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• Cover
• Title Page
• Copyright Page
• Dedication Page
• Brief Contents
• Contents
• Preface
• Contributors
• Chapter 1 The Illness Experience
• Introduction
• The Lived Experience
• Illness Perceptions
• Illness Perceptions of Patients and Their Partners
• Illness Perceptions of Patients and Physicians
• Illness Behavior
• Definitions of Illness Behavior
• Influences to Illness Behavior
• The Legitimization of Chronic Illness
• Illness Perceptions/Behavior and Chronic Disease
• Cardiovascular Disease
• Cancer
• Chronic Somatic Disease
• Professional Responses to Illness Behavior
• Interventions
• Social Media
• Mindful Presence
• Research
• Outcomes
• References
• Chapter 2 Social Isolation
• Introduction
• The Nature of Social Isolation
• Social Isolation Defined
• Social Isolation Versus Similar States of Human Apartness
• Social Isolation Versus Aloneness
• Social Isolation Versus Loneliness
• Social Isolation Versus Solitude
• Social Isolation and Chronic Illness
• From Ambiguity to Clarity: The Evolution of Social Isolation
• Typology of Social Isolation
• Social Isolation and Older Adults
• Functional Disability and Independence
• Risk Factors and Predictors of Social Isolation
• Physical Factors
• Psychological Factors
• Economic Factors
• Work/Family Changes
• Environmental Factors
• Demographic Factors
• Negative Outcomes of Social Isolation
• Physical Outcomes
• Psychological Outcomes
• Social Outcomes
• Identifying Social Isolation
• The Social Isolation Scale
• Social Components of Social Isolation
• Interventions
• Self-Management of Chronic Illness
• Respite for Caregivers
• Technology
• Social Isolation in the World of COVID-19
• Future Trajectory
• References
• Chapter 3 Health-Related Quality of Life
• Introduction
• Defining Quality of Life
• Defining Health-Related Quality of Life
• HRQOL Theoretical Frameworks and Models
• Measuring Health-Related Quality of Life
• Health-Related Quality of Life in the Context of Chronic Illness
• Interventions
• HRQOL Guidelines in Chronic Illness
• Evidence-Based HRQOL Interventions
• Interventions in Chronic Physical Illness
• Interventions in Chronic Mental Illness
• Technology Interventions and Health-Related Quality of Life
• Outcomes
• References
• Chapter 4 Powerlessness
• Introduction
• The Phenomenon of Powerlessness in Chronic Illness
• The Paradox of Powerlessness in Chronic Illness
• Theoretical Perspectives of Powerlessness and Power
• Self-Determination Theory
• Determinants of Health and Social Determinants of Health
• Problems and Issues Associated with Powerlessness
• Loss
• Uncertainty
• Chronic Illness Management
• Lack of Knowledge and Health Literacy
• Dignity
• Dignity, Rights, and Health
• Vulnerability
• Vulnerability Implies Susceptibility
• Marginalization
• Stigma
• Culture
• Healthcare System
• Interventions
• Empowerment
• Health Coaching and Care Transition
• Collaboration
• Self-Management
• Control
• Self-Determination
• Cultural/Linguistic Competence and Cultural Humility
• Knowledge
• Health Navigation
• Advocacy
• Motivational Interviewing
• Decision Making
• Anticipatory Guidance
• Outcomes
• References
• Chapter 5 Intimacy
• Introduction
• The Lived Experience of Intimacy and Chronic Illness
• Chronic Somatic Disease
• Stroke
• Cancer
• Influences on Intimacy
• Communication with Healthcare Professionals
• Interventions
• Outcomes
• PROMIS
• References
• Chapter 6 Coping
• Introduction
• Coping and Psychosocial Adjustment
• Factors Affecting Coping
• Coping Models
• Stress and Coping Theory
• Coping and the Stress and Coping Theory
• Common-Sense Model of Self-Regulation
• Coping and the CSM
• Couples’ Coping
• Dyadic Coping
• Communal Coping
• Commonalities and Differences in Coping Among Different Chronic Illnesses
• Researching Coping
• Instruments to Measure Coping
• What Is the Role of the Healthcare Professional in Coping?
