Living with Chronic Illness and

Disability: Principles for nursing

practice Esther Chang & Amanda
Johnson
Visit to download the full and correct content document:
https://textbookfull.com/product/living-with-chronic-illness-and-disability-principles-for-
nursing-practice-esther-chang-amanda-johnson/
More products digital (pdf, epub, mobi) instant
download maybe you interests ...

Loss and grief recovery help caring for children with

disabilities chronic or terminal illness Ashton

https://textbookfull.com/product/loss-and-grief-recovery-help-
caring-for-children-with-disabilities-chronic-or-terminal-
illness-ashton/

Ethics and Chronic Illness 1st Edition Tom Walker

https://textbookfull.com/product/ethics-and-chronic-illness-1st-
edition-tom-walker/

Neuroergonomics Principles and Practice 1st Edition

Chang S. Nam (Editor)

https://textbookfull.com/product/neuroergonomics-principles-and-
practice-1st-edition-chang-s-nam-editor/

Caring for Older People in Australia Amanda Johnson

https://textbookfull.com/product/caring-for-older-people-in-
australia-amanda-johnson/
Reflection for Nursing Life Principles Process and
Practice 1st Edition John Mckinnon

https://textbookfull.com/product/reflection-for-nursing-life-
principles-process-and-practice-1st-edition-john-mckinnon/

The Minor Illness Manual Gina Johnson

https://textbookfull.com/product/the-minor-illness-manual-gina-
johnson/

Children and Young People's Nursing: Principles for

Practice, Second Edition Alyson M. Davies

https://textbookfull.com/product/children-and-young-peoples-
nursing-principles-for-practice-second-edition-alyson-m-davies/

Integrative Medicine for Vulnerable Populations: A

Clinical Guide to Working with Chronic and Comorbid
Medical Disease, Mental Illness, and Addiction Julia
Hodgson
https://textbookfull.com/product/integrative-medicine-for-
vulnerable-populations-a-clinical-guide-to-working-with-chronic-
and-comorbid-medical-disease-mental-illness-and-addiction-julia-
hodgson/

Progressive care nursing certification : preparation,

review, and practice exams Second Edition Alejandro P.
Johnson

https://textbookfull.com/product/progressive-care-nursing-
certification-preparation-review-and-practice-exams-second-
edition-alejandro-p-johnson/
 You now have access to...
Your eBook Resources for students
and instructors

Access your content Enhance your learning experience

when, where and how with supporting resources such as
you want. test questions, case studies, critical
thinking exercises and more.

on
To activate your Elsevier To activate your
eBook on VitalSource: study resources:

GET STARTED 1. Visit evolve.elsevier.com REGISTER 3. Visit evolve.elsevier.com/AU/

Chang/chronicillness/
2. Enter your eBook ACCESS
CODE, click Submit and 4. Register and follow the prompts
follow the prompts to complete your access

eBook ACCESS CODE

(scratch here to reveal your code)
 Living with
chronic illness and disability
3rd edition
This page intentionally left blank
 Living with
chronic illness and disability
Principles for nursing practice
3rd edition
Edited by
Esther Chang
Amanda Johnson
Elsevier Australia. ACN 001 002 357
(a division of Reed International Books Australia Pty Ltd)
Tower 1, 475 Victoria Avenue, Chatswood, NSW 2067

This edition © 2018 Elsevier Australia.

2nd edition 2014; 1st edition 2008

All rights reserved. No part of this publication may be reproduced or transmitted in any
form or by any means, electronic or mechanical, including photocopying, recording, or any
information storage and retrieval system, without permission in writing from the publisher.
Details on how to seek permission, further information about the Publisher’s permissions
policies and our arrangements with organizations such as the Copyright Clearance Center
and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/
permissions.

This book and the individual contributions contained in it are protected under copyright by
the Publisher (other than as may be noted herein).

Notices
This publication has been carefully reviewed and checked to ensure that the content is
as accurate and current as possible at time of publication. We would recommend,
however, that the reader verify any procedures, treatments, drug dosages or legal content
described in this book. Neither the author, the contributors, nor the publisher assume
any liability for injury and/or damage to persons or property arising from any error in or
omission from this publication.

National Library of Australia Cataloguing-in-Publication Data

Living with chronic illness and disability: principles for nursing practice / edited by
Esther Chang, Amanda Johnson.
3rd edition.
9780729542616 (paperback)
Nursing–Practice.
Chronically ill–Care.
People with disabilities–Care.
Palliative treatment.
Chang, Esther, editor.
Johnson, Amanda, 1960- editor.

Senior Content Strategist: Libby Houston

Senior Content Development Specialist: Natalie Hunt
Senior Project Manager: Karthikeyan Murthy
Edited by Margaret Trudgeon
Proofread by Forsyth Publishing Services
Design by Natalie Bowra
Index by Innodata Indexing
Typeset by Toppan Best-set Premedia Limited
Printed by 1010 Printing International Ltd
 Contents
Contributors ix 4 Spirituality 61
John Xavier Rolley, Esther Chang and Amanda Johnson
Reviewers xiii
Introduction 61
Preface xiv Defining spirituality 62
The role of ritual in spirituality 64
SECTION 1 Why spirituality is important to nursing 66
The nurse as a spiritual being 68
Spiritual care in nursing practice 68
Frameworks for chronic Conclusion 72
illness and disability 1 5 Psychosocial care 75
Michelle Cleary and Catherine Hungerford
1 Chronic illness and disability: an overview 2
Amanda Johnson and Esther Chang Introduction 75
Chronic illness versus acute illness 76
Introduction 2
Lived experience versus health condition 76
Understanding key terms 3
Psychosocial considerations 77
The global perspective of chronic disease 5
Models 80
Global perspective on disability 8
Principles of care 81
Impact and challenges of chronic illness and
disability 10 Conclusion 90
Principles of practice 11
6 Stigmatisation of people living with a chronic
Conclusion 12
illness or disability 95
2 Partnerships in collaborative care 15 Lynne S. Giddings and Dianne E. Roy
Sheree M. S. Smith, Liz Isenring, Vanessa J. Rice, Introduction 95
Michael K. Baker, Angelica G. Thompson-Butel, Nurses and stigma 96
Geoffrey Mitchell, Michelle Bissett, Lee Zakrzewski,
Principles of nursing care when working with
Shane Lenson, Gisselle Gallego, Anthony Wright,
people living with chronic illness and or/impairment 101
Mark Hughes, Hilary Gallagher and Belinda Kenny
Conclusion 104
Introduction 15
Role of the nurse 16 7 Sexuality 108
Role of the dietitian 18 Tinashe M. Dune
Role of the exercise physiologist 21 Introduction 108
Role of the medical practitioner 25 Background 109
Role of the occupational therapist 29 Defining the terms 110
Role of the paramedic 31 Implications for health practice 116
Role of the pharmacist 33 Multidisciplinary approaches to addressing sexual
Role of the physiotherapist 35 health and wellbeing needs 122
Role of the social worker 37 Conclusion 123
Role of the speech pathologist 39
8 Developmental and intellectual disability 129
3 Models of care 43 Nathan J. Wilson and David Charnock
Vicki Drury and Samar Aoun Introduction 129
Introduction 43 Defining intellectual and developmental disability 130
Models of care for people with long-term conditions 44 Prevalence of intellectual and developmental
Indigenous Australians’ health programme and disability 130
chronic disease management 51 Causes of intellectual and developmental disability 131
Putting it all together 52 Health issues for people with intellectual and
Conclusion 57 developmental disability 131
vi Contents

Health promotion for people with intellectual and 12 Palliation in chronic illness 215
developmental disability 137 Christine Haley and James Daley
Health checks for people with intellectual and Introduction 215
developmental disability 140 An overview of historical developments 216
Role of the nurse for people with intellectual and A health promotion approach to palliative care 217
developmental disability 140
Levels of palliative care intervention 218
Conclusion 142
Symptom control 220
9 Management of chronic pain 146 Settings of care 220
Christine Chisengantambu and Paul McDonald The needs of older people at the end of life 221
Introduction 146 Providing culturally appropriate palliative care
for Indigenous people 221
Chronic pain defined 147
Paediatric palliative care 222
The economic and social impact of chronic pain 148
End-of-life care 222
Understanding chronic pain secondary to
disability 149 Bereavement and grief 223
Towards a biopsychosocial model of chronic Palliative nursing care response (Case Study 12.1) 223
disability-related pain 150 Palliative care nursing response (Case Study 12.2) 225
Psychosocial factors and chronic pain 152 Conclusion 228
Cultural determinants of the experience of
chronic pain 155 SECTION 2
Assessment of chronic pain 156
Management of chronic pain 162
Chronic pain and co-morbidities 163
Principles for
Conclusion 170 nursing practice 230
10 Rehabilitation for the individual and family 177 13 Principles for nursing practice: Schizophrenia 232
Julie Pryor, Bridget Lingane, Duncan McKechanie and Louise O’Brien
Gillian Garrett
Introduction 232
Introduction 177 Description of the disorder 232
Rehabilitation as a type of healthcare 178 Symptoms of schizophrenia 233
Rehabilitation is everyone’s business 181 The diagnosis of schizophrenia 233
The use of goals 181 What causes schizophrenia? 233
Nursing and rehabilitation 182 The course of schizophrenia 233
Brain injury – what is it? 184 Schizophrenia and chronicity 234
Spinal cord injury – what is it? 185 Effect of schizophrenia on the activities of daily living 235
Acute care – where rehabilitation begins 186 Stigma and schizophrenia 235
Pre-transfer education 188 Image of self 235
Inpatient rehabilitation 189 Quality of life 236
Nursing’s contribution to Aydin’s rehabilitation 193 Recovery 236
Life after inpatient rehabilitation 194 Principles of care 238
Conclusion 195 Psychosocial education 239
Family and carers 241
11 Impact of obesity 201
Peer support 242
Liz Isenring and Dianne Reidlinger
Implications for nursing 242
Introduction 201
Conclusion 244
What is overweight and obesity and why is it
a concern? 201 14 Principles for nursing practice: Depression 247
How is overweight and obesity defined? 202 Louise O’Brien
High-risk groups for obesity 203 Introduction 247
How to prevent and manage obesity? 207 The scope of the problem: the epidemiology
Screening for obesity 208 of depression 248
Bariatric surgery and medications 210 Identifying the disability impacts of depression 248
Conclusion 211 Depression, the workplace and disability 249
 Contents vii

Depression and medical illness 249 Motor neurone disease 311

Clinical features of depression and assessment Education for the person and family living with PD,
approaches 250 MS or MND 315
Recurrence and inter-episode functioning 252 Conclusion 316
Mapping the terrain: some issues in subtyping and
classifying depressive disorders 252 18 Principles for nursing practice: Persistent
The complex and multi-stranded causes of asthma 320
depression 254 Philip A. Stumbles, Prue Andrus, Charlotte Allen and
Approaches to the treatment and management of Christophe von Garnier
depression 256 Introduction 320
Combination of treatments: pharmacotherapy and Behaviours that contribute to the development
psychotherapy 259 of the condition 321
Principles of nursing care 259 The impact of persistent asthma on the quality
Conclusion 263 of life 324
Control-based management of asthma 325
15 Principles for nursing practice: Advanced Family and carers 330
dementia 267 Conclusion 338
Esther Chang, Amanda Johnson and Karen Hancock
Introduction 267 19 Principles for nursing practice: Chronic
Adopting a holistic approach 269 obstructive pulmonary disease 340
Assessing pain in people with advanced dementia 273 Colleen Doyle and Gail Roberts
Applying a systematic approach to the assessment Introduction – what is COPD? 340
of pain 276 How is COPD related to asthma and other lung
Principles of communication with family impact on function diseases? 341
the community 277 Burden of disease: COPD 342
Living with dementia: perceptions of people with Epidemiology of COPD 343
dementia and carers 279 Effects of COPD on physical health 344
Assessment of family carers 279 Pathophysiology of breathlessness 344
The family carer role in planning care for the person Effects of COPD on mental health and quality
with dementia 280 of life 346
Conclusion 281 Management of COPD 349
16 Principles for nursing practice: Stroke Nursing principles and interventions 351
(cerebrovascular accident) 287 Principles of nursing practice 352
Caleb Ferguson Conclusion 352
Introduction 287 20 Principles for nursing practice: Coronary
Stroke 287 heart disease 359
Risk factors and primary prevention 288 Angela M. Kucia
Pre-hospital care 291 Introduction 359
Diagnosis 291 CHD risk factors and behaviours that contribute
Types of stroke 292 to the development of CHD 360
Acute stroke care 292 Absolute risk assessment 363
Impact of stroke 294 Cardiac rehabilitation 363
Rehabilitation 294 Patient education: understanding the disease 364
Patient and caregiver education 296 Social isolation and lack of social support 372
Conclusion 296 Māori and Pacific Islanders 373
Conclusion 373
17 Principles for nursing practice: Parkinson’s
disease, multiple sclerosis and motor 21 Principles for nursing practice: Chronic
neurone disease 301 heart failure 377
Robin Ray and Anne Kavanagh Phillip J. Newton, Sunita R. Jha, Serra E. Ivynian and
Introduction 301 Patricia M. Davidson
Parkinson’s disease 302 Introduction 377
Multiple sclerosis 306 Definition of chronic heart failure 378
viii Contents

