Community as the client

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Community as the client
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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

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• 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.

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• 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)

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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 waybiologically, legally,
  or emotionally.
• Patients and families define their families.

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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.

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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.

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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.

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Five functions of the familyimportant to
understand

• Affective
• Socialization and social placement
• Reproductive
• Economic
• Health care

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Social Sciences Theories for understanding
families

• Duvalls 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.

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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

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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.
• Its aim is to generate Nursing diagnoses with
  goals and interventions for care created in
  collaboration with the child and caregivers.

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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.

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Genogram
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Ecomap
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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.

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FAMILY STRUCTURE

• The nuclear family is defined as a husband, wife,
  and their childrenbiological, 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.

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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.

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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?

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Approaches to analyzing data about families

• Systems theory
• Includes structural and functional components of
  the family as a system
• Structural Family Assessment considers familys
  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

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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 familys risk factors based on Healthy
  People 2010 criteria

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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 hasnt
  been exposed to the risk factor, and comparing
  rates of death or disease in the two groups

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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

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Developmental Assessment

• Four steps
• Determine familys developmental stage
• Consider family members health problems in
  context of tasks of their developmental stage
• Determine if family members are meeting the tasks
  at their individual levels of development
• Identify nursing interventions that would
  facilitate family meeting their developmental
  tasks

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Limitations of the Developmental Assessment
Approach

• Changing demographics, variations in family
  structures (not all families fit neatly into
  stages)
• Nurses viewpoint has to take structure into
  account, thus, assessment becomes more
  complicated
• Family conflicts cause difficulty, compounded by
  individuals role disruption from illness

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Structural Family Assessment

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

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Functional Family Assessment

• Six family functions
• Affective
• Healthcare and physical necessities
• Economics
• Reproduction
• Socialization and placement
• Family coping

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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

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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

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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 nurses 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

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

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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

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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

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Four Types of Interventions are Found in Health
Promotion/Disease Prevention

• Increasing knowledge and skills
• Increasing strengths
• Decreasing Exposure
• Decreasing susceptibility

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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
• Familys 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
• Changes in interaction patterns
• Effective communication
• Ability to express emotion
• Responsiveness to needs of members as individuals
• Problem-solving ability
• If goals are not met, review process

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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
• Secondary Prevention
• 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