1. Chapter 27 Family Development and Family Nursing Assessment

2. Objectives
Explain the multiple ways public health nurses work with families and communities.
Identify barriers to family nursing.
Describe family function and structure.
Describe family demographic trends and demographic changes that affect the health of families.
Compare and contrast four social science theoretical frameworks nurses use when working with the family.

3. Objectives, Cont’d Assess family needs to develop family action plans.
Discuss implications for social and family policy.

4. Definition of Family Family nursing
No universal agreement on definition of family
Definition used by family system and family nurses:
Family refers to two or more individuals who depend on one another for emotional, physical, and/or financial support. The members of the family are self-defined.
Family nursing is a philosophy and a science that is based on the following assumptions: health and illness are family events; what affects one family member affects the whole family; and health care practices, decisions, and behaviors are made within the context of the family.

5. Communication Difficulties
Lack of communication between health care systems
Incomplete or missing documentation from rushed assessments
Better communication if:
Hours of service matched family members’ schedules
Family member brings companion to office visits
Enhances shared decision making
Improves sharing of information
Improves self management of care
Improves health outcomes

6. Uninsured, Underinsured, and Limited Services
46.6 million Americans without health insurance (2008)
Fastest growing group of uninsured is young adults
Lack of insurance makes finding adequate services for patients and families difficult.

7. Family Functions The ways in which families meet the needs of
Each family member
The family as a whole
Their relationship to society
Family functions:
Economic function
Reproductive function
Socialization function
Affective function
Health care function

8. Family Structures
Refers to the characteristics and demographics (e.g., sex, age, number) of individual members who make up family units
Aspects to address when determining family structure:
The individuals who compose the family
The relationships between them
The interactions between the family members
The interactions with other social systems
Family structures have changed over time to meet the needs of the family and society. The great speed at which changes in family structure, values, and relationships are occurring makes working with families at the beginning of the twenty-first century exciting and challenging.

9. Family Demographics Marriage and Cohabitation
Additional Trends in Marriage
Births
Divorce or Dissolution of Cohabitation
Remarriage
Historically, family demographics can be analyzed by looking at data about the families and household structures and the events that alter these structures. Nurses draw on family demographic data to forecast and predict family community needs, such as family developmental changes, stresses, and ethnic issues affecting family health, as they formulate possible solutions to identified family community problems.
In 2007, in the United States, there were over 11.2 million households, with 67% being family households and the remaining 33% being nonfamily households. Family households include a householder and at least one other member related by birth, marriage, or adoption; whereas a nonfamily household is either a person living alone or a householder who shares the house only with nonrelatives, such as boarders or roommates

10. Marriage and Cohabitation
The probability that Americans will marry by age 40 is more than 80%; but cohabitation has become commonplace with a majority of young people projected to cohabitate at least once.
Reasons for cohabitation
Aging population and cohabitation
Factors affecting duration of marriage/cohabitation
Effects of cohabitation on children
Cohabitation is a couple living together who are having a sexual relationship without being married.

11. Additional Trends in Marriage
Increased age for first marriage
Increased number of interracial marriages
Increase in mother’s age at first birth
Average is 25 years of age rather than 21.4 years of age

12. Births Fertility rates differ by race and ethnicity
Not all cultures value limiting the number of children in a family

13. Divorce or Dissolution of Cohabitation
Divorce can be said to be increasing, declining, or remaining stable, depending on the time referent.
In 2001, the median length of a marriage for a divorcing couple was 8 years.
Effects on the divorced family:
Diminishment of the father’s role in the family
Negative impact on the children
Emotional problems for a number of persons involved
Reduced living standard
Divorce rates in the 1970s and into the mid-1980s climbed to 5.0/1000; but around 1985 through 2000 they began to decline to 4.0/1000 (U.S. Census Bureau, 2005).

14. Remarriage
1970s: Divorce replaced bereavement as leading cause of remarriage.
More than 50% of divorced people remarry.
Person who initiated divorce more likely to remarry
Blended families and issues of childcare

15. Family Health
A dynamic relative state of well-being that includes the biological, psychological, spiritual, sociological, and cultural factors of the family system
Holistic approach
Dysfunctional families
Family flexibility
Family cohesion
A popular term for nonhealthy families is dysfunctional families, also called non-compliant, resistant, or unmotivated—phrases that label families that are not functioning well with each other or in the world.
Families are neither all good nor all bad; rather, all families have both strengths and difficulties. All families have seeds of resilience and strengths upon which the nurse should work with the family to build interventions and design plans of action. Nurses should view family behavior on a continuum of need for intervention.
Families with strengths, functional families, and balanced families are terms often used to refer to healthy families that are doing well.

