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Moving to Family- Focused Care Sharon A. Denham

C H A P T E R 2

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

1. Differentiate between individual care and family-focused care. 2. Define key terms involved in family-focused care. 3. Describe differences between family as the context of care and family as the unit of care. 4. Compare and contrast a systems model and an ecological model. 5. Discuss some of the ecological dimensions of family health. 6. Introduce some ways in which family-focused care influences individual and family health.

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

● Ecological model ● Family ● Family as the context of care ● Family as the unit of care ● Family-centered care ● Family-focused care ● Family health

● Family Health Model ● Healthy family ● Individual care ● Patient ● Patient-centered care ● Systems Model

Introduction

Nursing practice is large in scope and often considered both an art and a science. Through- out this chapter you will see how ideas linked with thinking family and family-focused nursing care can improve the ways you care for patients. Those ideas outlined here will be more fully explained in following chapters. The term thinking family is an attitude or way to approach nursing and use a family-focused perspective. Some of the literature introduced in this chapter has served as a foundation for family nursing.

Understanding Family Health Terminology

Concepts are ideas that persons in a shared culture understand. Terms and concepts can be familiar and have specific meanings; however, because everyone does not share the same

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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 2022-05-21 19:03:13.

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vocabulary, ideas are often understood differently. This section focuses on the art of nursing and provides terms and definitions related to family-focused care.

Individuals and Their Health

Nurses mostly attend to individuals in clinical practice. The word individual suggests ideas of separateness, distinct needs, and differences. The word person is also used to refer to an individual. Nurses care for people; some share characteristics, values, beliefs, attitudes, and actions, but all have unique, distinct qualities, and diverse behavioral patterns.

Patient V ersus Person

In health care, the term patient is used to refer to those looking for and receiving medical and nursing care. For some, the word suggests dependence, lack of individuality, and even anonymity. Nurses and other health care professionals often view patients as dependent with needs to be fixed, repaired, or healed. When a person becomes a patient, he sometimes loses individuality and unique needs may be overlooked or ignored. Being a patient often means inability to be a free agent. Patients are often acted upon by others, by professionals they usually do not know. Nurses say “my patient” or “our patient,” suggesting ownership. But people seeking care do not belong to nurses, other health professionals, agencies, or institutions. Sometimes the term client is used to describe those seeking medical care. This word has some similar connotations to patient, but it also refers to a customer or consumer of care. This term might imply choice and the right to have a voice in care, and in the busi- ness world “the customer is always right.” Some health care providers like the idea of client, but some say it sounds too business-like and prefer the word patient. Regardless of the terminology used, these persons are care seekers needing professional help. They enter a care delivery setting like foreigners going to an unfamiliar country.

D if f erentiating Among Individuals

People want to be seen as individuals who are different and unique even though most still see themselves as parts of groups. People get classified based on many qualities: gender, age, race, sexuality, culture, ethnicity, economics, education, vocation, and social network. Personality, motivation, wisdom, values, beliefs, character, and attitudes are other differ- ences. Yet, they also want to show their uniqueness with clothing, hairstyles, tattoos, and piercings. In addition, most want to determine their own fate and be treated with respect. They want personalized, not generic, health care. Failure to see persons as part of a family and household unit can create unintentional barriers to optimal care (Table 2.1).

Family

Family is the basic unit of society. The word family refers to two or more people related biologically, legally, or emotionally. For generations, families followed what was considered a traditional pattern—two parents who reared and launched children, a nuclear family. Some argue that families should never have been characterized this way (Coontz, 1992, 1997), that this ideal comes from white middle-class American families and is not repre- sentative of the diversity that defines families (Coontz, 2006). Current marriage and co- habitation patterns seem radically different from those of the past.