Causes of chronic heart failure 379 Presentation and diagnosis of non-melanocytic

Deleterious compensatory mechanisms in chronic skin cancers 428
heart failure 380 Malignant melanoma 429
Signs and symptoms of chronic heart failure 380 Marjolin’s ulcer 431
Diagnosis of chronic heart failure 381 Wound management 433
Management of chronic heart failure 383 Alterations in body image 434
Team management approach to chronic heart Education for the person, family and community 435
failure management 383 Conclusion 436
Managing acute decompensated heart failure 385
Strategies to manage chronic heart failure on a 25 Principles for nursing practice: Osteoarthritis
daily basis across the disease continuum 385 and osteoporosis 439
Evidence-based treatment gap 386 Tiffany Northall and Steven A. Frost
Palliative and supportive strategies in chronic heart Introduction 439
failure 386 Osteoarthritis 440
Conclusion 388 Behaviours that contribute to the development
of osteoarthritis 440
22 Principles for nursing practice: Chronic Rheumatoid arthritis 444
kidney disease 392 Osteoporosis 445
Ann Bonner and Bettina Douglas Conclusion 449
Introduction 392
Understanding CKD 393 26 Principles for nursing practice: Diabetes 452
Trisha Dunning
CKD and accelerated cardiovascular disease 396
Screening for CKD 396 Introduction 453
Delaying progression 396 Type 1, type 2 and gestational diabetes 454
Preventing complications 397 Common symptoms and management goals 454
Treating complications 397 Diagnostic criteria 457
The patient with end-stage kidney disease 397 Managing diabetes 457
Symptom burden of CKD 398 Diabetes complications 466
Psychosocial burden of CKD 399 Self-management 468
Body image 399 Conclusion 470
Supporting effective self-management in CKD 402 27 Principles for nursing practice: HIV/AIDS 475
Family and carers 404 Stephen Neville and Jeffery Adams
Conclusion 406 Introduction 475
Background 476
23 Principles for nursing practice: Chronic
Statistics, transmission and prevention 476
diseases of the bowel 409
Progression and treatment 478
Michelle Woods
Interventions 484
Introduction 409
Conclusion 486
Inflammatory bowel disease: two distinctive
disorders 411 28 Principles for nursing practice: Cancer 489
Chronic diseases of the bowel: nursing implications 418 Patsy Yates
Behaviours that contribute to the development Introduction 489
of the condition or sustain remission 418
Reducing risk and detecting cancer early 490
Conclusion 422
Ensuring best possible treatment and support
during and after active treatment 492
24 Principles for nursing practice:
Nursing responses to key QOL concerns for people
Non-melanocytic skin cancers and melanoma 427
affected by cancer 493
Isabelle Skinner and Keryln Carville
Conclusion 497
Introduction 427
Behaviours that contribute to the development
of skin cancer 427 Credits 501
Basal cell carcinoma and squamous cell carcinoma 428 Index 505
Contributors
Jeffery Adams PhD
Senior Researcher, SHORE & Whariki Research Centre, Massey University, Auckland, New Zealand
Charlotte Allen RN, BSc, CertPaedNurs, DipPaedRespir(UK)
Clinical Nurse Specialist, Metabolic Medicine and Department of General Paediatrics, Princess Margaret Hospital, WA, Australia
Prue Andrus RN, DipAppSc, BSc, GradCertClinStim, MHMQL
Academic Lead for Simulation, School of Health Professions, Murdoch University, WA, Australia
Samar Aoun BSc(Hons), MPH, PhD
Professor of Palliative Care, Curtin University, Perth, WA, Australia
Michael K. Baker BAppSc, GradCertHEd, MAppSc, PhD, ESSAM, AES, AEP
Previously Senior Lecturer, Australian Catholic University, NSW, Australia
Associate Professor, Head of Program, Exercise and Sport Science, Faculty of Science, The University of Newcastle, NSW, Australia
Michelle Bissett BAppSc(Hons)(OccTherapy), GradCertBiostat, PhD
Senior Lecturer, Discipline of Occupational Therapy, Griffith University, QLD, Australia
Ann Bonner RN, BAppSc(Nurs), MA, PhD, CertRenal, MCN
Professor of Nursing, School of Nursing, Queensland University of Technology, QLD, Australia
Honorary Research Fellow, Kidney Health Services, Metro North Hospital and Health Services, QLD, Australia
Chief Investigator, NHMRC Chronic Kidney Disease Centre of Research Excellence, University of Queensland, QLD, Australia
Keryln Carville RN, PhD
Professor Primary Health Care and Community Nursing, Silver Chain and Curtin University, Perth, WA, Australia
Esther Chang RN, CM, DNE, BAppSc(AdvNurs), MEdAdmin, PhD, FRCNA
Professor of Aged & Palliative Care, School of Nursing & Midwifery, Western Sydney University, NSW, Australia
David Charnock CertSystFamTher, DipAdvEd, MSc, PhD, RNLD
Assistant Professor, The University of Nottingham, United Kingdom
Christine Chisengantambu RN, BSc, PGCertDE, PGCommH, MPubH, PhD, DNE
Lecturer, Australian Catholic University, NSW, Australia
Michelle Cleary RN, PhD
Professor, School of Health Sciences, University of Tasmania, Sydney, NSW, Australia
James Daley DipHlthSc(Nurs), GradCert(PalliatCare), GradCert(Oncol), Palliative Care CNC, WNLHD
Clinical Nurse Consultant, Palliative Care, Greater Western Area Health Service, Sydney, NSW, Australia
Patricia M. Davidson RN, MEd, PhD, FAAN
Dean & Professor, John Hopkins School of Nursing, Sydney, NSW, Australia
Professor, Faculty of Health, University of Technology, Sydney, NSW, Australia
Bettina Douglas RN, MMgt, MNurs(NursPrac), CertRenal
Nurse Practitioner, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
Senior Lecturer, School of Nursing, Midwifery & Social Work, University of Queensland, Brisbane, QLD, Australia
Colleen Doyle BA(Hons), PhD, MAPS
Professor of Aged Care, Australian Catholic University, Melbourne, VIC, Australia
Vicki Drury RN, BHSc(Nurs), BA(Ed), CertMensHlth, MCINurs, PGCertNurs(Psych), PhD, RMHN, OND
Independent Scholar, Educare Consulting, Australia
Adjunct Senior Research Fellow, Singapore Eye Research Institute, Singapore
Adjunct Associate Professor, Curtin University, Perth, WA, Australia
x Contributors

Tinashe M. Dune BA(Hons), MPH, PhD

Senior Lecturer in Interprofessional Health Sciences, School of Science and Health & Translational Health Research Institute,
Western Sydney University, NSW, Australia
Trisha Dunning RN, MEd, PhD, AM, CDE
Chair in Nursing, Centre for Quality and Patient Safety Research, Deakin University and Barwon Health Partnership, VIC, Australia
Caleb Ferguson RN, BSN, MHlth, PhD
Chancellor’s Post Doctoral Research Fellow, Centre for Cardiovascular & Chronic Care, Faculty of Health, University of Technology
Sydney, NSW, Australia
Steven A. Frost BSN, CertICU, MPH, PhD
Lecturer Intensive Care, Liverpool Hospital and Western Sydney University, NSW, Australia
Hilary Gallagher BSc(Hons), DipSocWk, MSocWk
Lecturer, Griffith University, QLD, Australia
Gisselle Gallego BAppSc(Pharm), PhD
Senior Research Fellow, School of Medicine, The University of Notre Dame Australia, WA, Australia
Visiting Professor, Department of Pharmacology and Clinical Neuroscience, Umeå University, Sweden
Gillian Garrett RN, CertNeurosci, GradCertChangeMgt, GradCertNurs(Rehab)
Clinical Nurse Consultant, Spinal Cord Injury Unit, Royal Rehab: The Rehabilitation and Disability Support Network, NSW,
Australia
Lynne S. Giddings RN, RM, PhD
Associate Professor, School of Clinical Sciences, Faculty of Health and Environmental Sciences, AUT University, Auckland, New
Zealand
Christine Haley RN, RM, BHSc(Nurs), GradCert(WomensHlth), MPHC
Lecturer in Nursing, School of Nursing & Midwifery
University of Western Sydney, NSW, Australia
Karen Hancock PhD, BSc(Psych)(Hons)
Psychologist, LifeMatters Practice, LifeWise Practice, Newcastle, NSW, Australia
Senior Research Psychologist, The Children’s Hospital at Westmead, NSW, Australia
Mark Hughes BSocWk(Hons), PhD
Professor of Social Work, School of Arts and Social Sciences, Southern Cross University, QLD, Australia
Catherine Hungerford RN, BA, BHSc, BCounselSt, GradDipEd, MLitt, MNurs(MentalHlth – NursPrac), PhD, FACMHN
Professor and Head of School, School of Nursing, Midwifery and Indigenous Health, Charles Sturt University, NSW, Australia
Liz Isenring PhD, AdvAPD
Head of Program, Master of Nutrition and Dietetics, Bond University, QLD, Australia
Serra E. Ivynian BMedSci(Hons)
Research Assistant, PhD candidate, Centre for Cardiovascular and Chronic Care, Faculty of Health, University of Technology
Sydney, NSW, Australia
Sunita R. Jha BMedSci(Hons)
Casual Academic, Faculty of Health, University of Technology Sydney, NSW, Australia
Amanda Johnson RN, DipT(Nurs), MHSc(Ed), PhD
State Head, School of Nursing, Midwifery & Paramedicine NSW/ACT, Australian Catholic University, Sydney, NSW, Australia
Adjunct Associate Professor, Western Sydney University, NSW, Australia
Anne Kavanagh CPSP, BAppSc(SpeechPathology)(Hons)
Senior Speech Pathologist, Cairns and Hinterland Hospital and Health Service, Queensland Health, QLD, Australia
 Contributors xi

