Chapter 9 The World of Health Care: Places, Procedures, and People PDF

Chapter 9 The World of Health Care: Places, Procedures, and People Seeking Medical Care 1. Perceiving symptoms: influenced by Individual differences ▪ Attention - individuals who pay a lot of attention to their internal states are consistently m...

Chapter 9 The World of Health Care: Places, Procedures, and People Seeking Medical Care 1. Perceiving symptoms: influenced by Individual differences ▪ Attention - individuals who pay a lot of attention to their internal states are consistently more likely than others to notice a symptom ▪ Mood – bad mood we notice or report more symptoms compared to good mood; in terms of depression symptom complaints may be delayed only recalled retrospectively (in past) but not in moment ▪ Genetic – recent study of monozygotic and dizygotic twins amount of complaints can be explained in part by genetics ▪ personality traits ▪ Stress – elevates symptom reporting, people notice more ; more vulnerable to illness with stress and more likely to seek health care  Illness anxiety disorder – an anxiety disorder whereby someone has a preoccupation with having or developing a serious illness and frequently seeks reassurance from health care practitioners that they are not ill; lead them to report stress related physiological changes such as accelerated heart rate or breathing as symptoms of illness ▪ Gender – sensitivity to internal bodily signals equivocal between men and women; women seek more health care than men do but they may delay longer in seeking that care. Men attribute minor symptoms to major problems more readily than women do ▪ Age differences – older people perceive normal age-related bodily changes as illness; others have suggested tendency for symptoms to increase as one ages may be partially due to the decreased cognitive performance that some adults experience as they age so they might overreport their symptoms; a study however showed that older adults less likely than younger adults to notice cancer symptoms; meta-analysis revealed that age was negatively correlated (one increases and other decreases) with awareness of symptoms ▪ Weight bias – those who experienced weight bias may delay seeking care when experiencing COVID-19 symptoms Situational factors: Environment - individuals are more likely to notice itching or tickling sensations in their throats and emit coughs during boring parts of movies than during interesting portions; similarly environments that are isolated or discourage interpersonal communications allow people to ponder their bodily sensations that is where talking is discouraged or where there is a great deal of noise (ex: factories). This means they may overestimate physiological functions. However when environment demands attention, people are less likely to report internal  symptoms. Inward attention more symptoms recognized while outward attention less likely to be recognized 2. Interpreting Symptoms ▪ Education and Health literacy ▪ Expectations about health ▪ Attentional resources ▪ Prior experience ▪ Cultural factors – western culture men socialized to avoid complaining as this is a sign of weakness and so report less symptoms; parents expectations about a cut provide child cues which symptoms to attend or not ▪ Lay referral system – an informal network of non-practitioners who offer their own interpretations long before any medical treatment is sought; mothers who consulted lay referral system were less likely to take children to emergency department; those who consulted for cancer were one and a half times likely to engage in health-enhancing behaviors such as eating fresh fruits and vegetables than those who did not; although much of the advice by lay referral network is helpful lay persons are far more likely than health professionals to recommend actions that worsen the condition or result in a delay seeking appropriate and needed treatment ▪ Internet – 73% respondents searched the internet for health advice, support or preparation for an appointment; internet searching could lead to great burden on health care system as individuals seek non-essential referrals or treatment; most people searching for health info did not determine its credibility, during COVID-19 there was a lot of misinformation on the internet so these factors influence cyberchondria, cyberchondria more common among females while males were more likely to share information without determining its credibility  Cyberchondria – excessive and repeated health-related information searching on the internet Seeking Help from the Health Care system Depends on ▪ Type of symptoms experienced ▪ More likely to seek help if symptoms are  New, unexpected, painful, disruptive, highly visible or affects highly valued parts of the body are interpreted as more serious and leads to more seeking of medical care  Symptoms from past and are believed to be unimportant or explainable such as muscle aches will probably be ignored, emergency situations are at times ambiguous; most heart attack victims are initially confused by gas pain, ulcers, gallbladder disease or even common cold. Even after they have correctly attributed the symptoms to a serious conditions such as a heart attack people will waste a  substantial amount of time before taking direct action to receive treatment. Delaying Medical Care 1. appraisal delay – the time it takes for a person to decide that a symptom is a sign of illness 2. illness delay – the time between recognizing one is ill and deciding to seek medical