The term family is prone to misinterpretation. Authors, policy makers, educators, and health care providers use the word, but may fail to describe what they mean. Terms such as family values, family health, family practice, and family care mean various things to

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different people. Religious activists, local politicians, physicians, and even nurses have ideas about families. These ideas may not match the thinking of peers, teachers, or those to whom they provide care. “No traditional [family] arrangement provides a workable model for how we organize family relations in the modern world” (Coontz, 1992, p 5). Marriage definitions have been hotly debated and are viewed in divergent ways by ethnic and cultural groups (Coontz, 2006). Shared ancestry, who lives under a single roof, or a common head of household may provide instructive guides. However, these distinctions are just guides and do not exhaust the ways family is defined.

Family has long been identified as “a group of people, connected emotionally and/or by blood, who have lived together long enough to have developed patterns of interaction and stories that justify and explain these patterns” (Minuchin, Lee, & Simon, 1996, p 29). Dr. Suzanne Feetham has contributed greatly to our understandings about family as the ‘unit of care’ needing nurses’ attention (Box 2.1). In this textbook, family is loosely defined as a collection of persons who call themselves family and have a general commitment to the care and well-being of one another. Although this is not a legal definition, it allows nurses to identify persons who see themselves connected as a family unit. This imprecise definition also offers flexibility in characterizing family units.

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TABLE 2-1 Ch anging Patient Roles

OLD PATIENT ROLE

Defer to authority of others.

Expectations of medical practitioners are primary concern in care.

Respect the expertise of the medical practitioner.

Seek solutions of problems or get “ fixed” by medical practitioners.

Depend upon the expertise of others.

Accept information as provided and not ask questions.

Answer questions when asked.

Give only information asked for by others.

Adhere to instructions of others or become labeled noncompliant.

Rely upon medical experts to solve problems.

Expect the health care practitioner to tell you everything you need to know.

Assume medical practitioners to tell you how you are doing.

Expect others to prescribe medicine and treatments needed.

NEW PATIENT ROLE

Become a partner in health and illness care.

Expectations of individual seeking care and medical practitioner should be mutually shared.

Respect is mutually shared between medical practitioner and person seeking care.

Be actively engaged in self-management and personal care of health or illness.

Identify different medical choices or diverse care options and participate in choosing.

Expect to have information presented to you in clear, easily understood language.

Come prepared with own questions and receive answers.

Share beliefs, values, and preferences.

Choose plan of care based upon wisdom of expert and personal preferences.

Seek expert medical support and actively engage in solutions to personal care needs.

Obtain additional information from a variety of external sources.

Assume responsibility for own care and monitor progress between care visits.

Consult with others and take personal responsibility for knowing whether what is prescribed is what is needed.

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Thinking Family

Thinking family is an attitude nurses use in clinical practice situations. Nurses who think family know that individuals value members of their family unit, and even when members are not present in the care delivery setting, they still need to be considered. Nurses who think family know individuals are influenced by a family point of view. Nurses often lack the time needed to clarify relationships of linked persons. But nurses can ask who are the important persons the individuals connect with in daily life. Some family members give important support; some create conflicts and burdens.

The Family Household

Family is a context that links members over the life course. Families have different expec- tations of their members. Some encourage individuation and originality, and others insist upon conformity. Some have tight boundaries. Others have no boundaries. The family household has many implications (e.g., a structure, shelter, neighborhood, tangible or in- tangible resources) for unique family units (Denham, 2003). The household is more than

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BOX 2-1

Family Tree

Suz anne Feetham, PhD (United States)

