NUR 460 Week 4 Uncertainty in Illness PDF

**[Week 4 -- Uncertainty in the setting of persistent and complex illness ]** **Purpose of uncertainty in illness theory** - helps measure the degree to which and individual is experiencing uncertainty during illness or an acute injury - the illness causes uncertainty that spreads into th...

**[Week 4 -- Uncertainty in the setting of persistent and complex illness ]** **Purpose of uncertainty in illness theory** - helps measure the degree to which and individual is experiencing uncertainty during illness or an acute injury - the illness causes uncertainty that spreads into the individual's life and breaks down the individual's point of view and reality. Slowly a new point of view is formed - Uncertainty is the driving force and is accepted as reality. Now the individual may see that many options are possible as opposed to only a cause-and-effect paradigm. +-----------------------+-----------------------+-----------------------+ | **Antecedents** | **Appraisal of | **Coping with | | | uncertainty** | uncertainty** | +=======================+=======================+=======================+ | - Things that cause | - Pt driven -- how | - Coping mechanisms | | initial shock: | do they determine | to protect | | symptom pattern, | if uncertainty is | themselves or to | | event familiarity | a threat or | move forward | | or lack of | opportunity? | | | congruency, exp | | - Different | | diff symptoms | - Pts will use | mechanisms used | | than the first | their past exp to | based on | | onset of illness | assess the | appraisal | | | current situation | | | - Cognitive | | **Danger** | | capacities | - Pts will attempt | | | | to use coping | - Seeking info | | - Structure | strategies to | | | providers -- info | deal with | - Maintaining | | as received from | uncertainty | vigilance | | credible | (dangerous) | | | authorities and | | - Taking action | | HCPs, social | - If it's an | | | supports and | opportunity, they | **Buffering** | | education | may want to use | | | | strategies that | - Avoidance | | - Uncertainty is | maintain | | | growing - | uncertainty | - Selective | | dependent on | | ignoring | | above | - Ex: pt diagnosd | (typically males) | | | with cancer, | | | - What is the pt's | don't want to | - Neutralizing | | ability to | know the tx | threatening info | | understand the | options, or the | | | info? What | prognosis, or | important for nurses | | supports do they | talk to others -- | to pick up on how the | | have? | ignorance is | pt is coping, so we | | | bliss | know how to support | | - As nurses -- our | | them | | ability to | Other pts will be | | | influence how the | the opposite and | - After the | | pt interprets the | want to know | mechanisms | | illness/symptoms | everything | adaptation pt | | they exp, can | | adjusts to the | | help them more | - That is to say | new experience | | accurately | all this | | | predict and | dependent on the | - Adaptation to the | | understand their | pt and how they | initial | | needs for | appraise the | uncertainty | | education, | situation | | | support, and how | | - They start | | to reduce the | | thinking about | | uncertainty they | | the immediate and | | exp | | long term things | | | | | | | | - Adaptation | | | | involves | | | | biological, | | | | psychological and | | | | social factors | +-----------------------+-----------------------+-----------------------+ **\ **  - **Original theory --** doesn't account for lasting change OT - Looks at the initial presentation and that specific uncertainty - When you look at uncertainty in healthcare it is usually ongoing (int or chronic) - **Reconceptualized theory --** looks at uncertainty and coping OT - Self organization -- continuous integration of uncertainty that leads to a new normal - Probabilistic thinking -- belief in word where one accepts things that aren't always predictable - End up with formulation of new life perspective - Look at the pt holistically -- include their whole healthcare journey starting from birth **Underlying Factors** - Pt is trying to return to previous level of function - Driving force: I just want to get better and feel well - Underlying factors that contribute to uncertainty: - Complexity - Unpredictability - Lack of information - Ambiguity - Mishel's uncertainty scale is made up of 33 items covering aspects of the four factors - Subjective scale - Where is the pt on this scale? - The scale will identify gaps/need for resources/ support from nurses - Allows pt to put forth the info of how they're feeling without us asking every little thing **Patient and Family Perspective** - When caring for pt, it's not just the individual - Family centered care **Uncertainty in persistent and complex illness** - Individuals living with chronic/acute on chronic illnesses may experience uncertainty when: - The cause of disease is unknown - Disease progression is unknown - When symptoms fluctuate or are unpredictable - When there is lack of knowledge about treatment options and outcomes **What is already known about uncertainty?