Family & Societal Nursing

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Family-Focused Nursing Actions Sandra K. Eggenberger ● Wendy Looman

C H A P T E R 14

C H A P T E R O B J E C T I V E S

1. Explain core processes from nursing and family perspectives. 2. Describe relationships among family, family context, core processes, and family-focused nursing

practices. 3. Discuss ways core processes are linked to health. 4. Identify ways nurses can use core processes to design nursing actions. 5. Describe family-focused nursing actions that lead to quality care outcomes.

C H A P T E R C O N C E P T S

● Caregiving ● Cathexis ● Celebration ● Change ● Communication

● Connection ● Coordination ● Core processes ● Family meetings ● Nursing actions

Introduction

In family-focused nursing practice, care involves intentional actions, family partnerships, and thinking family. Although actions are often specifically targeted to fulfill individual needs, they aim to optimize family health. Family nursing is holistic care for family units regardless of the nursing action being implemented. The Family Health Model (Denham, 2003) describes core family processes as part of the functional domain. Core processes attend to ways family members interact; they are potential areas of strengths. These processes are also linked with wellness, health, prevention, illness, care management, and other related needs. The seven core family processes—communication, caregiving, cathexis, celebration, change, connectedness, and coordination—are used to guide assess- ment, nursing actions, and outcome evaluation. Core processes are central to individual and family health.

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Denham, Sharon, et al. Family Focused Nursing Care, F. A. Davis Company, 2015. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/mnsu/detail.action?docID=1963709. Created from mnsu on 2022-06-26 02:28:20.

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Nurses who think family use the individual-nurse-family partnership to identify goals and plan actions directly linked to safe, therapeutic, and quality care outcomes. Nurses use core family processes to identify strengths, address health concerns, minimize health risks, and maximize health potentials (Denham, 2003) so they can identify and design strategic actions for family unit needs. Nurses who think family know that health and ill- ness can never be separated from the daily lives in shared family households. This chapter describes ways nurses use core processes to empower and support family units as they strive for member and family health. Relevant nursing actions and evidence related to each of the core process are presented.

Family-Focused Nursing Actions

Even when the family is not physically present, the family remains a significant force in the lives of persons seeking health or illness care. Therefore, family nursing actions are critical to all health and illness outcomes. The nurse can still think family even when focusing on individual needs. Individual care is directed toward the family unit because current evidence shows strong links between individual and family health (Kaakinen, Harmon Hanson, & Denham, 2010; Weihs, Fisher, & Baird, 2002). However, more re- search aimed at development, testing, implementing, and evaluating the effectiveness of nursing actions with the family unit is needed (Chesla, 2010).

The Family Health Model focuses on core family processes and provides a framework to plan, guide, and evaluate nursing actions (Denham, 2003). Delivering competent, safe, and quality care demands nursing actions that guide and evaluate progress toward individual and family goals. Action implies doing and influencing (Abate, 2002).

Nursing is a practice discipline and actions must be skillfully completed using relational and scientific elements (Chinn, 2008; Dahnke & Dreher, 2011). Effective family-focused nursing care considers the unique nature, experience, strengths, chal- lenges, and needs of family units (Almasri et al, 2011; Siminoff, Wilson-Genderson, & Baker, 2010). These actions consider the family’s beliefs, values, patterns, functioning, and culture (Kaakinen, Gedaly-Duff, Coehlo, & Harmon Hanson, 2010; Pavlish & Pharris, 2012).

Delivering Family-Focused Nursing Actions

When planning, delivering, and evaluating care, nurses have an obligation to partner with a family about the course of actions to be taken (American Nurses Association, 2001). Several elements of a nursing action need to be considered. First, who is the re- cipient of the nursing action? Is the action aimed specifically toward unique persons or the family unit as a whole? Even in a situation in which the nurse is focused on an individual’s acute care needs, there is still the opportunity to address and meet the needs of multiple household members (Fig. 14.1). Nurses can communicate with ill persons or arrange a family meeting to resolve caregiving decisions. At times the family unit is the direct care recipient, such as when a family is negotiating end-of-life care.

Second, nursing actions address the variable of concern or what can be influenced. What elements of the family’s experience, strengths, and needs are or are not being met? Do the nursing actions aim to increase family communication or ease suffering? Does the action focus on anxiety about caring for an ill or dying member? Communication must be clear and directed at the need.

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Third, consider the setting. Does the nursing action take place in an acute care hospital, a clinic, or the family’s home? What factors need to be addressed in this setting? What coordination needs to occur among care settings with multiple medical providers? Care needs influence the direction of nursing actions and nurses’ skills influence the effectiveness of the care delivered (Nelms & Eggenberger, 2010; Newman, 2008). Does the nurse inten- tionally include the family in care?

Care Models to Guide Nursing Actions

Evidence that family-focused nursing actions can improve health and illness outcomes exists, but family interventions still need to be fully developed and used in nursing prac- tice (Chesla, 2010; Duhamel, 2010). A variety of models that address family nursing actions exist. Earlier in this text (Chapter 7), four particular models to guide nursing practice were discussed: the Illness Beliefs Model, Calgary Family Intervention Model, Family Health System Model, and Family Management Style Framework. The Illness Be- liefs Model focuses on strengthening and facilitating beliefs and challenging constraining ones (Wright & Bell, 2009). The Calgary Family Intervention Model (CFIM) focuses on cognitive, affective, or behavioral domains of family functioning (Wright & Leahey, 2012). The CFIM suggests that interventions to promote, improve, or sustain family functioning should be offered (Wright & Leahey, 2013). The Family Health System (FHS) Model describes family realms of development, interaction, coping, integrity, and health processes, and suggests nursing actions in these areas (Anderson & Tomlinson, 1992). The Family Management Style Framework (FMSF) explains ways families respond to enduring children’s chronic illness by examining the component of definition of the situation, management behaviors, and perceived consequences (Knafl, Deatrick & Havill, 2012).

N ursing Actions Focused on Family C ore Processes

Family interviews are nursing actions that provide nurses with the opportunity to better understand members and household concerns in the initial and ongoing assessments (Nelms & Eggenberger, 2010; Wright & Leahey, 2013). Exploration of family processes during these assessments can be used to intentionally plan tailored interventions that are designed to meet unique family unit needs. Directing nursing care to family processes facilitates a

CHAPTER 14 ● Family-Focused Nursing Actions 377

FIGURE 14 -1 Multiple family members have various needs for nursing care.

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partnership to support family units as goals are set, plans are developed, and actions taken to identify strengths and concerns (Denham, 2003).

Core Family Processes

Core family processes provide ways to approach families and assist them to plan for needed changes. Process implies a course of action, series of changes, and progress (Abate, 2002). Families live their lives differently as they face health problems, manage illnesses, and work to prevent diseases or complications (Rolland & Walsh, 2005). On- going interactions among household members influence well-being and family health (Denham, 2003). If a parent experiences an acute illness it may disrupt prior patterns and roles and may create conflict. Chronic conditions can challenge members’ abilities and stretch their limits. Nurses can assist families in developing plans, understanding re- sponses, planning for the future, and managing needs (Chesla, 2010; Kaakinen et al, 2010; Segrin & Flora, 2011).

Core Processes— A Framew ork for Nursing Actions

Family processes can be disrupted when illness or a crisis strikes, and core processes can help guide assessment and suggest areas for nursing actions that can help (Denham, 2003). Figure 14.2 shows a range of nursing actions that can be used with families; each of these actions may be appropriate in different situations and in support of the various core processes. Figure 14.3 depicts linkages of nursing action, core processes, and targeted care outcomes for family units (Denham, 2003). Figure 14.4 identifies collaborative relation- ships for provision of coordinated care.

Nurses who think family consider the location and type of family household, as well as the neighborhood and community, which can influence planning, implementation, and

378 CHAPTER 14 ● Family-Focused Nursing Actions

Guide

Assessment of Core Processess

Listen

Counsel

Champion

Praise

Demonstrate

Instruct

Advocate

Teach

Assess Explain

Family Nursing Actions

Ce le

br at

io n

C o

n n

e c te

d n

es s

ha ng

e C

aregiving Communication C o

o rd

in a tio

n C

athexis

Nurses assess core processes of indviduals and family units, and then use nursing actions to plan, implement, and evaluate care.

Support

Comfort

Accompany

FIGURE 14 -2 Nursing actions, and core processes.