Dr. Suzanne Feetham, RN, PhD, FAAN, has held clinical, research, and leadership positions in academia, health systems (Children’s National Medical Center, Washington, D.C.), the federal government (U.S. Department of Health and Human Services [DHHS], National Institutes of Health (NIH), National Institute of Nursing Research (Deputy Director and Chief of the Office of Science Policy, Planning and Analysis), and Health Resources and Services Administration (HRSA). Her work has focused on health care for families, underserved populations, and health policy. She is recognized nationally and internationally for her research and scholarship in nursing research of families and the integration of genetics and genomics in national education, practice, and policy. Dr. Feetham has a program of research in the care of children with health problems and their families. She has numerous publications on nursing research about families, using research to effect change in practice, families and health policy, health and urban families, genetics education, and genetics and families. In 1977, she developed the Feetham Family Functioning Survey (FFFS). Currently, this survey instrument is used in research of families across disciplines and has been translated into several languages including American Sign Language, Spanish, Russian, Bosnian, Chinese, and Japanese and has reported application in more than 70 research publications. She was co-editor of the first state of the science Handb ook of Clinical Nursing Research in 1999, and in 2001, she edited a volume of Nursing and G enetics— L eadership for G lob al Health for the International Council of Nurses, Geneva, Switzerland. From 1996 to 2001 at the University of Illinois at Chicago, she was co-investigator on federally funded family studies, including a family intervention for Bosnian torture survivors, and was principal investigator for a funded interdisciplinary project to develop a Web-based course on clinical genomics for health professionals. As holder of the H. H. Werley Endowed Research Chair at the University of Illinois at Chicago, she was principal investigator on a study of families considering genetic testing for cancer susceptibility; she was also co-investigator on four family studies funded by the NIH. She has also served as a Visiting Professor at University of Wisconsin–Milwaukee, a research consultant at Children’s National Medical Center, Washington, D.C., and a board member for the International Family Nursing Association. In August 2011, the American Academy of Nursing announced that Dr. Feetham was a recipient of the Living Legends Award for her notable accomplishments.

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just the space the family inhabits; it is linked to place and social networks, things that affects members’ lives (e.g., power of one’s name, finances, access to health). Understanding the difference between the healthy family and family health concepts is useful for nurses.

H ealth y Family

Individuals initially learn about health and illness in their family households. The household is where people first deal with the basic facts of life, such as conflict, comfort, care, adver- sity, and suffering. Early experiences of health and illness (e.g., injuries, accidents, illness, disease, disabilities) occur at home. Many household experiences become health and illness determinants, because the household is the place where habits, routines, and responses to health and illness are learned.

The term healthy family has been identified with nurture and care that members offer one another; healthy family traits (e.g., good communication, respect, shared responsibility, balance of interactions, shared religious core) have long been described (Curran, 1984). Healthy family suggests that members come together for the common good and that they support one another’s growth and maturity. They share time, interests, traditions, and re- sources. A healthy family is vibrant, has a sense of stability, has access to needed supports, provides its members emotional support, and balances individual needs against those of the family unit (Denham, 2003). A healthy family is one that effectively balances competing aspects of the household that have health and illness consequences for its members’ well- being and is successful at accomplishing needed tasks. Members care for one another’s needs as resources are acquired and equitably distributed to individuals. The idea of healthy family does not always include a health-illness perspective or factors relevant to biomedical concerns.

B eing an U nh ealth y Family

An unhealthy family is one in which pain, biophysical symptoms, or emotional problems prevent or limit an individual’s self-efficacy and the family unit is unable to perform needed tasks linked with concerns. An inability to effectively complete needed tasks, fulfill roles, or meet social obligations might indicate a family is unorganized. Even though this situation could lead to being less healthy, the family might not see their circumstances as unhealthy. Judgments from the outside are not always aligned with what families view as reality. When physical pain, symptoms, or emotional suffering interfere with abilities to complete self-care or family care, an unhealthy situation might exist. If members are unable to perform roles, fulfill obligations, or complete duties, outsiders might call them un- healthy. When social expectation are unfulfilled, one might be tempted to place an unhealthy label. For example, a family using or dealing illegal substances or a home where neglect or abuse occurs might be labeled an unhealthy family. Social values often influence what is or is not viewed as healthy. Thus, labeling a family healthy or unhealthy should occur with great caution.

Making H ealth J udgments

Nurses need to be careful about making judgments about what is and is not healthy. Some health care providers use the terms dysfunctional and noncompliant, referring to individ- uals or families that do not follow what is prescribed. To ensure a therapeutic relationship, nurses need to avoid judgmental attitudes. Families have ideas about what they need, and these ideas can differ from what nurses think.