care ▪ It is important to call the doctor for prescription on time or for consulting for check-ups 3. behavioral delay – the time that elapses between the decision to seek medical care and acting on this decision by making an appointment 4. medical delay – (scheduling and treatment), the interval between making an appointment and first receiving medical care ▪ Not in part of our control but dependent upon medical professionals or practitioners Much of the recent research investigating delay behaviors has focused on cancer patients as delays in treatment for cancer have a significant influence on survival rates; 30% of women with breast cancer symptoms delay seeking medical care advice for 3 months or more. Appraisal delay accounts for the majority of the total delay time Factors associated with delays in the case of cancer patients: Fear - High and low level of fear are associated with longer delays in reporting breast cancer symptoms. Trust - Those who are trustful of others are less likely to delay seeking care Social influences – role responsibilities of married women with children influence delay behavior Age of patient – women and older patients tend to delay seeking medical care longer, other studies reveal older men delay seeking help for symptoms that might be viewed embarrassing such as STIs The Hospital There were over 3 million Canadians hospitalized in acute care facilities in 2019-2020, the hospitalizations rate was 7699 per 100,000 in 2019-2020. This is smaller in number down 4.4% from 8054 per 100,000 in 2015-2016. The average length of stay has remained unchanged over recent years at 7 days. The mist common reason for hospitalization in 2019-2020 was for giving birth with an average length of stay for 2.2 days. Next common reason was chronic obstructive pulmonary disease or bronchitis (7.1 days) and was followed by myocardial infarction (4.9 days) A hospital is a unique culture: o Professionals use high-tech language o Asks personal questions o People dress and act differently  o Procedures may seem to be ritualistic, unknown o Loss of control over one’s health and well-being o You are not feeling well Patients Different types of patients can have very different experiences Outpatients – Do not stay overnight, seen in office, clinic, or ambulatory care facility Inpatient – admitted for at least overnight Day care patients – more involved than a simple procedure, but patient does not stay overnight; admitted during the day and discharged in late afternoon, need to be accompanied by someone so they reach home safe; also get identification wrist bands Emergency patients – length of stay depends on severity In 2019, 250 people dies while waiting for organ transplants, 3014 received solid organ transplants in Canada in 2019. Yet 4400, still waiting 30-year-old man who suffered a spinal cord injury had to spend 116 days rehabilitating in a hospital. A Hospital Patient’s Loss of Control Patient’s shared decision-making control with their physician such as 49% shared this approach when the medical condition involved chest pain, whereas only 1% wanted totally autonomous decision-making control and 50% wanted to give total control to the physician. The more trust the patients felt, the more control they wanted the physician to have Better outcomes (low death rates and higher transplantation rates) for those patients who led their decision-making process compared to those whose decisions were led by the medical team “Total Institution” (Goffman, 1961) – The hospital takes control of virtually every aspect of a patient’s life Reactance – behaviors of the “bad patient” are viewed as reactance; non-compliant behaviors and attitudes of patients who perceive hospital rules and regimens as an unacceptable challenge to freedom and arouses anger, behaving counter to recommendations in response to feeling that one has lost personal control over health behaviors. Patients who are young, better educated or accustomed to control their environment are more likely to respond to reactance Learned helplessness – patients care that yields independence and results in learned mastery; explain why empowering care yields independence and disempowering care yields dependence also disempowering care results in learned helplessness whereas empowering care results in learned mastery Closely linked to need for information o Monitors – seek information and benefit from information o Blunters – avoid information, are worse with too much information Patients are less stressed when given an amount of information consistent with their coping style Monitors given a large amount of information showed low physiological stress and blunters who were given little information showed low physiological stress Some practitioners and researchers argue that an informed patient simply copes better so all patients should receive information in their preparation for everything from coping with chronic pain to a hospital stay. This homogenous approach is called the uniformity myth Uniformity myth – the belief that all patients should receive the same amount of information in their preparation for a hospital stay regardless of their personal style of coping with stress The preparation for hospital stays, it would be a mistake to adopt a “one size fits” all approach to the provision of such information Miller and Mangan study (1983) reminds us that health care providers should match the amount of information they provide with an individual’s coping style, research has shown that all patients, regardless of their coping style, benefit from relaxation prior to surgery Monitors tend to experience greater stress and anxiety generally, as they scan for information and ruminate over the problem at hand. Thus, monitors benefit from the relaxation and blunters from the distraction it provides. The exact amount of information provided would be matched with coping style. Depersonalization Depersonalization - taking away a person’s sense of individuality Dehumanization – the tendency to see people as objects or body parts rather than human beings o Results from...  