Fundamentals of Nursing Chapter 18 PDF - Pearson

UNIVERSITY OF THE SUNSHINE COAST LIBRARY Copyright© Pearson Australia (a division of Pearson Australia Group Pty Ltd) 2021 Pearson Australia 707 Collins Street Melbourne VIC 3008 www.pearson.com.au Authorised adaptation from the United States edition entitled Kozier & Erb's Fundamentals of...

UNIVERSITY OF THE SUNSHINE COAST LIBRARY Copyright© Pearson Australia (a division of Pearson Australia Group Pty Ltd) 2021 Pearson Australia 707 Collins Street Melbourne VIC 3008 www.pearson.com.au Authorised adaptation from the United States edition entitled Kozier & Erb's Fundamentals of Nursing: Concepts, Process and Practice, 11th edition, by Berman, Audrey T.; Frandsen, Geralyn, Snyder, Shirlee, published by Pearson Education, Inc., Copyright© 2020. Fifth adaptation edition published by Pearson Australia Group Pty Ltd, Copyright© 2021. The Copyright Act 1968 of Australia allows a maximum of one chapter or 10% of this book, whichever is the greater, to be copied by any educationa l institution for its educational purposes provided that that educational institution (or the body that administers it) has given a remuneration notice to Copyright Agency Limited (CAL) under the Act. For details of the CAL licence for educational institutions contact: Copyright Agency Limited, telephone: (02) 9394 7600, email: [email protected] All rights reserved. Except under the conditions described in the Copyright Act 1968 of Australia and subsequent amendments, no part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the copyright owner. While every effort has been made to ensure that the content of this text is accurate at the time of publication, no responsibility will be taken for inaccuracies, omissions or errors. All examples used are for teaching purposes only, and should not be used as a substitute for advice or treatment from a licensed practitioner, and in accordance with app licable regulations and guidelines. The publisher does not accept liability to any person for the information obtained from this publication, or for loss or damages in curred as a result of reliance upon the material contained in this text. This book contains photographs of people from Aboriginal and Torres Strait Islander communities. It may cause distress to some Indigenous Australians to view photographs of any of these people who may have subsequently died. This text was in the final stages of production during the COVID-19 pandemic of 2020. Due to the evolving situation and ongoing medical research in this area, content relating to COVID-19 has not been incorporated into this text, but will be considered for future editions. Senior Portfolio Manager: Mandy Sheppard Development Editor: Anna Carter Senior Project Manager: Bronwyn Smith Editorial and Design Production Manager: Bernadette Chang External Production Manager: Katie Millar Product Manager: Erin Nixon Rights and Permissions Editor: Emma Gaulton Lead Editor/Copy Editor: Katie Millar Proofreader: lntegra Software Services Indexer: lntegra Software Services Cover and internal design by Natalie Bowra Cover image from PinkCactus/Shutterstock Typeset by lntegra Software Services Printed in Malaysia (CTP-WP) ISBN 9781488626609 1 2 3 4 5 25 24 23 22 21 !hdwDn~ A catalogue record for this work is available from the NATIONAL LIBRARY National Library of Australia OF AUST RALIA Pearson Australia Group Pty Ltd ABN 40 004 245 943 @ Pearson LEARNING OUTCOMES KEY TERMS After completing this chapter, you will be able to: acute illness 315 aetiology 315 Differentiate between health, wellness and wellbeing. chronic illness 316 Describe five dimensions of wellness. compliance 313 concordance 314 Compare various models of health outlined in this chapter. disease 315 Identify factors affecting health status, beliefs and practices. exacerbation 316 Describe factors affecting health care concordance. health 305 health behaviour 31 0 Differentiate illness from disease and acute illness from chronic illness. health belief 310 Identify Parsons' four aspects of the sick role. health status 31 0 Explain Suchman's stages of illness. illness 315 illness behaviour 316 Describe effects of illness on individuals' and family members' roles and functions. lifestyle 311 locus of control (L0C) 312 remission 316 risk factor 311 wellbeing 307 wellness 306  CHAPTER 18 HEALTH, WELLNESS AND ILLNESS 305 Nurses' understanding of health and wellness largely deter- Bircher and Kuruvilla. (2014) define health as a dynamic mines the scope and nature of nursing practice. People's health state of wellbeing characterised by a physical and mental po- beliefs also influence their health practices. Some people think tential that satisfies the demands of life in terms of culture, of health and wellness (or wellbeing) as the same thing or, at age and personal responsibility, and encompasses the social the very least, as accompanying one another. However, health determinants of health. In terms of health being culturally de- may not always accompany wellbeing. A person who has a ter- termined, the way many Aboriginal and Torres Strait Islander minal illness may have a sense of wellbeing; conversely, an- people define health is a good example. To them, health refers other person may lack a sense of wellbeing yet be in a state of not just to a state of physical wellbeing of the individual but good health. For many years, the concept of disease was the also to the social, emotional, spiritual and cultural wellbeing of yardstick by which health was measured. In the late nineteenth the whole community (National Health and Medical Research century, the 'how' of disease (pathogenesis) was the major con- Council 1996), capturing within the definition the concept that cern of health professionals. The twentieth century focused on health relates to the life-death-life cycle, supporting the holis- finding cures for diseases. Currently, health care providers are tic view taken by the WHO. increasing their emphasis on preventing illness and promoting Health has also been defined in terms of role and perfor- health and wellness for individuals, families and communities. mance. Talcott Parsons (1951), an eminent sociologist and cre- ator of the concept 'sick role', conceptualised health as the abil- ity to maintain normal roles. Understanding 'health' in these CONCEPTS OF HEALTH, WELLNESS terms has a profound impact on how communities, individuals, AND WELLBEING care providers and governments respond to managing 'health'. Health, wellness and wellbeing have many definitions and in- terpretations. The nurse should be familiar with the most com- Personal definitions of health mon aspects of these concepts and consider how they may be Health is a highly individual concept. Consider the follow- individualised with specific people to enhance a person-centred ing examples of individuals who would probably say they are approach to care. healthy even though they have physical impairments that some would consider an illness: Health A 15-year-old with diabetes takes injectable insulin each Traditionally, health was defined in terms of the presence or morning. He plays on the school football team and is a mem- absence of disease. The word 'health' is derived from the old ber of the high school choir. English word hoelth, which meant a state of being sound, and A 32-year-old paralysed from the waist down needs a was generally used to infer a state of soundness of the body wheelchair for mobility. He is studying accounting at a (Awofeso 2005). Nightingale defined health as a state of be- nearby TAPE college and uses a specially designed car for ing well and using every power the individual possesses to transportation. the fullest extent (Nightingale 1859/1969). The World Health A 72-year-old takes antihypertensive medications to treat Organization (WHO) takes a more holistic view of health. Its high blood pressure. She plays lawn bowls once a week, is constitution defines health as 'a state of complete physical, a member of a local golf club, makes handicrafts for a local mental and social wellbeing and not merely the absence of dis- charity and travels for 2 months each year. ease or infirmity' (WHO 1948). This definition: Many people define and describe health as the following: reflects concern for the individual as a total person function- ing physically, psychologically and socially. Mental pro- being free from symptoms of disease and pain as much as cesses determine people's relationship with their physical possible and social surroundings, their attitudes about life and their being able to be active and to do what they want or must interaction with others being in good spirits most of the time. places health in the context of environment. People's lives, These characteristics indicate that health is not something and therefore their health, are affected by everything they that a person achieves suddenly at a specific time. It is an ongo- interact with- not only environmental influences such as cli- ing process- a way of life- through which a person develops mate and the availability of food, shelter, clean air and water and encourages every aspect of the body, mind and feelings to to drink, but also other people, including family, lovers, em- interrelate harmoniously as much as possible (see Figure 18.1). ployers, co-workers, friends and associates. Many factors affect individual views of health. Definitions However, there is a view that the WHO definition is 'uto- vary according to an individual's previous experiences, expec- pian, inflexible and unrealistic' , and that including the word tations of self, age and sociocultural influences. 