For example, a nurse might meet a person with type 1 diabetes based upon laboratory results. A 36-year-old man presents with a blood glucose level of 198 mg/dL on a routine

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physician visit. The high blood glucose level might mean this person has failed to follow doctor’s orders, lacks personal motivation, or is irresponsible. However, before lecturing this man about the problem, be sure that fact finding is complete. The nurse may only know part of the story. He may think that he is working very hard on daily management efforts. He might lack family support. Maybe he has inadequate health insurance coverage and can’t afford the medical supplies. Maybe he doesn’t know how to manage his diet or has not been adequately instructed about needs for physical activity. The high cost of test strips might prevent regular daily glucose checks. He might be focused on pressing personal problems. A family assessment might reveal that he has great emotional and financial stress about a child with a serious and worsening disability. Nurses who think family know that individuals seldom have one problem at a time. They learn about holistic needs before making judgments.

Family H ealth

When terms like family as a system, family system, and family nursing practice are not defined, confusion about what is implied can occur. Medical professionals often focus on medical care for single persons. Implications for the family unit are largely ignored. A lack of conceptual clarity about family health contributes to this neglect. Nursing students often learn about family care needs when infants or children are involved. Families are largely ignored when adults need care unless they are disabled or need end-of-life care.

The term healthy family speaks to attributes of interacting members. It refers to ways members support and care for one another. The idea of family health is somewhat fuzzy. It is often referred to in the literature and identified as a goal of nursing, but it is seldom defined (Loveland-Cherry, 1996). Family health is a phenomenon that explains the com- plex interactions and relationships of a family household unit as they collaborate to maximize individual abilities for wellness and maintain what they view as healthful (Denham, 2003). Family health is connected to the whole family unit. Family health aims to maximize potentials of member actions (e.g., resilience, organization, adapta- tion, stability, support, caregiving) that contribute to the family unit’s health and well- being. Family health occurs when household resources are used to enhance member and unit well-being.

Families uniquely organize their lives. Some live in disorganized fray. It is useful to con- sider ways members relate and possible implications on health and illness. Family health refers to the health status of the whole family unit and how well the group is functioning. How well do members use their actions, abilities, and resources for the good of the whole, but also meet unique individual needs? A family focused on wellness will likely instill ideas about good nutrition and physical activity from cradle to grave. At the same time, individ- ual factors can alter the family unit. Early work on addictions demonstrates that an indi- vidual member can radically alter the family health of the entire unit by using enabling behaviors (Steinglass, Bennett, Wolin, & Reiss, 1987). A child born with a severe disability places great demands on family resources over a lifetime. Thus, family health is strength- ened or damaged based upon the family unit’s abilities and willingness to satisfy the needs for its members (Fig. 2.1).

Family Health Patterns

The family household is where members’ shared lifestyles produce uniquely constructed health patterns and routines. It is where health behaviors are taught, learned, and practiced (Denham, 2003.) Households are the basic units of analysis for collecting U.S. census data.

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The census defines a family household as: where two or more persons related by birth, marriage, or adoption, but unrelated people live. Non-family households are places where people live alone or share the place with unrelated individuals. Members of non-family households are connected to other households where they are still viewed as immediate or extended family members. Less than half of Americans are currently married, and similar reductions have been noted in other advanced postindustrial societies. Social class, culture, age, and race often influence family forms. Households members experience a continuum of wellness-illness care needs. This continuum is influenced by many things (e.g., genetics, culture, religion, peers, beliefs, values, attitudes, available resources). Developing individ- uals respond to things that threaten or support health and care management daily. The scale and forms of family influence upon individuals differ. Nurses can ask individuals about family priorities in caring for health and illness.

Individual Health

Research about family health identified that being healthy is more than merely the absence of disease (Denham, 1999a, 1999b, 1999c). Health is often described as holistic, but it is often viewed in terms of the presence or absence of disease or illness. Ask someone you know about her health. She might tell you about an illness or disease or say that she is not sick. She might describe her inability to be active, complete activities, care for basic needs, or do things for herself. Few will answer the question in terms of well-being.