** - Patients with life-limiting illness commonly experience considerable uncertainty, yet uncertainty is under-researched in the context of life-limiting illness - Uncertainty influences pt experience as it affects patient/family information needs, preferences and future priorities for care - Much of this uncertainty cannot be eliminated, yet clinicians are often reluctant to discuss uncertainty with their patients - If poorly addressed uncertainty can result in poorer psychological outcomes for patients and increase use of health care resources - It's okay to say idk to your pts - We may not be able to predict everything - Cannot remove uncertainty **Patient in waiting** - Increasingly sophisticated screening techniques can make anyone a patient - We can feel well and be asymp. But always be aware of the potential for becoming symptomatic - Being at risk creates new identity -- an uncertain status of no longer being healthy but not really being sick **Assessment** - Diagnosis may cause anxiety, hopelessness, emotional distress **Interventions** - What can we teach? - Don't try to change their perception of uncertainty - If it is positive support that - If it is a danger then we assess how best to support that - Interventions may not always help everyone - Depends on how receptive that pt is - Emotional support -- assess their thoughts and beliefs regarding disease - Assess if we need social work, palliative care, chapel support **Outcomes** - Did anything change? - Psychologically -- is it better? Are they coping? Do they feel emotionally better? - Have they returned to a new level of function? -- it may not be possible to return to previous level, but have they adapted to a new normal? This would confirm proof of coping - Re-eval of uncertainty -- have we decreased any uncertainty? (even if its miniscule) **Nursing metaparadigm** - Person -- how does the individual, and their family cope with the uncertainty of new or chronic illness? - The person experiences uncertainty gradually, beginning as the illness insidiously invades life - Questioning one's self as the body changes with progression of illness, and how this will change their interpersonal relationships is common in uncertainty - Uncertainty in illness theory helps to address this effect on the pt and assist with coping mechanisms - Health -- how does the uncertainty impact a person's health? Mental health, physical health, emotional health, spiritual health, financial health? - Uncertainty in illness has been researched primarily in the hospital setting - Illness affects many aspects of life (physical, mental, emotional, spiritual, financial) - It is important to identify what the pt's perception of their own health is - Nursing -- nurses can offer credible information and facilitate adaptation in this model - Offering person centered care, FCC, sharing info can reduce stress in pts and caregivers - Giving information can allow pt to be in control - Nurses can assist the pt by constructing a personal scenario for illness which includes: - Why or how the illness began - How it will progress - How the pt can recover - Incorporating the uncertainty is an approach where there is a change in the pt's and family's perspective in life, away from an orientation to control and predict towards an acceptance of unpredictability and uncertainty as normal - Help the pt makes sense of what is happening - Help pt learn how to live with uncertainty -- this is valuable - Environment -- the milieu that a patient exists in has a great impact on their uncertainty - How does the pt feel about the environment? - By using Mishel's Uncertainty in Illness Scale (MUIS) tool nurses can identify the areas of illness that are causing the greatest uncertainty - Addressing these areas and assisting the pt to build better coping mechanisms will improve the pt's health during times of illness **Process of recognizing uncertainty** - For nurses, recognizing uncertainty involves the processes of assessing, reflecting, questioning, and/or being unable to predict aspects of the pt situation - Some uncertainty related to future illness cannot be avoided. It is imperative that nurses understand how patients cope with uncertainty and how it affects their support needs and preferences for communication - For some, disease complexity, poor information provision and the unpredictability or ambiguity of events interfere with patients' ability to confer meaning, thereby increasing uncertainty - Uncertainty is not always negative -- some patients may find prognostic uncertainty protective, which others find