Chapter 10
Chronic illness, disability and rehabilitation
211
providers’ recommendations) may have contributed to their
chronic disorders. Self-determination is a right that should
be preserved for all patients, and clinicians should work with
patients, building a rapport and negotiating meaningful goals
with them.
CLINICAL REASONING CHALLENGE
A 51-year-old man has been recently diagnosed with renal
disease. He was very active in sports and involved with his
peers but has become too tired to continue. He says he is
not interested in learning about his condition, refuses to
learn to give erythropoietin injections to himself, and eats
and drinks whatever he wants. How would you approach
goal setting and establishing a plan of care with this
man? What mental health issues will you consider in your
teaching?
Managing patients’ reactions to disability in
chronic illness
Psychosocial adaptation to chronic illness may include stress,
crisis, loss and grief, body image, self-concept, stigma, uncer
tainty and unpredictability, and quality of life (Lubkin &
Larsen, 2013). The most frequently reported chronic illness
and disability-triggered reactions include shock, which is a
short-lived reaction experienced at the onset of a traumatic
and sudden injury or the onset of a life-threatening or chronic
and debilitating illness; anxiety, which is a panic-like state as
the nature and magnitude of the event is processed; denial,
which is a defence mechanism used to ward off anxiety and
other intense emotions; depression, which reflects the realisa
tion of the permanence and magnitude of the chronic illness
or disability; anger and hostility that are both self-directed
and externalised; and adjustment, which is exemplified by
self-acceptance as a person with a chronic illness or disability
and marked by reintegration into the community. Finally,
chronic illness and disability-associated coping strategies are
those psychological strategies that are used to decrease, modify
or diffuse the impact of stressful life events. Individuals with
chronic illnesses or disabilities may choose to disengage from
the recovery process (e.g. through denial or substance abuse)
or actively engage in activities to meet challenges associated
with the chronic illness or disability (e.g. information seeking,
problem solving, planning).
All professionals involved in healthcare, including nurses,
should recognise the emotional and psychological needs of
patients and should be able to intervene by providing effec
tive information, compassionate communication, and general
psychological support. The nurse should take time to listen
to patients talk about their disabilities; be respectful of their
values and beliefs; and understand that grief, anger, regret,
resentment and acceptance are all part of the healing process.
Chart 10-3 lists concerns unique to older adults.
The patient’s pre-existing coping abilities play an important
role in the adaptation process. One patient may be particularly
independent and determined, whereas another may be depen
dent and feel powerless. One goal of managing disability is to
help the patient gain a positive self-image through effective
coping. The nurse must recognise different coping abilities and
identify when a patient is not coping well or not adjusting to
the disability or chronic illness. The patient and family may
benefit from participation in a support group or talking with a
mental health professional to achieve this goal, and the nurse
may need to refer them to someone who can help them with
particular challenges.
Expected nursing outcomes
Helping the patient and family to integrate changes into their
lifestyle is an important part of the process. Change takes time,
patience and creativity and often requires encouragement from
the nurse. Validation by the nurse for each small increment
towards goal accomplishment is important for enhancing
self-esteem and reinforcing behaviours. Success may be defined
as making some progress towards a goal when a patient is
unable to implement rapid and dramatic changes in his or her
life. If no progress is made, or if progress towards goals seems
too slow, it may be necessary to redefine the goals, the inter
vention or the timeframe. The nurse must realise and accept
that some people will not change. Patients share responsibility
for management of their conditions, and outcomes are as much
related to their ability to accommodate the illness and carry
out regimens as they are to nursing intervention.
Providing continuing and collaborative care
Patient and family teaching is an important nursing role that
may make the difference in the ability of the patient and family
to adapt to chronic conditions. Well-informed patients with
good levels of health literacy are more likely than uninformed
patients to do what is necessary to manage their chronic con
dition (White, Chen & Atchison, 2008). They are also more
likely to manage symptoms, recognise the onset of complica
tions, and seek healthcare early (Weis, 2007). Knowledge is
the key to making informed choices and decisions during all
phases of the chronic illness trajectory. Teaching strategies and
teaching materials should be adapted to the individual patient,
so that the patient and healthcare providers share understand
ing (Meehan, 2009). For instance, teaching materials should
be tailored for people with low literacy levels and be available
in several languages and in various alternative formats (e.g.
Braille, large print, audiotapes). It may be necessary to provide
sign interpreters. This is part of the National Chronic Disease
Strategy, as Health Literacy Australia reports that 59% of
the Australian population does not have a sufficient level of
Gerontological Considerations
Concerns of adults ageing with
disabilities
• Loss of independence, which is a source of self-respect and
dignity
• Increased potential for discrimination or abuse
• Increased social isolation
• Added burden on spouse, who may also have impaired
health
• Less access to community services and healthcare
• Less access to religious institutions
• Increased vulnerability to declining health secondary
to other disorders, reduced physiological reserve, or
pre-existing impairments of mobility and balance
• Fears and doubts about ability to learn or relearn self-care
activities, exercises, and transfer and independent mobility
techniques
• Inadequate support system for successful rehabilitation
CHART
10-3