Health could be described as the ability to have an active life. It might include things like taking part in family life, having emotional strength, feeling spiritually connected, or doing meaningful tasks. Some might think of health in terms of routines (e.g., eating a nutritious diet, being physically active, refraining from risky behaviors). Those living with a serious disease or a terminal illness might see themselves as healthy if basic self-care needs (e.g., take part in valued daily living activities, fulfill usual roles, do meaningful things) can be completed. Health is an adaptive state experienced as persons seek meaningful ways of being and wrestle with personal, family, household, and environmental liabilities across the lifespan (Denham, 2003). Family nurses help persons and family units clarify their expectations and engage in healthful activities they value.

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FIGURE 2-1 Nurses think family health and individual health.

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Models for Understanding Family Nursing

Ideas about family nursing have been evolving for decades. Many nursing scholars have contributed to a growing body of evidence about the value of family nursing. Yet, the ques- tion remains: How should family nursing be defined? In this textbook, we define family nursing as clinical practice approaches that address the person and family unit even when only one individual is present for care. Family nurses focus on families and their home set- tings where health problems are addressed and endeavors to create a healthy family are targeted (World Health Organization, 2000). Family nurses assist individuals and families to manage all aspects of wellness, health, illness, disease, and chronic disabilities. Family nurses realize that care needs exist beyond health care settings and aim to deliver coordi- nated care to family households.

In nursing, the application of a variety of theories and models offers different ways to define and deliver nursing care. Some grand nursing theories (e.g., Orem, Roy, Neuman) have been generated by nurses to guide nursing practice. Many of these frameworks have had several revisions and were updated so family perspectives were better addressed. The- ory can help nurses understand different approaches to clinical care. Theories directly linked with family nursing have emerged over the past several decades. These family the- ories offer distinct ways to think about how individual health is influenced by the family unit and household. Ideas about family systems nursing have been advanced through the Calgary Family Assessment Model and the Calgary Family Intervention Model (Wright & Leahey, 2013). These models are discussed later in this textbook. In many of the following chapters, a variety of middle-range theories useful in family-focused nursing practice are introduced.

A Systems Perspective

A non-nursing theory often used by nurses is general systems theory (von Bertalanffy, 1950). It can be used to think about care of individuals and families and encourages the nurse to consider the whole as more than the sum of its parts. Systems thinking provides ways to understand the connectedness and feedback responses as individuals interact with family members and their environment. Systems theory suggests that too much focus on the whole can result in overlooking the importance of the parts and too much attention to the parts risks the possibility of overlooking the whole.

Systems theory has been influential, but critics say it tends to emphasize some perspec- tives and ignore others. Systems theory can help one understand some aspects of family member interactions, but influential historical, cultural, and political factors are often ig- nored. Understanding about equilibrium might cause one to assume that individuals and families seek balance, but this assumption is not always true. Using systems theory, one might think that experiences or conditions are linear or circular in progressing from cau- sation to outcomes, but life more often is random and chaotic. Systems thinking can help nurses understand that multiple interacting forces are in play when an illness occurs or when needs to promote wellness arise. However, nurses might find some implications vague or difficult to apply in a practical way.

No clear-cut rules govern the ways family members interact with each other. The family is more than the sum of its members. How can one explain family health without taking into consideration the complexity of multiple member interactions outside the family unit? Is the family even fully explained by the members? Do other things also need to be taken into account? The uniqueness of family units, their discrete traits, and the roles of members need consideration. Systems theory aims to explore the whole, but the number, type, and

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magnitude of multiple member interactions and their implications for individual and family health can be overlooked. In systems thinking, ideas about environment are often vague and clear distinctions about values and relationships ignored.