'complete' in the definition makes it highly unlikely that anyone Nurses should be aware of their own personal definitions or would be healthy for a reasonable period of time and is no longer views of health and appreciate that other people have their own relevant given the explosion of chronic disease. It also appears individual perspectives as well. A person's view of health influ- that a state of complete physical, mental and social wellbeing ences their behaviour in relation to health and illness. By un- corresponds more to happiness than to health (Huber et al. 2011). derstanding people's perceptions of health and illness, nurses 306 UNIT 4 HEALTH BELIEFS AND PRACTICES 1. Physical. The ability to carry out daily tasks, achieve fitness (e.g. pulmonary, cardiovascular, gastrointestinal function), maintain adequate nutrition and proper body fat, avoid abusing drugs and alcohol· or using tobacco products and generally practise positive lifestyle habits. 2. Social. The ability to interact successfully with people and within the environment of which each person is a part, to develop and maintain intimacy with significant others and to develop respect and tolerance for those with different opinions and beliefs. 3. Emotional. The ability to manage stress and to express emotions appropriately. Emotional wellness involves the ability to recognise, accept and express feelings and to ac- cept one's limitations. 4. Intellectual. The ability to learn and use information Figure 18.1 Satisfaction with work enhances a sense of effectively for personal, family and career develop- wellbeing and contributes to wellness. ment. Intellectual wellness involves striving for contin- Source: Blaj Gabriel/123RF. ued growth and learning to deal with new challenges can provide more meaningful assistance to help them regain or effectively. attain a state of health and facilitate person-centred care. For 5. Spiritual. The belief in some force (nature, science, reli- aid in developing a personal definition of health, see Box 18.1. gion or a higher power) that serves to unite human beings and provide meaning and purpose to life. It includes a per- Wellness and wellbeing son's own morals, values and ethics. 6. Occupational. The ability to achieve a balance between Wellness is a state of wellbeing. Basic aspects of wellness in- work and leisure time. A person's beliefs about education, clude self-responsibility; an ultimate goal; a dynamic, growing employment and home influence personal satisfaction and process; daily decision making in the areas of nutrition, stress relationships with others. management, physical fitness, preventive health care and emo- 7. Environmental. The ability to promote health measures tional -health; and, most importantly, the whole being of the that improve the standard of living and quality of life in individual. the community. This includes influences such as food, wa- Anspaugh, Hamrick and Rosato (2010) propose seven com- ter and air. ponents of wellness (see Figure 18.2). To realise optimal health and wellness, people must deal with the factors within each component: - Developing a personal definition of health The following questions can help nurses develop a personal definition of health. Is a person more than a biophysiological system? Is health more than the absence of disease symptoms? Environmental Physical Is health the ability of an individual to perform work? Is health the ability of an individual to adapt to the environment? Is health a condition of a person's actualisation? Is health a state or a process? Is health the effective functioning of self-care activities? Spiritual Is health static or changing? Emotional 3 Are health and wellness the same? 5 Are di!sl ease and illness different? Intellectual Are there levels of health? Are w~llness, health and illness separate entities or points along a continuum? Is health socially determined? Figure 18.2 The seven components of wellness. How do you rate your health and why? Sources: Based on D. J. Anspaugh, M. H. Hamrick & F. D. Rosato (2010). Wellness: Concepts and Applications (8th ed.), p. 4; lterum/Shutterstock.com. \.  CHAPTER 18 HEALTH , WELLNESS AN D ILLNESS 307 REAL-WORLD PRACTICE Health, wellness and illness are terms commonly used to indicate lifestyle. Conversely, Sheila, a 64-year-old woman with a similar di- or measure the wellbeing of an individual. However, people's in- agnosis to Jane, considers herself ill and does not perceive herself terpretation of these terms indicates that the definitions are highly as having the potential to experience wellness. subjective and can vary from person to person and from commu- The person's perception of health, wellness and illness must be nity to community. considered in order to provide individualised, person-centred qual- Consider Terry, a 54-year-old quadriplegic. His permanent con- ity health care. Challenges may arise when the person's interpreta- dition may lead some to believe that a state of illness exists or that tion of these terms varies significantly from those of the health care a state of wellness is not experienced. However, Terry is gainfully professional. While it is important to value our own definitions, the employed (as a tax assessor) and he participates in various so- views of the individual must be kept in focus and, in many cases, cial activities including visits to the theatre and sporting events. determine the interventions taken. Wellness may not necessarily He views himself as 'healthy' and enjoys a state of wellbeing. co-exist with health, and the presence of illness does not negate Variations in the definitions of health, wellness and illness set the the opportunity to experience wellbeing. An individualised interpre- state for situations in which illness and wellness can co-exist. tation of these terms sets the foundation for the provision of quality Consider Jane, a 78-year-old woman who has advanced con- health care that best meets the needs of the people in our care. gestive cardiac failure, hypertension and late-onset diabetes. She understands the limitations imposed by medical conditions, but by -Paula McKean, RN, Community Registered Nurse, Silver Chain, adhering to her health care plan she enjoys an active and fulfilling Perth, Western Australia The seven components overlap to some extent and factors Models of health include the clinical model, the role per- in one component often directly affect factors in another. For formance model, the adaptive model, the eudemonistic model, example, a person who learns to control daily stress levels from the agent-host-environment model, the health-illness continua a physiological perspective is also helping to maintain the emo- and the 4+ model of wellness. tional stamina needed to cope with a crisis. Wellness involves working on all aspects of the model with wellbeing seen as Clinical model a subjective perception of vitality and feeling well, described The narrowest interpretation of health occurs in the clinical objectively, experienced and measured, and plotted on a con- model. People are viewed as physiological systems with related tinuum (Hood & Leddy 2009). functions and health is identified by the absence of signs and symptoms of disease or injury. It is considered the state of not being 'sick'. In this model, the opposite of health is disease or MODELS OF HEALTH AND injury. WELLNESS Health professionals who use the clinical model with a focus Because health is such a complex concept, various researchers on the relief of signs and symptoms of disease and elimination have developed models or paradigms to explain health and, in of malfunction or pain believe that when these signs and symp- some instances, its relationship to illness or injury. Models can toms are no longer present, the individual's health is restored. be helpful in assisting health professionals to meet the health and wellness needs of individuals. Nurses need to clarify their Role performance model understanding of health, wellness and illness for the following Health is defined in terms of the individual's ability to fulfil soci- reasons: etal roles; that is, to perform their work or role in society. People usually fulfil several roles (e.g. mother, daughter, friend) and cer- Nurses' definitions of health largely determine the scope tain individuals may consider non-work roles paramount in their and nature of nursing practice. For example, when health lives. According to this model, people who can fulfil their roles is defined narrowly as a physiological phenomenon, nurses are healthy even if they have clinical illness. For example, a man confine themselves to assisting people to regain normal who