16. Four Approaches to Family Nursing
Family as context
Family as patient
Family as a system
Family as a component of society

17. Theories for Working with Families in the Community
Family systems theory
Family development and life cycle theory
Bioecological systems theory

18. Working with Families for Healthy Outcomes
Plan for Family Assessment
Pre-encounter Data Collection
Determine Where To Meet
Making an Appointment
Planning Your Own Safety
Interviewing the Family
Assessment Instruments
Family Health Literacy
Designing Family Interventions
Evaluation Of The Plan

19. Plan for Family Assessment
Why are you seeing the family?
Are there any specific family concerns that have been identified by other sources?
Is there a need for an interpreter?
Who will be present during the interview?
Where will you see the family and how will the space be arranged?
What are you going to be assessing?
How are you going to collect the data?
What services to you anticipate the family will need?
What are the insurance sources for the family?
Assessment of families requires an organized plan before you see the family.

20. Pre-encounter Data Collection
Begins when an actual or potential problem is identified by a source, which may be the family, the physician, a school nurse, or a caseworker
Pre-encounter data:
Referral source
Family
Previous records

21. Determine Where To Meet
Before contacting the family to arrange for the initial appointment, the nurse decides the best place to meet with the family.
Home
Clinic
Office

22. Making an Appointment
Remember that the assessment is reciprocal and the family will be making judgments about you when you call to make the appointment.
Introduce yourself and the purpose for the contact.
Do not apologize for contacting the family. Be clear, direct, and specific about the need for an appointment.
Arrange a time that is convenient for all parties and allows the most family members to be present.
If appropriate, ask whether an interpreter will be needed during the meeting.
Confirm place, time, date, and directions.
Data collection starts immediately upon referral to the nurse. The following are suggestions that will make the process of arranging a meeting with the family easier.

23. Planning Your Own Safety
Leave a schedule at your office.
Plan the visit during safe times of day.
Dress appropriately, little jewelry or money.
Avoid secluded places if you are by yourself.
Obtain an escort; take a co-worker or neighborhood volunteer.
Sit between the patient and the exit.
If you feel unsafe, do not visit or leave immediately.
Check in with your work at the end of the day.
It is critical to plan for your own safety when you make a home visit. Learn about the neighborhood you will be visiting, anticipate needs you may have, and determine if it is safe for you to make the home visit alone or if you need to arrange to have a security person with you during the visit. Always have your cell phone fully charged and readily available. In addition, the following strategies will help to ensure your own safety when you visit families in their homes.

24. Interviewing the Family
Start with informal conversation.
Involve each family member in the conversation.
Shift to formal interview by asking the family to share their story about the current situation.
Purpose of the interview is to gather information and help the family focus on their problem and determine solutions.
Spending some initial time on informal conversation helps put the family at ease, allows them time to assess the person/nurse, and disperses some of the tension surrounding the visit.

25. Interviewing the Family, Cont. Therapeutic Questions
What is the greatest challenge facing your family now?
On which family member do you think the illness has the most impact?
Who is suffering the most?
What has been most and least helpful to you in similar situations?
If there is one question you could have answered now, what would that be?
How can I best help you and your family?
What are your needs/wishes for assistance now?
Box 27-4 lists a variety of additional interview questions that will help uncover the family story.

26. Assessment Instruments
Assessment tool should:
Be written in uncomplicated language at a fifth-grade level
Only take 10 to 15 minutes to complete
Be relatively easy and quick to score
Offer valid data on which to base decisions
Be sensitive to gender, race, social class, and ethnic background
Genograms
Ecomaps

27. Family Health Literacy
Functional health literacy
Use following techniques:
Use black ink on white paper
Use short sentences
Use bullets no longer than seven items
Information should be written at the fifth-grade level
Remove all extra words
Print in upper- and lowercase letters
If using a computer, use 14-point font with high contrasting Arial or Sans Serif print
Have plenty of white space
Rather than spend time determining the extent of the health literacy in a family, it is most important that nurses employ the following techniques when writing out plans of care, listing directions, discussing medication management or writing telephone numbers.
Families retain more information when nurses use a variety of communication methods, including both visual materials and visual language. Families need direct clear information to assist in their decision making and carrying out the plans of action.

28. Designing Family Interventions
We need the following type of help.
We need the following information.
We need the following supplies.
We need to involve or tell the following people.
To make our family action plan happen, we need to…
(List five things in the order they need to have happen.)
The following action plan approach helps focus the family on things they can immediately do to help address the problem.

29. Evaluation of the Plan Determine whether:
The plan is working
The plan is working fast enough to address the problem
The plan is addressing only part of the problem
The plan needs to be revised based on changes
If plan is not working, nurse and family work together to determine the barriers interfering with the plan

30. Barriers in Family Nursing
Family-related:
Family apathy
Family indecision
Nurse-related:
Nurse-imposed ideas
Negative labeling
Overlooking family strengths
Neglecting cultural or gender implications

31. Social and Family Policy Challenges
Social policy
Health care access and coverage, low-income housing, social security, welfare, food stamps, pension plans, affirmative action, and education
Family Medical Leave (1993)
Debate as to what constitutes a family
Teen pregnancy prevention
Health care insurance
Affordable Health Care Act (2010)