An Ecological Perspective: The Family Health Model

There are different ways to consider individual and family health. Research findings about family health suggested that an ecological perspective could be a better model to describe family health, one with a household and community lens to better understand the family unit (Denham, 2003). The Family Health Model moves the focus away from acute episodic clinical care to more mindful thoughts about an individual’s relationships with the family unit, household, lived spaces, and the needs posed by daily life. An ecological model is a good way to think about multiple factors relevant to health such as:

• Relationships of shared and separate events and contexts • Individual and collective experiences • Interactive behaviors within and outside the family household • Effects of social networks, larger communities, and environmental circumstances • Perceived meanings, beliefs, values, or interpretations tied to health and illness • Multiple personal and family interdependent factors linked with health or illness

The Family Health Model suggests ways to identify interconnecting events and circum- stances. Nurses can use these interrelated ideas to complete assessments and complete nurs- ing actions or interventions. This model views family health as a socially constructed phenomenon. The Family Health Model has three domains: context, function, and struc- ture. Each domain provides a way to understand factors linked with individual and family health and to identify nursing practice actions (Fig. 2.2).

The Family Health Model provides a framework for thinking about nursing practice that includes relationships, needs, connectedness, and environment (Fig. 2.3). It is a way to think about the many obscure, interacting, and conflicting factors associated with health and ill- ness. Family health is influenced by the family’s internal and external environments. Box 2.2 provides some explicit points about the Family Health Model. This model includes ways individuals view themselves in connection to their family unit and household, but also offers ways to consider how these and other relationships or environments influence health and illness. This model suggest that things be considered over time and place. The lived shared experiences of multiple household members and their shared internal and external environ- ments have potential to affect their well-being, life quality, and illness or disease potentials.

Ecological thinking implies that multiple interacting, dynamic, and enduring factors across the life span are important. Family nurses can use these varied factors to see that intrinsic and extrinsic factors are assessed. When first using ecological thinking, one can be overwhelmed. New terminology is introduced. This thinking offers many different areas to assess—so many ways care might be delivered. Keep in mind that nurses do not address all factors with every person. Instead, these ideas can be used in conjunction with presenting clinical problems. Consider the following questions: What is most important at this time? Are there other factors that should be considered? What features about this person’s family unit and household might be relevant to this situation? Answers to these questions give directions for assessment areas that might lead to needed nursing actions.

Family C ontex t

The Family Health Model also suggests that health and illness are influenced by the family context, which is the first domain to consider when conducting an assessment. The term

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family context explains the deeply connected experiences that family unit members share over a lifetime. While the family unit is the context for its members, this unit is embedded into other complex systems (e.g., neighborhoods, communities, nations). These larger systems have other factors that influence health and illness (e.g., institutions, organizations, political milieu). Family members have discrete and shared viewpoints and often experience things differently. It is paradoxical that while families are somewhat predictable, they are also dynamic. Members and families evolve; they change over time. Nurses who think fam- ily know that family socialization and experience are critical factors when it comes to health and illness. The larger cultural, social, and physical environment exerts negative and positive potentials.

Family context mirrors some aspects of the larger societal systems. It is the stage for relationships and social discourse. The household is the place internal and external environments meet and exchange ideas that influence behaviors. The household is where many unique identities, values, beliefs, and attitudes are formed. It is where genetics, religion, culture, traditions, history, and behaviors, among other things, are shared. Care

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Contextual Domain • Individuals • Extended family members • Genetics, culture, ethnicity • Family household(s) • Friends, peers, co-workers • Neighborhood, community,

nation • Larger social context

(history, policy, time orientation) • Available resources • Time

Functional Domain • Developing individuals • Developing and maturing family • Roles and expectations • Core processes • Member interactions with each other • Member interactions with outsiders • External influences on family

members • Immediate and latent conditions

Structural Domain • Individual and family

routines • Routine meanings • Routine types • Routine characteristics • Routine purposes • Routine participants • Timing of routines conditions

Factors Influencing

Individual and Family Health

FIGURE 2-2 Factors influencing individual and family health.

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FIGURE 2-3 Ecological influences on individual and family health.