• Outcomes of Coping
• References
• Chapter 7 Self-Management
• Introduction
• Self-Management of Chronic Illness
• Definitions of Self-Care, Self-Management, and Disease Management
• Supported Self-Management
• The Environment of Self-Management
• Policy Incentives for Self-Management of Chronic Disease
• Middle-Range Theories of Self-Management
• The Meaning of Self-Management
• A Balancing Act
• Home and On-the-Go Resources for Self-Management
• Self-Determination and Shifting Identities
• Self-Realization as Self-Transformation
• Nursing Interventions
• Coaching as a Technique to Enhance Self-Management and Family Management
• Medication Self-Management
• A Model of eHealth Medication Self-Management
• Advanced Practice Nurse–Led Group Visits
• Ethical Considerations in Self-Management
• Outcomes
• Condition Outcomes
• Individual Outcomes
• Family Outcomes
• Environmental Outcomes
• Proximal Versus Distal Outcomes
• Client-Reported Outcome Measures
• National Study of Chronic Disease Self-Management
• Summary
• References
• Chapter 8 Spirituality
• Introduction
• Spirituality and Health
• Historical Perspectives of Spirituality in Chronic Illness
• Definitions
• Spirituality in Nursing Theories
• Impact: Spirituality and Chronic Illness
• Well-Being
• Dementia
• Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome
• Heart Disease/Heart Failure
• Depression
• Type 2 Diabetes Mellitus
• Interventions
• Spiritual Assessment
• Spiritual Nursing Interventions
• Spiritual Measures and Tools
• Nursing Education in Spiritual Care
• Outcomes
• References
• Chapter 9 Client and Family Education
• Introduction
• The Teaching–Learning Process
• Significance of Client and Family Teaching to Practice and Healthcare Costs
• Major Learning Considerations of Children, Young and Middle-Age Adults, and Older Adults
• Health Literacy
• Evaluating the Quality of Research to Guide Educational Interventions
• Teaching Patients How to Evaluate Health Websites
• Client Education Using Social Media and Telehealth
• Assessment of the Learner
• Influences on Teaching and Learning
• Family Structure and Function
• Culture
• Gender and Learning Styles
• Readiness to Learn, Self-Efficacy, and Readiness to Change
• Developmental Stage
• System Factors That Influence the Teaching and Learning Process
• Educational Interventions for the Client and Family
• Development of the Teaching Plan
• Teaching Strategies
• Learning Curve
• Evaluation
• Example of a Teaching Plan
• Outcomes
• References
• Chapter 10 Social Support
• Introduction
• Research Trends
• Implications for Healthcare Professionals
• Evolution of Social Support
• Social Support Defined
• Key Concepts of Social Support
• Structural Social Support
• Functional Social Support
• Typology of Social Support
• Social Capital
• Incidence and Prevalence of Social Support
• Risk Factors for Social Support
• Sociodemographics
• Quantity and Quality of Social Support
• Chronic Illness
• Aging
• Health Behaviors
• Social Support and Healthcare Utilization
• Negative Health Outcomes
• Instruments to Measure Social Support
• Interventions
• Peer Support Interventions
• Family Support Interventions
• Group Support Interventions
• Technology
• Online Social Networking Sites
• E-Health Interventions
• Healthcare Professionals
• Conclusion
• References
• Chapter 11 Adherence
• Introduction
• Goals for Healthy People 2030
• Adherence and Chronic Illness
• The Adherence Label
• Prevalence
• Components of Adherence
• Factors Contributing to Adherence Behavior
• Individual Characteristics
• Patient–Provider Interactions
• Ethics and Adherence Behavior
• Theoretical Underpinnings of Adherence Behavior
• Health Belief Model
• Health Promotion Model
• Common-Sense Model of Self-Regulation
• The Theory of Reasoned Action and the Theory of Planned Behavior
• Cognitive Social Learning Theory
• Transtheoretical Model of Change (Stages of Change)
• Ecologic Perspective
• Measuring Adherence Behaviors
• Indirect Measures
• Direct Measures
• Interventions to Enhance Adherence Behavior
• Education and Coaching
• Behavioral Strategies to Enhance Adherence
• Tailoring
• Simplifying the Regimen
• Providing Reminders
• Ethnocultural Interventions
• Outcomes
• References
• Chapter 12 Culture and Health Disparities
• Introduction
• Defining Terms
• Culture
• National CLAS Standards
• Racial and Ethnicity Classification
• Impact of Culture on Health Outcomes
• Social Determinants of Health
• Racism in Health Care
• Health Disparities