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CHAPTER 14 ● Family-Focused Nursing Actions 379

Family Health Model (assess needs in

contextual, functional, and structural domains)

Nursing Actions Aimed

at Individual and Family Unit

Care Needs

Core Processes

Individual and Family Unit Care

Outcomes

FIGURE 14 -3 The Family Health Model: family needs and care outcomes.

evaluation of care. Family-focused nursing actions view the core processes of the family sys- tem within the community and societal systems. Although time is not depicted in Figure 14.4, it is considered as its passing means development, social, and political changes that affect care needs. The nurse can use a framework of core family processes to identify family strengths and incorporate these into the plan for care, set goals, and evaluate outcomes. The individual-nurse-family partnership is used to set goals and plan ways to achieve them.

Health Care Professionals

Care Coordination

Health and Illness Care

Services

Individual and Family Members

Community Cont ext

Fam ily-Focused Nurses

FIGURE 14 -4 Nursing actions in care coordination.

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Using Core Processes to Meet Complex Care Needs

Core processes are not discrete; they are connected to the life surrounding the family. Family units have complex interactions with the larger community. Core processes can be used to understand ways particular families respond to life experiences and daily life that affect family health. Nurses who think family know family members live interdependent lives, with shared experiences linked to life outside their household boundaries. Although personality, motivation, genetics, and other factors influence lives, these factors are bound to environmental factors often beyond their control. Family-focused nurses understand that continuity of care reaches beyond the walls of health care settings. Change is certain in families with multiple transitions, but they are still a family. However, the meanings of these transitions to the family must be considered when planning nursing actions. A nurse’s challenge is to help families identify solutions they value and offer support that empowers them to adjust to change and make needed changes in their own world.

Intentional Nursing Actions to Guide Core Family Processes

Core family processes provide ideas about ways family nurses can assist family units to at- tain, maintain, and regain health and manage illness experiences. Nurses act as advocates, guides, coaches, teachers, coordinators, counselors, and evaluators (Hamric, Spross, & Harmon Hanson, 2009; Kaakinen, 2010). Intentional actions are necessary to address care needs. An ecological point of view can guide intentional thinking and acting to address needs in a complex world. Family nurses know that effective actions are singularly focused but must address the complexity that surrounds interactions. Family connections beyond household boundaries and within the community create potential threats and supports. Social and political realms might seem outside the family, yet they may intensify threats and strengthen supports linked with health and illness. An ecological perspective helps one see community linkages, and social networks are windows to risks and strengths. Core processes address broad factors associated with individual and family health.

Nurses who think family use evidence to support actions. Living with illness, maintaining health, or preventing disease are not singular actions, but involve complicated family system interactions with social and institutional networks. As nurses identify health in relationship to the family unit’s past, present, and future, core processes offer a framework for addressing needs. They inform the planning, development, and evaluation of nursing actions that meet a breadth of health and illness experiences across the life span. Table 14.1 lists the core processes suggested by the Family Health Model (Denham, 2003) and provides examples of assessments, actions, and evaluation strategies to be used in nursing practice. Interview questions, family dialogue, and conversations are used during assessment and care. This intentional nursing action invites reflection, relationship development, and inquiry. Use of core processes suggests goals or outcomes to evaluate as care is planned.

Case Introduction

This chapter refers to the Zimanske family, previously introduced in Chapter 11 as a family experiencing chronic illness. The family includes Michael, diagnosed with Schimke immune-osseous dysplasia (SIOD) at age 7, a sibling named Jessica, and parents Theresa and Don. This family experienced an unexpected journey filled with times of uncertainty and struggles. An obscure diagnosis was followed by years of illness and multiple acute exacerbations requiring hospitalization. The family experienced other member illnesses during this time. Throughout this section of the chapter content related to the core process

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CHAPTER 14 ● Family-Focused Nursing Actions 381

TABLE 14 -1 Core Family Process: A ssessment and Family -Focused Nursing A ction

CORE FAMILY FAMILY NURSING FAMILY-FOCUSED PROCESS ASSESSMENT NURSING ACTION EVALUATION

Cathexis

Communication

Caregiving

Create and discuss a family genogram and ecomap with family members.

Explore a family’s emotional connections.

Sample question: Can you tell me how

your family members are linked to each other?

This must be difficult for your family to see your son and brother’s condition constantly deteriorating.

How would you describe your family’s communication about this illness?

In what ways does your family’s communication influence health?

What type of care does your family member require from your family?

Can you describe how your family cares for members?

What is the most difficult part of caring for your family member?

What is the most positive element of caring for your family member?

Discuss the differences in ways family members view health and illness experiences and the influence on the emotional bonds.

Allow time for reflection on family connections (Moules, Thirsk, & Bell, 2006).

Discuss aspects of grief using intergenerational perspectives (O’Leary, Warland, & Parker, 2011).

Explore the ongoing nature of grief.

Arrange a family meeting focused on developing individual understandings about needs and coping of the family unit.

Guide family discussion of family needs.

Explore with the family data collected during creation of the genogram and ecomap.

Identify member roles in providing care for the ill individual.

Describe support needed for family caregiving roles.

Find ways family can access needed resources.

Commend members for strengths in caregiving roles.

Identify priority concerns related to caregiving roles in the family.

K nowledge of family structure, function, and relationships are evident to health care providers.

Family begins to explore their relationships and influence on health promotion, maintenance, and illness care.

Family members express improved comprehension of beliefs about illness, coping, emotions, responses, and communication.

Family members describe communication patterns that support health.

Families set goals for improving communication.

Concerns about priority areas of caregiving identified are resolved.

Family members are building on strengths in caregiving roles.

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382 CHAPTER 14 ● Family-Focused Nursing Actions

TABLE 14 -1 Core Family Process: A ssessment and Family -Focused Nursing A ction— cont’ d

CORE FAMILY FAMILY NURSING FAMILY-FOCUSED PROCESS ASSESSMENT NURSING ACTION EVALUATION

Celebration

Change

Connections

Help family communicate about stress and strain of caregiving.

Identify possible ways family can continue valued family traditions.

Create a list of celebrations that can still occur and note needed modifications.

Consider options for new activities to share in the future.

Identify family beliefs that support healthy changes (Wright & Bell, 2009).

Coach ways to move toward positive health changes (Hamric, Hanson, Tracy, & O’Grady, 2014).

Commend strengths (Wright & Leahey, 2013).

Provide information about local support services or groups.

Discuss ways family can fulfill family roles and responsibilities and still care for self.

Identify ways members can access supports (e.g., church, friends, social networks).

Explore ways the Internet can be used to link with those experiencing a similar condition.

How can I most help you as you care for your ill family member?

Tell me the ways your family enjoys spending time together?

What are times that you enjoy being together?

How does your family usually celebrate a holiday?

What changes do you foresee will need to occur so that your family can enjoy special time together?

Can you describe the most difficult change you and your family will need to make as a result of this chronic illness?

Describe concerns about family routines that will need to change.

Examine social connections in the ecomap developed with the family.

What ways are you involved with the community?

Tell me about your relationships with your health care providers.

How do your social networks provide needed support?

Family’s celebrations, rituals, and routines are viewed as meaningful.

Family activities are viewed as special and valued times.

Family members identify specific steps to making needed changes.

Family members discuss ways conflicts can be negotiated

Arrangements are made for needed changes.

Family members maintain caring relationships that provide needed support.

Individuals have adequate personal time each week.

Respite care is arranged through a network of neighbors and other friends.

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CHAPTER 14 ● Family-Focused Nursing Actions 383

TABLE 14 -1 Core Family Process: A ssessment and Family -Focused Nursing A ction— cont’ d

CORE FAMILY FAMILY NURSING FAMILY-FOCUSED PROCESS ASSESSMENT NURSING ACTION EVALUATION

Coordination Identify available community resources that can support the family.

Provide a list of social agencies where additional care services might be accessed.

Contact health care provider(s) about a referral to social services for needs in the home.

How does your family work together to coordinate care for your family member?

What are the biggest struggles that your family experiences as you try to coordinate available services with needs?

Family members develop a schedule that identifies who will regularly perform various tasks.

The nurses, social worker, and family arrange for needed home services.

will be introduced with quotes from the family providing the opportunity to apply the knowledge. This case illustrates ways nurses can use core processes to facilitate family- ocused nursing actions. The narratives are linked with core family processes to demonstrate family needs and nursing actions.

Cathex is: Core Family Process

Cathexis is “the emotional bond that develops between individuals and family as members invest emotional and psychic energy into loved ones” (Denham, 2003, p 125). This term is a useful way to understand the attachment that develops among family members. Bonds are often expressed as warmth, care, love, and regard—factors that promote family health (Denham, 2003). Childhood attachments continue into adulthood and throughout family life act as driving forces for family functioning and routines (Wood, Klebba, & Miller, 2000). Family members depend on one another for emotional, physical, and economic support (Denham, 2003).

