/family activities.

34. Customer & Client Services Client Service Strategies Goal is customer services satisfaction Who are the healthcare services customers? There are internal & external customers Internal customers are those who work in the healthcare industry & external customers are those who come to the healthcare provider for services, such as customers, clients, & patients. Patients & clients come to the healthcare provider for a number of reasons: sudden illness, an emergency situation, to obtain information about preventative measures to avoid future health problems, or a routine evaluation or physical examination. Whatever the reason, patients/clients/families expect high quality professional services (Juliar, p. 292)

35. Customer & Client Services Customer satisfaction & quality of care must be a goal of the healthcare worker What are some ways healthcare workers can promote high quality patient/client services? Stay focused on the client’s needs Listen attentively to the clients & their families & report any concerns to your supervisor in a timely manner Clients/families may have positive outcomes of their medical treatment, but may be dissatisfied with the experience due to a cold food tray, delay in answering a call light, waiting for tests, delayed treatments, an un-emptied bedpan, or delayed pain medications

36. How can healthcare workers promote quality healthcare services? H ealthcare workers should recognize the client’s stage of development & how this impacts the client’s needs Recognize the impact of family in the client’s receiving of healthcare services Remember that in every healthcare setting, the client/family has feelings of vulnerability & may be in crisis (expect changes in usual behaviors)

37. Customer Satisfaction Maintain good relationships with internal & external customers 1. Look for & praise coworker for a job well done 2. Respect & show courtesy 3. Give a quick response to a situation or in providing assistance to another 4. Arrive at work on time & ready to provide client- focused care 5. Leave personal problems at home 6. Seek professional development opportunities to promote one’s own development (Juliar, pp. 294-295)

38. Customer Service Healthcare workers should: Value seeing health care situations ‘through the patients’ eyes’ Respect & encourage individual expression of patient’s values, preferences & expressed needs Value the patient’s expertise with their own health & symptoms Honor learning opportunities with patients who represent all aspects of human diversity (QSEN, 2011)

39. Customer Service Healthcare workers should: Seek to understand one’s personally held attitudes about working with patients from different ethnic, cultural & social backgrounds Willingly support patient-centered care for individuals & groups whose values differ from one’s own Value cultural humility Seek to understand one’s personally held values & beliefs about the management of pain or suffering Value shared decision-making with empowered patients and families, even when conflicts occur (QSEN, 2011)

40. Common Expectations for Service Healthcare services should be done in a timely manner Services should be client-centered or family- centered Service should include caring & compassion (Juliar)

41. References Berman, A., Snyder, S.J., Kozier, B., & Erb, G. (2008). Promoting family health. In A. Berman, S.J. Snyder, B. Kozier, & G. Erb (Eds.). Kozier & Erb’s Fundamentals of nursing: Concepts, process, and practice (8 th ed.) (pp.428- 441). Upper Saddle River, NJ: Prentice Hall Duffy, S.K. (2006). Rehabilitation nursing. In B.L. Christensen & E. O. Kockrow (Eds.). Foundations and adult health nursing (5 th ed.) (pp. 149-187). St. Louis, MO: Elsevier, Mosby Juliar, K. (2003) Minnesota Healthcare Core Curriculum (2 nd ed.). Clifton Park, NY: Delmar Publishers Maurer, F., & Smith, C. (2009). Community/public health nursing practice: Health for families and populations (4 th ed.). St. Louis, MO: Elsevier. Neill, J. (2006, December 6). What is locus of control? Retrieved from http://wilderdom.com/psychology/loc/LocusOfControlWhatIs.html Polan, E.U. (2006). Life span development. In B.L. Christensen & E. O. Kockrow (Eds.). Foundations and adult health nursing (5 th ed.) (pp. 149-187). St. Louis, MO: Elsevier, Mosby Ramon, P.R. & Niedringhaus, D. M. (2008). Promoting culturally proficient care. Fundamental nursing care (2 nd ed.) (pp. 16-26). Upper Saddle River, NJ: Person Prentice Hall