• Race and Ethnicity
• Sexual and Gender Minorities
• Interventions
• Nursing Theoretical Models
• Giger and Davidhizar’s Transcultural Assessment Model
• Purnell Model for Cultural Competence
• Leininger’s Culture Care Diversity and Universality Theory
• Cultural Humility
• Cultural Awareness and Sensitivity
• Cultural Competence
• Education to Increase Knowledge of Culturally Competent Care
• Addressing the Social Determinants of Health
• Outcomes
• References
• Chapter 13 Family Caregiving
• Introduction
• Current Family Caregiving
• Context of Caregiving
• Caregiving and Family Systems
• The Heterogeneity of Caregiving
• Types of Care Provided by Family Caregivers
• Caregiving Trajectory
• Family Relationships and Shifting Roles
• The Future of Caregiving
• Challenges and Concerns
• Effects of Caregiving
• Strain or Burden
• Compassion Fatigue
• Grief, Bereavement, and Ambiguous Loss
• Social Isolation and Loneliness
• Elder Abuse and Neglect
• Positive Aspects of Caregiving
• Spirituality and Caregiving
• Financial Impact of Caregiving
• Employment
• Caregiver Assessment
• Planning the Care
• Family-Centered Care and Family-Integrated Care
• Interventions
• The Interface of Informal and Formal Caregiving Networks
• Providing Support and Building Skills
• Emerging Technologies and Caregiving Support
• Telehealth and Virtual Visits
• Internet-Based Resources
• Mobile Health and Smart Device Applications
• COVID-19 and Technology Advancement
• Programs, Services, and Resources for Family Caregivers
• Respite Programs and Services
• Adult Day Services
• Family-Centered Interventions
• Faith-Based Support
• Evidence-Based Practice
• The Influence of Public Policy on Family Caregiving
• Increasing Awareness and Advocacy to Address Caregiver Needs
• Outcomes
• Care Recipient, Caregiver, and Caregiving System Outcomes
• Quality of Life
• Family Stress and Coping
• Social Functioning
• Societal Outcomes
• Transitioning from Care at Home to Residential Care
• References
• Chapter 14 Models of Care
• Introduction
• Historical Perspectives
• Impact
• Disease Management Versus Illness Management
• Integrating Care
• Chronic Care Model
• Patient-Centered Medical Home: Comprehensive Primary Care
• Collaborative Care
• Integrating Social Care Needs into Health Care
• Home- and Community-Based Medicare–Medicaid Waiver Programs
• Program of All-Inclusive Care for the Elderly
• VNSNY CHOICE Program
• Transitional Care
• Patient-Centered Outcomes Research Institute
• Community Paramedicine Programs
• Population- and Community-Based Models for Disease Prevention and Self-Management
• Centers for Medicare and Medicaid Services Innovation Models
• Integration of Technology in Chronic Disease Management Programs
• Telehealth and the VA
• Emerging Evidence in Technology in Health Care
• Health Information Exchange Networks
• COVID-19 and Telehealth
• Common Themes in Emerging Models
• Person-Centered or Family-Integrated Care?
• Outcomes
• References
• Chapter 15 Primary Care
• Introduction
• History and Definition
• Comprehensive Medicine and Primary Physicians
• Roots of Nursing in Primary Care
• Current State of Primary Care
• Definition and Core Attributes
• Primary Care Clinicians and Practices
• Impact of Primary Care on Chronic Illness
• Access to Primary Care
• Financial Barriers
• Structural Barriers
• Personal and Cultural Barriers
• The Triple Aim and Equity
• Triple Aim
• Other Aims
• Equity
• Primary Care Nurses in Chronic Illness Management
• Registered Nurses
• Team RNs
• RN Care Coordinators
• Outcomes
• 2016 Josiah Macy Conference on Preparing RNs for Enhanced Roles in Primary Care
• Advanced Practice Registered Nurses
• Chronic Illness Models of Care
• Nurse/APRN-Led Models of Care
• Other Models
• Team-Based Models
• Patient-Centered Medical Homes
• Chronic Care Model
• Integrated Care Models
• Focus of Models
• Setting of Models
• Outcomes/Evidence
• Processes of Care
• Patient Health Outcomes
• Healthcare Utilization
• Cost-Effectiveness
• Patient/Family Satisfaction and Engagement
• Other Outcomes
• Overall Summary
• Models for Chronic Illness Care
• Implementation of Models
• Future/Next Steps
• Conclusion
• References
• Chapter 16 Community Care
• Introduction
• Definitions: Public Health, Population Health, Community Health
• Theoretical Models
• An Ecological Model of Care
• Community-Based Models of Care Delivery for People with Serious Illness
• Competencies in Community Health Nursing
• Health Promotion Interventions