Belinda Kenny PhD, CPSP, MSPAA

Lecturer, Work Integrated Learning, Faculty of Health Sciences
The University of Sydney, NSW, Australia
Angela M. Kucia ProfCertPharmNurs, BNurs, GradCertEd, CCUCert, MA, PhD
Senior Lecturer, School of Nursing and Midwifery and Clinical Practice Consultant Chest Pain Assessment, Lyell McEwin Hospital,
SA, Australia
Shane Lenson BN, MPH, MSN(Nurse Prac), FCENA
Lecturer and National Practice Lead – Paramedicine, Australian Catholic University, ACT, Australia
Bridget Lingane RN, CertGeronNurs, GradCertNurs(Rehab), GradDipAdultEdTrain, MEd, MACN
Senior Nurse Educator, Royal Rehab: The Rehabilitation and Disability Support Network, NSW, Australia
Paul McDonald RN, RGeriN, ROncN, BHSc(Nurs), MNurs(Clinical), MPET, GCHE
Lecturer, Aged Care, Australian Catholic University, NSW, Australia
Duncan McKechanie RN, BNurs(Hons), DipPublicSafety, GradCertNurs(Rehab)
Clinical Nurse Consultant, Royal Rehab: The Rehabilitation and Disability Support Network, NSW, Australia
Geoffrey Mitchell MBBS, PhD, FRACGP, FAChPM
Professor of General Practice and Palliative Care, Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland,
Brisbane, QLD, Australia
Stephen Neville RN, PhD, FCNA(NZ)
Associate Professor and Head of Department (Nursing), School of Clinical Sciences, Auckland University of Technology, Auckland,
New Zealand
Phillip J. Newton RN, PhD, FCSANZ, FESC, FAHA
Associate Professor, University of Technology Sydney, NSW, Australia
Tiffany Northall RN, BNurs, GradCertClinEd, MNR, PhD candidate
Lecturer, School of Nursing and Midwifery, University of Western Sydney, NSW, Australia
Louise O’Brien RN, BA, PhD
Conjoint Professor of Mental Health Nursing, University of Newcastle, NSW, Australia
Julie Pryor RN, BA, GradCertRemoteHlthPrac, MNurs, PhD, FACN
Clinical Associate Professor, University of Sydney, NSW, Australia
Nursing Research and Development Leader, Royal Rehab: The Rehabilitation and Disability Support Network, NSW, Australia
Robin Ray RN, BEd, MHSc, PhD
Associate Dean Research Education, College of Medicine and Dentistry, James Cook University, QLD, Australia
Dianne Reidlinger BBus, PGCertAcPrac, MND, PhD
Assistant Professor, Faculty of Health Sciences and Medicine, Bond University, QLD, Australia
Vanessa J. Rice PhD, AEP, ESSAM, ATC
Senior Lecturer, School of Exercise Science, Australian Catholic University, VIC, Australia
Gail Roberts RN, MA, GradDipCouns, CertIV TAE
Senior Project Officer, Research, Royal Australian College of General Practitioners, VIC, Australia
John Xavier Rolley RN, BNurs(Hons), PhD
Associate Professor & Head of School, School of Nursing and Midwifery, University of Canberra, ACT, Australia
Dianne E. Roy RN, PhD, FCNA(NZ)
Associate Professor, Nursing, Health Care Practice Pathway, Unitec Institute of Technology, Auckland, New Zealand
Isabelle Skinner RN, RM, MPHTM, MBA, PhD
Professor, Charles Darwin University, NT, Australia
xii Contributors

Sheree M. S. Smith BNurs, MSocPlanDev, PhD

Professor, School of Nursing and Midwifery, Western Sydney University, NSW, Australia
Philip A. Stumbles PhD
Senior Lecturer in Pathology, Murdoch University, WA, Australia
Angelica G. Thompson-Butel BAppSc(ExSpSc), PhD, ESSAM, AEP
Lecturer, School of Exercise Science, Australian Catholic University, NSW, Australia
Honorary Appointee, Department of Rehabilitation, St Vincent’s Hospital, NSW, Australia
Research Affiliate, CRE Brain Recovery and Stroke Rehabilitation, VIC, Australia
Christophe von Garnier MD
Chief Physician, Associate Professor, Bern University Hospital, Bern, Switzerland
Nathan J. Wilson DipHlthSc, BSocSc, MSc, PhD
Senior Lecturer, School of Nursing and Midwifery, Western Sydney University, NSW, Australia
Michelle Woods BSc RN, GradDipHlthEd, MSN-NP, DNSc
Nurse Practitioner, Tasmanian Health Service, TAS, Australia
Adjunct Senior Lecturer, University of Tasmania, Hobart, TAS, Australia
Anthony Wright BSc(Hons)Phty, GradCertEd, MPhtySt(ManipTher), PhD
Professor, School of Physiotherapy and Exercise Science, Curtin University, WA, Australia
Patsy Yates PhD, RN, FAAN, FACN
Head, School of Nursing, Queensland University of Technology, QLD, Australia
Lee Zakrzewski BAppSc(OccTherapy), HScD
Previously Senior lecturer, Occupational Therapy, Western Sydney University, NSW, Australia
Reviewers
Angela Casey RN, MEd(LeadMgt), CertCritCare, MACN
Lecturer in Nursing, La Trobe University, VIC, Australia
Joyce Cousins RN, GradDip(Cardiothoracic), MNurs(ClinNurs), GradCert(NursPrescribing), GradCert(Ed), PhD candidate
Lecturer, Discipline of Nursing, Avondale College of Higher Education, NSW, Australia
Lorna Adrianne Davies RN, BA(Hons), MA, DTLT
Senior Lecturer, Nursing, Midwifery and Allied Health, Ara Institute of Canterbury, Christchurch, New Zealand
Helen Donovan RN, RM, MEd, PhD, FRCNA
Lecturer, Queensland University of Technology, Brisbane, QLD, Australia
Susan Furness RN, DipHSci(Nurs), DipAmbPara, MICA Paramedic, GradDipEmergHlth, MHSc, PhD candidate
Senior Lecturer, La Trobe University Paramedicine, VIC, Australia
Karen Missen RN, BHSc, GradDip(ICU), MHSc, PhD
Senior Lecturer, School of Nursing, Midwifery & Healthcare, Federation University, Gippsland Campus, VIC, Australia
Anna Williams DipAppSc(Nurs), BHlthSc(Nurs), MPH
Lecturer, School of Nursing, University of Notre Dame Australia, NSW, Australia
Conjoint Lecturer, Centre for Primary Health Care and Equity, Faculty of Medicine, University of New South Wales, NSW, Australia
Kristin Wicking RN, BSN, GradCertEd(Tertiary Teaching), MSN, PhD
Senior Lecturer, College of Healthcare Sciences, James Cook University, QLD, Australia
Preface

We hope you enjoy using the third edition of this text, and that it inspires and
encourages you to give the best quality of care for people living with chronic illness
and disability. We also hope that this text will improve your knowledge and the
development of your skills, and at the same time enhance your confidence when
caring for people with chronic illness and disability.
This book is developed for undergraduate nursing students, students in the TAFE
sector, newly registered nurses and other health professionals who share our com-
mitment to providing quality of care to people living with chronic illness and
disability. This book continues to champion the principles for practice supported
by evidence from Australian and international literature to enhance the understanding
of some of the issues and challenges of caring for a person living with chronic
illness and disability. Across all chapters, the text illustrates a holistic approach
highlighting quality of life in all aspects of care for chronic illnesses and disability.
Concepts essential for underpinning best practice in self-management of chronic
illness and disability are included, such as spirituality, individual education strategies,
valuing the person’s expertise, resources, culture, minimising socially stigmatising
processes and social isolation. Issues affecting carers and family are also addressed.
Attention to these concepts recognises the important shift nurses and other health
professionals are making towards working in partnership with individuals, their
family and carers. Through education and empowerment, individuals, their family
and carers are supported in their adjustment and adaptation to chronic illness and
disability to achieve optimal outcomes.
This third edition provides new case studies and reflective questions on chronic
illness and disability for discussion. Where relevant, the text is supported by current
statistics to illustrate key aspects of the discussion. Acquiring the knowledge and
skills for people living with a chronic illness and/or disability is vital in giving
competent care. You will find viewpoints that are challenging, but at the same
time motivating and thought-provoking. The exercises and learning activities that
are presented throughout the text offer a range of helpful suggestions in understanding
the context. Chapter 2 of this edition also includes the roles of pharmacist, paramedic
and exercise physiologist, and their responsibilities in the interdisciplinary/multi-
disciplinary team. In addition, each chapter has recommended readings and online
resources for further exploration.
Nurses and other health professionals in clinical practice and academic roles have
been involved in producing this text resource. We hope that you will find the text
scholarly, accessible, reality-based and practically useful. It is a resource intended
for every student, practising nurse, educator and administrator in understanding
the issues of caring for people living with chronic illness and disability. By reading
 Preface xv

the text, reflecting on the issues and posing possible answers, you should be able
to gain a comprehensive view of the issues, challenges and opportunities ahead of
them in their practice.
We gratefully acknowledge a number of key people who contributed and assisted
us in preparing this third edition for publication. We wish to extend our heartfelt
thankfulness and appreciation to the contributors for their shared interest and
concern in the issues and challenges of caring for people and their families in
nursing. This book would not be possible without them. We would like to extend
our special appreciation to members of the Elsevier team: Natalie Hunt, Libby
Houston, Karthikeyan Murthy, Margaret Trudgeon and Jon Forsyth for their
encouragement and support. Elsevier Australia joins us in thanking all the reviewers
who were involved in providing invaluable feedback during the development process
(listed on page xiii). Finally, we would also like to thank our families for their
endless support and encouragement through the years.

Esther Chang and Amanda Johnson

This page intentionally left blank
 SECTION 1

Frameworks for chronic

illness and disability

1 Chronic illness and disability: an overview

2 Partnerships in collaborative care
3 Models of care
4 Spirituality
5 Psychosocial care
6 Stigmatisation of people living with a chronic illness or disability
7 Sexuality
8 Developmental and intellectual disability
9 Management of chronic pain
10 Rehabilitation for the individual and family
11 Impact of obesity
12 Palliation in chronic illness
 CHAPTER 1
Chronic illness and disability: an overview
Amanda Johnson and Esther Chang

Learning objectives Key words

When you have completed this chapter, you will be able to: chronic disease
• describe the global and local contexts of chronic disease chronic illness
and disability disability
• describe the key terms used in relation to chronic disease
nurse
and disability
risk factors
• understand the role of modifiable risk factors and their
prevention in reducing the presence of chronic disease and
disability in the community
• develop an understanding of the impact that living with a
chronic disease and/or disability poses for the individual
and their family, health system and wider community
• appreciate the need for the implementation of holistic care,
inclusive of a multidisciplinary approach to promote
self-management and optimal functioning.

Introduction
The greatest health challenge facing the world now and into the 21st century is the rising prevalence
of chronic disease, the burden this poses for communities and its impact on healthcare systems. (Chronic
disease may also be referred to in the literature as non-communicable diseases (NCDs), chronic illness
or long-term conditions.) As we have the technology and treatments to keep us living longer, the
world’s populations are growing older, which also gives rise to the presence of chronic disease. This
health challenge has the potential to lead to one or more of the following developments: disability;
co-morbidity; multimorbidities or premature death. Thus, the presence of chronic disease in our society
poses a significant burden – social, economic, wellbeing and productivity – on the individual, family
and wider community. Chronic disease is and will continue to place pressure on existing services,
which are frequently designed for single disease management and are not necessarily responsive or
coordinated to meet the needs of individuals and/or their family. Importantly, the rising prevalence
of chronic disease can be reversed if individuals take responsibility for their health, modify risk factors
(for example, New Zealand reports that over one-third of all health-loss related to chronic disease is
preventable (Ministry of Health (MoH) 2016a), and governments institute healthcare policy focused
primarily on prevention rather than intervention.

