Psychosocial Impact of Acute Illness Stress & Coping y Hospitalized patient s experience stress from certain sources such

as physiological dysfunction, circadian rhythm disturbances, and limited access to family, familiar objects, and surroundings. Uncertainty regarding the illness, its consequences and effects on others add to the stress.

Stress defined: a relationship between the person and the environment that is appraised by the person as exceeding his resources and endangering his well being. -How a person reacts to stress depends on 2 process: 1. Cognitive appraisal: this is a two-phase process where a person evaluates the stressor and its potential effect on well being. Phase I: primary appraisal- person evaluates what is at stake. Example: Is the person s life, or that of a loved one in jeopardy? Characteristics that help define these stakes that are relevant are: Values, beliefs, and hardiness. Phase II: Secondary appraisal- person evaluates what can be done to overcome the stressor. Example: To what extent will a particular action relieve danger? Various coping options are evaluated in this phase. 2. Coping: Refers to the persons cognitive and behavioral efforts to manage, reduce, master, or tolerate the stressor and its effects. Coping has 2 functions: A: dealing with the problem that is causing the distress (problemfocused coping). This is aimed at changing or managing the situation. An example of these behaviors is: planful problem solving, seeking information, and aggressive efforts to alter the situation. B: dealing with emotions that arise from the problem (emotion-focused coping). This is aimed at changing or managing the person s reaction to the situation. Example of these behaviors are: wishful thinking, escape or avoidance behaviors (drinking, using drugs, exercising), rationalization, accepting responsibility, using humor, and developing a positive outlook. -Flexibility in coping strategies is advantageous. It allows people a variety of responses and ability to come to terms with the experience and use it to further growth and adaptation. A number of coping strategies may be "tried out" to find the best approach to the situation especially after discharged to a more familiar environment where coping skills are not limited like they would be in a hospital. Social Support defined -An exchange of resources between people that enhance the well being of the recipient, a factor that may affect the patient s appraisal and response to stress.

Types of support that may be provided are: 1. 2. 3. Instrumental support: direct support (financial support or assistance with household chores) Informational support: giving of needed information (help with problem solving) Emotional support: communication of love, caring, trust, or concern or facilitation of ties to a clergyman.

-Social support may serve as a buffering mechanism to decrease the negative effects. This is done by altering appraisal of the stressful event or by intervening between the experience of stress and onset of outcomes. -Remember just because family members are present does not mean they are an adequate social support. Uncertainty -This is a factor that may interfere with a person's coping efforts. Uncertainty is a cognitive state created when an event occurs that cannot be defined due to lack of information -The degree of uncertainty produced is influenced by: 1. 2. 3. complexity of the event amount of ambiguity surrounding the event Other factors such as previous experiences.

-A hospitalized patient with an acute illness or trauma has uncertainty due to unfamiliar sight and sounds, unfamiliar procedures and treatment can increase uncertainty. The positive side of uncertainty is it may facilitate hope. A person who is unsure about a diagnosis may focus on the possibility that things will work out. The negative side of uncertainty is there is no clear perception of what will happen next. Coping processes may not work because the person may not know how to help or change the situation and therefore may do nothing. Hardiness -Helps a person explain the differences in coping with acute illness. It helps a person adapt to stressors by influencing their perception of the stressors, the coping strategies or social resources used. Hardiness has 3 dimensions: 1. 2. 3. Control: the perception of control motivates a person to seek explanations as to why something is happening and to be actively involved in making decisions. Commitment: being involved in health related activities for the patients situation. (deep breathing exercises) Challenge: the reappraisal of a stressor as an opportunity for personal growth, rather than as threat. These people are able to use available resources to cope with the stressors they experience.

Psychosocial Assessment of the acutely ill -Includes determination of impact and meaning of the acute illness experience. Include the person s perceptions and characteristics such as new and on going stressors, the meaning of the stressors to the patient and personal resources that affect the patients ability to cope with them. A nurse can develop an effective plan of action by knowing how the patient and family perceive the current situation, how stressors were approached in the past, what other stressor the patient has and how they deal with uncertainty. Find out how previous crisis has been handled.

-Each illness or traumatic event have individual and cultural meanings, therefore it is important that the family and patient understand the meaning of the illness event. Example: a gunshot wound carries different meanings depending on how the injury occurred. Characteristics of the disease The following characteristics of the disease should be considered when assessing the impact of acute illness on the patient and family: 1. 2. 3. 4. 5. Timing of the disruption. (Was this illness expected or unexpected?) Severity of the illness. Degree of physiological stress. (degree of pain, disability, loss of function) Symptoms and predictability of the illness Factors involved in the disease or treatment process that influences the patient s response. (Lack of privacy, noise, loss of contact with loved ones and familiar objects, loss of routine).