Cathexis refers to family members’ invested efforts in one another as they rely on and care for one another. Decathexis is the disconnecting or disentangling needed when a family member grieves the loss of a close attachment following death or other loss (Denham, 2003; Rando, 1984). Decathexis occurs as those left alone learn to separate their lives from persons or things once essential in life. Grief experts suggest loss is an evolving disconnec- tion from the deceased that allows the family to continue life without a person (Moules, Simonson, Fleiszer, Prins, & Glasgow, 2007; Moules, Simonson, Prins, Angus, & Bell, 2004). Decathexis causes separation and interrupts attachments. Divorce or diseases that affect a member’s proximity and personhood (e.g., Alzheimer’s disease) create needs for decathexis. Cathexis is about strengthening attachments and relationships for the good of individual members and the family unit.

C ath ex is as a Family- Focused N ursing Action

Commitment and attachment are central to family life with bonds developing as members are added to the family unit (Boss, Doherty, LaRossa, Schumm, & Steinmetz, 1993). The nurse can use an understanding of cathexis to support healthy family bonds. For example,

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384 CHAPTER 14 ● Family-Focused Nursing Actions

BOX 14-1

Evidence-Based Family Nursing Practice

Living with advanced lung disease can be a challenging experience for individuals and their family members, an area of care not often addressed in the literature. Treatment often occurs as episodic and isolated events focused on individual needs; rarely is chronic obstructive pulmonary disease (COPD) viewed as a family event. Individual’s symptoms of breathing difficulties, fatigue, malnutrition, anxiety, and depression are likely to increase over time. Costs to families such as caregiver burden and increased care expenditures are reasons this is a serious chronic condition. An outpatient clinic at Landspitali University Hospital in Reykjavik, Iceland, uses a nurse clinic for persons with breathing problems. The focus is on the unmet health care needs of individuals and family members. A holistic approach and collaborative partnership occur between the family unit and health professionals. A nursing partnership framework is used to focus on the entirety of health- related problems to foster possibilities. Through a relational dialogue, areas of family involvement, living with symptoms, and access to health care are addressed. The dialogue allowed meanings to emerge that were then acted upon. Nurses focused on positive regard, building trust, and respect for personal values and ways of being. As all think together, whatever emerges as the concerns becomes the focus of the care. Using both quantitative and qualitative research methods, the number of hospitalizations showed about an 80% decrease. Individuals reported a more satisfactory quality of life and a decrease in symptoms caused by the disease. Families gained greater capacity to manage the disease at home as they better understood the disease and the consequences of actions and gained independence in care decisions. Nurses established trusting relationships that enabled more coherent actions to be taken. Health professionals became more accessible and interactions more meaningful.

Source: Ingadottir, T., & Jonsdottir, H. (2010). Partnership-based nursing practice for people with chronic obstructive pulmonary disease and their families: Influences on health-related quality of life and hospital admissions. J ournal of Clinical Nursing, 1 9 (19/20), 2795–2805. doi:10.1111/j.1365-2702.2010.03303.x

after a child is born, nurses support bonding between parent and newborn and teach skills to care for and protect the baby. Children and adults need similar bonding in their shared lives to influence health. Commitment among family members in particular and across family units varies. An individual’s health affects the family unit and family health affects individual members (Kaakinen et al., 2010). Emotional bonds unite families and strong committed support is a foundation to build upon. These bonds are threatened when dis- ruptions and conflicts occur and during times of stress and illness (Eggenberger & Nelms, 2007; Siminoff et al., 2010). Box 14.1 describes a program of research that addresses the individual-nurse-family partnership.

Nurses can focus on cathexis during transitions and changes surrounding illness, se- vere stress, or death (Moules, Thirsk, & Bell, 2006; O’Leary, Warland, & Parker, 2011). Box 14.2 identifies potential concerns linked with the cathexis process—commitment, loss, grief, chronic sorrow, and ambiguous loss—which are areas for identifying nursing actions. Grief and loss are expected life aspects, but are difficult for most people. Chronic sorrow lacks a predictable end and can occur when living with a disability or an increas- ingly worsening chronic illness. This sorrow occurs with childhood problems and also with older persons’ caregivers (Burke, Eakes, & Hainsworth, 1999; Moules et al., 2007; Zerwekh, 2006). Ambiguous loss occurs with physical or psychological absence or if a body is missing because of a natural disaster (Boss, 2006; Garwick, Detzer, & Boss, 1994). Loss triggers needs for family members to cling together; hence, cathexis or drawing together often needs to occur.

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C ase Study Ap p lication: Family Illness and C ath ex is

Throughout Michael’s chronic illness, the Zimanske family experienced needs and con- cerns linked with cathexis. The family was strongly connected at the time of diagnosis and during illness, but members lived independent lives and a shared journey with chronic illness. Chronic sorrow was a recurring part of their lives each time Michael faced a critical change. As he moved from walking to a scooter to a wheelchair to attend school they faced grief and sorrow. Theresa struggled to keep Michael in school to be with friends and normalize life. Family members had continuous losses as the disease progressed. Life was a roller-coaster with remissions interrupted by exacerbations. Nurs- ing actions to address chronic sorrow would have been useful throughout the illness and even after his death. The Zimanskes lived with the unending nature of the illness, emo- tional pain, and loss over time. Even after Michael’s death, anniversaries were reminders of hopes and dreams unfulfilled. Some families bond more closely together as they share experiences known only to them. Sometimes conflicts and internal stress develop because individuals pull away as they grieve differently. Cathexis is about coming together as a family to strengthen bonds, stretch capacities, and make use of limited resources.

THERESA: “Our family had a strong emotional attachment to each other and the fam- ily. Michael’s illness was a grief process over time. We were mad and angry about the diagnosis. It was hard to hear that my son was chronically ill and would die. Jessica, Michael’s sister, had a big role in the illness and her bonds with Michael were strong. Yet, nurses often consider the parents with an ill child, but not the sibling. When I was diagnosed with breast cancer I was forced to think about myself and what my possible loss could mean for the family.”

Table 14.2 identifies aspects of cathexis, areas of strengths, and potential concerns that often emerge in family life. Focused nursing actions and possible evaluation methods are proposed. Family assessments are actions that help the nurse and the family gain understandings of family strengths and find ways to build on those strengths.

CHAPTER 14 ● Family-Focused Nursing Actions 385

BOX 14-2

Phenomena Related to Cathex is

Family commitment and affiliation: Bonds develop between family members and unit.

● Family transitions may require committed supports for health and illness care (Meleis, 2010).

Loss: Family loses an attachment to a person or object through life-changing and family experience.

● Grief involves working to incorporate loss into life and move forward. ● Complicated loss may suggest need for referral to family support services (Holtslander &

McMillan, 2011; Moules, Simonson, Fleiszer, Prins, & Glasgow, 2007; Worden, 2009).

Chronic sorrow : Ongoing emotional response that ebbs and flows when a functional loss occurs in oneself or another attached person

● Recurring and pervasive loss with no predictable end triggered by events that remind one of the continuous gap between what might have been and realities faced

● Often triggered by events that remind one of the continuous gap between what might have been and realities faced (Eakes, 1993; Eakes, Burke, & Hainsworth, 1998; Isaakson & Ahlstrom, 2008; Lindgren, Burke, Hainsworth, & Eakes, 1992; Melvin & Heater, 2004; Moules et al, 2007).

Ambiguous loss: Absence of a person either physically or psychologically

● Examples of physical absence could be a war causing a family member’s death, divorce in the family, or child’s death. Psychological absence can be a family member’s depression or neurological disorder, such as Alzheimer’s disease (Boss, 2006).

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TABLE 14 -2 Potential A reas of Focus in Cath ex is

NURSING ASSESSMENT FAMILY-FOCUSED NURSING ACTION EVALUATION

Commitment and affiliation within the family unit and individual members: Explore genogram and ecomap to identify strengths and needs related to family bonds.

Loss: Use assessment

techniques that invite family dialogue and nurse-family conversation.

Chronic sorrow: Assess chronic sorrow

using instrument such as Chronic Sorrow Q uestionnaire (Burke, 1989).

Therapeutic communication, such as:

Tell me about you, your family, and this illness.

Ambiguous loss: Explore family’s

perception of loss.

Recognize cultural and individual variations in the view of family commitment (Giger & Davidhizar, 2007).

Help family to develop skills and techniques that facilitate attachment and commitment (Veltri, 2010).

Observe and praise behaviors of warmth and care that develop between parents and children, new members of a family, and societal networks (Davidson, London, & Ladewig, 2012).

Explore changes in family dynamics and relationships during times of transitions with additions or changes in family members (Meleis, 2010).

Recognize cultural and individual variations in the view of loss for each family (Shaefer, 2010).

Invite family members to express grief, and listen to the answer of each family member (Shaefer, 2010).