Globally, nurses hold a pivotal role in coordinating
care and acting as educators and advocators. In this
context, the role requires nurses to develop caring
attitudes, have knowledge of, and the skills in, the
principles of nursing practice to provide optimal care
to individuals, their family and the wider community.
Subsequent chapters in this text use key chronic
diseases and/or disabilities to illustrate the nurses’ role
and explain how it contributes to an individual self-
managing and achieving optimal functioning.
The use of a multidisciplinary approach to care has
been reported as making significant improvements in
the health outcomes for people with chronic diseases
(McDonald, Cumming, Harris et al 2006). More often
than not, the care coordination role within the mul-
tidisciplinary team is undertaken by the nurse (Parker
& Fuller 2016), however, it is not exclusive to the
nursing profession and other health professionals are
just as able. Chapter 2 explores the role of nurses and
other health professionals within a multi-disciplinary
approach, as it relates to chronic disease management.
Understanding what it means for individuals, families
and the wider community to live with chronic disease
and disability is as important as having specific practice
knowledge, attitudes and skills in providing care.
The intention of this book, therefore, is to give
equal emphasis to what it means to live with a chronic
disease and/or disability and to gaining specific practice
knowledge, attitudes and skills. The chapters are
constructed to reflect this emphasis through the case
studies presented, highlighting that the person and
their family are central to the nurse’s understanding
of their needs, as they commence the illness trajectory
related to chronic disease and associated disability.
What follows in this chapter is a discussion on
the key terms used throughout the text; an overview
of the global context of chronic disease and disability
followed by information specific to the Australian
and New Zealand contexts.
Understanding
key terms
To support your engagement in the reading of this
text it is important to understand what is meant by
chronic disease and the various forms of expression
that are used interchangeably in the literature. Irrespec-
tive of the term or expression used, it is the challenges
arising from these diseases that are the focus of this
text. There are also a number of key terms related to
Chapter 1 Chronic illness and disability: an overview 3
chronic disease that need further explanation to
facilitate your understanding.
Chronic disease
Chronic disease is often difficult to define and frequently
several terms are used interchangeably across the
world and within countries. When chronic disease is
referred to in a global context and reported on by the
World Health Organization (WHO), the term used is
‘non-communicable diseases’ (NCD) (WHO 2014).
Non-communicable diseases are considered to be long-
term in nature, not acquired by transmission between
people, but share many common lifestyle-related risk
factors (WHO 2014). In Australia, the term ‘chronic
disease’ is more frequently used, and relates to a group
of diseases that are long-lasting (Australian Institute of
Health and Welfare (AIHW) 2014a). Chronic diseases
constitute the main cause of illness, disability and death
(90%) in Australia (AIHW 2014b). There are eight most
frequently occurring chronic diseases: arthritis; asthma;
back problems; cancer; chronic obstructive pulmonary
disease (COPD); cardiovascular disease (CVD); diabetes;
and mental health conditions (AIHW 2017a). The New
Zealand literature is most likely to report on chronic
disease using the term ‘long-term conditions’ (MoH
2016b) and are described in the New Zealand context
to be ongoing, long-term or recurring conditions that
have a significant impact on people’s lives.
Despite the differences in the form of expression,
the common features of chronic disease include:
■ complex causality, with multiple factors leading
to their onset
■ a long development period, for which there may
be no symptoms
■ a prolonged course of illness, perhaps leading to
other health complications
■ associated functional impairment or disability
(AIHW 2012).
Risk factors
Risk factors constitute determinants of health which
impact on our health negatively. They may be demo-
graphic, behavioural, biomedical, genetic, environmen-
tal, social or other factors acting independently or in
combination (AIHW 2016). Initially, it was thought
that risk factors were exclusively adult behaviours;
however, we now understand their importance from
the period of gestation until death; for example, the
increased numbers of overweight and obese children
4 Section 1 Frameworks for chronic illness and disability
and the increasing incidence of type 2 diabetes found
in the younger generation (WHO 2014). In relation to
chronic disease, they can affect the onset, maintenance
and prognosis of chronic disease. The risk factors
associated with chronic disease are:
■ poor nutrition
■ physical inactivity
■ smoking
■ risky alcohol consumption and illicit drug use
high blood pressure
■
■ high blood lipids
■ overweight and obesity
■ impaired fasting glucose (AIHW 2016).
Significantly, the vast majority of these risk factors
are modifiable to prevent chronic disease from occur-
ring. The lifestyles engaged in by the populations of
developed countries has seen an increasing rise in the
prevalence of chronic disease, while those who are
vulnerable and poor in our communities tend to have
one or more of these risk factors present. As you read
over the chapters about specific chronic diseases, you
will learn about the identification of risk factors in
relation to disease and how these are best prevented
and/or managed to prevent development of the chronic
disease in the first instance.
Risk factors in the development of
chronic disease
Controlling body weight, eating nutritious foods, avoid-
ing tobacco use, controlling alcohol consumption and
increasing physical activity may lead to the prevention
or delay of many chronic diseases (AIHW 2005, p. 1).
Controlling some risk factors and effectively
managing others through initiatives such as screening
and early intervention programs (AIHW 2006;
National Public Health Partnership (NPHP) 2006)
can significantly reduce the presence of chronic disease
within communities. In Australia, health promotion
is acknowledged as the key to preventing chronic
disease via prevention and management of risk factors
(AIHW 2006, p. 13). The most common modifiable
risk factors contributing to chronic disease are
unhealthy diet, which leads to raised glucose levels,
increased body mass and abnormal blood lipids; physi-
cal inactivity, which leads to increased body mass,
increased blood pressure and increased blood lipids;
and tobacco use, which leads to raised blood pressure
(AIHW 2006, p. 13; WHO 2017). These risk factors
are said to be modifiable because chronic disease can
be prevented by the person changing their behaviour
and/or medical intervention (AIHW 2006, p. 13).
The two key non-modifiable risk factors contributing
to the development of chronic disease are age and
heredity (WHO 2005, p. 48). Identification of these
factors within population groups allows for the develop-
ment of prevention and management strategies that
may be constructed to meet the cultural and linguistic
needs of the group (AIHW 2006, p. 13).
Chronic illness
In this text, chronic disease is referred to as chronic
illness. This form of expression has been chosen for
this book because it emphasises the totality of the
illness as experienced by the person. Chronic illness
is described as: ‘the irreversible presence, accumulation
or latency of disease states or impairments that involve
the total human environment for supportive care and
self-care, maintenance of function and prevention of
further disability’ (Curtin & Lubkin, cited in Lubkin
& Larsen 2013, p. 6). The term takes account of the
resulting impact on all aspects of the person’s life and
the requirement by health professionals to address
the person’s needs holistically (Larsen 2013). The
implication, therefore, for nurses and other health
professionals is the need to recognise that all dimen-
sions of personhood are affected by the presence of a
chronic disease and/or disability.
Disability
Globally, The International Classification of Function-
ing, Disability and Health (2001) (Fifty-Fourth World
Health Assembly 2001) defines a person as being
disabled when a level of difficulty is experienced in
one or more of the following interconnecting areas.
The first area is that of impairment. A person with
an impairment experiences issues related to body
function or alteration to body structure (WHO 2011).
The second area is activity limitations. In this area
people face challenges in carrying out everyday activi-
ties (WHO 2011). The final area identified is participa-
tion restrictions. In this area an individual faces
problems in any area of their life, not just health-related
(WHO 2011). Further, disability arises from several
contextual elements: those of health conditions
(diseases or disorders), along with environmental and
personal factors which can influence an individual’s
capacity to live in society. This means that interven-
tions need to be much broader than just medical and
frequently involve education and welfare support

(WHO 2011). In relation to chronic disease, a person
may experience disability independent of the disease
state, for example, a person who has arthritis but
develops cardiovascular disease; or disability may be
a consequence of the disease, for example, a person
with diabetes who develops blindness; or disability
may be present as a side-effect to treatment, for
example, a person who recovers from cancer but has
reduced hearing due to ototoxcity related to the
chemotherapy drugs. It is important to understand
that in some contexts the terms ‘disability’, ‘chronic
disease’ and ‘impairments’ are used interchangeably
within the literature and may mean the same thing.
Co-morbidity
The term co-morbidity describes the presence of two
diseases occurring simultaneously in a person (AIHW
2017a). Frequently because of shared risk factors, there
is a relationship between the original disease and the
second disease that emanates; for example, a person
who has diabetes and the person’s diabetic state has
lead to the development of atherosclerosis and
cardiovascular disease. Of importance to note here is
that all of these diseases are preventable through
surveillance and prevention. Getting older is also a
factor, as with increased life expectancy there is greater
opportunity for other conditions to emerge; for
example, an older person who has cancer but also has
the presence of significant arthritic changes and
experiences severe restrictions with mobility as a result.
Multimorbidity
Since our first edition, the term co-morbidity has fast
been replaced by the term multimorbidity, where an
individual experiences more than three conditions
concurrently. For example, in New Zealand one in
four adults report two or more long-terms conditions
(MoH 2016b). People are living longer and as a
consequence are acquiring chronic disease earlier
and therefore are presenting to health services with
multimorbidity; for example, in the United States,
50% of older people have three or more chronic
conditions (American Geriatrics Society 2012),
necessitating complex interventions.
The global perspective
of chronic disease
Now, more than ever, there is a need to globally
prevent and control the rise of chronic disease. The
Chapter 1 Chronic illness and disability: an overview 5
world and individual countries, whether low-, middle-
or high-income, can no longer sustain now and into
the future the human, social, economic and health
impacts of chronic disease. In particular, it is the poor
and vulnerable populations who are most at risk (WHO
2014). By 2030, it is projected that chronic disease
will account for 82% (55 million) of all deaths
worldwide; this projection is an increase of 17 million
from 38 million in 2012 (WHO 2013). Of the 56
million deaths reported in 2012, 68% (38 million)
were attributed to chronic disease; more than 40%
(16 million) were premature deaths under 70 years
of age, and 48% of them occurred in low- to middle-
income countries (WHO 2014). Of concern is the
projected increase in these deaths underpinned by
four risk factors: tobacco use; unhealthy diet, physical
inactivity and harmful use of alcohol (WHO 2013),
all of which are directly preventable. The leading
deaths specifically attributable to these risk factors
are: cardiovascular disease; cancers; chronic respiratory
disease and diabetes (WHO 2013). These deaths, and
the resultant co-morbidities, multimorbidities and
disability evoke much human suffering, impacting at
social, economic and public health levels on the
individual, their family and the wider community.
Individual behavioural change is important; however,
the effects of globalisation on marketing and trade,
rapid urbanisation and population ageing (WHO 2014,
p. vii) are also significant contributing influences that
no one person can control, but where governments
need to provide leadership.
To support countries in the leadership of preventing
and controlling chronic disease, The World Health
Assembly endorsed the WHO Global Action Plan for
the Prevention and Control of NCDs 2013–2020 (WHO
2013). The Action Plan offers a means by which to
guide countries in establishing multi-sectoral action
plans and policies to achieve a reduction in premature
deaths by 25% (WHO 2013) . The plan articulates
nine voluntary global targets for attainment by 2025:
1. a 25% reduction in overall mortality from
cardiovascular diseases, cancer, diabetes or
chronic respiratory diseases
2. a 10% reduction in the harmful use of alcohol
3. a 10% reduction in prevalence of insufficient
physical activity
4. a 30% reduction in intake of salt/sodium
5. a 30% reduction in the prevalence of tobacco use
6. a 25% reduction in the prevalence of high
blood pressure
6 Section 1 Frameworks for chronic illness and disability
7. a halt in the rise of diabetes and obesity
8. at least 50% of people receiving drug therapy
and counselling (glycemic control) to prevent
heart attacks and strokes
9. an availability of the affordable basic
technologies and essential medicines to treat
NCDs (WHO 2013, p. 5).
In 2014, WHO conducted a review on the progress
of these targets, documenting varying degrees of success
by different countries against the targets. It is evident
from the 2014 WHO report that the majority of
countries are off-course to meet their global targets
and as an imperative need to set national targets and
a monitoring framework to track progress towards the
2025 date. The burden of disease for OECD countries
(including Australia and New Zealand) is similar;
however, the rates for both ischemic heart disease
and lung cancer in Australia are significantly lower
than in other OECD countries (WHO 2013). This
reduction has been directly attributed to the health
promotion educational activities.
Australian and New Zealand context
Australia and New Zealand are both fortunate
countries as the vast majority of their inhabitants
have high life expectancies and consider themselves
to be in ‘good’ health (AIHW 2016; MoH 2016a).
However, both countries also report chronic disease
as a growing problem which is exerting significant
pressure on an already strained healthcare system and
is a burden on the community (AIHW 2016; MoH
2016b). In Australia, for example, chronic diseases
are the leading cause of ill health and death (AIHW
2016). Both countries have recognised that to meet
the health challenges they face now and into the
future, the health system will need to adapt and be
responsive to the changing care needs and the level
of complexity presented by chronic disease. Currently
in New Zealand, health spending represents 22%
of the overall budget in line with other developed
countries. However, this current funding level is not
sustainable (MoH 2016b); an increased life expec-
tancy and greater percentage of the population with
long-term health conditions necessitates a model of
care that is different to current practice. The model
needs a focus on prevention of long-term condi-
tions or slowing down the development of chronic
disease and related co-morbidities/multimorbidities.
Further discussion on models of care can be found in
chapter 3.
Australian profile
Australian governments are informed by the WHO’s
strategic directions, which lead to a series of National
Health Priority Areas (NHPAs) first being identified
in 1996. At the current time, there are nine NHPAs
(refer to the list below). They are diseases and condi-
tions that successive Australian governments have
chosen to focus attention on because they contribute
significantly to the burden of illness and injury, and
if addressed will result in the improved health of the
Australian population.
The nine priorities are:
■ cancer control (first set of conditions, 1996)
■ cardiovascular health (first set of conditions,
1996)
■ injury prevention and control (first set of
conditions, 1996)
■ mental health (first set of conditions, 1996)
■ diabetes mellitus (added 1997)
■ asthma (added 1999)
■ arthritis and musculoskeletal conditions (added
2002)
■ obesity (added 2008)
■ dementia (added 2012) (AIHW 2017c).
In 2014–15 more than 11 million people had at least
one of the eight selected diseases and seven out of
ten (73%) of all deaths were related to chronic
disease (AIHW 2016). Many of these diseases also
share common risk factors which are preventable
or modifiable. One in four (23%) Australians had
two or more of the eight selected diseases (AIHW
2016), the most common co-morbidities being
cardiovascular disease (7.4%) or arthritis (5.1)%. Of
growing concern is the emergence of the population
group with multiple morbidities, which places even
more pressure on the healthcare system. Two-thirds of
the burden created by chronic disease is the result of
cancer, cardiovascular disease, mental and substance-
use disorders, musculoskeletal disorders and injuries
(AIHW 2016). Examples of people with a multiple
morbidity are: of the one-third of Australian people
(31.8%) who experience a psychotic disorder, they
also experience chronic pain; one-fifth (20.8%) have
diabetes and just over one-quarter (26.8%) have a heart
or circulatory problem (AIHW 2016). By targeting
specific areas that impose high social and financial costs
on Australian society, collaborative action can achieve
significant and cost-effective advances in improving
the health status of Australians. Of the modifiable risk