works all day at his job as expected is healthy even though physiological functioning and may lack the capacity or in- an x-ray of his lung indicates a tumour. It is assumed in this sight into person-centred care as a result. When health is de- model that sickness is the inability to perform one's work role. fined more broadly, the scope of nursing practice enlarges correspondingly. People's health beliefs influence their health practices. A Adaptive model nurse's health values and practices may differ from those of In the adaptive model, health is a creative process ; disease is a other people. Nurses need to ensure that a plan of care devel- failure in adaptation, or maladaptation. The aim of treatment oped for an individual relates to the person's conception of is to restore the ability of the person to adapt; that is, to cope. health rather than the nurse's belief system. Otherwise, the According to this model, extreme good health is flexible adap- individual may fail to respond to the health care regimen. tation to the environment and interaction with the environment 308 UNIT 4 HEALTH BELIEFS AND PRACTICES to maximum advantage. Sister Callista Roy's adaptation model disease. Physical environment aspects include climate, of nursing (Roy 2008) views the person as an adaptive system living conditions, sound (noise) levels and economic sta- (see Chapter 3). The focus of this model is stability, although tus. Social environment includes interactions with others there is also an element of growth and change. and life events, such as the death of a spouse or partner. Because each of the agent-host-environment factors con- Eudemonistic model stantly interacts with the others, health is an ever-changing The eudemonistic model incorporates a comprehensive view state. When the variables are in balance, health is maintained; of health. Health is seen as a condition of actualisation or re- when variables are not in balance, disease or illness occurs. alisation of a person's potential. Actualisation is the apex of the fully developed personality, described by Abraham Maslow Health-illness continua (see Chapter 17). In this model, the highest aspiration of people Health-illness continua (grids or graduated scales) can be used is fulfilment and complete development, which is actualisation. to measure a person's perceived level of wellness. Health and Illness, or a deviation from wellbeing in this model, is a condi- illness (or disease) can be viewed as the opposite ends of a health tion that prevents self-actualisation. continuum. From a high level of health, a person's condition Pender, Murdaugh and Parsons (2015) include stabilising can move through good health, normal health, poor health and and actualising tendencies in their definition of health where extremely poor health, eventually to death. People move back health is seen as the actualisation of inherent and acquired hu- and forth within this continuum day by day. There is no distinct man potential through goal-directed behaviour, competent self- boundary across which people move from health to illness or care and satisfying relationships with others, while adjustments from illness back to health. How people perceive themselves are made as needed to maintain structural integrity and har- and how others see them in terms of health and illness will also mony with relevant environments. affect their placement on the continuum. The ranges in which people can be thought of as healthy or ill are considerable. Agent-host-environment model The agent-host-environment model of health and illness, also Dunn's high-leve wel ness grid called the ecological model, originated in the community health Dunn (1959) described a health grid in which a health axis work of Leavell and Clark (1965) and has been expanded into and an environmental axis intersect. The grid demonstrates the a general theory of the multiple causes of disease. The model interaction of the environment with the illness-wellness con- is used primarily in predicting illness rather than in promot- tinuum (see Figure 18.4). The health axis extends from peak ing wellness, although identification of risk factors that result wellness to death and the environmental axis extends from very from the interactions of agent, host and environment is helpful in promoting and maintaining health. The model has three dy- Habitat axis namic interactive elements (see Figure 18.3): Very beneficial habitat l. Agent. Any environmental factor or stressor (biological, chemical, mechanical, physical or psychosocial) that by its presence or absence (e.g. lack of essential nutrients) can lead to illness or disease. Prolonged poor Pre-eminent 2. Host. Person(s) who may or may not be at risk of acquir- health (in a wellbeing positive habitat) (in a positive ing a disease. Family history, age and lifestyle habits in- habitat) fluence the host's reaction. 3. Environment. All factors external to the host that may or may not predispose the person to the development of Health/ wellness axis Death Peak wellness Reduced Developing health (in an high-level unbeneficial wellbeing (in an habitat) unbeneficial habitat) Very unbeneficial habitat Figure 18.4 Dunn's health grid: its axes and quadrants. Source: Based on H. L. Dunn (1959). High-level wellness for man and society. Figur 18.3 Agent-host-environment model. American Journal of Public Health, 49(6), 786-792, Figure 1.  CHAPTER 18 HEALTH, WELLNESS AND ILLNESS 309 beneficial to very unbeneficial. The intersection of the two axes In contrast, movement to the left of the neutral point indicates forms four quadrants of health and wellness: progressively decreasing levels of health. Travis and Ryan be- lieve it is possible to be physically ill and at the same time l. Pre-eminent wellbeing in a positive habitat. An example oriented towards wellness, or be physically healthy and at the is a person who implements healthy lifestyle behaviours same time function from an illness mentality. and has the biopsychosocial, spiritual and economic re- The model also compares the traditional treatment model sources to support this lifestyle. with the wellness model. The former can help an individual 2. Developing high-level wellbeing in an unbeneficial hab- move from the left only to the neutral point where symptoms of itat. An example is a person who has the knowledge to the illness are alleviated. For example, a man who takes an an- implement healthy lifestyle practices, but does not imple- tihypertensive medication to reduce blood pressure and relieve ment adequate self-care practices because of family re- any associated symptoms moves to the neutral point. However, sponsibilities, work demands or other factors. wellness-oriented measures such as reducing weight or ceasing 3. Prolonged poor health in a positive habitat. An example to smoke are needed to move the person beyond the neutral is an ill person (e.g. one with multiple fractures or severe point to a higher level of wellness. Note that wellness inter- hypertension) whose needs are met by the health care sys- ventions can be initiated at any point on the continuum. Thus, tem and who has access to appropriate medications, diet the wellness model and the treatment model can work together. and health care instruction. 4. Reduced health in an unbeneficial habitat. An example is a young child who is starving in a drought-stricken country. The 4+ model of wellness A newer model, the 4+ model of wellness (Baldwin & Conger Family wellness enhances wellness in individuals. In a well 2001), consists of the four domains of the inner self- physical, family that offers trust, love and support, the individual does spiritual, emotional and intellectual-plus the elements of the not have to expend energy to meet basic needs and can move outer systems (environment, culture, nutrition, safety and many forward on the wellness continuum. By providing effective san- other elements). The nurse assesses the inner self for strengths itation and safe water, disposing of sewage safely and preserv- and excesses, sources of nurturing and depletion, and the inter- ing beauty and wildlife, the community enhances both family actions between the inner self and the outer systems. This model and individual wellness. Environmental wellness is related to encourages critical thinking about the issues of wellness and is the premise that humans must be at peace with and guard the useful when working with individuals, families or communities. environment. Societal wellness is akin to cultural safety and is significant because the status of the larger social group affects the status of smaller groups. Dunn believes that social wellness VARIABLES INFLUENCING HEALTH must be considered on a worldwide basis. STATUS, BELIEFS AND PRACTICES Travis's illness-wellness continuum Many variables influence a person's health status, beliefs and The illness-wellness continuum (see Figure 18.5) devel- behaviours or practices. These factors may or may not be un- oped by Travis ranges from high-level wellness to premature der conscious control. People can usually control their health death (Travis & Ryan 2004). The model illustrates two arrows behaviours and can choose healthy or unhealthy activities. pointing in opposite directions and joined at a neutral point. In contrast, people have little or no choice over their genetic Movement to the right of the neutral point indicates increasing make-up, age, sex, culture and sometimes their geographical levels of health and wellbeing for an individual. This is achieved environments. Box 18.2 differentiates health status, beliefs and in three steps: (1) awareness ; (2) education; and (3) growth. behaviours or practices. 