Lack of information  Impersonal interactions – run through an examination relaying all facts which cannot be retained by the patient  Hospital clothing  Being referred to by illness – not by name  Lack of privacy Patient-Centered Care Patient-centred care – an approach in which patients and families become active members of the treatment team Adopted around the world Patients and families become active members of the treatment team  E.g., making rooms more homelike  E.g., provide more personalized care, and increase health education (Martin et al., 1998)  Governments are seeking input from patients in creating policies to ensure that the patient-centred care approach is fulfilling patient desires Better satisfaction and healing Care for pregnant mothers should adhere to the patient-centred approach Emergency Room (ER) Common point of entry for patients Patients often come in a state of distress or even disorientation Treatment needs are pressing, but so are those of others around them Admission procedure is key  Triage – sorting of patients to determine priority of need and treatment location Psychological concerns drop in priority Admission and other staff must also have the interpersonal skills needed to communicate a sense of caring Recovering from Surgery Patients in recovery must cope with: o Varying degrees of incapacitation – deprived of strength or power o Unfamiliar body sensations o Painful or uncomfortable instructions o Uncertainty about rate of recovery Pre-operative information is one way to help patients through postoperative → Psychoeducational care o One way to help many patients through the postoperative period is by helping them develop accurate expectations regarding the surgical experience o Patients may not like being dependent on other people to relieve their pain, in asking for pain medication, patients might feel that they are weak. They might not want to give the impression that their recovery is not going well and thereby they risk lengthening their stay in hospital o Undermedication will discourage the patient and be ineffective and overmedication may be harmful when strong drugs such as opioids are used Pain Management One of the most important factors determining a patient’s satisfactory recovery from surgery ▪ Affects mood, which affects length of stay Challenges in pain management: ▪ Issue of control ▪ Ascertaining correct dosages Pain - Controlled Analgesia (PCA) Pain-controlled analgesia – analgesic administration that is independently controlled by the patient; also involves: ▪ Depression device which allows practitioners to set dosages – when pressed, releases a certain dosage of the prescribed analgesic intravenously ▪ Lock-out interval (time period between allowable doses) PCA patients tend to use less medication and experience less pain, also indicate a greater quality of life related to their physical health over time after surgery compared to those who were not provided ▪ Patients with a more passive or avoidant preoperative coping strategy tend to self- administer more analgesic when using PCA than do people with more active coping strategies ▪ Older patients tend to administer less analgesic medications than younger patients do ▪ PCA reduces opiate consumption and increase patient satisfaction ▪ PCA should only be offered to patients who are alert enough to follow the instructions ▪ Prior patient education and positive staff attitudes can positively affect PCA use Intensive-Care Unit (ICU) Modern technology more prominent than any other unit in the hospital Lowest nurse-to-patient ratio in hospital Patients in the ICU go through 3 phases: (PallaviciniGonzalez et al., 1995): 1. Incommunication phase – a period in ICU during which a patient is either unconscious or barely conscious, memories for experience are poor 2. Readaptation stage – a period in ICU dealing with dependence on machines, sense a struggle to recover 3. Reflection stage - a period during which a patient who was in ICU attempts to piece together the details of their recent experience Machines can be reassuring or scary Not all patients experience these stages, and some are moved out of ICU before they get through all these stages which might explain why some patients have no recollection at all of their time in the unit. Upon discharge from ICU, patients can experience relocation stress sometimes called translocation stress Relocation stress (translocation stress) – the stress caused by being separated from those things that were keeping patients alive – the one-on-one care and the technology Communication is key for a patient’s experience in the ICU, but: o Inhibited because patients in ICU tend to be unresponsive or unconscious; if they are conscious, they may have tubes inserted in their throats o Inhibited by ventilation – after recovering indicate that not being able to communicate while in this situation is “horrid” o Health care workers feel they have a lack of training and technology to communicate with