Provide accurate information about the death, loss, and grief (Shaefer, 2010).

Acknowledge and discuss family members’ various forms of coping with the loss and encourage family members to talk with each other (Segrin & Flora, 2011).

Statements such as: “ I am so sorry for your loss. This must be a

difficult experience for you and your family.” Q uestions such as: “ How can I help you? ” Then, listen to the answer

of each family member (Shaefer, 2010). Assist family in grief work though efforts such as

finding meaning in the experience (Moules, Simonson, Gleiszer, Prins, & Glagow, 2007).

As appropriate, refer family members to needed and available resources (McDaniel, Campbell, Hepworth, & Lorenz, 2005).

Validate the presence of chronic sorrow with the family and provide reassurance of the normality of this reaction (Bettle & Latimer, 2009; Isaakson & Ahlstrom, 2008).

Assist family members in recognizing and building on existing strengths (Bettle & Latimer, 2009).

Assist family as they attempt to find meaning in loss (Boss, 2006).

Guide individual family members and the family in planning the future (Boss, 2006).

Assist family members as they identify individual and family past strengths and develop sources of support (Boss, 2006).

Bonds within and outside the family unit develop that promote health of members and family unit.

Members and family unit function to address needs linked with activities of daily living and meeting goals.

Individuals and family experience losses, but manage in ways that support health and well-being of all members.

Individuals understand that grief processes may differ, but look for ways to communicate needs and concerns to each other.

Individuals and family recognize problems associated with chronic sorrow and develop strategies to effectively manage problems.

Individuals and family express understandings about the meanings of loss and identify specific ways to manage uncertainties over time.

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Communication: Core Family Process

Family communication is a continuous, complex, and changing process that affects the mental and physical well-being of individuals and family units (Segrin & Flora, 2011; Weihs et al, 2002). As a core process, communication is used to interact around needs related to health and illness. Communication patterns are shaped in families by their unique histories, life experiences, and current events. Family systems form different communication patterns as individual, dyadic, and triadic forms influence family routines and rituals (Denham, 2003; Segrin & Flora, 2011). Mutually supportive member relationships and clear direct communication about an illness and its management can contribute to individual and family health (Denham, 2003; Weihs et al, 2002).

The complex nature of family communication emerges from the extensive relationships and influencing factors within the family unit and beyond. Ongoing interactions among family members and their extended network can be continual communication challenges. Social networks can act as strengths or threats. Interactions with nurses and health care professionals during times of illness bring additional layers of complexity to communica- tion. Families also must grapple with competing messages received from the media, com- munity, and political milieu. Multiple networks of formal and informal communication confront families daily.

C ase Study Ap p lication: C ommunication Among Family Members

Family communication patterns are worthy of attention during illness experiences. Some families have continuous open dialogue about health and illness. Other families manage silently with little attention given to health or illness. Although people do not speak every- thing on their minds, lack of shared concerns about health or illness can make changes difficult. Usual forms of communication can intensify during times of crisis or stress. Communication can become a strength to build upon, while some techniques can cause conflict and be disruptive (Segrin & Flora, 2011). Effective or ineffective communication not only influences member relationships, but also influences abilities to interact with health providers around health and illness. For example, family communication filled with criticism and blame can lead to hostility and discord, creating more individual or family health risks (Weihs et al, 2002). Silence and avoidance about an illness can contribute to suffering, turmoil, and disagreements (Wittenberg-Lyles, Goldsmith, Ragan, & Sanchez-Reilly, 2012; Zhang & Siminoff, 2003). Nurses who think family know the importance of discourse to facilitate meaningful conversations around health, illness, and caring actions. Families experiencing illnesses and related challenges can be additionally burdened with ineffective communication to manage existing problems or needs.

THERESA: “With seven brothers and sisters in my family it can be a challenge to com- municate, but we put everything on the table. We had open and honest discussions about what was happening and going to happen. My husband’s family had a different style of communication that made it difficult for our extended families to manage and deal with Michael’s illness.”

Clear communication between families and nurses is critical to health and illness experiences. Members experience emotions, navigate the health care system, manage multiple concerns linked with illness, and learn necessary actions linked with disease self-management (Chesla, 2010; Clabots, 2012). Nurses who think family invite questions and communicate to:

• Ensure that consistent messages are delivered and understood. • Deliver a constant exchange of relevant and timely information. • Acknowledge the individual and family unit experience of health and illness.

Nurses who think family aim to build trusting individual-nurse-family partnerships. A caring nursing presence acknowledges family difficulties, advocates for members, and guides

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supportive communication as members wrestle with time uncertainty, distress, and decisions (Agard & Maindal, 2009; Sveinbjarnardottir, Svavarsdottir, & Hrafnkelsson, 2012).

L istening and R esp onding to th e Family Story

Nurses need to be present, listen, and communicate with those seeking care for health and illness. Nurses can help break silences and use communication to guide decisions, learn new information, and resolve conflicts related tohealth and illness management (Segrin & Flora, 2011; Zhang & Siminoff, 2003). Effective family communication can be protective, support resilience, and decrease difficulties of managing illness (Black & Lobo, 2008). Constructive and purposeful communication is needed for collaborative individual-nurse-family relationships.

THERESA: “It seemed that health care providers wanted to act independently. They often seemed to have the belief that they did not need to include the family. We had care conferences and meetings when there was a crisis. It would have been so helpful to be more proactive and meet as a family with care providers. It would have been helpful to have a nurse who could help us talk and plan because they were the most consistent persons providing Michael’s care. They could have provided us with information and guided us in the dialogue and decisions.”

The nurse can use the core process of communication to help families develop, understand, and learn protective communication methods rather than criticism and conflict (Weihs et al, 2002). Interventions that promote direct communication, foster emotional expression, and assist a family to deal with loss and conflict can improve care outcomes (Chesla, 2010; Weihs et al, 2002). Nursing actions focused on communication and relationships have improved outcomes compared to usual care that may not focus on this process (Chesla, 2010).

THERESA: “At times it seemed that the providers wanted to put the burden on the family to say the words they don’t want to say. We were often left crying in the waiting room with no nurse present to listen or help my family talk to each other. We need a nurse to help share the burden and help us say the words.”

Families involved in the care and support of their family member with illness have improved recovery (Black, Boore, & Parahoo, 2011). The family’s perception of nurse support, collaboration, and respect is increased with good communication (Mitchell, Chaboyer, Burmeister, & Foster, 2009). When nurses invite family to participate in family member care, the flow of information and communication is easier, family members believe they receive greater support, and are more satisfied with care (Roberti & Fitzpatrick, 2010). Table 14.3 examines concerns that often emerge around communication.

Caregiving: Core Family Process

Children, adults, and the aged all have caregiving needs. The unique illness management tasks and caregiving skills are not always inherent in the family, but often need to be taught and learned. Some caregiving arises as family bonds generate strong attachments that encourage a milieu of protective watchfulness and attention to development, health and illness (Carr, 2014; Denham, 2003). As a core process, nurses can use caregiving to address wellness, health promotion, prevention, and care management for acute episodic, chronic, or debilitating con- ditions. Many families welcome adding children and assume caregiving tasks to guide healthy development into adulthood. Ideally, families socialize members to practice healthy behaviors and interact in ways that serve member, family, and societal needs. Wellness, health promotion, and disease prevention are closely tied to family health routines and caregiving. A family ex- periencing an acute illness or chronic condition often needs to acquire caregiving skills and knowledge (Hsiao & Van Riper, 2010; Li & Loke, 2013). An acute illness suggests needs for caregiving tasks (Boyoung, Fleischmann, Howie-Esquivel, Stotts & Dracup, 2011; Kamban

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CHAPTER 14 ● Family-Focused Nursing Actions 389

TABLE 14 -3 Potential A reas of Focus in Communication

NURSING ASSESSMENT FAMILY-FOCUSED NURSING ACTIONS EVALUATION

Identify the following: • Family communication

strengths • Disruptions in family

communication • Ability to engage in useful

communication that meets needs of individual and the family

• Whether communication supports individual and family unit needs

Use therapeutic questioning, such as: " Tell me about the ways your family has effectively solved problems in the past.”

“ In the past, when your family has faced troubles, what kinds of things worked best as you tried to resolve the problems? ”

Family members’ communication patterns help them solve problems, make decisions, and promote well- being of family unit members.

Communication is effectively used to identify meaningful goals and negotiate differences to achieve goals.

Promote family dialogue to continually exchange information, and convey emotions that protect and support family (LeGrow & Rossen, 2005; Nelms & Eggenberger, 2010).

Explore past family communication patterns and compare with current ones (Segrin & Flora, 2011).

Educate family members about the importance of communication and explain ways it can positively influence health and illness.