factors previously discussed, the AIHW 2016 report
identifies that 31% of chronic disease in Australia
could have been prevented by reducing exposure to
tobacco use, harmful alcohol use, high body mass,
physical inactivity and high blood pressure.
In addition to the NHPAs, the Commonwealth
Government, through the Department of Health, has
sought to establish a National Strategic Framework
for Chronic Conditions in conjunction with the five
states and two territories of Australia. The framework
is still under development, but will seek to provide a
national approach to guide planning, design, delivery
of policies, strategies, actions and services to reduce the
impact of chronic conditions in Australia (Australian
Government Department of Health 2017). It will
move away from the more traditional approach of
managing diseases specifically to generating principles
that can be applied more broadly. Another element
to the framework will be how best to provide care
through a coordinated approach drawing on a diversity
of health and care providers to deliver services. Once
completed, it will replace the National Chronic
Disease Strategy 2005 (NHPAC 2006). This strategy
emerged in response to the growing impact of chronic
disease and was aimed at encouraging a coordinated
approach.
In 2014–15, more than 50% (11 million) of the
Australian population experienced a chronic disease
(AIHW 2016). Specifically, those aged 65 and over
constituted 87% of the 11 million experiencing a
chronic disease, reflecting the ageing population. The
AIHW 2016 report also demonstrates that 55% of
those with a chronic disease come from the lowest
socioeconomic areas in Australia, predominantly in
regional and remote areas (54%), compared to the
major cities (48%). This is an important statistical
fact to consider in understanding how services are
planned to promote access and uptake in regional
and remote areas. The AIHW report (2016) on the
self-reported data showed that the most commonly
reported chronic diseases for the period 2014–15 were:
cardiovascular and mental health conditions (18%
each), followed by back pain (16%). In the age group
45–64 and those 65 years or older, cardiovascular
disease (27%) and arthritis (26%) were most commonly
identified.
New Zealand profile
New Zealanders are living just as long as Australians,
with 88% of the population experiencing some form
Chapter 1 Chronic illness and disability: an overview 7
of health loss as a consequence of long-term mental
and physical disease (MoH 2016a). In 2013, the
Ministry of Health reported over half of the health
loss (52%) was attributable to a disability. Furthermore,
mental health and dementia are the leading causes
of health loss (19%), two areas of practice that are
providing the biggest challenges (MoH 2016a).
Another emerging area contributing to health loss is
the rise of musculoskeletal disorders (13%) due to a
higher incidence of obesity (MoH 2016a). As is the
case for Indigenous Australians, Māori and Pacific
Islanders experience serious inequalities in health
outcomes relative to the total population (MoH
2016a). For example, high smoking rates continue to
be present in Māori adults, especially for those living
in the most deprived areas and Pacific adults experience
higher rates of diabetes than any other ethnic group
in New Zealand (MoH 2014).
Indigenous populations
Worldwide, there are vast disparities in the health of
Indigenous people and their subsequent experience
of chronic illness and/or disability, as compared to
non-Indigenous people (WHO 2008). This disparity
is attributable to a life expectancy that is 10–20 years
less than for the main population; infant mortality
1.5 to 3 times greater than the national average; and
a large proportion of Indigenous people suffering from
malnutrition and communicable diseases (WHO 2008).
Indigenous people’s health is further exacerbated by
damage to their habitat and resource base (WHO
2008). In 2008 WHO, in its report Primary Health
Care: Now More Than Ever, made explicit that health
service providers need to take better account of the
lack of services and the disadvantage that remoteness
plays in Indigenous people accessing and achieving
the same health status as non-Indigenous people.
The health disparity presented worldwide is also
true for both the Australian and the New Zealand
Indigenous populations. They are more likely to have
an increased presence of chronic disease; to be less
healthy; to die at a much younger age; and to have
a lower quality of life than non-Indigenous people
(AIHW 2012; MoH 2012). At the present time,
Australian Indigenous people experience 80% mortality
as a direct link to chronic disease (AIHW 2017b).
In particular, the National Aboriginal and Torres
Strait Islander Health Measures Survey (NATSIHMS),
shows that Indigenous people are more than three
times likely to have diabetes; have triglyceride levels
8 Section 1 Frameworks for chronic illness and disability
that are nearly double the normal levels of good
cholesterol, leading to cardiovascular disease, and are
twice as likely to have signs of chronic kidney disease
(ABS 2014). Of significance, not only do Indigenous
Australians experience more chronic disease than
non-Indigenous Australians, but they also experience
it at a much younger age – 35years onwards as compared
to 45–55 years depending on the disease (ABS 2014).
This report also revealed that four in ten Indigenous
people are obese, a level that is one and a half times
more than for the non-Indigneous population (ABS
2014). Obesity is a strong predictor for many chronic
diseases, for example: heart disease, diabetes, high
blood pressure and some forms of cancer (AATSHIS
2014). In 2008, Australian Indigenous people were
more than twice as likely as non-Indigenous people
to have a disability (and to have a life expectancy of
less than 10 years) (ABS 2013). In New Zealand, the
most recently reported figures (2006) show life
expectancy for Pacific males as 6.7 years less than
total males and for Pacific females it was 6.1 years
less than total females (MoH 2012a, p. 25). In New
Zealand it is estimated that 18 700 Pacific adults had
a disability. For 43% (n = 8100) the most common
cause of their disability was most likely attributed to
chronic disease or illness (MoH 2012a, p. 27).
By way of illustrating the disparity, in 2011 Austral-
ian Indigenous peoples were 12% more likely than
non-Indigenous Australians to experience cardio-
vascular disease; were 3.4 times more likely to report
some form of diabetes, and had a 27% increased risk
of having a respiratory disease (Thomson, MacRae,
Brankovich et al 2011). In New Zealand, the rate of
diagnosed diabetes was significantly higher for Pacific
men and women (45–64 years age group) than men
and women in the total population by approximately
20% and 12% respectively (MoH 2012a, p. 43). In
terms of respiratory disease, the Ministry of Health
(2012a) reports Pacific men as being three times more
likely to present for hospitalisations and Pacific women
five times more likely than the total population.
The factors identified which contribute to Indig-
enous health are: nutrition; physical activity; body
weight; immunisation; breastfeeding; tobacco smoking;
alcohol use; and illicit drug use (MoH 2012a; Thomson,
MacRae, Brankovich et al 2011). Indigenous peoples
have and continue to experience substantial social
disadvantage in relation to their health through limited
education; reduced employment opportunities; lower
than national average income; higher levels of poverty;
poorer housing; greater exposure to violence; limited
access to services; underdeveloped social networks;
connection with land; racism and incarceration; and
impaired communication when English is a second
language (McMurray & Clendon 2011; MoH 2012a;
Thomson, MacRae, Brankovich et al 2011). It is
important to recognise that for Indigenous populations
both the social determinants of health and the cultural
concepts of indigenous health strongly influence the
health status of their communities (McMurray &
Clendon 2011; MoH 2012a; Thomson, MacRae,
Brankovich et al 2011). The presence of these risk
factors either singly or in combination lead to a higher
proportion of the Indigenous population developing
chronic disease and/or disability as compared to the
non-Indigenous population.
As a consequence, Indigenous Australians suffer
much more ill health than non-Indigenous Australians
(AIHW 2012). Indigenous Australians experience
higher levels of disability when compared to the general
population (36%): 8% experience a severe limitation
of a core activity (AIHW 2006, p. 56), which is twice
that experienced by non-Indigenous Australians
(AIHW 2006, p. 56). In terms of chronic disease,
Indigenous Australians experience a higher mortality
rate from diabetes (14 times higher than the general
population), chronic kidney disease (8 times) and
heart disease (5 times) (AIHW 2006, p. ix). The
resulting outcome for Indigenous Australians is that
they are four times more likely to experience death
as compared to non-Indigenous Australians (AIHW
2006).
In New Zealand, 24% of Māori experience disabil-
ity, followed by 18% of Europeans, and 17% of Pacific
peoples (MoH 2005, p. 8). As a consequence, Māori
and Pacific peoples have a lessened life expectancy
by 8.5 years compared with the European population,
largely attributable to the increased incidence of
chronic disease in these population groups (McMurray
& Clendon 2011; National Health Committee 2007,
p. 10).
Global perspective
on disability
Globally 15% of the world’s population experience
some form of disability and it continues to rise (WHO
2011). Reasons for this continued rise relate to: more
people getting diseases which can cause disability;
people cannot always get access to healthcare; people
who are disabled by war, and natural disasters. The

15% equates to 15 out of every 100 people being
disabled with 2–4 of those people having severe dis-
ability preventing their productive participation in
society (WHO 2011). WHO reports several factors
that have contributed to this increase: an increasingly
ageing population; the rapid spread of chronic disease
and better ways of reporting on disability (2011). It
is also recognised that there are more vulnerable groups
within our communities, for example, the poor; women;
older people; those with no employment; those with
low levels of education qualification; minority ethnic
groups; all of whom are more likely to experience
higher rates of disability within their group (WHO
2011). This figure is expected to rise as a result of the
world’s ageing populations and the higher presence
of disability in older people, as well as the global rise
of chronic diseases (WHO 2011, p. xi).
The global impact of disability on communities
has only been recently acknowledged by the first world
report on disability, The WHO Report on Disabilities
(WHO 2011b). This report demonstrates the attitu-
dinal, physical and financial burdens a person experi-
ences every day with a disability. Further, this report
shows the need for governments to remove the barriers
to participation and to provide sufficient funds to allow
people with disability access to health, rehabilitation,
support, education and employment (WHO 2011b,
p. ix). Finally, the report concludes by illustrating the
need for policymakers, researchers, practitioners,
advocates and volunteers in disability to work together
at local, national and international levels. This is
necessary to bring about a reduction of the burden of
disabilities to society, to bring about changes to practice
and to value more explicitly the contribution that
people with disability can make to the productivity
of the community.
Australian profile of disability
The National Disability Strategy 2010–2020 has as
one of its six priority areas: ‘People with disability
attain the highest possible health and wellbeing
outcomes throughout their lives’ (Australian Govern-
ment Department of Social Services 2014). It is telling,
however, that the health outcomes for people who
are disabled are not well featured as part of the national
health report (AIHW 2016). In 2015, nearly 1 in 5
Australians (18.3% or 4.3 million) experienced some
form of disability (ABS 2015). This figure increased
significantly for those aged 65 years or older with
50.7% reporting a disability (ABS 2015). This is
Chapter 1 Chronic illness and disability: an overview 9
important to understand in the context of Australia
growing its 65 years or older portion of its total popula-
tion faster than any other age group. It results in 1
in 7 or 15.1% of the population being in this age
group (ABS 2015). Such a result plays a role in the
determination of healthcare services into the future.
The most common disability people experience is
impairment to communication, mobility and/or self-
care. In 2015, 5.8% (1.4 million) of the population
experienced this form of disability requiring the greatest
assistance. More than half those aged 65years or older
were affected (ABS 2015). It is also important to
understand that those with a disability were also 3.3
times more likely to have a long-term health condition
(AIHW 2016). Two illustrations of why this is the
scenario are: 1. in adults with a profound to severe
disability they were 70% more likely to be overweight
or obese as compared to a person without a disability
and 2. those who are profoundly or severely disabled
are twice as likely to smoke than those without a
disability (AIHW 2016). Services to support Austral-
ians who are disabled has fallen under the National
Disability Agreement (NDA) with over half the users
(55%) in 2013–14 having an intellectual or learning
disability (AIHW 2014a). The most commonly
reported conditions were: mental and behavioural
problems; followed by back problems; deafness;
arthritis; cardiovascular diseases; asthma and migraine
(AIHW 2016). It is also evident that comorbidity
between mental and physical disability exists and is
expanding. For example, people with a disability and
depression are more likely to develop diabetes (AIHW
2016) as a consequence to changes in lifestyle.
Aboriginal and Torres Strait Islander people
with a disability
A large disparity exists between Aboriginal and Torres
Strait Islander people and non-Indigenous populations
of Australia. Aboriginal and Torres Strait Islander
people are more than 1.7 times more likely to have
a disability than non-Indigenous people (ABS 2012).
This disparity exists because of the difference in
socioeconomic circumstances and access to healthcare
services between these two populations. The report
‘Aboriginal and Torres Strait Islander People with a
Disability 2012’ revealed notable differences in the
rates of disability in Aboriginal and Torres Strait
Islander people and non-Indigenous populations. These
differences were: Aboriginal and Torres Strait Islander
people experience a higher rate of disability across all
age groups and gender than non-Indigenous people;
10 Section 1 Frameworks for chronic illness and disability

