Community as the client

Mosby items and derived items © 2005, 2001 by Mosby, Inc. Two ways that nurses identify families (by Gilliss (1993)) family as contex: individuals are assessed, the emphasis is on the individual family as a client: family is treated as a set of interacting parts and assessment of the dynamics among these parts is emphasized

The legal definition emphasizes relationships through blood ties, adoption, guardianship, or marriage. The biological definition focuses on perpetuating the species. Sociologists define the family as a group of people living together. Psychologists define it as a group with strong emotional ties. Traditional definitions usually include a legally married woman and man with their children.

Family is a group of two or more persons related by birth, marriage, or adoption and residing together. the U.S. Bureau of the Census (2000)

Definitions of family The family, despite its changing and increasingly diverse nature, remains the basic social unit. The word "family" refers to two or more persons who are related in any way— biologically, legally, or emotionally. Patients and families define their families.

Nursing theories for understanding families Neuman's System Theory (1983): –The family is described as an appropriate target for both assessment and nursing interventions. The way each member expresses self influences the whole and creates the basic structure of the family. –The major goal of the nurse is to help keep the structure stable within its environment.

Nursing theories for understanding families Roy's Adaptation Theory (1983): –The client is an individual, family, group, or community in constant interaction with a changing environment. The family system is continually changing and attempting to adapt. –The goal of nursing is to promote adaptation and minimize ineffective responses.

Social Sciences Theories for understanding families Structural-Functional Theory: –The family is viewed as part of the social system, with individuals being parts of the family system. –The family, as a social system, performs functions that serve both the individual and society. –Individuals act in accordance with a set of internalized norms and values that are learned primarily in the family through socialization.

Five functions of the family important to understand: Affective Socialization and social placement ReproductiveEconomic Health care

Social Sciences Theories for understanding families Duvall’s developmental or life-cycle theory (1977): –Families experience growth and development in much the same way as individuals. –Critical role transitions of individual members, such as birth, retirement, and death of a spouse, are viewed as resulting in a distinct change in the family life patterns. –Families develop and change over time in predictable ways. –Families and their members perform certain timespecific tasks that are decided upon by themselves, within their cultural and societal context. –Family behavior is the sum of the previous experiences of its members as incorporated in the present and in their expectations for the future.

8 Duvall's Developmental Stages Beginning family Childbearing family Families with preschool children Families with school-aged children Families with teenagers Families launching young adults Middle-aged parents Families in later years

FAMILY ASSESSMENT is the process of collecting data about the family structure, and the relationships and interactions among individual members. It is a continuous process. It’s aim is to generate Nursing diagnoses with goals and interventions for care created in collaboration with the child and caregivers.

Assessment Instruments A genogram is a format for drawing a family tree that records information about family members and their relationships over a period of time, usually three generations. An ecomap is a visual representation of a family in relation to the community. It demonstrates the nature and quality of family relationships and what kinds of resources or energies are going in and out of the family.

Genogram

Ecomap

In-depth Family Assessment Calgary Family Assessment Model (Wright & Leahey, 1994):  Gather information about family structure, development and functioning. Friedman Family Assessment Model (Friedman, 1998):  consists of six broad categories of interview questions.

FAMILY STRUCTURE The nuclear family is defined as a husband, wife, and their children—biological, adopted, or both (Friedman, 1998) The extended family consists of those members of the nuclear family and other blood-related persons such as grandparents, aunts, uncles, and cousins. A blended or stepfamily occurs when a divorced, widowed, or never-married single parent forms a household with a new partner; both partners or only one may have children.

FAMILY STRUCTURE Single parent family occurs by means of divorce, separation, death of a spouse, or choice. 90% of them are comprised of single mothers and their children. Gay and lesbian families are increasing in numbers. Because homosexuality is stigmatized in our society, many of these parents are not open about their sexual orientation.

Working with Gay and Lesbian Families When working with families, do not assume that all parents are heterosexual. In obtaining the family history, the following questions may be asked: –(1) Who makes up your family? –(2) Do you have a partner? –(3) Do you share parenting responsibilities with anyone else? –(4) Who else is responsible for the child's care if you are not available?