Coach family members in effective communication that fosters resiliency, using clarity, open emotional expressions, and collaborative problem solving (Black & Lobo, 2008).

Facilitate family negotiation to solve problems and resolve conflicts (Black & Lobo, 2008).

& Svavarsdottir, 2013). Chronic conditions require watchful attention, learning new skills, or modifying family health routines (Davis, Gilliss, Deshefy-Longhi, Chestnutt, & Molloy, 2011; McGhan, Loeb, Baney, & Penrod, 2013).

C aregiving in C h ronic Illness

Caregiving roles linked with chronic conditions are long-term requirements. More family caregivers are needed (Pierce & Lutz, 2013; University of Michigan Health System, 2006) to care for a growing portion of society:

• Growing numbers of adults over 65 years of age are living with multiple chronic illnesses. • Approximately 15% to 18% of children are now living with chronic conditions. • Over one-third of young adults already suffer from a chronic condition.

These statistics mean families need to take on roles as informal caregiving systems with regular responsibilities for assisting members. Caregiving demands can be needs for emo- tional support or actual assistance (Pierce & Lutz, 2013). New family roles might need to be learned, personal care services provided, concerns linked with employment resolved, care for an ill member provided, and other family household needs addressed (Pierce & Lutz, 2013; Siminoff et al, 2010). As health and illness transitions occur new caregiving roles are needed. Caregiving strain and burden are often related to the stress, struggles, and conflicted feelings about caregiving roles (Hunt, 2003). The strain and burden of prolonged caregiving can result in caregiver depression and increased mortality risk (Bastawrous, 2012; Perkins et al, 2013; Pierce & Lutz, 2013; Siminoff et al, 2010). Nurses who think family realize the core process of caregiving requires intentional thoughts and actions so nursing actions guide a family in planning and delivering caregiving.

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C ase Study Ap p lication: Family C aregiving E x p erience

The Zimanske family worked together. Theresa changed jobs so she could work near the school so Michael could continue attending. She became his transportation and closest care provider. As a family unit, they jointly cared for Michael and reached out to friends and support systems. Yet, they still needed support as caregivers. They wanted nurses to demonstrate understanding about the strains of caregiving experiences. The years of de- mands were not easy. The family needed nurses to recognize their stress and the burden of continuous caregiving demands and responsibilities.

THERESA: “I recall one situation where I had taken Michael to a clinic appointment. I had no time to shower, care for myself, and I was struggling. I needed support in my care- giving role. The next day a nurse called me to make a follow-up check. She asked, ‘And how are you doing? Yesterday I noticed that you were tired. This must be difficult for you.’ It was important for a nurse to check on me and follow up. I wanted nurses to try to walk in my shoes for just a moment. I appreciated that telephone follow-up and concerns for me as the caregiving mother.”

Nurses in all care settings can strengthen caregivers’ abilities as they provide necessary care for members. Family-focused nurses address caregiving, encourage and support family caring, and help them meet concerns that surface in caring for members (Couture, Ducharme, Lamontagne, 2012; Lubkin & Larsen, 2013). Nursing actions start with listening and observing. Regardless of the practice setting, thinking family implies focusing actions on development of caregiving capacities (Pierce & Lutz, 2013). Family-focused nurses empower, enable, equip, and prepare families. Boxes 14.3 and 14.4 highlight the contributions of faculty committed to developing the practice of nurses with families.

Family-focused nursing actions enable families to identify and mobilize strengths and resources to manage care situations, satisfy members’ needs, and sustain usual family life as much as possible (Cleek, Wofsy, Boyd-Franklin, Mundy, & Howell, 2012; Pierce & Lutz, 2013). Nursing actions to build confidence are often more effective than merely focusing on education; self-confidence in new caregiver skills is necessary (Couture et al, 2012). Ac- tions tailored and responsive to needs of family units produce the best care outcomes (Williams & Bakitas, 2012). Table 14.4 identifies the core process of caregiving and provides examples of assessment, nursing actions, and evaluation.

390 CHAPTER 14 ● Family-Focused Nursing Actions

BOX 14-3

Family Tree

Dorothy W hyte, BA, PhD, RN, RCN, HV, RNT (Scotland, United K ingdom)

Dorothy Whyte, BA, PhD, RN, RCN, HV, RNT, was enrolled in a doctoral program in the Department of Nursing Studies, Edinburgh University, Scotland, when she learned about the First International Family Nursing Conference scheduled in Calgary, Alberta, Canada, in 1988. Her attendance at this landmark conference greatly influenced her writing and thinking about families. Her doctoral research, completed in 1990, focused on chronic illness in children. In her subsequent role as a faculty member at Edinburgh University, she developed the first family nursing course. In 1997, she edited the book Ex plorations in Family Nursing. Through the use of case studies written by her students and colleagues, she demonstrated the relevance of family nursing in the United Kingdom. Dr. Whyte and her colleagues co-developed the Family Nursing Network Scotland [FNNS] in 1997. The aim of this network is to support clinical nursing, education, and research with families. Until her retirement from Edinburgh University in 1999, Dr. Whyte supervised and mentored master’s and doctoral family nursing students from the United Kingdom and other European countries. Her influence continues to be felt and acknowledged by these former students who are now providing significant leadership in family nursing in their countries.

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CHAPTER 14 ● Family-Focused Nursing Actions 391

BOX 14-4

Family Tree

K az uk o Suz uk i, DSN, PHN, RN (Japan)

Dr. Suzuki has made the growth of family nursing in Japan a key priority and believes this has been her most important life work. Her foundational leadership at Chiba University and Tokai University was especially significant in the development of family nursing in Japan. Tokai University was the second university in Japan to offer master’s level preparation for clinical nurse specialists in family nursing. Dr. Suzuki taught family nursing for 5 years at Chiba University and for 11 years at Tokai University where she mentored a large number of clinical nurse specialists in family nursing. She continued this teaching focus at Tokai University until her retirement in 2008. In 1995, Dr. Suzuki coauthored (with Hiroko Watanabe) the first textbook in Japan on family nursing titled Family Nursing: Theory and Practice (Japan Nursing Association Publishing Company), which has now been published its fourth edition. She served as a board member of the Japanese Association for Research in Family Nursing (JARFN) from its beginning in 1994 and was the second president (2004–2007). In 2011, Dr. Suzuki was awarded an Innovative Contribution to Family Nursing Award from the J ournal of Family Nursing at the 10th International Family Nursing Conference in Kyoto, Japan.

TABLE 14 -4 Potential A reas of Focus in Caregiving

FAMILY ASSESSMENT FAMILY-FOCUSED NURSING ACTIONS EVALUATION

Health maintenance and disease prevention

Available family resources and networks

Difficulties adjusting to caregiving trajectories such as:

• Assuming the caregiving role

• Seeking formal care assistance

• Leaving the role

Caregiver stress, strain and burden

Assess using caregiver burden and strain measures

(Rodakowski, Skidmore, Rogers, & Schulz, 2012).

Shifting family roles

Family promotes emotional and physical health for all members.

Family has maximized use of available resources for health of all members.

Family is confident and empowered with caregiving roles and transitions (Pierce & Lutz, 2013).

Family accesses resources and recognizes strengths and limitations as caregivers.

Family adjusts to changes in family roles and coordinates changes.

Educate about health maintenance and teach illness prevention.

Identify and mobilize family strengths. Consider cultural differences and

expectations linked with caregiving tasks.

Explore resources of family and community.

Discuss with family the potential ways to access networks.

Provide information in a variety of forms. Build family caregiver confidence (Pierce

& Lutz, 2013). Support family presence and vigilance as

appropriate (Carr & Clarke, 1997).

Help caregiver gain access to services. Obtain respite care. Arrange phone conference with family

members and health care providers. Provide access to Internet chats. Provide caregiving Web sites.

Explore past, current, and changing family roles with caregiving.

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Celebration: Core Family Process

Almost everyone loves a celebration, but it is not usually the first thing on nurses’ minds when they think of health or illness. The core process of celebration points to unifying family events with positively shared family meanings to commemorate (Denham, 2003). Celebrations, traditions, and rituals are tied to belonging, and they contribute to family identity and integrity (Denham, 2003). Family rituals often include celebrations that can generate family healing as members connect, empower one another, and decrease stresses of daily life and illness (Moriarty & Wagner, 2004). Children’s birthday cele- brations are an example of family rituals that are often repeated multiple times through- out the evolving family’s life and have potential to contribute to family well-being and family connections (Lee, Katras, & Bauer, 2009). A ritual such as a birthday celebration may be unique among families. Families tend to view celebrations positively and when an event is not celebrated as usual stress or even grief might occur. Family ritual as a shared time to promote close relationships is a prominent aspect of resilient families (Black & Lobo, 2008; Walsh, 2003). Nurses who think family know some celebrations are valued and take note of special times and facilitate and encourage the family’s observance of those special events.