Aboriginal and Torres Strait Islander children between illness and/or disability, and the resources available
0-14 years of age were more than twice as likely to to manage the condition are highly variable, largely
have a disability than non-Indigenous people; and determined by each person’s individual situation
Aboriginal and Torres Strait Islander people aged 35-54 (Guillett 2004).
years were more than 2.7 times likely to have a disabil- Chronic disease is often thought of as a disease of
ity than non-Indigenous people. It was also noted the aged and while it is more prevalent in that age
that 7.8% of Aboriginal and Torres Strait Islander group, we are now seeing evidence of chronic disease
people had a profound or severe disability impacting in younger generations, which are directly attributable
on their capacity to communicate, be mobile and or to lifestyle risk factors; for example, children who are
self-care (ABS 2012). overweight and obese (AIHW 2016) (Table 1.1). The
implications of this are that individuals who acquire
a chronic disease early on in life will need to live and
New Zealand profile of disability adapt to their illness and sequelae for the rest of their
In 2013, the total New Zealand population had a life, placing a significant burden on the community.
disability rate of 24% partially explained by an increase People living with a chronic illness are more likely
in the age of the population (Statistics New Zealand than the general population to experience periods of
2015) reflecting a similar pattern to the Australian hospitalisation as a consequence of acute flare-ups of
and worldwide context. Those aged 65 years or older their underlying chronic disease. What is emerging
were more likely to be disabled (59%), with physical is that due to the increasing prevalence of chronic
limitations being the main form of impairment disease, many admissions to hospital now constitute
(Statistics New Zealand 2015). the underlying pathology of chronic disease.
The challenges presented to health professionals
Māori people with disability by chronic illnesses and disabilities are vast. Considera-
New Zealand’s Indigenous population suffers a similar tion must be given to finding new ways of prevention
health disparity to Indigenous Australians. In 2013, to control the prevalence of chronic disease within
the Māori population identified 26% (176 000) of our community. Controlling the prevalence of chronic
its population as being disabled in a younger age
group, an increase of 6% since 2001 (Statistics New
Zealand 2015). This equates to one in four Māori
who are disabled with an impairment, mostly related
to mobility. Impairments for Māori stem primarily TABLE 1.1 Risk factors and determinants for
(40%) from disease or illness (Statistics New Zealand chronic diseases
2015). Low socioeconomics, ethnicity, poor housing
and limited education combine to contribute to the MODIFIABLE RISK FACTORS BROAD INFLUENCES
Māori population experiencing a higher percentage of May or may
disability than the non-Māori population (Statistics not be Non-
New Zealand 2015).
Behavioural Biomedical modifiable modifiable
Tobacco Excess weight Socio- Age
Impact and challenges smoking environmental
factors
of chronic illness Excess alcohol High blood Psychosocial Gender
use pressure factors
and disability Physical High blood Early life Indigenous
It is difficult to quantify the impact of chronic illness inactivity cholesterol factors status
and disability experienced by the individual, family Poor diet Other Political factors Ethnic
and community, as many of the costs are invisible. background
For example, in Australia 65% of people who expe- Other Family history
rienced a severe or profound core activity limitation
Genetic
relied on informal carers for such activities as self-care, make-up
mobility and communication (AIHW 2006, p. 49).
The difficulty arises due to the nature of the chronic Australian Institute of Health and Welfare (AIHW), 2006.

disease is not the sole responsibility of government
or health services, but must emanate from individuals
taking ownership of their health behaviours, working
in collaboration with government and health services
to eradicate the increasing presence of chronic disease
in our communities (WHO 2014). Some challenges
that have been articulated are the rising costs of care,
the number of people needing to access chronic disease
care, inequities between the Indigenous and general
populations, the changing composition of the popula-
tion experiencing chronic disease and/or disability,
ethical issues, providing culturally competent care,
caregiver issues (AIHW 2016; MoH 2016; Remsburg
& Carson 2006, pp. 591–599), the mismatch between
the needs of people with a chronic condition and
what the health system offers (NHC 2007, p. 13).
Other ways in which these challenges can be
addressed include: improving the health experiences
of various disadvantaged groups in Australia and New
Zealand; providing public health programs in a more
cohesive and non-fragmented manner; adopting a
model of practice that recognises the importance of
early life factors and their contribution to creating
chronic disease in adulthood; using a multifaceted
approach involving others outside the healthcare area
to reduce the prevalence of conditions such as obesity
and depression to foster social norms of active living;
acknowledging the contribution of psychosocial factors,
such as resilience and family environment, to chronic
disease and the need for multiple strategies to address
these factors; and adopting a holistic approach in
developing prevention and management strategies
(NPHP 2001, p. 2) (Table 1.2).
Principles of practice
To provide optimal care to a person and their family
experiencing a chronic illness and/or disability which
ensures all needs are met, a number of key principles
of practice must be implemented by nurses in conjunc-
tion with other members of the multidisciplinary
healthcare team. These principles are to:
■ recognise that chronic illness and/or disability
affects all dimensions of personhood: physical,
psychosocial, emotional, cognitive and spiritual
(Guillett 2004; Larsen 2013)
■ recognise that cultural responses to illness are
important when providing care (Larsen 2013)
■ provide holistic care by incorporating a team
approach to providing care that is relevant to
Chapter 1 Chronic illness and disability: an overview 11
the needs of the person experiencing the
chronic illness and their family (Guillett 2004,
p. 19)
■ adopt a ‘whole of life’ approach, recognising
that risk factors occur across the lifespan and
play a significant role in the development of
chronic disease (NPHP 2001, p. 4)
■ provide care that is person-centred and
inclusive of the family, however the person
defines this for themselves (Morris & Edwards
2006).
As you read through the following chapters you will see
further expansion and application of these principles
that will assist you in your understanding of chronic
illness and disability, as applied to the Australian and
New Zealand context. The authors discuss critical
components related to understanding the experience
of chronic illness, such as: behaviours that contribute
to the development of the condition; the relationship
between chronic illness and activities of daily living;
the impact of body image and identity on the person
and their family or carers; issues concerning quality
of life; a range of interventions to support restorative
function and quality of life; the role of family and
carers; and education of the person and family. Case
TABLE 1.2 Comparison between acute and chronic
care models
ACUTE MODEL CHRONIC CARE MODEL
Disease-centred Person-centred
Doctor-centred Team-centred
Focus on individuals Population health approach
Secondary care emphasis Primary care emphasis
Reactive, symptom-driven Proactive, planned intervention
Episodic care Ongoing care
Cure focus Prevention/management focus
Single setting: hospital, Community setting,
specialist centres, general collaboration across primary
practice and secondary care
1 : 1 contact through visit by 1 : 1 or group contact through
patient visit by patient or health
professional, email, phone or
Web contact
Diagnostic information provided Support for self-management
National Health Committee, 2007.
Another random document with
no related content on Scribd:
 Lighting a match and setting ablaze a stick he picked up from the
dry floor of the cave in the rocks, Farmer Joel led the way toward the
back of the dark hole. The blazing stick gave light like a torch.
It grew colder and colder the deeper they went into the cave, and
Mrs. Bunker, with a little shiver, exclaimed:
“It is cold in here!”
“We won’t stay very long,” said Mr. Todd. “I’ll just show the children
the pile of ice and then we’ll go back to the front part of the cave
where the air is warmer. This shower will soon be over and we can
go outside again.”
They walked on a little farther and suddenly Rose cried:
“Oh, I see it! I see a big pile of ice!”
The light from Farmer Joel’s blazing stick glittered on a sparkling
mass of ice and snow in the deepest, darkest part of the cave.
“Is it real?” asked Mun Bun.
“Touch it and see,” advised his father.
Mun Bun put his little hand on the sparkling pile. He drew it quickly
back with a murmur of wonder.
“Oh, it’s terribly cold!” he exclaimed.
“It’s real ice, all right,” laughed Farmer Joel.
“How does it get in here?” Russ asked.
“There is a hole in the roof of the cave—the roof that is made of
rocks,” explained the farmer. “You can see where some water is
pouring in now from the rain.” The children looked and saw drops
falling on top of the pile of ice.
“Not as much water comes in here in the summer as in winter,”
explained Farmer Joel; “for now the holes in the rocky roof are filled
with bushes and leaves. But in the winter, when the leaves dry out,
there is quite an opening. Rain and melted snow runs in and it is so
cold here that a big, solid chunk of ice is frozen.”
 “But what makes it stay here when summer comes?” asked Rose.
“Because the warm sun cannot shine inside the cave to melt the
ice,” explained her father.
“That’s right,” added Farmer Joel. “Some years we can come here
even in the middle of August and chop out chunks of ice.”
“I should think you could make ice cream,” said Russ.
“Sometimes we do,” replied Mr. Todd.
“Oh, could we do that now?” cried Rose eagerly.
“We haven’t any freezer nor the things to make ice cream with,”
objected her mother.
“Couldn’t we take some of the ice home in the wagon?” Russ
wanted to know.
“Yes, you could do that,” said Farmer Joel kindly.
For a few minutes longer the six little Bunkers remained looking at
the big mass of ice—ice in the middle of summer. Then as the torch
was burning out and as it was chilly after the warm outdoors, Mrs.
Bunker told the children to go to the front of the cave.
“But we’ll come back and get some of the ice to make ice cream,”
stated Russ.
“Yes,” agreed Farmer Joel.
As he had said, the storm did not last long. Soon the black clouds
rolled away, the thunder and lightning ceased, and the sun came out,
warmer than before. Out of the ice cave rushed the children, merrily
shouting and laughing.
“Be careful now!” called their mother. “The woods are very wet!”
But dry places were found under thick evergreen trees, and there
the six little Bunkers played until it was time to go home.
“And now for the ice!” cried Russ, as the wagon was driven up
close to the entrance to the cave.
“I want to break off a chunk!” cried Mun Bun.
 But it was decided best not to let the smaller children go into the
ice cave while pieces were being broken off to take to the farmhouse
for ice cream. So Russ and Rose were the only ones allowed to see
Farmer Joel, Daddy Bunker, and Adam North break off pieces of ice
with heavy sticks of wood. Out to the wagon the chunks were
carried. There they were covered with straw to keep them from
melting too much.
“Now for some ice cream!” cried Russ, as they drove home. “I
don’t believe you could find ice in the summer time in many places,
could you?” he asked.
“Well, no,” his father told him. “Not every place has an ice cave,
though they are not as rare as you might suppose. Sometimes, in
deep, rocky glens where the sun seldom shines, I have seen ice as
late as the end of May. But I never saw a real ice cave before.”
“A polar bear could live in that cave, couldn’t he?” asked Mun Bun
on the way home.
“Yes, it might for a little while,” said Farmer Joel, “but I guess it
would miss the ocean. Polar bears need salt water to swim in, as
well as ice chunks to keep them cool.”
“I hope no polar bear comes to live in that cave while we’re here,”
remarked Margy.
“Don’t worry, darling!” laughed her mother. “None will.”
There was plenty of the ice left when the farmhouse was reached.
Russ and Laddie took it from the wagon and cracked it in burlap
bags, while Farmer Joel brought out some coarse salt with which to
mix it. Salt always causes ice to melt faster, and it is only when ice
melts and gives out the cold locked up in it that ice cream can be
made.
Norah soon had the freezer full of a mixture of sugar, cream and
some sliced bananas, since the children liked that flavor, and in a
little while Russ and Laddie were turning the handle.
By supper time the ice cream was frozen, and for dessert they had
a dainty dish made from ice brought in the middle of summer from
the dark cave. The six little Bunkers thought it quite wonderful.
The next day Rose saw Farmer Joel carrying what seemed to be a
pail of thick, yellow sour cream out of the kitchen.
“What are you going to do with that?” asked Rose. “Are you going
to feed it to the pigs?” For she had often seen sour milk taken to the
pen of the big and little squealers.
“Give this to the pigs? I guess not!” laughed Farmer Joel. “This is
rich, sour cream, and if my sister were here she would churn it into
butter. But as she is gone I’m taking it to my neighbor, Mr. Ecker. His
wife will churn it for me.”
“Oh, couldn’t I churn?” asked Rose. “I’d love to!”
Farmer Joel set the pail of cream down on a chair and rubbed his
chin thoughtfully.
“Churning is hard work,” he said. “Sometimes it’s a long while
before the butter comes. Of course we have a churn, but——”
“Oh, I’ll get Russ to help me and we’ll take turns churning!” cried
Rose. “Please let me.”
And Farmer Joel did. He brought up the dasher churn from the
cellar. Norah scalded it out with hot water, and when it was cool the
sour cream was put in it and the cover made fast. Then Rose took
hold of the handle of the dasher, which was like the handle of a
broom, and moved it up and down through a hole in the cover, as
Farmer Joel told her to.
Chug! Chug! Ker-chug! went the churn dasher, splashing up and
down in the thick, yellow cream. Some of it, in little golden balls,
came up on the handle of the dasher, above the cover.
“That’s butter,” Rose told Mun Bun and Margy, who were watching
her.
Margy put out a chubby finger, got a yellow dab and tasted it.
“’Tisn’t a bit like butter!” she said, disappointedly.
“It will be when it is salted,” her mother told her.
 When Rose grew tired Russ took a turn, and so did Laddie and
Violet, and soon the dasher was so heavy that none of the children
could lift it.
“I guess the butter has come,” said Farmer Joel. “Yes, there it is.
Look!” he added as he took off the cover, and the children saw big
golden yellow lumps floating about in what was now white buttermilk,
for all the cream had been changed into butter.
“How are you going to get it out?” asked Rose.
“I’ll show you,” answered Farmer Joel, who had often watched his
sister do this work. He moved the flat dasher up and down, slowly
turning it the while, and in a minute or two there was gathered on the
top of the dasher all the floating lumps of butter.
These were lifted out and put in a wooden bowl and Norah
“worked out” the buttermilk, leaving, finally, a firm, yellow lump of
butter.
“There you are!” cried Farmer Joel. “When it is salted you may eat
some on your bread for supper.”
And the six little Bunkers did, saying it was the best they had ever
tasted. Daddy Bunker and his wife drank some of the buttermilk left
in the churn after the butter was taken out. But when Russ tasted it
he made a funny face and cried:
“Sour! Ugh! Sour!”
“Of course!” laughed his mother. “Buttermilk is always sour. But it
is good for you, and I like the taste of it.”
“You can have all of mine,” said Russ.
“And I don’t want any, either,” Rose made haste to say.
Thus it was that butter was made, and it came out well except that,
almost at the last minute, Mun Bun took the plug out of the bottom of
the churn and let some of the buttermilk run over the floor. But Norah
soon wiped it up.
The next day Russ decided that he would make a larger mill for his
water wheel in the brook to turn, and Laddie offered to help him. The
two boys went down to the stream with bits of wood, a hammer and
nails, and they were busy for some time. Mrs. Bunker had taken the
other children for a walk in the forest not far away.
While Russ was working at the new mill Laddie piled up stones
and bits of sod on top of the dam already built, to make it higher so
the water back of it would be deeper.
“The deeper the water is and the higher we have the dam,” Russ
explained to Laddie, “the faster the wheel will turn.”
“Yes, it’ll be fine,” agreed Laddie, tugging at a big stone to get it on
top of the dam.
Russ was putting the new play mill in place and was getting ready
to connect it to the water wheel when suddenly he heard a big
splash up at the dam, which he could not see plainly because a bush
was in the way.
“What happened, Laddie?” asked Russ. “Did you drop something
in the water?”
“I—I dropped—my—myself—in!” gasped Laddie. “Oh, Russ, I’m all
the way—in! I—I’m all—the—way—in!”
 CHAPTER XIX
A FIGHT