Family Assessment -Family assessment is guided by knowledge of the most common stressors that families experience during an episode of acute illness such as concern about an uncertain prognosis, disability or death, lack of privacy. For example: A family coping with cancer. The family can become a buffer between the ill person and others cognitive actions (provide information, soften the blow, being present, resisting disruptions of family and individual routines). Knowing what coping behaviors have been effective in the past can help the nurse in selecting interventions to ease the impact of the illness event. -The level of stress in the family may persist after the event, even when the physiological problem is resolved. They have a delayed reaction to a trauma once the loved one is out of danger and they realize the full impact of the experience. -Caregiver stress is common, especially at time of discharge. It is demonstrated toward nurses as caregiving is turned over to the family. The better prepared the family is and more predictable the care or outcome, the easier it is for the family to cope. Planning -The main focus is to conserve the patient s energy and healing because crisis is exhausting. -The goal is to return the patient to their highest level of functioning and healing of the psychological wound. -The goal of nursing interventions is to support effective coping strategies used by the patient and family. -During a time of crisis, short-term realistic goals are needed to help the patient and family reestablish equilibrium. -Clinical Nurse Specialists (CNS) may assume the role of a contact person and interpreter of events for the patient and family therefore she is an invaluable asset to the family. The CNS can help establish the formation of support groups. In a support group, the family members can burden their concerns and fears to others in similar circumstances. -The flexibility of families being allowed to see patients and stay longer has resulted in positive outcomes such as improved orientation, decreased anxiety and increase sleep. This balances the need for physical closeness and encourages communication and collaborative relationships between family and staff.

Intervention -Sharing information such as the patient s perceptions & feelings, decisions & actions is as important as any other care provided. Information must be concrete and understandable. -Anxiety or distress is relieved by explaining expected sensory experiences associated with procedures (what will be felt, seen or smelled). -Sensory information is also used for the patient to be able to predict or interpret symptoms associated with an illness. This provides the sense of mastery and self-confidence. -Family information needs include such as -information booklets, videos, telephone contact and pagers can be used as concrete information and keep families updated on the patient condition. -As time passes, the story of the event becomes more important, therefore the patient needs to tell and retell the story in order to define and come to terms with the illness. The nurse assists with this process by encouraging the telling of the story, defining the situation and interpreting the events and reframing the event as the patient and family progress through the crisis. The patient may make -Self blaming comments. The patient and family must be able to forgive themselves and move on. -The nurse promotes hardiness and adaptation by suggesting stress-reducing activities. Meeting the patient and families basic needs helps reduce perception stress. Evaluation -Effectiveness of interventions is done through behavioral indicators of reduced stress and reengagement in usual activities. Follow up assessments and ongoing interventions may be necessary for the patient and family to resume their usual activities and quality of life. Effects on the nurse -Burnout in critical care is more common than in any other field of nursing. -The concept of hardiness plays an important role in preventing caregiver burnout. The nurse needs adequate educational preparation and continued mentoring to establish a sense of control and minimize the effects of uncertainty. Orientation programs that facilitate the development of mentoring relationships are the most advantageous. The relationship between a novice nurse and more experienced nurse is important in that it builds personal hardiness through nurturance of competitive clinical practice. The verbal and nonverbal support of a mentor reduces the uncertainty of a situation and increases the novice nurses sense of mastery.

Psychosocial care for cancer patients in primary care

Psychosocial problems are common in patients throughout the cancer journey. The Department of Health has emphasized the need for psychosocial problems to be addressed,and in the USA guidelines have already been brought out. At present, psychosocial problems are encountered at all levels of care. However, management of systems already in place remains a problem. Our experience and the experience of others suggests that primary care professionals can be well equipped to undertake such work, decreasing stigma associated with psychiatric disorders and utilizing skills used to treat other chronic diseases. In this paper, we will review the relevant