C ase Study Ap p lication: C elebration

Nurses do not always think about family celebrations in nursing roles. Yet, a family’s times of sharing together are valued and provide a reprieve from life’s struggles. Taking time away from stressful needs can help preserve family resiliency. Nurses can encourage families to share stories about past celebrations and describe the value or meanings of events and their cultural and religious significance.

THERESA: “At 10 years old, Michael’s favorite holiday was Halloween. He was hos- pitalized on Halloween and stressed about not being able to go to school. Even though he was isolated, nurses figured out a way that kids from his class could connect with him to celebrate the holiday. School friends came in their costumes. The nurses even came in costumes and they helped him dress up for Halloween. This meant a great deal to Michael and our family.”

Nurses can assist families to find ways to continue celebrations despite barriers. Families can benefit from community resources such as the mission of the Make-A-Wish Foundation to create celebratory events that enrich the lives of children who have life-threatening medical conditions. Children with diabetes may be able to attend a diabetes camp and gain confidence, knowledge, and skills as they join with other children at camp events. Nurses can use actions to help families construct new celebrations or modify old ones in response to an illness or other life transition (Denham, 2003).

Change: Core Family Process

Change is a constant element of family life with ongoing alterations in the family social systems and larger environments (Denham, 2003; Wright & Leahey, 2013). Change, as a core process, can be defined as the dynamic family process that requires alteration or modification, redirection of attentions or resources, or substitutions (Denham, 2003). Needs for change come in unexpected and unpredictable forms that can be demanding to the family. Developmental changes occur throughout life as family members grow and develop, but when an unknown situation or uncertainty surfaces, preparation for change can be limited. Life events such as death, war, unemployment, or serious illness in one family member can initiate changes affecting the family unit (Wright & Leahey, 2013).

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Individual changes due to health or illness often require changes in others and precipitate significant transitional needs (Meleis, 2010). Nurses who think family assist members as they face, manage, and engineer the uneasy stressors that accompany change. Individ- ual-nurse-family relationships can assist family units by sorting out the implications of abrupt alterations, teaching new things, coaching in lifestyle changes, or counseling about options and choices.

Health behavior changes in a family often are a key to prevention and management of illness (Shumaker, Ockene, & Riekert, 2009). For example, tobacco use, unhealthy diets, and physical inactivity play roles in causation and progression of chronic disease (United States Department of Health and Human Services, 2012). Objectives to increase life quality and not just years of life aim to eliminate health disparities and improve lifestyle behaviors (United States Department of Health and Human Services, 2012). Nurses have a responsibility to help create a context for some anticipated changes (Wright & Bell, 2009; Wright & Leahey, 2013). Family units exist within a social system and physical environment linked to change, some of which cannot be controlled by them (Denham, 2003). Thus, nursing actions can assist family members in attending to house- hold concerns as adjustments to change are needed.

Nurses use teaching, coaching, and collaboration to facilitate changes that support health and illness (Hamric, Hanson, Tracy, & O’Grady, 2014; Wright & Leahey, 2013). Providing and exchanging useful information is a critical first step in addressing change. Families often need someone to listen as they face changes. They need to be guided to solve problems or adopt new routines. Nurses can support health-promoting changes through actions that build confidence and empower (Pierce & Lutz, 2013). Empowering provides information, skills, and resources to manage circumstances and needed changes (Hulme, 1999; Pierce & Lutz, 2013).

Managing change requires skill to navigate through conflicts and resistance and emerge with successful outcomes (Mason & Butler, 2010). This is not easy for families or nurses. It takes time, practice, and support when failure occurs. Motivational interviewing is useful in identifying and altering behaviors (Mason & Butler, 2010; Rollnick, Miller, & Butler, 2008) through several actions:

• Ask questions, be curious. • Listen and understand the family’s desires for change. • Guide the family by suggesting options. • Plan and take actions aligned with family values. • Create confidence and empower the family.

Nurses need to understand and be sensitive to family concerns linked with change. Education and interventions linked with emotions and relationships need attention.

C ase Study Ap p lication: C h ange

Change can occur quickly or over time; it is not usually a particular one-time event (Mason & Butler, 2010). Stages of change—precontemplation, contemplation, preparation, action, maintenance, and termination—are viewed as places where people are as they confront needs for change (Prochaska, Johnson, & Lee, 2009). Precontemplation refers to the time when the individual is not intending to change; contemplation is when the person intends to change in the next 6 months. Preparation is when action is expected in the immediate future and action includes modifications. Maintenance is when an individual is likely to continue the change. Termination of the change process occurs when the person will not return to unhealthy ways.

Nurses can help families identify the stage at which members are in readiness to change. Different nursing actions are needed at each stage. The first critical step is assessing where

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individuals and families are in the change process. Most people need to know the benefits of change and the risks associated with not changing. Nurses can provide positive supports re- gardless of where persons are in readiness to change. Nurses who think family recognize that nursing actions to address change depend upon readiness to change and other family factors.

Inviting change through therapeutic communication is central to family nursing practice (Wright & Bell, 2009). Respecting beliefs and managing constraining beliefs sets the stage for nursing actions and supports (Wright & Bell, 2009). Family members need skills to solve problems and resolve difficult situations.

THERESA: “Michael’s illness kept changing. It would have been helpful to know what change may be next. Every family is different. Our family needed help to redesign our vision of family life. It’s an evolution and process that takes repeated conversations. Our family was often in disbelief about what was happening around us. Our emotions, visions, and dreams had not caught up with the changes. We needed guidance in how to deal with the countless changes in Michael, our family, and each of our own lives.”

G oals

When change is needed, the individual-nurse-family relationship provides ways to collaborate and partner as goals are set and strategies developed. Nurses assist families by asking ques- tions and then working with them to set specific goals tied to a needed change and develop strategies or actions to accomplish that change. The actions should be measurable.

• Who—Who in the family do we need to involve? • What—What needs to be accomplished by the individuals or the family unit? Does

the nursing action fit this family? • When—By what time/date can the family accomplish this? • Where—Where does this need to be addressed? Is it something to do at home, school,

or work? • Which—Which barriers, constraints and resources need to be addressed by the

family? • Why—Why is this change necessary? What are the benefits if the family meets the

goal? What are the risks if they fail to meet goal? • How—How does the family view this change? How do individual family members

influence this change?

A goal has specific criteria to measure progress. Focusing on whether a goal is attainable assists the nurse and family to realistically consider capacity to attain it. What are the mem- ber attitudes, abilities, skills, and family resource factors? Goals are set to be accomplished and measured within a particular timeframe. What barriers need to be overcome? What resources are needed? Goal achievement requires nursing actions that fit family needs (Wright & Leahey, 2013). Family beliefs, values, roles, member processes, and culture need to be considered (Bulecheck & McCloskey, 1992). Family nurses respect unique beliefs and partner to attain optimal health outcomes as changes are managed (Table 14.5).

Connection: Core Family Process

Connection, another core process, refers to bonds and links among family members, the family as a system, and systems external to the family household. Connections occur among relational bonds, commitments, and resources. Connections may be simple, as in a shared music interest or a biological relationship to a grandparent. Connections can also be complex, as in the network of multiple members in a blended family and various resources linked to the family system or particular members (Fig. 14.5). For example, a

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child from an earlier relationship might be covered under a different health insurance plan from other family members. Connection sometimes varies among members in a single household. Connections within a family can be strengthened or weakened over time. Boundaries between family systems and ecological environments influence some family connections. For instance, if family members believe they should be self-sufficient in man- aging problems, they may be reluctant to seek help from outsiders. This could limit their access to available resources. On the other hand, a family with open boundaries might pursue every resource possible.

CHAPTER 14 ● Family-Focused Nursing Actions 395

TABLE 14 -5 Potential A reas of Focus in Ch ange

ASSESSMENT FAMILY-FOCUSED NURSING ACTIONS EVALUATION

Engage in a family conversation that encourages family members to tell their story and invites reflection on beliefs about health and illness

(Wright & Bell, 2009). Assess context of

the family that influences health (e.g., cultural influences, social environment)

(Schneider & Stokols, 2009).

Family sets goals. Family engages in

planned strategies that facilitate meeting goals.

Changes are made and goals are accomplished.

Create collaborative relationship with family. Explore illness beliefs, strengthen facilitative

beliefs, challenge constraining beliefs (Wright & Bell, 2009).

Listen and understand family’s reason for making or not making changes.

Increase family awareness of need for change. Identify supports for change. Set goals and identify strategies for making the

change. Establish a timetable for making changes.

FIGURE 14 -5 Family connections.