not knowing distressing - When assessing a pt: - What are all the contributing factors? - Ask the patient questions related to them -- avoid dumping a bunch of information - Don't be afraid to say I don't know - Determine how your patient is coping so you know how best to assist them **Implications for Practice** - When managing patients with advances illness and an uncertain prognosis, professionals should realize that uncertainty is often a central feature of patients' illness experience - Nurses should consider an individual patient's preferences in terms of temporal focus, information needs and engagement with illness - Tailor discussions with patients so that patients' priorities are addressed, and information and support are provided according to their preferences - Quality vs. quantity - Better understanding and communication around uncertainty in the clinical setting can improve information provision, help to engage and empower patients and facilitate patient-centered care - Understand the patient perspective in health care - Having them wait in the ER for hours can increase anxiety due to uncertainty and lack of communication from HCP - More is not always better **Summary of article: How nurses influence the patient experience** - Nurses, who have the largest presence in hospitals, influence patient outcomes through direct care, interprofessional collaboration, and participation in initiatives aimed at enhancing patient safety and satisfaction. **Key patient experience categories that nurses affect include:** 1. **Courtesy and Respect**: Patients perceive nurses based on their attitudes and behaviors, such as friendliness and compassion. 2. **Care Coordination**: Nurses are crucial in ensuring care plans reflect patient and family preferences and that communication is smooth between the care team and the patient. 3. **Careful Listening**: Nurses must listen attentively to patients' concerns, even in chaotic environments. 4. **Patient Education**: Nurses are responsible for providing education and ensuring patients understand their health care instructions, accounting for health literacy. 5. **Patient-Centered Care**: Nurses play a vital role in making patients feel involved in their care. 6. **Responsiveness**: Nurses are measured on their promptness and attentiveness to patient needs. 7. **Safety**: Nurses ensure patients feel safe through clear communication and adherence to safety protocols. 8. **Service Recovery**: Nurses handle complaints and concerns, emphasizing clear communication and resolution. - The article also emphasizes the importance of best practices like bedside shift reports, nurse leader rounding, and purposeful interval rounding, collectively known as the \"nursing bundle.\" These practices are proven to improve patient perceptions and the overall human experience in health care. Nurses are encouraged to consistently implement these strategies to ensure high-quality care and patient satisfaction. **Summary of article: A concept analysis of family caregivers' uncertainty of patient's illness** **Key Findings:** 1. **Attributes of Family Caregivers\' Uncertainty:** - **Illness probability: Uncertainty about the likelihood of the illness and its trajectory.** - **Caregivers\' perception of the illness: Their ability to process information about the patient\'s illness.** 2. **Antecedents of Uncertainty:** - **Characteristics of the patient's illness.** - **Family caregivers' cognitive capacity and lack of information or support.** - **Family responsibilities and roles in caregiving.** 3. **Consequences of Uncertainty:** - **Emotional outcomes: Stress, fear, and sadness.** - **Psychological outcomes: Anxiety, depression, and distress.** - **Financial outcomes: Short-term and long-term financial strain.** **Cases to Illustrate the Concept:** - **Model Case:** Demonstrates full attributes of uncertainty (fear, confusion). - **Borderline Case:** Shows partial uncertainty (initial uncertainty resolved by provided information). - **Related Case:** Similar concept but focused on the burden of new caregiving roles, not uncertainty. - **Contrary Case:** Demonstrates none of the defining attributes of uncertainty. **Measurement Tools:** - Mishel Uncertainty in Illness Scale-Family Member (PPUS-FM) to measure uncertainty. - Hospital Anxiety and Depression Scale (HADS) for psychological outcomes. **Limitations:** - Focused only on family caregivers of adult patients. - Excluded perspectives from other disciplines (e.g., psychology, sociology). - Didn\'t address uncertainty among caregivers of pediatric patients or non-caregivers in public health crises like COVID-19. **Conclusion:** - Family caregiver uncertainty is an important consideration in patient care. - Differentiating uncertainty between patients and caregivers can aid in providing family-centered care