Approaches to analyzing data about families Systems theory –Includes structural and functional components of the family as a system –Structural Family Assessment: considers family’s composition; roles and relationships –Functional Family Assessment: nurse collects info re: how well family is fulfilling basic functions in the context of continual change in the system as information and energy are exchanged between the family and the environment

Approaches to data analysis continued Developmental theory –Approaches family from tasks and stages of progression through its life cycle and tasks that need to be accomplished –The stages of family development are used as a guide to categorize and analyze the baseline data Risk factor assessment –Identify family’s risk factors based on Healthy People 2010 criteria

The Family from a Risk Factor Perspective In the risk factor theory, the family is the most important social support system involved in lowering risks for its members Risk factors can be estimated for death or diseases by comparing a group that has been exposed to a risk factor with a group that hasn’t been exposed to the risk factor, and comparing rates of death or disease in the two groups

Risk & families continued Probabilities of risk change throughout the life cycle The stages of family development are used to classify risk factors Many chronic health problems are related to behavioral excesses that are learned through the family

Developmental Assessment Four steps: 1. Determine family’s developmental stage 2. Consider family member’s health problems in context of tasks of their developmental stage 3. Determine if family members are meeting the tasks at their individual levels of development 4. Identify nursing interventions that would facilitate family meeting their developmental tasks

Limitations of the Developmental Assessment Approach Changing demographics, variations in family structures (not all families fit neatly into stages) Nurse’s viewpoint has to take structure into account, thus, assessment becomes more complicated Family conflicts cause difficulty, compounded by individuals’ role disruption from illness

Structural Family Assessment Considers composition of family Can be very helpful to nurse in many situations May be a good assessment to start with

Functional Family Assessment Six family functions: 1.Affective 2.Healthcare and physical necessities 3.Economics 4.Reproduction 5.Socialization and placement 6.Family coping

Characteristics of Healthy Families There is a facilitative process of interaction among family members The family enhances the development of its individual members Role relationships are structured effectively The family actively attempts to cope with problems The family has a healthy home environment and lifestyle The family establishes regular links with the broader community

Characteristics of Healthy Family Interactions Communication among members is open, direct, and honest, with shared feelings Family members express self-worth with integrity, responsibility, compassion, and love to, and for, one another All members know the family rules. Rules are clear and flexible and allow individual members their freedom The family has regular links with society, which demonstrate trust and friendship Family members belong to various groups and clubs

Nursing Process The purpose of writing a family nursing diagnosis is to help the family promote health through the life cycle and prevent disease through low-risk-taking behaviors In planning phase, delineate expected outcomes for family health; Use mutual goal-setting with family  Process of collaborative goal-setting should have positive influence on nurse’s interactions with families  Also facilitates adherence to agreed-upon plan of care  Remember: Assessment is a two-way enterprise; the family is assessing you, as well

Examples of Family Nursing Diagnosis Theoretical Model Model Stage Stage Health Health Status Status Pattern Pattern Problem Problem Developmental Family with Preschoolers Potential for physical injury Health-Perception-HealthManagement Medications & poisonous cleaning substances within reach of children Family with adolescentsPotential alteration in parentingRoles-relationshipspattern Value systems of Parents & adolescent members in conflict Risk Factors Young couple Compromised & ineffectiveCoping-stress- tolerance pattern Teenage marriage Pregnancy before age 16 From: C. Edelman & C. Mandle (2002) Health promotion throughout the lifespan. St. Louis: Mosby.

Steps in the Planning Process 1. Prioritize problems & potential problems 2. Determine which items can be handled by the nurse and the family, and items that must be referred to others 3. Decide on actions and expected outcomes

Goals Goals describe a desired outcome Goal statements include: –The expected behaviors of the family –The circumstances under which the behaviors will be demonstrated –Criteria by which to determine when and how the behaviors will be performed Health promotion goals reflect a desire to function at a higher level of health and to grow beyond maintaining health or preventing disease Health promotion goals reflect a desire to function at a higher level of health and to grow beyond maintaining health or preventing disease

Implementation With The Family Family nursing interventions aim to assist family members in carrying out functions that the members cannot perform for themselves –Health promotion: the nurse assists the family in improving their capacity to act on its own behalf Three Broad Categories of Interventions with Families –Cognitive interventions –Affective interventions –Behavioral interventions

Four Types of Interventions are Found in Health Promotion/Disease Prevention Increasing knowledge and skills Increasing strengths Decreasing Exposure Decreasing susceptibility

Evaluation With The Family Purpose of evaluation is to determine how the family has responded to the planned interventions. Concrete objectives are easier to measure Family’s baseline data needs to be used as comparative criteria in evaluation Five measures of family functioning that can be used to determine effectiveness of interventions 1.Changes in interaction patterns 2.Effective communication 3.Ability to express emotion 4.Responsiveness to needs of members as individuals 5.Problem-solving ability If goals are not met, review process

Health Promotion/Prevention Strategies as Applied to the Family Primary Prevention Completing a family genogram and assessing health risks with the family to contract for family health activities to prevent diseases from developing Completing a family genogram and assessing health risks with the family to contract for family health activities to prevent diseases from developing Secondary Prevention Using a behavioral health risk survey and identifying the factors leading to obesity in the family Using a behavioral health risk survey and identifying the factors leading to obesity in the family Tertiary Prevention Developing a contract with the family to change nutritional patterns to reduce further complications from obesity Developing a contract with the family to change nutritional patterns to reduce further complications from obesity