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In the Family Health Model (Denham, 2003), connections are described as ways in- dividuals are committed to and linked through interests, values, roles, and identities. Social ties are potential resources linked to positive health outcomes (Giordano, Bjork, & Lindström, 2012; Looman, 2006). For example, neighborhood characteristics such as attachment and informal social control are linked with mothers' parenting mastery (Carpiano & Kimbro, 2012). Living in a neighborhood where social connections are strong may help families access supportive networks and needed resources.

A study of Swedish families indicated that high degrees of family, school, and neighbor- hood connectedness facilitated higher levels of child well-being (Eriksson, Hochwolder, Carlsund, & Sellström, 2012). Connectedness was measured using responses to such cues as “You can trust people around here” and “People say ‘hello’ and often stop to talk to each other on the street” (Eriksson et al, 2012). Trusting attitudes and friendly neighbors affect individual and family health. If trust and social connections are interconnected, stronger social networks help families use relationships to access resources (Giordano et al, 2012). Table 14.6 provides direction for assessment, nursing actions, and evaluations linked with connection.

C ase Study Ap p lication: G enograms and E comap s Provide C onnections

Connections can be health promoting. Nurses can use knowledge about community resources to help families access resources. Tools discussed earlier in the book, such as genograms and ecomaps, can be used to assess family connections. Genograms provide a picture of the family and related health risks. An ecomap is a snapshot of social relationships that can help identify potential resources (Rempel, Neufeld, & Kushner, 2007; Wright & Leahey, 2013).

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TABLE 14 -6 Potential A reas of Focus in Connection

NURSING ASSESSMENT FAMILY-FOCUSED NURSING ACTIONS EVALUATION

Create and discuss a family genogram with members of the family.

Create and discuss the family’s ecomap

Family members share perceptions about the family structure, roles, and connections within and across generations.

Goals and a plan of action are generated.

Family members identify existing resources and potential connections to needed resources for support that promotes health and manages illness.

Goals and a plans of action are generated.

Ask family members to share in the process of creating the genogram.

Identify actual and potential sources of support from extended family members.

Identify any barriers or threats that need attention.

Engage the family in a discussion of ways family members facilitate or create barriers to connections within and outside the family.

Identify sources of support, through social network connections and links to supportive resources over time.

Identify any barriers or threats that need attention.

Discuss existing connections as potential, but untapped resources.

Explore shared perceptions and meanings about connections.

Identify supports outside the family boundaries.

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Used interactively, the genogram, a graphic representations of information about family, usually over at least three generations, can aid thinking about family as a system connected to the larger world (McGoldrick, Gerson, & Petry, 2008). The genogram can identify ways members are connected legally, emotionally, socially, and genetically. Discussions can lead to learning about member roles and values. This is a nonthreatening way to ask questions about member connections or relationships and identify ways members interact with one another (McGoldrick et al, 2008). A completed genogram offers a tangible map of the fam- ily story. It may reveal connections to resources that may not have been recalled before the exercise.

Creating an ecomap, a graphic representation of social networks and bonds within them, can generate dialogue as information about key sources of support is gathered (Hartman, 1995). Sources include kin, friends, support groups, schools, religious affiliations, employers, and professionals (Rempel et al, 2007). The ecomap can be used to discuss strengths and directions of relationships. The ecomap creation may reveal strong or weaker connections and help discern boundaries that exist between members and systems external to the family household.

Creating a genogram and ecomap with the Zimanske family provided nurses with broader historical data and information about social contexts. For example, extended family members played important roles in the Zimanske family’s life. Theresa had a large number of siblings and several living nearby in a rural farming area and they were instru- mental supports and willing to stay with Michael or offer assistance as needed, including emotional supports. Faith-based activities played important roles in the family’s social and spiritual lives. Their church affiliation linked them to caring congregants over many years. Their faith connected them to a higher power to trust and seek spiritual guidance during the long illness. Nurses knew the information on the Zimanske family genogram and ecomap. “We became human . . . we began connecting as human beings rather than as doctor-patient,” explained Teresa. Theresa believed that these tools helped nurses provide their family more effective care.

Coordination: Core Family Process

Coordination, as a core process, refers to cooperative sharing of resources, skills, abilities, and information within and outside the family. There are several purposes of coordination:

• Use time and other resources wisely. • Optimize efforts to achieve individual and family health. • Achieve individual and family goals.

Coordination involves decisions about daily activities, routines, networking with support systems, and negotiating a satisfactory balance between available resources and needs of individuals and the family unit. Coordination is important to the promotion of care maintenance for wellness, prevention, illness, disease, or disability.

Family coordination includes participation, organization, focalization, and affective contact (Fivaz-Depeursinge & Corboz-Warnery, 1999; Lavadera, 2011). These factors address the following:

• Participation is the ability of family members to interact and not exclude certain members in shared activities.

• Organization is clear communication that honors members’ roles in a family activity. It is what helps a family complete needed tasks.

• Focalization is the ability to focus attentions as activities are carried out. • Affective contact pertains to members encouraging and appreciating everyone’s

contribution and promoting fun and harmony during activities.

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Coordination involves members’ unique processes, communicating, respecting roles, paying attention to goals, and recognition of member contributions.

Coordination entails cooperative sharing of resources, skills, abilities, and information within the family and exchanges with larger contextual systems (Denham, 2003). Working together and sharing resources can optimize health potentials and goal accomplishment. Effective coordination is often a silent and unrecognized family strength because it occurs without overt negotiation or discussion (Denham, 2003). Lack of family cooperation is a problem when activities and behaviors are not effective in meeting goals, lead to disputes or stress, and are unaddressed. For example, schedules may be disrupted when a parent is hospitalized because of an automobile accident. This interferes with usual coordination of meal preparation, child care, or transportation. This disruption may manifest itself as a crisis of time management for others and lead to unexpected stress. A teenager may be asked to assume a role of child care and rebel when it interferes with plans. Nurses who think family assess family routines and identify disruptions. What coordination needs to occur to help this family organize? Table 14.7 identifies some areas for assessment, nursing actions, and areas to evaluate in the coordination process.

C ase Study Ap p lication: C oordination

Coordination assists family members by enabling them to work in unity and share re- sources, skills, abilities, and information. Begin with assessment of the family’s collective awareness of needs and resources linked to a specific situation. Do family members agree or disagree on the problem and what is needed? An acutely ill father is being discharged after a lengthy hospitalization. Do the spouse, teen children, and extended family agree about the family’s most pressing needs? The coordination process suggests nursing actions that assist the family unit in the following:

• Recognize and include needs of all members. • Communicate and respect roles. • Attend to family unit stress, concerns, and frustrations. • Appreciate the contributions of each member. • Identify available resources, shared goals. • Include all in shared decision making.

In the Zimanske family, Michael had many lengthy hospitalizations, including one in which he received a kidney transplant from a family member. Coordination as a core family process required each family member to recognize and include others in the preparation for discharge after transplant. Although not all members were physically present when Michael was discharged, the process considered the concerns of various member needs during the recuperation phase, such as Jessica’s social needs and Theresa and Don’s work schedules, so there would always be a caregiver present. It also included the needs of Michael’s aunt, the kidney donor, who would be simultaneously recovering at a different home. Nurses who think family recognize that coordination involves support, roles, relationships, resources, threats, and balanced attention to individual and family needs in addition to the skills and information needed to ensure safe physical care.

Coordination as a family process is important for health promotion and during times of stress. In a study of healthy dual-income families, findings indicated “busy families lead lives where more than half of all activities unfold as non-routine,” and “family members do not have perfect knowledge of each other’s routines (Davidoff, Zimmerman, & Dey, 2010, p 2469). The families studied were not ill, but were leading

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typical lives as a busy family. Theresa described her family’s experience during this transplant as “stress times a million.” Stability of routines is important in family lives and the adaptation of new behaviors can be stressful (Denham, 2003). Stressful events require families to negotiate unfamiliar situations and coordinate or share in needed changes. Box 14.5 provides a case to explore family processes and family-focused nursing actions.

CHAPTER 14 ● Family-Focused Nursing Actions 399

TABLE 14 -7 Potential A reas of Focus in Coordination

NURSING ASSESSMENT FAMILY-FOCUSED NURSING ACTIONS EVALUATION

Identification and collective awareness of needs

Identification and collective awareness of resources

Identification of family goals

Cooperation

Decision making

Family members have a shared understanding of individual and collective family unit needs.

The family names one or more current needs that were previously implied.

Family members identify a set of resources available to satisfy identified needs.

Families identify and call upon existing strengths as resources.

Family members have a shared understanding of goals to achieve.

Resources are coordinated to meet identified needs.

Family members are willing to “ give and take” and share.