0 Neutral point (No discernible illness or wellness) Figure 18.5 Travis's illness-wellness continuum. Source: J. W. Travis & R. S. Ryan (2004). Wellness Workbook (3rd ed.). Berkeley, CA: Celestial Arts. © 1981, 1988, 2004 by John W. Travis, MD. Reprinted with permission.. 310 UNIT 4 HEALTH BELIEFS AND PRACTICES - Age is also a significant factor. The distribution of disease Health status, beliefs and varies with age. For example, arteriosclerotic heart disease behaviours is common in middle-aged males but occurs infrequently in Health status. State of health of an individual at a given younger people; such communicable diseases as whooping time. A report of health status may include anxiety, cough and measles are common in children but rare in older depression or acute illness and thus describe the adults, who may acquire immunity to them. individual's problem in general. Health status can also de- Developmental level has a major impact on health status. scribe such specifics as pulse rate and body temperature. Consider these examples: Health beliefs. Concepts about health that an individual believes are true. Such beliefs may or may not be founded Infants lack physiological and psychological maturity so on fact. Some of these are influenced by cultu re, such as their defences against disease are lower during the first years the belief by some Indigenous Australians that an injection (which penetrates the skin) is more likely to prove beneficial of life. than an oral medication because the mode of delivery com- Toddlers who are learning to walk are more prone to falls plies with their t raditional beliefs about the healing benefits of and injury. scarification. For additional information about cultural views Adolescents who need to conform to peers are more prone to of health and illness, see Chapter 19. risk-taking behaviour and subsequent injury. Health behaviours. The actions people take to understand Declining physical and sensory- perceptual abilities may their health state, maintain an optimal state of health, prevent limit the ability of older adults to respond to environmental illness and injury, and reach their maximum physical and mental potential. Behaviours such as eating wisely, exercis- hazards and stressors. ing, paying attention to signs of illness, following treatment advice, avoiding known health hazards such as smoking , Psychological dimension taking time fo r rest and relaxation and manag ing one's t ime effectively are al l examples. The psychological (emotional) factors influencing health in- Health behaviour is intended to prevent illness or disease, or clude mind-body interactions and self-concept. to provide for early detection of disease. Nurses preparing a Mind-body interactions can affect health status positively person-centred plan of care wit h an individual need to con- or negatively. Emotional responses to stress affect body func- sider the person 's health beliefs before they suggest a change tion. For example, a student who is extremely anxious before a in health behaviou r. test may experience urinary frequency and diarrhoea. A person worried about the outcome of surgery or about the behaviour of a teenager may chain smoke. Prolonged emotional distress Internal variables may increase susceptibility to organic disease or precipitate it. Internal variables include biological, psychological and cogni- Emotional distress may influence the immune system through tive dimensions. They are often described as non-modifiable central nervous system and endocrine alterations. Alterations variables because, for the most part, they cannot be changed. in the immune system are related to the incidence of infections, However, when internal variables are linked to health problems, cancer and autoimmune diseases. the nurse must be even more diligent about working with the Increasing attention is being given to the mind's ability to person to influence external variables (such as exercise and diet) direct the body's functioning (Hamilton 2010). Relaxation, that may assist in health promotion and prevention of illness. meditation and biofeedback techniques are gaining wider rec- Regular health exams and appropriate screening for early de- ognition by individuals and health care professionals. For ex- tection of health problems become even more important. ample, women often use relaxation techniques to decrease pain during childbirth. Other people may learn biofeedback skills to Biological dimension reduce hypertension. Genetic make-up, gender, age and developmental level all sig- Emotional reactions also occur in response to body condi- nificantly influence a person's health. tions. For example, a person diagnosed with a terminal illness Genetic make-up influences biological characteristics, innate may experience fear and depression. Self-concept is how a per- temperament, activity level and intellectual potential. It has been son feels about the self (self-esteem) and perceives their phys- related to susceptibility to specific disease, such as diabetes and ical self (body image), needs, roles and abilities. Self-concept breast cancer. In some cases, genetic predisposition for health affects how people view and handle situations. Such attitudes or illness is enhanced when parents are from the same ethnic can affect health practices, responses to stress and illness, and genetic pool. For example, people of African heritage have a the times when treatment is sought. An example is an anorexic higher incidence of sickle-cell anaemia and hypertension than woman who deprives herself of needed nutrients because she the general population, but may be less susceptible to malaria. believes she is too fat even though she is well below an accept- Gender influences the distribution of disease. Certain ac- able weight level. Self-concept is discussed in detail in Chapter quired and genetic diseases are more common in one gender 40. Self-perceptions are also associated with a person's defi- than in the other. Disorders more common among females in- nition of health. For example, a 75-year-old man who can no clude osteoporosis and autoimmune disease such as rheuma- longer move large objects as he was accustomed to do may toid arthritis. Those more common among males are stomach need to examine and redefine his concept of health in view of ulcers, abdominal hernias and respiratory diseases. his age and abilities.  CHAPTER 18 HEAL TH, WELLNESS AND ILLNESS 311 Cognitive dimension produce smoke, which pollutes the air). Other substances in Cognitive or intellectual factors influencing health include life- the environment, such as asbestos, are considered carcinogenic style choices and spiritual and religious beliefs. (i.e. they cause cancer). Tobacco is 'hazardous to one's health' , Lifestyle refers to a person's general way of living, includ- with rates of some cancers higher among both smokers and ing living conditions and individual patterns of behaviour that those who live or work near smokers (passive smoking). are influenced by sociocultural factors and personal charac- Another environmental hazard is radiation. The improper teristics. In brief, lifestyle is often defined as behaviour and use of x-rays, for example, can harm many of the body's or- activities over which people have control. Lifestyle choices gans. Another common source of radiation is the sun's ultra- may have positive or negative effects on health. Practices that violet rays. Light-skinned people are more susceptible to the have potentially negative effects on health are often referred to harmful effects of the sun than are dark-skinned people. as risk factors. For example, overeating, poor dietary choice, The main component of acid rain is sulphur dioxide, pro- getting insufficient exercise and being overweight are closely duced by ore smelters and related industries. The other com- related to the incidence of heart disease, arteriosclerosis, diabe- ponents are nitrogen oxides. These emissions are thought by tes and hypertension. Excessive use of tobacco is clearly impli- scientists to damage forests, lakes and rivers. cated in lung cancer, emphysema and cardiovascular diseases. Another environmental hazard is an increase in the 'green- See Box 18.3 for examples of healthy lifestyle choices. house effect' or 'global warming'. The glass roof of a green- Spiritual and religious beliefs can significantly affect health house permits the sun's radiation to penetrate but the resulting behaviour. For example, Jehovah's Witnesses oppose blood heat does not escape back through the glass. Carbon dioxide transfusions, some religious fundamentalists believe that a in the