ventilated patients o Post-intensive care syndrome - helps reduces long lasting trauma is to have the patients and family members journal about their experience in ICU diaries, helps fill in the gaps in their memories from their hospitalization; some patients need to revisit the ICU after their recovery to put the experience behind them o Staff must assume that patients can hear them, and they must provide feedback regarding the patient’s condition and progress Communication with family, patient, HCP ▪ Communication with family is extremely important because sometimes decisions need to be made in ICU and NICU (neonatal intensive care unit) and these can involve end of life issues o Expertise model – implies that the physician and the intensive care team are best equipped to make end-of-life decisions. They are best informed and most objective o Negotiated model - implies a sharing of the decision between the practitioners, patient and family Patients develop posttraumatic stress disorder after the ICU experience commonly referred to as the post-intensive care syndrome NICU (neonatal intensive care unit) is the most emotionally intense unit in the hospital for both parents and staff Discharge Discharge planning – post-hospital care is organized and risks such as social problems and lack of support are assessed Goal: to ensure a seamless discharge for the patient, resulting in decreased length of stay in hospital and a reduced rate of readmissions Things to consider:  Social problems, support, dependency on others due to medical conditions  Additional expenses (equipment, in-home nursing care)  Elderly tend to have more difficult time at discharge because they have grown accustomed to hospital support and routine  Length planning – should involve patient  To reduce stress associated with discharge involves conducting an accurate assessment of the patient’s cognitive functioning upon admission to hospital. This level of functioning helps predict a patient’s ability to cope when discharged  Older patients may shun assistance or attempt to reject discharge plans that create an impression of dependence rather than independence Palliative Care Progressive illness – continues to worsen in spite of treatment Advanced progressive illness – at a stage where death is imminent (about to happen) Care becomes an attempt to develop a regimen intended to control pain and other symptoms – Primary goals: pursuit of good quality of life, family support, helping patient deal with concepts of life and death Palliative care – care intended to maintain quality of life as best as possible for a patient who is in the advanced stage of an illness. The focus is on controlling pain and other symptoms as opposed to curing of the illness In hospital, home, or hospice – three choices where palliative care will be administered - most people in Canada indicate that their wish is to die at home surrounded by loved ones; however 60% die in hospitals and 15% received publicly funded palliative home care in their last year of life Hospice – represents a compromise between comfort of home and the medical support of a hospital – Team approach: nurses, physicians, social workers, chaplains, psychologists Major problem: pain management Staff must learn to deal with death, euthanasia, ethical debates etc. ▪ Euthanasia – the deliberate ending of a patient’s life to relieve suffering  ▪ do-not-resuscitate (DNR) order – stating that CPR or other interventions will not be used if the patients stops breathing - these discussions are initiated with patients who are expected to live less than 6 months Mixed management model of care – at this point the palliative care units provide MMMC and prepare the patient for eventual death while at the same time providing life-sustaining treatments - preparing patient for death while providing life sustaining treatments Bill C-14 was passed to support Canadians’ freedom of choice and autonomy regarding end-of-life decisions Medical assistance in dying is the direct intervention of a life-ending medication, often a barbiturate whereby a health practitioner administers or the patient; comprised 2% of all deaths, 95% a physician is the one who administers a MAID; approx. 82% of those who received MAID had received palliative care services o Must be 18 years of age and voluntarily make the request o Also a 10-day waiting period Psychological Impact of Medical Procedures Psychology of colonoscopy – colorectal cancer is the second leading cause of cancer-related death in Canada; most common screening procedures are colonoscopy and fecal occult blood test (FOBT) - FOBT followed by colonoscopy had been estimated to reduce 10-year mortality due to colorectal cancer by 16.7 % in Canada – Can reduce 10-year mortality by 16.7% – Cost benefit analysis from Health Belief Model – psychological costs of colonoscopy include the possibility that the test will yield worrisome results Pain ratings tend to be higher for women than men, explained in part that women have longer colons - peaceful talk during colonoscopy reported lower pain experience and hypnosis in an American study was used to eliminate sedation The Psychology of Mammography – Moderately invasive – physically invading the body; embarrassing or shame or discomfort if it intrudes into intimate parts of the body; however results outweigh invasiveness as a predictor of stressfulness – Psychologically distressing – Benefits of reduced mortality (Sasienie, Adams, & Cuzick, 2003) – High rate of false-positives (1-14%) (Lynge et al., 2003) o