Individual and

Family Members

Family Household

Household Neighborhood

Household Community

Multiple Households Over Time

Multiple Interacting Environments

Social Influences

Government, State, Local, and Social Policy

Historical Period

given to individuals in clinical environments seldom reveals the complexities of family unit and household needs. Nursing assessment findings that take families into consider- ation help the nurse figure out the best ways to address care needs.

Family Function

In the Family Health Model, the functional domain is used to explain the interactive processes that occur as family members develop, mature, share time and experiences, and change within their household (Denham, 2003). The functional domain pertains to ways members interact, communicate, and relate within and outside the household and it helps explain roles, processes, and behavioral interactions. Members use many forms of relational processes to meet personal and collective needs.

Parents and others give social cues to developing children about ways to respond to health and illness. Family members often test these experiences as they engage the larger community (i.e., for work, play, school, faith, social or public policy). Ways to respond to wellness or disease are learned behaviors over time. Some ideas are steadfast, and others can be altered, but basically those ideas are formed as members interact with family. Some

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families encourage healthy lifestyle behaviors, but others do not. Some factors (e.g., resilience, identity, adaptation, accommodation) are influenced by family, but peer groups also play roles. Time alters some behaviors, but others change little. Some life events (e.g., mental ill- ness, disability, crisis, tragic death) can have dire effects on family units. Nurses who think family consider how these functional factors pertain to an individual’s health and illness.

Nurses need to know ways to interact with both well-functioning and troubled families. In clinical practice, nurses meet and aim to help people from all walks of life; some have multiple troubles that extend beyond the reason for currently seeking care. Nurses often meet people facing distressful life situations, critical incidents, and long-standing troubling predicaments. The Family Health Model suggests ways that nurses can use core processes (e.g., communica- tion, cooperation, coordination, caregiving) to address functional aspects of health and illness (Denham, 2003). These processes are described in Chapter 14. Each indicates ways nurses can use caring, treatments, education, counseling, and other nursing actions. Dr. Peri Bomar, in the late 1980s, published the first book to address health promotion with families (Box 2.3).

Family Structure

The third aspect of the Family Health Model is the structural domain (Denham, 2003). This domain focuses on patterns of behaviors, which includes habits and family health

36 CHAPTER 2 ● Moving to Family-Focused Care

BOX 2-2

K ey Principles of the Family Health Model

1. Developing persons experience individual and family health in relationship to all aspects of their lives; both can be either stable or dynamic over time.

2. Individual and family health are inextricably tied to the family household and communities. These influences can be positive and negative aspects of individual health and the health of the family unit.

3. Individual and family health are affected by the ecological relationships that connect family members within the family household to the larger environments with which they directly or indirectly interact.

4. The family is a microsystem that includes those viewed as part of the family and encompasses all the interactions occurring among individuals as they interact with external environments in everyday life.

5. The family and its members interact with multiple external environments (e.g., home, work, school, peer groups) that have the potential to affect individual and family health both negatively and positively.

6. The family and its members interact with diverse environments (administrative decisions by parent’s employer, boards governing school policies, etc.) that have the potential to affect individual and family health even when members are not direct participants.

7. Larger societal systems that represent the ideologies of the evolving world (e.g., legislation, social policy, culture, media, history) can potentially affect individual and family health.

8. Time and historical experiences have the potential to influence the family, its members, and their health in positive and negative ways.

9. Family health results from the complex interactions of the family, its members, and larger environments over time as the multiple interacting factors have potential to maximize or minimize the health and illness of individuals and the family unit.

10. Family health routines are important ways to discuss, describe, assess, intervene, and evaluate interventions and outcomes pertinent to individual and family health.

Source: Adapted from Denham, S. A. (2003). Family health: A framew ork for nursing. Philadelphia: F. A. Davis.