earth's atmosphere acts like the glass roof of a green- serious illness is a punishment from God and should be sto- house and, as carbon dioxide levels increase due to industrial ically tolerated, some religious groups are strict vegetarians and vehicle emissions, the surface temperature of the earth is and religious Jews perform circumcision on the eighth day of also increasing. The environmental impact of global warming a male baby's life. The influence of spirituality and religion is is likely to have a dramatic effect on the economic and social discussed further in Chapter 42. aspects of health as climate change affects food production and the spread or development of disease and illness. Other sources of environmental contamination are pesticides, microplastics External variables and chemicals used to control weeds, plant diseases and pests. External variables affecting health include the physical envi- These contaminants can be found in some animals and plants ronment, standards of living, family and cultural beliefs, and that are subsequently ingested by people. In excessive levels, social support networks. they are harmful to health. Environment Standards of living People are becoming increasingly aware of their environ- An individual's standard of living (reflecting occupation, in- ment and how it affects their health and level of wellness. come and education) is related to health, morbidity and mortal- Geographical location determines climate and climate affects ity. Hygiene, food habits and the propensity to seek health care health. For instance, malaria and malaria-related conditions advice and follow health regimens vary between high-income occur more frequently in tropical climates than in temperate and low-income groups. ones. Pollution of the water, air and soil affects the health of Low-income families often define health in terms of work; cells. Pollution can occur naturally (e.g. lightning-caused fires if people can work they are healthy. They tend to be fatalistic and believe that illness is not preventable. Because their present problems are so great and all efforts are exerted towards sur- - Regular exercise. Weight control. Examples·of healthy lifestyle choices ,: Avoidance of saturated fats. ,. vival, an orientation to the future may be lacking. The environmental conditions of lower socioeconomic ar- eas also have a bearing on overall health. Poorer suburbs may have housing that is overcrowded and in a state of deteriora- tion. Sanitation services may be inadequate and streets may be strewn with rubbish or discarded home goods, with rodents and Avoidance of excessive salt. other vermin being common. Fires, injury and crime may also Tobacco avoidance. be more constant threats. Recreational facilities may be almost Moderation of alcohol intake. non-existent, forcing children to play in streets and alleys and Seat belt use. exposing them to abuse and neglect. Bike helmet use. Occupational roles also predispose people to certain Immunisation updates. illnesses. For instance, some industrial workers may be exposed Regular dental check-ups. to carcinogenic agents. Affluent people may have stressful so- Regular health maintenance visits for screening examinations cial or occupational roles that predispose them to stress-related or tests. diseases. Such roles may also encourage overeating or the so- cial use of drugs or alcohol. 312 UNIT 4 HEALTH BELIEFS AND PRACTICES Family and cultural beliefs Social support networks The family passes on patterns of daily living and lifestyles to Having a support network (family, friends or a confidant) and offspring. For example, a person who was abused as a child job satisfaction help people avoid illness. Supportive people may physically abuse their own children. Physical or emotional also help the person confirm that illness exists. People with abuse may cause long-term health problems. Emotional health inadequate support networks sometimes allow themselves to depends on a social environment that is free of excessive ten- become increasingly ill before confirming the illness and seek- sion and does not isolate the person from others. A climate of ing therapy. Support people also provide the stimulus for an ill open communication, sharing and love fosters the fulfilment of person to become well again. the person's optimum potential. Culture and social interactions also influence how a person perceives, experiences and copes with health and illness. Each HEALTH BELIEF MODELS culture has ideas about health and these are often transmitted Several theories or models of health beliefs and behaviours from parents to children. Heritage and cultural influences on have been developed to help determine whether an individual health are discuss~d in detail in Chapter 19. is likely to participate in disease prevention and health promo- People of certain cultures may perceive home remedies or tion activities. These models can be useful tools in develop- traditional health customs as superior to, and more dependable than, the health care practices of Western medicine. For exam- ing programs for helping people change to healthier lifestyles and develop a more positive attitude towards preventive health ple, a person of Asian origin may prefer to use herbal remedies and acupuncture to treat pain rather than analgesic medications. measures (see also Chapter 17). Cultural rules, values and beliefs give people a sense of cultural safety and stability and of predictable outcomes. The challeng- Health locus of control model ing of long-held beliefs and values by second-generation cul- Locus of control (LOC) is a concept from social learning tural groups may give rise to conflict, instability and insecurity, theory that nurses can use to determine whether individuals in turn contributing to illness. Traditional and alternative health are likely to take action regarding health; that is, whether practices are discussed in detail in Chapter 20. people believe that their health status is under their own or K. Balkenbush (2018). Childhood obesity: Prevention and treatment. Today's Dietitian , 20(8), 52- 58. The prevalence rate of obesity among children in the Western Implications Evidence suggests that overweight children have at world including Australia has been rising in recent years , with least one associated biochemical or cardiovascular risk factor and the Dietitians Association of Australia (2016) and the Australian that 25-50% of obese children will progress to obesity in adulthood. Institute of Health and Welfare (AIHW) (2016) indicating that 25% The need for effective programs to help control Australia's growing of young Australians are either overweight or obese, and that the waistline among our youngest citizens is becoming imperative. It prevalence of obesity in young ch ildren has tripled between 1985 is suggested that the engagement of primary health care provid- and 1995. The Dietitians Association of Australia (2016) add that ers, many of whom are nurses and midwives, is needed to initiate a 25-50% of obese children go on to become obese adults with systematic approach to managing childhood obesity. The need for associated risks of type 2 diabet es and heart disease. early intervention is becoming increasingly important, as is curb- Balkenbush (2018) indicates that the risk to child ren of physi- ing kilojoule intake, reducing access to sugar-filled foods, using cal and psychological comorbidities from obesity is complex and smaller portion sizes, limiting eating out, not skipping breakfast and high. This is supported by substantial literature and research ev- increasing physical activity (Balkenbush 2018). Other interventions idence that recognises that an increase in metabolic risk factors, will involve practice protocols, assessment tools, support material, internalising disorders and attention deficit disorders is decreasing health provider collaboration and effective referral pathways. As health-related quality of life. with other chronic health issues, obesity requires the establishment The AIHW (2016) indicates that the incidence of childhood obe- of long-term supportive relationships between the nurse and the in- sity has increased in all age groups in the past few decades. In dividual seeking treatment. Nurses can contribute to and encourage 1995, it was estimated that 4.7% of boys and 5.5% of girls aged lifestyle alterations to improve people's health by modelling behav- 7-15 years were obese and a further 15.3 % of boys and 16 % iours, providing educational materials and counselling. of girls were overweight but not obese. However, in 2011 , Haby Recognising the implications of a growing obesity problem, the et al. (2012) suggested that childhood obesity will increase for N ational Obesity Taskforce was established in Australia (in 2002) both male and female children so that by 2025 about one-third of w ith the aim of tackling the problem with a number of strategies. To Australian children will be overweight or obese, as will 83% of men this end , it has published Action Strategies for Children and Young and 75% of women aged over 20 years, significantly impacting on People (Aged 0-1 Byears) , with one aim being to support families the burden of disease. and offer community-wide education (Department of Health 2011 ).  