Family is adapting as needed to manage changing needs for support and resources.

Family members prioritize needs, act on decisions, resolve problems, and meet individual and family unit needs.

Encourage family members to verbalize perceived needs.

Offer guidance in naming needs family member express that might be implied, but not spoken.

Facilitate identification and “ cataloging” of available resources, skills, abilities, and information.

Commend families and individuals when resources, skills, and abilities are apparent.

Assist the family to identify goals for health or illness management and move toward consensus.

Offer guidance in negotiations. Assist family to coordinate resources to

meet member and family unit needs.

Facilitate decision making by listening. Reflect on problem identification that

needs resolution. Prioritize needs.

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BOX 14-5

Family Circle

Maria Sanchez is a 78-year-old woman who has lived alone in a small rural community in the Midwest. Maria’s husband is deceased and her three adult children live on the east and west coasts. Maria has been independent since her husband’s death 10 years ago, but recently her eldest son James has noticed she seems forgetful when he calls. He decides to fly home for a visit. When he arrives, he notices that she keeps leaving the stove on and seems unable to safely drive to get groceries. She says she has not been feeling good and has little appetite. A few days later, Maria becomes seriously ill. James takes her to the hospital and she is admitted with pneumonia. She is eating little and has a temperature of 101° F. Maria asks the nurses if she is going to get to return home soon. She is on intravenous antibiotics, but is not improving. James contacts his sister, and the nurse caring for Maria in the room hears their conversation as she cares for the other person in the room. James tells his sister that she is going to have to come be with their mother. He tells her that he has to return to his business. His sister Sarah says she has no one to watch the children and cannot leave them. The nurse hears James say they that it would be useless to call their brother Peter because he can hardly take care of himself.

General Q uestions:

● What is the nurse’s responsibility in taking care of Maria Sanchez? ● What concerns will the nurse have for Maria’s discharge? ● What do you think the nurse might do after she hears this conversation?

Family-Focused Q uestions:

● What family nursing actions might the nurse consider for this family? ● Using family-focused actions, what core family processes might be concerns in this situation? ● Consider the opportunities that family-focused nursing actions might create compared to

individual-focused actions.

Core Processes and Family Meetings

Family nursing places families at the center of nursing actions. A nurse-led family meeting is a specific nursing action that includes the family unit and provides opportunities to hear and address needs and concerns. Core processes are part of a toolbox of ideas to approach nursing care for families. Family meetings can be used to communicate with the family, make decisions, or identify strategies to resolve pending problems. Most families value time to meet with a nurse who will guide, mentor, and inform them about illness management, care treatments, and behavior changes (Hamric et al., 2014 McDaniel et al., 2005). Nurses may need to initiate these meetings because many families have not had a previous experi- ence with them and, therefore, would not request them.

Family meetings are a time when nurses can directly target family processes, member concerns, and support needs. Bringing a family together has healing potential and can ease family suffering and distress (Legrow & Rossen, 2005; Wiegand, 2006; Wright & Leahey, 2013). The therapeutic nature of a family meeting allows questions, exploration of family beliefs, and relationship building (Nelms & Eggenberger, 2010). These meetings have the potential to decrease frustrating confrontation, misunderstandings, and family dissatisfaction (Nelms & Eggenberger, 2010; Hannon, O’Reilly, Bennett, Breen, & Lawlor, 2012). Table 14.8 describes purposes, strategies, and potential outcomes of family meet- ings. These meetings need to be inclusive and welcome all interested members. Dialogue to support understanding is encouraged, directions are identified, and guidance offered to improve care outcomes. Family meetings facilitate family processes and communication with the health care team (Box 14.6).

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CHAPTER 14 ● Family-Focused Nursing Actions 401

TABLE 14 -8 Purpose, Strategy , and O utcomes of Family Meetings

STRATEGIES FOR FAMILY-FOCUSED PURPOSE NURSING ACTIONS OUTCOMES

Share and exchange information.

Encourage healthy patterns of communication.

Identify family beliefs that influence health.

Facilitate understandings of individual family members’ thinking.

Informed family with increased trust.

Open, honest, respectful family communication during stress of illness experience.

Respectful understandings of differences and consensus among family members (Wiegand, 2006).

Move toward facilitating beliefs.

Family members acknowledge the needs and concerns of other members.

Provide consistent communication with family and interprofessional team.

Create a comfortable and welcoming atmosphere.

Model communication facilitative techniques to family members.

Help individuals to share ideas. Respect beliefs; avoid stereotypes and

assumptions.

Clarify individual and family unit beliefs. Identify facilitating and constraining beliefs

(Wright & Bell, 2009).

Direct attention to individuals during the meeting.

Strive for consensus. Use negotiation as a tactic for resolving

conflicts.

BOX 14-6

Research Evidence Ab out Family Meetings

Selected research findings about the benefits of family meetings:

Arranging family participation in the nursing home setting is a way to improve the well-being of the older adult resident while maintaining the family’s ongoing participation in the care of their loved ones (Dijkstra, 2007).

Including family caregivers of clients living with cancer in psychoeducational interventions has been found to alleviate caregiver distress (Doorenbos et al, 2007).

Involving parents of children with diabetes in interventions increases parents’ knowledge and supports coping with the illness (Chesla, 2010).

Developing skills through interventions that improve family relations while managing a chronic illness demonstrates improved outcomes, such as a decrease in family members' anxiety, depression, and sense of illness burden, when compared to usual care (Chesla, 2010).

Providing quality end-of-life care in hospital settings requires the involvement of family, and family conferences are a way to facilitate decision making with end-of-life issues (Fineberg, Kawashima, & Asch, 2011; Wiegand, 2006).

Participating in family meetings that aim to attend to spiritual and psychosocial needs can be a potentially useful intervention according to patients, family members, and staff in a palliative care setting; however, strategies to overcome implementation barriers are needed (Tan et al., 2011).

Facilitating family meetings at predetermined scheduled times in the acute care setting can minimize the uncertainty and distress of the family experience (LeGrow & Rossen, 2005; Nelms & Eggenberger, 2010).

Arranging conferences with families in primary care settings provides the best outcomes for patient and moves the family and provider toward common understandings (McDaniel et al., 2005).

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402 CHAPTER 14 ● Family-Focused Nursing Actions

BOX 14-7

Successful Communication Through Family Meetings

Before conducting a family meeting, the nurse can use the following steps to address the needs of those taking part:

● Consider the purpose and what needs to be accomplished through the family meeting. ● Identify and invite all family members who need to be present; consider privacy needs as

members are included. ● Provide quiet environment with room for family members. ● Arrange a time that is convenient for the majority of family members. ● Identify the health care team members who need to be present. ● Provide ample time for opportunity to listen to family members. ● Plan for the need to begin, maintain, and terminate the meeting with appropriate statements

and actions.

Case Study Application: Family Meetings

Conducting family meetings requires careful planning and implementation. Nurses often rely on someone like the chaplain, social worker, or physician to lead these meetings and manage family dynamics. Although others might participate in a family meeting, it is often the nurse who has the greater understanding of the family needs and works with them most closely. Nurses familiar with family situations and who have some relation- ship with the family are likely the best ones to lead family meetings. As the meeting be- gins, identify the purpose of the meeting and goals to address. Set a time limit so the family will know how long you will be available. Do not overestimate what might be accomplished, but recognize that even brief conversations with a family can have a pos- itive influence on the family (Halldórsdóttir & Svavarsdóttir, 2012; Svavarsdottir & Sigurdardottir, 2013) and family meetings can be beneficial to patients and families (Tan, Wilson, Olver, & Barton, 2011).

THERESA: “I asked for family meetings, but they only occurred when we had a crisis event. It would have been helpful to be more proactive. The registered nurses would have been great conveners of family meetings because they knew Michael and us so well. Family meetings could have helped us think, talk and share our concerns.”

Nurses can use family meetings to:

• Listen and understand the family experience. • Integrate their knowledge or expertise linked to illness and treatments with the

family’s experiential expertise of the individual who is ill and each other. • Identify the emotional issues or care barriers and facilitate action plans.

Box 14.7 describes some strategies to use for successful family meetings.

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Chapter Summary

Family-focused nurses intentionally place the family unit in the center of practice and treat them as the unit of care. The core processes from the Family Health Model (Denham, 2003) provide guides for nurses’ actions with families. Core processes of communication, caregiving, cathexis, celebration, change, connectedness, and coordination are guides for intentional nursing actions. Therapeutic conversations and family meetings bring nurses and families together so they can collaborate through individual-nurse-family partnerships to satisfy unique needs,, consider choices of action, resolve problems, and make decisions. Nurses who think family recognize family processes are central to family life and require nursing actions that recognize areas of concern and strength.

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