False-positives – a result that indicates abnormality when none exists; a perfectly reliable test has no false=positives but mammograms are not perfectly reliable o Anxiety related to false-positives results is more short-term than long-term – Women with false positives are more likely to attend regular screening as feel susceptible to cancer Benign breast biopsy – a false-positive result that leads women with abnormal mammograms being called back for a biopsy procedure, and the results show no evidence of malignancy Negative results outnumber positive results so the majority fit into the benign category - greater shorter psychological distress who experienced benign breast biopsy - women think that the cancer might show up even if results are negative People Physicians – After a decade of declining numbers, Canada saw a 4% increase in physicians since 2000 – 2019 survey: 71% of general practitioners and 75% of specialists either satisfied or very satisfied with their professional lives (CMA, 2019a) Physicians’ Emotional Involvement in Their Work Key to understand the emotional intensity of a physician’s day-to-day life – Can read about their dilemmas in journals It’s a job full of ups and downs – E.g., life and death Many cope by distancing themselves from patients, though this makes it harder to appear compassionate - Medical students learn to dehumanize their patients by referring to them as body parts rather than people. This is one way to maintain emotional control - Another is to use humour, which can neutralize situations that would otherwise be very sad. For ex: some physicians will use the initials CTD to describe a patient who is one a slow but inevitable decline to death; CTD stands for “circling the drain” Physicians and Stress 38% of Canadian physicians described their practice as very or extremely stressful (Burke and Richardson, 1990) – Task of communicating bad news adds stress – Many patients want to be “fit in” right away – Male and female physicians experience stress differently (e.g., more role strain for females) o Women face greater strain between their work and family roles o Female physicians tend to report lower degrees of job satisfaction than males o Daughters felt more stress and less satisfaction than their mother had – Burnout – a condition that is similar to the compassion fatigue and includes symptoms of physical exhaustion, depersonalization of patients, and feelings of discouragement and low accomplishment - almost half 48% stated they were not physically active, receiving an average of 6.7 hours of sleep per night, working an average of 48 hrs a week - published guidelines on the giving of bad news are helpful in reducing patient distress, but more attention has to be paid to the distress felt by the physician - suicide is the only cause of mortality that is higher in physicians than the general public - 40% more likely to die by suicide and risk to female physicians is more than double - suicide ideation i.e. suicidal thoughts high in medical students - physicians experiencing suicide ideation and depression encounter additional barriers to care compared to non-physicians Uncertainty As a Source of Stress - uncertainty – a significant source of stress for physicians resulting from the fact that the consequences of medical decisions are often unknown Medicine is NOT a precise science – clinical examinations and diagnostic tests are imperfect and the consequences of medical decisions are inherently uncertain at the decisive moment Diagnoses can be uncertain and prognosis are even more uncertain - prognosis – a prediction of how a medical condition will change in the future - physicians work with probabilities rather than absolute certainties – Patients underestimate how uncertain medicine really is and do not always understand probabilities General and family practice physicians experience greater uncertainty than specialists – Physicians face wider range of symptoms that are in earlier stages than specialists and may not recognize the pattern of symptoms – Specialists see a narrower range of problems and symptoms and usually at a stage where the diagnosis is clearer Physician Impairments Physician impairment - a state in which stress-related symptoms interfere with the physician’s ability to perform his or her job – One of the most troubling causes of physician impairment is substance abuse (e.g., prescription drugs) because of access to drugs Physicians are often reluctant to seek treatment because of the implications for their licensing - this treatment is most effective when it is uninterrupted and residential, featuring family involvement and prudent return to practice with adequate support and follow-up Gender Issues in Medical Practice Among physicians, males and females: Bring different attributes to their work Make somewhat different career choices – female physicians place more importance on their private lives when making professional life decisions; important for women is type of practice, personal satisfaction, fulfilling needs feminization of medicine – the trend towards increased proportions of female physicians in the profession  Perceive their work differently Communicate with their patients differently – female physicians more likely to involve patients as partners in care decisions, females considered skill providers of patient-centred care which has positive impact on treatment outcomes Patients’ own gender influences their preferences for the gender of their physicians Gender Issues in Medical Practice The “Feminization