CHAPTER 18 HEALTH , WELLN ESS AND ILLNESS 313 others' control. People who believe that they have a major if the person is a drug addict or a homosexual, however, the influence on their own health status- that health is largely perceived threat of illness is likely to increase because the self-determined- are called internals. People who exercise. susceptibility is combined with seriousness. internal control are more likely than others to take the initia- tive on their own health care, be more knowledgeable about Modifying factors their health and adhere to prescribed health care regimens such as taking medication, making and keeping appointments Factors that modify a person's perceptions include the with doctors, maintaining diets and giving up smoking. By following : contrast, people who believe their health is largely controlled Demographic variables. Demographic variables include age, by outside forces (e.g. chance or powerful others) are referred gender, race and ethnicity. An adolescent may perceive peer to as externals. approval as more important than family approval and as a Research has shown that locus of control plays a role in a consequence may participate in hazardous activities or adopt person's choices about health behaviours. In some cases, ex- unhealthy eating and sleeping patterns. ternals demonstrate better adherence to medical regimens; in Sociopsychological variables. Social pressure or influence others, internals have better adherence. For example, Leong, from peers or other reference groups (e.g. self-help or voca- Molassiotis and Marsh (2004) found that externals adhered bet- tional groups) may encourage preventive health behaviours ter to weight-loss regimens whereas internals adhered better to even when individual motivation is low. Expectations of oth- exercise programs. ers may motivate people, for example, not to drive a motor LOC is a measurable concept that can be used to predict vehicle after drinking alcohol. which people are most likely to change their behaviour. Many Structural variables. Knowledge about the target disease measurement instruments are available to assess LOC. One and prior contact with it are structural variables that are widely used example is the Multidimensional Health Locus of presumed to influence preventive behaviour (e.g. adherence Control (MHLC) Scale (Wallston, Wallston & DeVellis 1978), rates of prescribed treatments are higher among mothers most recently expanded to Form C (Wallston, Stein & Smith whose children have frequent ear infections and occurrences 1994). Nurses can use LOC results to plan internal reinforce- of asthma). ment training if necessary in order to improve efforts towards Cues to action. Cues can be either internal or external. Internal better health. cues include feelings of fatigue, uncomfortable symptoms or thoughts about the condition of an ill person who is close. Rosenstock and Becker's health belief models Likelihood of action Rosenstock and Becker's health belief model (Rosenstock, The likelihood of a person's taking recommended preventive Strecher & Becker 1988) is based on the assumption that health action depends on the perceived benefits of the action health-related action depends on the simultaneous occur- minus the perceived barriers to the action. rence of three factors: (1) sufficient motivation to make Perceived benefits of the action. Examples include that in or- health issues be viewed as important; (2) belief that one is der to prevent lung cancer one refrains from smoking and to vulnerable to a serious health problem or its consequences; maintain weight one eats nutritious foods and avoids snacking. and (3) belief that following a particular health recommen- Perceived barriers to action. Examples include cost, incon- dation would be beneficial. The model includes individual venience, unpleasantness and lifestyle changes. perceptions, modifying factors and variables likely to affect Nurses play a major role in helping people implement healthy initiating action. behaviours. They help people monitor health, they supply an- Individual perceptions ticipatory guidance and they impart knowledge about health. Nurses can also reduce barriers to action (e.g. by minimising Individual perceptions include the following: inconvenience or discomfort) and support positive actions. Perceived susceptibility. A family history of a certain disor- Murdaugh, Parsons and Pender (2019) have modified this der, such as diabetes or heart disease, may make the individ- health belief model to develop a health promotion model. ual feel at high risk. According to Murdaugh et al. (2019), the health belief model Perceived seriousness. In the perception of the individual, explains health-protecting or preventive behaviours but does does the illness cause death or have serious consequences? not emphasise health-promoting behaviours. See the health For example, concern about the spread of acquired immu- promotion model in Chapter 17. nodeficiency syndrome (AIDS) reflects the general public's perception of the seriousness of this illness. Perceived threat. Perceived susceptibility and perceived se- HEALTH CARE CONCORDANCE riousness combine to determine the total perceived threat of an illness to a specific individual. For example, a person Compliance is a medical term commonly used to indicate who perceives that many individuals in the community have that a person is following the health practitioner's advice; that AIDS may not necessarily perceive a threat of the disease; is, the extent to which an individual's behaviour (e.g. taking 314 UNIT 4 HEALTH BELIEFS AND PRACTICES medications, following diets or making lifestyle changes) co- incides with medical or health advice. In Australia and the ASSESSMENT INTERVIEW United Kingdom, the term non-compliance has been used, but this term is being used less and less as it implies a custodial Determining the risk for medication and paternal relationship between person and health profes- non-concordance sional. In recent years, the term concordance has been used Are you having side effects from any of your medications? to describe the involvement of people in the treatment pro- Do you think your medications are helping? cess, and it means something very similar to compliance. In this regard, though, the language used is significant in that Do you have 'triggers' to remind you to take your medication? compliance and non-compliance imply a degree of 'authority' Examples could be an alarm or environmental cues (e.g. 6 or 'orders' from the health practitioner in a tone_similar to o'clock news). one a parent might take with a child. As health profession- Is there someone at home who helps you with your medications? als are not the person's parents and as individuals are not the How many times per day are your medications prescribed? health professional's children, it is far more appropriate that How many pills do you take every day? person-centred care is employed with individuals seen as, and treated as, partners in their care or treatment regimen; thus, Are there any special storage requirements for your medications? the term concordance is proposed as a more appropriate term, How much do your medication requirements interfere with implying equality, parity, effective communication, explana- your lifestyle? tion, the person's involvement and the presentation of a range How well are you able to follow special dosing requirements? of options and choice. The degree of concordance may range How many doses of your medications have you missed over from disregarding every aspect of the recommendations to the past 3 days? following the total therapeutic plan. There are many reasons why some people participate in their care and others do not (see Box 18.4). When a nurse identifies non-concordance, it is important to To enhance concordance, nurses need to ensure that the per- take the following steps: son is able to perform the prescribed therapy, understands the necessary instructions, is a willing participant in establishing Establish why the person is not fallowing the regimen. goals of therapy and values the planned outcomes of behaviour Depending on the reason, the nurse can provide information, changes. Examples of questions to be included in assessment correct misconceptions, attempt to decrease expense, or sug- are found in the 'Assessment interview' box. gest counselling if psychological problems are interfering with concordance or additional treatment if the reason is an- - other underlying issue or illness; for example, depression. It Factors influencing concordance is also essential that the nurse evaluate the suitability of the health advice provided. In situations where the individual's cultural beliefs or age conflict with planned therapies, the People's motivation to become well. nurse needs to consider ways to repattern and restructure care Degree of lifestyle change necessary. that will preserve and accommodate the person's practices. The use of treatments that are effective in circumstances See 'Providing cultural