Russ sprang to his feet, knocking aside the pieces of his mill in
doing so, and rushed around the bush to see what had happened to
Laddie. It was just as the smaller boy had said—he had fallen in the
deepest part of the water back of the dam.
But, after all, it was not very deep, for the brook was a small one.
The water would not have been over Laddie’s head if he stood
upright. But the trouble was that Laddie had slipped as he was about
to lift a heavy stone on top of the dam, and had gone down
sideways.
“I’m coming! I’m coming!” Russ shouted, as he saw Laddie
floundering and struggling in the water.
“I—I guess—blub—blub—glub-ub!” was what Laddie answered.
He started to say that he guessed he could get out by himself,
when his foot slipped on some mud at the bottom of the brook and
his face went under water.
“Oh, Laddie!” cried Russ in alarm.
But he need not have been worried, for Laddie managed to get up
on his feet again, and by this time Russ was beside him, holding out
his hands to his small brother to help him to shore.
“Are you hurt?” Russ asked, as Laddie, gasping for breath and
with water dripping from every part of him, stood on the bank of the
brook.
“No, I—I’m not exactly hurt,” Laddie answered. Then he smiled
and said: “But I’m awful wet!”
“I should say you were! And muddy, too!” chuckled Russ. “It’s a
good thing you had your old clothes on. I guess mother won’t scold
much. She expects us to fall in once or twice. I heard her tell Farmer
Joel that. How did it happen, Laddie?”
“Oh, I guess that stone was too heavy for me. I almost had it
where I wanted it and it began to slip away from me. I made a grab
for it and I slipped and I went down—and in!”
“Yes, you went in all right,” laughed Russ. “Well, come on up to the
house and get on dry things.”
“No,” objected Laddie.
“Why not?” asked his brother. “Are you afraid mother will scold?”
“No, I guess not. But what’s the use of getting dry clothes on when
maybe I’ll get all wet again fixing the dam? As long as I’m wet I might
as well finish the dam, and then we can work the water wheel.”
“Well, maybe that is the best way,” agreed Russ. “It won’t take long
to fix the dam now, and you might fall in again.”
And Laddie did. Once more, as he was lifting a stone to the top of
the dam, he slipped and fell in, but this time he only laughed and
kept right on working. And when the dam was finally built higher, so
that more water poured over to turn the wheel, Laddie went to the
house and put on dry clothes.
His mother, who had come back from the woods, did not scold him
when he told her what had happened, but she made him wash the
mud from his clothes and hang them out to dry, since she said it was
only right that he should do this to save Norah work.
Laddie and Russ had much fun playing at the water wheel and
with the new and larger mill. Rose and the other children went to
look at the splashing mill wheel and thought it very fine indeed.
“If I see that boy sneaking around here, and if he throws stones at
your mill, shall I drive him off?” asked Mun Bun.
“What boy?” Russ wanted to know.
“That peddler boy who took Rose’s strawberry shortcake,” Mun
Bun replied.
 “Why, have you seen him again?” asked Mrs. Bunker, in surprise.
“Yes, I saw him going along the road yesterday,” Mun Bun said.
“But he didn’t come in and try to sell any shoe laces.”
“He’d better not come around here again!” declared Russ, with
flashing eyes as he clenched his fists. “If he comes I—I’ll hit him!”
“You mustn’t fight, Russ,” his mother said. “But I hardly believe it is
the same boy. He wouldn’t stay around here after being so bold as to
take Rose’s shortcake the way he did. It must have been some other
peddler, Mun Bun.”
“No, it was the same one,” insisted the little fellow, and later they
found out that he was right.
Two days after this a little girl who lived down the road from
Farmer Joel’s house invited Rose, Violet, and Margy to come to a
party.
“It’s funny she didn’t invite us,” said Russ.
“She isn’t going to have any boys this time,” Rose explained. “But
maybe she will next time, and then you can go.”
“Maybe next time we won’t want to!” answered Russ. “Anyhow,
we’re going fishing now. Come on, Laddie!”
“All right,” agreed the other. “Fishing is more fun, anyhow, than
parties.”
“Can I come fishing?” asked Mun Bun.
As Russ and Laddie promised to look after him, Mun Bun’s mother
allowed the little fellow to go with the other two boys. There was a
small stream, larger than the brook, about half a mile away across
Farmer Joel’s fields, and toward that place Russ, Laddie, and Mun
Bun went in the afternoon.
“Now be careful, Russ, that your brothers don’t fall in and don’t let
them get fish hooks in their hands,” warned Mr. Bunker, for, to his
delight, Mun Bun was allowed to fish with a real hook and not with a
bent pin, with which he never had any luck. This was to be a real
fishing party.
 “I’ll take care of them,” promised Russ.
Away went the boys over the fields toward the little river, Russ
merrily whistling. On a shady, grassy bank, under a big buttonwood
tree, the boys sat down and cast their baited hooks into the deep
water of an eddy, where, in the quiet pool, there were said to be
large fish.
Presently the cork on the line attached to Russ’s pole began to
bob up and down. Then it went under water.
“You have a bite, Russ!” excitedly called Laddie.
“I know I have! Keep still or you’ll scare it away!”
Russ waited a moment longer. The cork went away under.
“Now I have him!” cried Russ.
He pulled up his line. On the hook was a good-sized fish which
Russ landed back of him on the grass.
“Oh, I wish I could get one!” sighed Laddie enviously.
“Look at my cork! Look!” suddenly cried Mun Bun.
“He’s got a bite, too!” cried Laddie. “Pull in, Mun Bun! Pull in! I’ll
help you!”
Laddie pulled out the little fellow’s line, and, surely enough, Mun
Bun had caught a fish, not as large as the one Russ had landed, but
still Mun Bun was much delighted.
“I wonder if I’ll get one?” sighed Laddie.
He did a little later. Then Russ caught a second one, and after a
while Laddie said he would go farther downstream to another “hole”
he knew of.
“The fish are biting good to-day,” Russ said, as he baited his hook
and threw it in again.
A little later a shadow fell on the grass behind Russ and Mun Bun.
Russ turned around and saw—that ugly peddler boy who had taken
the shortcake Rose had baked!
 “Huh!” sneered the peddler, as he walked up with a pole in his
hands. “What right you fellows got to fish here?”
“This is Farmer Joel’s land, and we’re staying at his house,” said
Russ. “Course we have a right to fish here!”
“You have not!” cried the peddler. “And you’d better get away
before I make you. I’ll punch you—that’s what I’ll do!”
Russ leaped to his feet and started toward the peddler lad, who
was larger than Russ.
“Oh! Oh!” cried Mun Bun.
Then suddenly the peddler drew back his fist and struck Russ,
knocking him down.
 CHAPTER XX
YELLOW AND WHITE