literature regarding the detection and treatment of psychosocial issues in primary care. The aim of the paper is to outline psychosocial needs of cancer patients and determine how these needs either are, or could be, met within primary care, in addition to the secondary care setting. The three main objectives are to describe the current systems for delivering psychosocial care to cancer patients, to consider how psychosocial care is delivered in primary care in other chronic diseases and describe the role primary care could develop as part of a more integrated system for providing psychosocial care for cancer patients. Improved outcomes are a primary focus for all professionals involved in cancer care. Psycho-oncology is concerned with relationships between cancer and the mind. Psycho-social oncology is a similar term with broader implications that cancer concerns not just individual patients but their families, friends and colleagues, and the society in which they live. Physical, psychological and social problems in cancer The diagnosis and treatment of cancer is associated with substantial physical, psychological and social morbidity for a significant minority of patients. Physical side effects of both disease and treatment include fatigue, hair loss, oral inflammation, immunosuppression, anorexia, nausea, vomiting, pain, weakness and disfigurement, and are a significant burden for many patients. Side effects may be acute and short term (e.g. hair loss), chronic (e.g. weakness) or variable in their course. Up to a third of patients will develop a major depressive disorder, generalized anxiety disorder or adjustment disorder after a cancer diagnosis, representing an increased relative risk of three times the prevalence in the general population. At the less severe end of the morbidity spectrum, all cancer patients experience some distress. Distress can be seen as an unpleasant experience of an emotional, psychological, social, or spiritual nature that interferes with the ability to cope with cancer treatment. It extends along a continuum, from common normal feelings of vulnerability, sadness and fears, to problems that are disabling, such as true depression, anxiety, panic, and feeling isolated or in spiritual crisis In addition, cancer patients must contend with changes to their domestic and working lives, with some patients experiencing problems with daily living, finances and employment. Studies of psychological morbidity among cancer patients in secondary care suggest that only a small number of distressed patients are identified and treated. The model for treatment used in some cancer centres (Table 1) identifies need and projected numbers of distressed patient requiring treatment. A critical review assessing psychosocial interventions (education, behavioural training, individual psychotherapy and group interventions) for cancer patients identified that a structured, psychiatric intervention consisting of health education, stress management and behavioural training, including problemsolving techniques, and psychosocial group support offers the greatest potential benefit. A lack of systematic psychological screening and under-treatment are due to a combination of factors including under-reporting of symptoms, a lack of awareness or understanding of psychological services and under-recognition of psychological morbidity by health professionals. There is some evidence which suggests that psychosocial needs change over time. Lev et al. suggest that cancer patients' quality of life and self-efficacy decrease over time. Post-operatively, the majority of breast cancer patients experience high levels of psychosocial dysfunction; however, these problems resolve within 1 year. After the first year, psychosocial problems experienced by breast cancer patients appear to plateau, and remain unchanged when assessed at 2 and 3 year intervals. It remains important to know at what point in the cancer journey psychosocial issues arise.

Table 1 Psychological service delivery needs Time since diagnosis Diagnosis Need Percentage of patients and relatives with this need 100 50

General emotional support and information (accurately and sensitively delivered) to cope with distress Diagnosis Short-term interventions and crisis management to deal with levels of anxiety and depression severe enough to affect quality of life Six months after Management to deal with levels of anxiety and depression severe diagnosis enough to affect quality of life One year after diagnosis Recurrence Management of specialist psychological and/or psychiatric intervention to deal with high level symptoms Management to deal with levels of anxiety and depression severe enough to affect quality of life

25 10 50

Current provision of psychosocial services In the past, the availability of services to meet patient needs has grown out of consumer- and professional-led initiatives, e.g. the Tak Tent service which offers support and information, founded by Sir Kenneth Calman. Currently, cancer patients can receive structured psychosocial support from secondary care health professionals with backgrounds in social work, psychiatry and mental health, in addition to services provided by communitybased organizations. Services in the community include support groups, information and counselling services, and financial assistance. However, the number of patients using these services and how effective they are in addressing psychosocial needs is difficult to establish. One study suggests that one in four distressed patients had accessed psychological services, and although distressed patients reported a strong desire to access other support services, fewer than one in 10 did so. Ideally, an overall management system for the detection and treatment of psychological and psychosocial problems, integrating community- and primary care-based services, may improve service delivery. Psychosocial care can be properly delivered in secondary care, where highly intensive treatment is carried out; however, as treatments of cancer become more mobile (e.g. ambulatory chemotherapy administration units), we can begin to think about seamless care across the service continuum. Until recently, psychosocial standards for oncology care have not been present. However, American standards now call for: repeated screening of cancer patients for distress; clinical practice guidelines for treatment of psychosocial problems; a multidisciplinary approach; and the inclusion of distress as a quality assurance measure. There remains a dearth of published articles regarding changes in patient management in secondary and tertiary care despite the fact that research has demonstrated increased levels of psychosocial distress. Barriers may include the poor identification of psychosocial problems by health care staff, and reluctance on the part of patients to initiate discussion of psychosocial issues (e.g. patients prefer the opening to come from the oncology doctor). In one recent paper, one in three patients who indicated need for service had support, 9% of patients were not offered support and only 22% of patients who were offered support accepted.