nursing care' in Chapter 19. when they are required. Demonstrate caring. Show sincere concern about the per- Perceived severity of the health care problem. son's problems and decisions and at the same time accept Value placed on reducing the threat of illness. the person's right to a course of action. For example, a nurse Difficulty in understanding and performing specific behaviours. might tell an individual who is not taking his heart medica- Degree of inconvenience of the illness itself or of the tion, 'I can appreciate how you feel about this but I am very regimens. concerned about your heart'. Beliefs that the prescribed therapy or regimen will or will Encourage healthy behaviours through positive reinforce- not help. ment. If the man who is not taking his heart medication is Complexity, side effects and duration of the proposed therapy. walking every day, the nurse might say, 'You are really doing well with your walking'. Specific cultural heritage that may make adherence difficult. Use aids to reinforce teaching. For instance, the nurse can Degree of satisfaction and quality and type of relationship with the health care providers. leave pamphlets for the person to read later or make a 'pill cal- endar', a paper with the date and number of pills to be taken. Overall cost of prescribed therapy. Establish a therapeutic relationship that is person-centred and The development of trust between the individual and the health professional (which limits embarrassment and pro- promotes people's freedom, mutual understanding and mu- motes questions and the exercise of choice). tual responsibility with the person and support persons. By Impact of another unrelated illness or disease; for example, providing knowledge, skills and information, the nurse gives depression. individuals control over their health and establishes a cooper- ative relationship, which results in greater concordance.  CHAPTER 18 HEALTH, WELLN ESS AN D ILLNESS 315 a ihii,iii.UHMi;i,jnm Chronic illness of the normal lifespan. Traditionally, intervention by doctors has the goal of eliminating or ameliorating disease processes. often requires complicated treatment regimens for lengthy periods Primitive people thought 'forces' or spirits caused disease. that may include significant adverse reactions and be very costly. Later, this belief was replaced by the single-causation the- Thus, people with chronic illnesses may be at increased risk for ory. Today, multiple factors are considered to interact in treatment non-concordance. causing disease and determining an individual's response to treatment. Aspects influencing individuals of varying ages are found in The causation of a disease is called its aetiology. A descrip- the 'Lifespan considerations' box. tion of the aetiology of a disease includes the identification of all causal factors that act together to bring about the particular disease. For example, the tubercle bacillus is designated as the biological agent of tuberculosis. However, other aetiological ILLNESS AND DISEASE factors, such as age, nutritional status, living conditions, social Illness is a highly personal state in which the person's physi- circumstances and even occupation, are involved in the devel- cal, emotional, intellectual, social, developmental or spiritual opment of tuberculosis and influence the course of infection. functioning is thought to be diminished. It is not synonymous There are many diseases for which the cause is unknown (e.g. with disease and may or may not be related to disease. An multiple sclerosis). individual could have a disease (e.g. a growth in the stom- Nurses have traditionally taken a holistic view of people and ach) and not feel ill. Similarly, a person can feel ill (e.g. feel base their practice on the multiple-causation theory of health uncomfortable) and yet have no discernible disease. Illness problems. is highly subjective; only the individual person can say they There are many ways to classify illness and disease; one are ill. of the most common is as acute or chronic. Acute illness is Disease can be described as an alteration in body func - typically characterised by severe symptoms of relatively short tions resulting in a reduction of capacities or a shortening duration. The symptoms often appear abruptly and subside Medication non-concordance Adolescents Children Several causes of non-concordance are specific to teenagers. It is important for the nurse to consider these when working with ado- Microbial resistance to antibiotics has increased significantly in lescents because adolescents: recent years (Ventola 2015), making it critical that antibiotics are may not consider the consequences of thei r actions given to children only when they are absolutely necessary, are adm inistered correctly by parents in the home and are taken as are in the early stages of problem solving prescribed. Providers, parents and children must work together assert independence by rejecting adults ' values in order to increase the concordance rates in taking this type of conform to thei r peers and don 't like being 'different' medication. focus on self-concept and body image Concordance is influenced by: live in the 'here and now' may reg ress developmentally at times of stress or illness attitudes towards medications-some parents may th ink that when their ch ild is feeling better the medication is no longer may be unable to distinguish benefits from disadvantages. necessary Older adults past experience-child ren may remember a bad experience Issues that influence concordance in older adults include the following: with taking a medication and resist parents' efforts to give a medication of this sort again lifestyle choices and individual responsibility for health maintenance cost of medication -generi c drugs are less costly than brand- availabil ity of home and commu nity-based services to maxim- name drugs and can be equally effective ise independence cultural issues-providers must work with fam ilies who have housing and home modifications to accommodate the physical language or cultural differences to make sure they understand aspects of ageing t he family's needs and commun icate the health care provider's affordable and accessible transportation recommendations accessibility to mental health services number of doses necessary-concordance improves if there the careg iving crisis that overbu rdens some family and informal are fewer doses per day and fewer days that the medication will caregivers be taken forgetfulness taste and palatability-pharmaceutical compan ies continue to develop liquid medication that will be more acceptable to dementia young children. feeling that they have lived their life and it is time for life to end. 316 UNIT 4 HEALTH BELIEFS AND PRACTICES quickly and, depending on the cause, may or may not require 1. the physical experience of symptoms intervention by health care professionals. Some acute illnesses 2. the cognitive aspect (the interpretation of the symptoms in are serious (e.g. appendicitis may require surgical interven- terms that have some meaning to the person) tion), but many acute illnesses, such as colds, subside without 3. the emotional response (e.g. fear or anxiety). medical intervention or with the help of over-the-counter med- During this stage, the unwell person usually consults others ications. Following an acute illness, most people return to their about the symptoms or feelings, validating with a spouse or normal level of wellness. support people that the symptoms are real. At this stage, the A chronic illness is one that lasts for an extended period, sick person may try home remedies. If self-management is in- usually 6 months or longer, and often for the person's life. effective, the individual enters the next stage. Chronic illnesses usually have a slow onset and often have pe- riods of remission, when the symptoms disappear or diminish, Stage 2: assumption of the sick role and exacerbation, when the symptoms reappear. Examples of chronic illnesses are arthritis, heart and lung The individual now accepts the sick role and seeks confir- mation from family and friends. Often people continue with diseases, and diabetes mellitus. Nurses are involved in caring for self-treatment and delay contact with health care professionals chronically ill individuals of all ages in all types of settings- as long as possible. During this stage, people may be excused homes, nursing homes, hospitals, clinics and other institutions. from normal duties and role expectations. Emotional responses Care needs to be focused on promoting the highest level possi- such as withdrawal, anxiety, fear and depression are not un- ble of independence, sense of control and wellness. People often need to modify their activities of daily living, social relation- common depending on the severity of the illness, perceived de- ships and perception of self and body image. In addition, many gree of disability and anticipated duration of the illness. When symptoms of illness persist or increase, the person is motivated must learn how to live with increasing physical limitations and to seek professional help. discomfort. Stage 3: medical care