• Promoting the Nation’s Health
• Promoting Health Through Nursing Care
• Levels of Health Promotion
• Community Health Nursing-Led Interventions Addressing Chronic Illness
• Health Education Interventions
• Case Management
• Collaboration
• Digital Health
• Social Justice
• Summary
• References
• Chapter 17 Post-Acute Care
• Introduction
• Definitions
• Long-Term Care
• Rehabilitation
• Restorative Care
• Vocational Rehabilitation
• Historical Perspectives: Long-Term Care
• Historical Perspectives: Rehabilitation
• The Continuum of Post-Acute Care: Services and Settings
• Long-Term Care Hospitals
• Hospitals and Freestanding Rehabilitation Facilities
• Subacute Care/Transitional Care Units
• Community-Based Care
• Geriatric Care Management
• Adult Day Services
• Program of All-Inclusive Care for the Elderly
• Retirement Communities
• Residential LTC Settings
• Group Homes
• Assisted-Living Facilities
• Green House Model
• Skilled Nursing Facilities or Nursing Homes
• Challenges and Issues in Post-Acute Care
• Provision of Care
• Organization of Services in LTC
• Care Transitions and Discharge Planning
• Admission and Assessment in the LTC Setting
• Admission and Assessment in the Rehabilitation Setting
• International Classification of Functioning, Disability, and Health (ICF)
• Funding
• Medicare
• Medicaid
• Long-Term Care Insurance
• Worker’s Compensation
• Private Insurance
• Social Security Disability Income
• Disability Benefits for Veterans
• Vocational Rehabilitation
• Staffing and Standards
• Long-Term Care Standards
• Rehabilitation
• Inequities Among Disabled Americans
• Stigma of Disability
• Americans with Disabilities Act
• Ethical Issues in Post-Acute Care
• Client Autonomy Versus Dependence
• Mental Health Issues
• End-of-Life Decision Making
• Abuse and Neglect of Vulnerable Adults
• Ethical Dilemmas
• Interventions
• Preservation of Autonomy of the Person
• Autonomy
• Guardianship
• Advocacy: The Role of the Ombudsman
• Interprofessional Care
• Team Approach
• Nursing Care
• Disease Prevention/Health Promotion
• Pain Management
• Substance Abuse
• Fall Risk Reduction and Safety
• Delirium
• Depression and Anxiety
• Dementia
• Outcomes and Quality Improvement
• References
• Chapter 18 Palliative Care
• Introduction
• Historical Perspectives
• Differentiating Palliative Care, End-of-Life Care, and Hospice Care
• Palliative Care Nursing
• Clinical Practice Guidelines for Palliative Care
• Settings of Care
• Palliative Care Data
• Issues and Barriers to Palliative Care
• Identifying Patients Who Could Benefit from Palliative Care
• Late Identification of Patients in Need of Palliative Care
• Lack of Knowledge About Palliative Care
• Other Factors
• Interventions
• Nursing Assessment
• Determining the Goals of Care
• Communication
• Early Integration of Outpatient Palliative Care
• Clinical Interventions
• Palliative Care in Heart Failure
• Advance Care Planning
• Education of Healthcare Professionals
• Research in Palliative Care
• Outcomes
• Clinical Outcomes
• Cost Savings
• Quality of Life
• References
• Chapter 19 Complementary and Integrative Health
• Introduction
• National Center for Complementary and Integrative Health
• Definitions
• Complementary Health Therapies
• 2012 National Health Interview Survey—Adult Alternative Medicine
• Trends from NHIS 2002, 2007, and 2012
• National Health Inventory Survey, 2017
• Users
• Costs
• Common CAM/CIM Therapies
• Natural Products
• Herb and Drug Interactions
• Echinacea
• Gingko Biloba
• St. John’s Wort
• Mind–Body Practices
• Yoga
• Acupuncture
• Meditation and Mindfulness
• Other CAM Practices
• Traditional Chinese Medicine
• Issues
• Research
• Safety and Regulation of CAM
• CAM Practitioners
• Paradigm Issues
• Interventions
• Self-Reflection of the Healthcare Professional
• Communication Between the Patient and the Healthcare Professional
• Selecting a CAM Practitioner
• Outcomes
• References
• Chapter 20 Health Policy
• Introduction
• Health Policy Defined
• Major Stakeholders in the U.S. Healthcare Industry
• Issues
• U.S. Health Care: A Fragmented System of Healthcare Delivery
• Health Insurance
• Traditional or Conventional Health Insurance
• Managed Care Organizations and High-Deductible Health Plans
• Medicare
• Medicaid
• Children’s Health Insurance Program
• Costs, Access, and Quality
• Costs
• Access to Care
• Quality
• Interventions: Engaging in Health Policy Discussions
• Stages of Influencing Policy
• Nursing Interventions: Action Steps
• Outcomes
• References
• Index