Mun Bun felt like bursting into tears. To see his beloved big
brother, Russ, knocked down in this fashion was enough to make
any small boy cry. It was almost like the time when Russ was so
nearly run over by the truck.
But suddenly it came to Mun Bun that he must be brave. If Russ
were badly hurt Mun Bun must do something about it—just what, of
course, Mun Bun did not know. But he felt he must not cry.
So he “squeezed back” the tears, as he said later, and then he did
what perhaps was not just right, but what, I think, most children
would have done had the boy who started the fight been a big boy,
as was the peddler lad.
Mun Bun caught up a stone and threw it at the peddler boy.
“You let my brother alone!” cried Mun Bun angrily. “I’ll throw
another stone at you if you don’t. And I’ll call my father! I’ll go get my
father now—and Farmer Joel and Adam! That’s what I’ll do!”
Usually Mun Bun was not a very straight shot with a stone or a
baseball. Generally, when Mun Bun threw, Russ would laugh and
say the safest place was right in front of the little fellow. For Mun Bun
seldom hit the thing he aimed at.
However, this time, as luck would have it, the stone he threw
struck the peddler boy on the shoulder. And then the peddler boy ran
away, leaving Russ lying there. I think the peddler boy ran more
because of what Mun Bun said about Mr. Bunker being called than
because of the stone, for it was a small one and could not have hurt
him much.
“There! He’s gone, Russ!” cried Mun Bun, as he ran to his brother.
“You needn’t be ’fraid any more!”
 “Pooh! I’m not afraid!” boasted Russ, as he arose. He had been
stunned by the blow and the fall, and really was not much hurt. “I
was going to get up and punch him,” went on Russ. “He hit me too
sudden, or he wouldn’t have knocked me down. I was just getting up
to hit him.”
“He ran away. I made him run!” cried Mun Bun. “I hit him with a
stone and he ran away!”
“Good for you!” exclaimed Russ, and then Laddie came back from
down the stream where he had gone to fish.
“What’s the matter?” asked Laddie.
“Oh, that mean peddler boy was around again,” said Russ. “He hit
me and knocked me down. He hit me before I had a chance to fight
him.”
Laddie dropped his pole and line.
“Where is he?” cried the little fellow. “I’ll fix him!”
“Mun Bun fixed him,” chuckled Russ, telling what had happened.
“I wonder what’s the matter with that fellow, anyhow?” asked
Laddie, when he had looked around among the bushes and made
sure the ugly peddler chap was not to be seen. “What’s the matter
with him, stealing things and knocking folks down?”
“I don’t know,” answered Russ, with a shake of his head. “That’s
like one of your riddles, Laddie, only it isn’t so easy to answer. He
didn’t have any good reason for hitting me.”
“We’ll tell Farmer Joel on him,” said Mun Bun.
And this was done when the boys went back to the house after
each catching a few more fish. They really did very well, and Mrs.
Bunker said they had enough for what Norah called a “mess,”
meaning enough to cook so all would have some to eat.
“That boy is a rascal,” said Farmer Joel, when he heard what had
happened. “I’ll tell the constable about him, and if he finds out where
the peddler is staying I’ll have him arrested.”
 “And if I find him,” threatened Adam North, “I’ll set him out among
the beehives and let him get stung three or four times. That will cure
him of wanting to knock people down.”
“Speaking of bees,” said Mr. Bunker to Farmer Joel, “did you ever
find that swarm that got away?”
“No, I didn’t,” answered Farmer Joel. “But I wish I could, for that
was a valuable queen. I guess they’re somewhere in the woods, but
I’m afraid I’ll never get them back.”
Russ had a little bruise on his chin where the peddler boy had
struck him, and Mother Bunker bathed the sore spot with witch
hazel, which made it feel better.
Aside from this little happening and small accidents that occurred
from day to day, the six little Bunkers had wonderfully good times at
Farmer Joel’s. They played all day long out of doors when it did not
rain, and when it showered there was the big barn.
As the summer passed many good things to eat ripened on the
trees in the farmer’s orchard. There were apples, plums, peaches,
and pears, and Mrs. Bunker had a hard time to keep the children
from eating so much fruit that it would make them ill.
One day they were all out in the orchard helping gather the apples.
Farmer Joel, Adam, another hired man and Mr. Bunker were picking
the apples and packing them in boxes and baskets to be sent away.
Care was used in picking the apples not to let them fall, for if they
were bruised they soon rotted. Apples that fell to the ground were not
packed and shipped away with the best fruit. Farmer Joel was very
particular with his apples.
I said the six little Bunkers were helping pick the apples, but of
course the four smaller ones could not do much more than pick up
those that fell to the ground when the tree was shaken by the men
climbing up in it. To their great delight, Russ and Rose were allowed
to climb up some of the low trees.
Mun Bun was running about in the orchard, laughing and having a
good time, when he suddenly gave a howl, calling:
 “Oh, that boy hit me! That peddler boy hit me on the head with a
stone! Look out for the peddler boy!”
“What’s that?” cried Farmer Joel. “Is that rascal here?”
Mun Bun sat down on the ground, and this time he cried real tears.
“That boy hit me on the head with a stone!” he sobbed.
For a time there was some excitement, the men coming down out
of the trees to look for the peddler boy. But a moment later along
came Ralph Watson from the next farm, and with him was his dog
Jimsie.
“Did you see anything of a peddler boy?” Ralph was asked.
“No,” he answered.
“I don’t believe Mun Bun was hit by a stone at all!” suddenly
exclaimed Mrs. Bunker, looking at Mun Bun’s head. “I don’t believe
that peddler boy has been here, either.”
“But something hit me, Mother!” insisted Mun Bun.
“Yes, but it was an apple falling from one of the trees,” his mother
said. “Look, here is an apple leaf in your hair, Mun Bun. It was an
apple that hit you.”
And, surely enough, when they looked, there on the ground beside
Mun Bun was an apple. They were more sure it was a bit of fruit that
had hit him a moment or two lately for suddenly Jimsie, the dog, let
out a howl, and they all saw an apple fall and hit the dog on the
head.
This made Mun Bun laugh, and he said:
“Jimsie got hit just like me, didn’t he?”
“And he howled pretty nearly as loudly,” chuckled Russ.
“Perhaps I’d better take the smaller children in from the orchard,”
said Mrs. Bunker, after a while. “A lot of apples are falling, and some
are so large and hard that little heads might be hurt.”
“I think it’s as well,” agreed Mr. Bunker.
 “You may gather the eggs, if you wish,” said Farmer Joel. “It’s
about time.”
“Oh, that’ll be fun!” cried Violet.
“An’ I want a basket all by myself!” insisted Margy.
“So do I,” said Mun Bun, forgetting all about being hit by a falling
apple.
So off to the barn went Mrs. Bunker, with Margy and Mun Bun,
Laddie and Violet, while Russ, Rose, and Ralph remained in the
orchard to help pick the apples.
Most of the hens laid in nests in the big hen-house built for them,
but there were some of the chickens that “stole their nests,” as
Farmer Joel said, going in the barn, or even under it.
The children had been around long enough now to know where
most of these hidden nests were, and they scattered and began
looking for the eggs.
Mrs. Bunker had the basket with the most of the eggs in, for she
did not dare trust them to the children. She was coming out of the
hen-house with Laddie and Violet when Mun Bun, who had gone into
the barn with Margy, came running up to his mother.
“Oh! Oh!” cried the little fellow. “You ought to see her!”
“See whom?” asked Mrs. Bunker.
“Margy!” gasped Mun Bun. “She’s all yellow and white!”
 CHAPTER XXI
A MAD BULL

Violet almost dropped her basket of eggs, she was so excited.

“Oh! Oh!” she cried. “Maybe Margy’s getting the chicken pox or
something like that. All yellow and white! Oh, dear!”
“It isn’t chicken pox,” said Mrs. Bunker, trying not to laugh.
“Though I think it has something to do with chickens—and eggs. You
say Margy is all yellow and white, Mun Bun?” she asked.
“Yes’m, but the yellow shows most. It’s all over her face and her
dress——”
“The poor thing!” murmured Violet.
“I’ll go and help her,” offered Laddie, not stopping to make a riddle
this time, though he said later that he had one about a chicken and
an egg if he could only think of it.
“She’s right around here—under the barn,” went on Mun Bun,
leading the way from the hen-house.
“Under the barn?” asked Mrs. Bunker. “Is she caught fast there?”
“No, Mother,” replied Mun Bun. “She’s just all whites and yellows.
She crawled under the barn to get some eggs, and when she came
out with ’em in her dress, why—now—she—she slipped and she fell
down and—and—the eggs all busted and——”
“There she is now!” interrupted Violet, as they came within sight of
the unfortunate Margy. Well might Violet murmur: “Poor dear!”
Margy seemed covered with the whites and yellows of broken
eggs from her head to her feet. And, as Mun Bun said, the “yellow
showed the most.”
“Oh, you poor child!” exclaimed Mrs. Bunker, trying not to laugh.
“Come to the house and I’ll wash you clean. Poor Margy! Never
mind, dear!” for Margy was crying.
“I—I didn’t—mean—to break the—the—eggs!” she sobbed. “You
s’pose Farmer Joel—you s’pose he’ll be very mad?”
“Of course not!” Mrs. Bunker hastened to say. “He doesn’t mind a
few eggs. The hens will lay more.”
“If she’d had on a rubber apron it would have been all right,” said
Laddie, as they went on toward the house.
“How do you mean?” Violet, as usual, asked a question.
“Why, if Margy had had on a rubber apron the whites and yellows
of the eggs wouldn’t ‘a’ soaked out and she could carry ’em to the
kitchen and Norah could make a cake. She says broken eggs are
just as good for cakes as other eggs.”
“Yes,” agreed Violet. “’Cause you have to break eggs, anyhow, to
get them into a cake. But even if Margy had these in a rubber apron,
there’d be a lot of shells.”
“That’s so,” agreed Laddie. “I guess even a rubber apron wouldn’t
be much good. The best way is not to break eggs. Now I’m going to
make a riddle about them.” And he did. He himself said afterward it
wasn’t a very good riddle. Laddie would ask:
“How can you get an egg out of the shell without breaking it?”
And after every one had given up he would answer:
“You can’t.”
Sometimes Laddie made up better riddles than that.
Margy was washed and a clean dress was put on her, and by this
time the men and Russ and Rose came in from the apple orchard
and it was almost time for supper.
Norah had cooked a good meal, and it was well that she had, for
every one had a hearty appetite. Working in the apple orchard and
gathering eggs made them all hungry.
It was several days after this that, when Mrs. Bunker was taking
the four smaller children for a walk through the fields, a distant
rumbling sound was heard.
“Is that thunder?” asked Violet, looking toward the sky.
“I think not,” her mother answered. “If it is, the storm is a distant
one and will not break until we get home.”
“It isn’t thunder,” announced Laddie, after the rumbling sound was
heard again.
“What is it?” Mun Bun wanted to know.
“It’s Farmer Joel’s bull,” said Laddie. “I can see him down in that
field,” and he pointed to a distant pasture in which, all alone, was the
big bull, roaming around, pawing the ground, shaking his head, and
now and then uttering the low, rumbling bellow, which sounded like
distant thunder.
“Oh, so it is the bull,” remarked Mrs. Bunker, when, from a distant
hill, they had watched the powerful animal running about.
“I hope the fence is good and strong so he can’t get loose,” said
Violet.
“I guess Farmer Joel wouldn’t turn the bull into a field unless the
fence was good and strong,” replied Mrs. Bunker.
“Mother, what would we do if the bull got loose and chased us?”
Margy asked.
“The best thing to do, I suppose,” said Mother Bunker, “would be
to run and get on the other side of a strong fence, if it could be done.
Or climb a tree. Bulls can’t go up trees.”
“But after you got up into the tree he might hit the tree with his
head and knock you out and hook you, mightn’t he?” asked Violet.
“Well, he might,” replied her mother. “Perhaps it would be best not
to go anywhere near the bull. But if he should come after you—run
away somewhere or get behind a fence or something.”
“He’s terrible strong, isn’t he?” observed Mun Bun, as he watched
the bull hitting his head against the fence as if trying to knock it over.
 “He is, indeed. Bulls are very strong,” said his mother. “I should
think Farmer Joel would be afraid this one would knock the fence
down. But perhaps it is all right.”
However, the fence was not all right, or else the bull was stronger
than was supposed, for a few days later something very alarming
took place.
Russ and Rose had been left in charge of the four smaller Bunkers
while their father and mother went visiting a distant farmer whom Mr.
Bunker had known some years before.
“Let’s go down and look at the water wheel,” suggested Russ, for
Laddie, Violet, Mun Bun and Margy never seemed to tire of this.
“Will that old peddler boy come and hit you again?” Mun Bun
wanted to know.
“No, I guess he’s gone away,” answered Russ.
Down to the brook they went, a merry, happy group of children.
They threw stones into the water, set little bits of wood afloat,
pretending they were boats, and had a good time watching the
splashing water wheel.
Suddenly Laddie, who had wandered off a little way to gather
some brown cattails growing in a swampy place, came running back,
fear showing on his face.
“He—he’s coming!” gasped Laddie.
“Who? That peddler boy?” demanded Russ, clenching his fists.
“No! The mad bull! He’s coming! Look out!” shouted Laddie.