of Medicine”: Females are coming to dominate: o 1997: 25% of all physicians were female (Canadian Institute for Health Information) o 2018: 43% of all physicians were female (Canadian Institute for Health Information) o 2018: 56% of medical students were female (CMA, 2019c) o Qc 2018: more female than male physicians (Picard, 2018) o May affect balance between cure and care o May affect patient-physician interactions o Female physicians more likely involve their patients as partners in care decisions Nurses - care associated with nurses’ role while cure associated physician role Nurses must stay current on their knowledge Roles in the hospital care expanding Nurses must balance care with cure Advanced Practice Nursing – the role of a nurse working within a specialty area where superior clinical skills and judgement are acquired through a combination of experience and education (Canadian Nurses Association) Compassion fatigue: a lack of energy among health care professionals, particularly nurses who are constantly working in an environment in which suffering is common - can affect patient safety - when limits are exceeded, nurses with compassion fatigue must either become less compassionate ore reduce the patients they treat - in trauma-relates settings, the symptoms of compassion fatigue mimic PTSD, anxiety, exhaustion and sleep disruption - compassion fatigue negatively impacting patients, safety by contributing to accidents Also susceptible to burnout - nurses miss more shifts so patients miss seeing nurses, those who suffer prolonged burnout tend to leave the profession - turnover is related to patient health outcomes, each loss of a full time nurse, risk of infection increased by 30% and hospitalization by 80% New nurses – sources of stress include: o Reality shock – reaction to the discrepancy between training and actual work o Learning the system, long hours  o Having to sacrifice care for higher volume o Sense a gap between the high standards of care they were taught and the lower standards that are the reality of nursing due to heavy demands and limited resources Experienced nurses: o Volume of work (multitasking is key) o Long hours – moved to 12-hour shifts, stress higher in those hours than 8-hour shifts o At any given moment, a nurse may be required to take numerous tasks Nurses can deal with stress through: o Personal factors – including personality characteristics and coping strategies such as high self-esteem and clear sense of control are less prone to stress o Social factors – elements of a nurse’s social network (ex: family, friends, coworkers) o Taking care of selves before the patients o Psychological empowerment – a personal factor in stress that can include finding work meaningful, having a sense of autonomy, feeling competent, and having a positive impact Oncology nurses: o Moderate to high degrees of emotional exhaustion o Unexpected patient death during surgery – stress because staff may feel that death was cause by intervention; unexpected death during surgery was human error which staff feel even if surgery was the only hope for patient Job-strain model – a high strain job has high demands and low control -> reduce nurses’ strain by enhancing their sense of control People in health care not immune to lifestyle-related illnesses – illnesses they spend so much time treating Other Health Care Professionals Physiotherapists - physical rehabilitation has a major psychological component that involves: o Goal setting – physiotherapist AND patient. Short term goals such as mobility, hygiene, communication and patient safety while long-term goals addressing such needs as social functioning o Adherence – up to the patient; patient must work diligently on rehabilitation on her own, if Mary feels she was part of the goal setting process she will feel more committed to achieving these goals and will be more likely to adhere to the regimen o Behavioral interventions – reinforcement; many rehabilitation patients need some form of external reinforcement the encouragement and praise from physiotherapists, friends, family and other practitioners; need to find ways of self-reinforce praising oneself or rewarding oneself for accomplishments; Mary should measure how much farther she walked and how much clearly can she  speak so objective criteria is main like bread and butter, downside is psychological goals might get ignored by the practitioner adopting this focus o Cognitive interventions – thoughts/attributions, cannot focus solely on behavioral strategies, it may also focus on her thinking, and that is the stuff of cognitive interventions o Three areas in which it may be crucial 1. May must be ready to make the necessary changes and to take on the challenges of rehabilitation 2. She must believe that she can reach an identified goal, for instance, efficacy beliefs the extent to which one thinks a course of action will actually work; it isn’t usually enough to simply tell people they are capable of doing something those messages must be based on evidence that the patient will accept as reasonable 3. Patient’s attributions – the explanations people give for events such as their successes and failures, in May’s case as with all patients it will be essential that she attributes her success internally, if she attributes her success to Joyce her physiotherapist, Joyce must politely deflect back to May - positive efficacy beliefs and internal attributions of success greatly increase the likelihood that May will adhere to her regimen when Joyce is not around