contact Illness behaviours Sick people seek the advice of a health professional either on When people become ill they behave in certain ways that so- their own initiative or at the urging of significant others. When ciologists refer to as illness behaviour. Illness behaviour, a people seek professional advice they are really asking for three coping mechanism, involves ways individuals describe, moni- types of information: tor and interpret their symptoms, take remedial actions and use the health care system. How people behave when they are ill 1. validation of real illness is highly individualised and affected by many variables, such 2. explanation of the symptoms in understandable terms as age, sex, occupation, socioeconomic status, religion, eth- 3. reassurance that they will be all right or prediction of what nic origin, psychological stability, personality, education and the outcome will be. modes of coping. The health professional may determine that the person does Parsons (1979) described four aspects of the sick role: not have an illness or that an illness is present and may even 1. People are not held responsible for their condition. be life threatening. The person may accept or deny the diagno- 2. People are excused from certain social roles and tasks. sis. If the diagnosis is accepted, the person usually follows the 3. People are obliged to try to get well as quickly as possible. prescribed treatment plan. If the diagnosis is not accepted, the 4. People or their families are obliged to seek competent help. person may seek the advice of other health care professionals or quasi-practitioners who will provide a diagnosis that fits the Suchman (1979) described five stages of illness: symptoms, person's perceptions. sick role, medical care contact, dependent role and recovery or rehabilitation. Not all people progress through each stage. For Stage 4: dependent role example, the person who experiences a sudden heart attack After accepting the illness and seeking treatment, the person is taken to the emergency department and immediately en- becomes dependent on the professional for help. People vary ters stages 3 and 4- medical care contact and dependent role. greatly in the degree of ease with which they can give up their Other people may progress through only the first two stages independence, particularly in relation to life and death. Role and then recover. Details of Suchman's five stages follow. obligations- such as those of wage earner, father, mother, stu- dent, football team member or choir member-complicate the Stage 1: symptom experiences decision to give up independence. At this stage the person comes to believe something is wrong. Most people accept their dependence on health profes- Either someone significant mentions that the person looks un- sionals, although they retain varying degrees of control over well or the person experiences some symptoms such as pain, their own lives. For example, some people request precise in- rash, cough, fever or bleeding. Stage 1 has three aspects: formation about their disease, their treatment and the cost of  CHAPTER 18 HEALTH , WELLN ESS AND ILLN ESS 317 treatment, and they delay the decision to accept treatment until in self-concept: loss of body parts and function , pain, dis- they have all this information. Others prefer that the health pro- figurement, dependence on others, unemployment, financial fessional proceeds with treatment and do not request additional problems, inability to participate in social functions, strained information. relationships with others and spiritual distress. Nurses need For some people, illness may meet dependence needs that to help individuals express their thoughts and feelings and have never been met and thus provide satisfaction. Other to provide care that helps the person effectively cope with people have minimal dependence needs and do everything change. possible to return to independent functioning. A few may Ill individuals are also vulnerable to loss of autonomy even try to maintain independence to the detriment of their and the state of being independent and self-directed without recovery. outside control. Family interactions may change so that peo- ple may no longer be involved in making family decisions Stage 5: recovery or rehabilitation or even decisions about their own health care. Nurses need During this stage, the person is expected to relinquish the to support an individual's right to self-determination with dependent role and resume former roles and responsibilities. person-centred care and autonomy as much as possible by For people with acute illness, the time as an ill person is gen- providing them with sufficient information to participate in erally short and recovery is usually rapid. Thus, most find it decision-making processes and to maintain a feeling of being relatively easy to return to their former lifestyles. People who in control. have long-term illnesses and must adjust their lifestyles may Illness often necessitates a change in lifestyle. In addition to fi nd recovery more difficult. For people with a permanent participating in treatments and taking medications, the ill per- disability, this final stage may require therapy to learn how son may need to change diet, activity and exercise, and rest and to make major adjustments in functioning to find their new sleep patterns. normal. Nurses can help people adjust their lifestyles by these means: Effects of illness providing explanations about necessary adjustments Illness brings about changes in both the involved individ- making arrangements wherever possible to accommodate the ual and the family. The changes vary depending on the person's lifestyle nature, severity and duration of the illness, attitudes asso- encouraging other health professionals to become aware of ciated with the illness by the person and others, financial the person's lifestyle practices and to support healthy aspects demands, lifestyle changes incurred, adjustments to usual of that lifestyle roles and so on. reinforcing desirable changes in practices with a view to making them a permanent part of the person's lifestyle. Impact on the individual Ill people may experience behavioural and emotional Impact on the family changes, changes in self-concept and body image, and life- style changes. Behavioural and emotional changes associated A person 's illness affects not only the person who is ill but with short-term illness are generally mild and short-lived. The also the family or significant others. The kind of effect and individual, for example, may become irritable and lack the its extent depend chiefly on three factors: (1) the member of energy or desire to interact in the usual fashion with family the family who is ill; (2) the seriousness and length of the members or friends. More acute responses are likely with se- illness; and (3) the cultural and social customs the family vere, life-threatening, chronic or disabling illness. Anxiety, follows. fear, anger, withdrawal, denial, a sense of hopelessness and The changes that can occur in the family include the feelings of powerlessness are all common responses to se- following: vere or disabling illness. For example, a person experiencing role changes a heart attack fears for their life and the financial burden it task reassignments and increased demands on time may place on his family. Another individual, informed about increased stress due to anxiety about the outcome of the a diagnosis of cancer or HIV/AIDS , or crippling neurological illness for the person and conflict about unaccustomed disease may, over time, experience episodes of denial, anger, responsibilities fear and hopelessness. financial problems Certain illnesses can also change the person 's body image loneliness as a result of separation and pending loss or physical appearance, especially if there is severe scar- change in social customs. ring or loss of a limb or special sense organ. The person 's self-esteem and self-concept may also be affected. Many See Chapter 25 for further information about the effects of factors can play a part in low self-esteem and a disturbance illness on the family. 318 UNIT 4 HEALTH BELIEFS AND PRACTICES CASE STUDY Jerry and Joe have both suffered heart attacks. Jerry, upon advice from his health professional, started exercising, changed his dietary intake, entered stress reduction classes and returned to work 6 weeks after his heart attack. He has a positive outlook, is doing well and talks about being 'well'. Joe also changed his dietary habits and started exercising. However, Joe has been unable to quit smoking even though he wants to and has been advised to do so. Joe is frequently despondent, is very fearful of having another heart attack, has not yet returned to work and frequently talks about being 'ill'. Fundamentals of Care Framework in Context Context of Care 1. How does Jerry's psychological dimension of health status differ from Joe's? 2. Both Jerry and Joe have heart disease. Jerry considers Integration of Care himself 'well' whereas Joe considers himself 'ill'. Explain this System Policy phenomenon based on the health locus of control model. Level Level