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routines. These patterns develop as members interact within the family household and with other larger environments. Family health routines have distinct traits: they are recognized by others, are shared in some instances, and have the potential to affect the health-illness continuum (Denham, 2003). These patterns, while not static, seem firm or stable over time. Routines may not be visible or of concern until something conflicts with them. Family members can often describe each other’s behaviors with great accuracy.

Family health routines are relevant to behaviors with disease risks. Nutrition and dietary routines are one category with great significance for wellness or disease management. For example, food consumption has many linked routines (e.g., meal plans, shopping, label reading, food preparation, meal patterns). Diets often include sugary drinks and chemical- laden processed foods with large portion sizes and high-calorie snacks. Despite the rele- vance of habitually shared behaviors in family households, questions about them are rarely asked. Nurses who think family know that family routines influence individual risks and can include these concerns when doing assessments and planning nursing actions. A person diagnosed with type 2 diabetes needs to modify his diet. What needs to be known about current individual and family dietary routines? How can long-standing family behaviors be changed? What are the goals or outcomes to measure?

Nurses who think family assess linked individual and family behaviors. They consider the family unit and household resources in goal setting. Strategies for change identify mean- ingful, achievable, and measurable outcomes. A dietary assessment (e.g., proximity of gro- cery store, food costs and availability, preparation time, nutritional knowledge, literacy level) that considers contextual, functional, and structural factors is an important step to- ward change. One needs to know what is currently happening before real change can be planned. Things like mealtime interactions of young children with asthma have been found to influence the quality of life (Fiese, Winter, & Botti, 2011). Disease management for young and older persons almost always involves family in some way. Family-focused care requires collaborative planning and decision making. Deconstructing risky routines and constructing new ones takes planning and intentionality. Nurses who think family begin by learning what is valued. They identify members’ cooperative spirit. They evaluate motivation or readiness for change. Medical care often involves needs for change that are

CHAPTER 2 ● Moving to Family-Focused Care 37

BOX 2-3

Family Tree

Perri Bomar, PhD

Dr. Perri Bomar’s first degree was a nursing diploma from a hospital school in Canton, Ohio. Subsequently she earned a BSN, MSN, and PhD. Her career took her to various institutions, the U.S. Department of Health and Human Services, the University of San Diego, and the University of North Carolina Wilmington (UNCW). At UNCW she served as Associate Dean and was instrumental in establishing the first master’s degree program in nursing, which began in 1998. Her first edition of Promoting Health in Families, in 1989, was recognized as the American J ournal of Nursing Book of the Year and the Nursing Outlook Book of the Year. Two follow-up editions of this text were published. This book has been used by nurses in the United States, Canada, Japan, Thailand, and other nations. As an African American nurse, Dr. Bomar has been instrumental in modeling the value of graduate education and has mentored many students who have sought her guidance and support. A number of her graduate students have progressed to doctoral studies with a focus on family or health disparities in underserved populations. Her most recent research is focused on describing and developing family nursing interventions that incorporate community-participatory research methods using evidence-based research focusing on self-management, spirituality, and the rural environment to improve health promotion with African American families.

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not easy. Family-focused care includes multiple members who either support or thwart behavioral changes.

Nurses who understand the importance of shared routines linked with health and illness use them during assessment, planning care interventions, and evaluating outcomes. Six areas of family health routines are identified in the Family Health Model (i.e., self-care, safety and prevention, mental health behaviors, family care, illness care, family caregiving). Families organize daily routines in ways viewed as meaningful and replacing old routines with new ones is difficult. Nurses who think family assist them in identifying goals and ac- tion steps that are Specific, Measurable, Attainable, Realistic, and Timely (SMART goals). Changing routines takes planning, strategies for making changes, and steps to evaluate along the way.

Moving Toward Family-Focused Care

Providing family-focused clinical care takes forethought and reflection. Nurses who think family plan care that considers the family unit needs. The frantic pace of daily work does not make it easy to always be thoughtful about what will be done, but taking the time to consider family needs can pay a big return. This next section describes differences between family-centered care and family-focused care.

Family as Contex t of Care V ersus Family as Unit of Care

Nurses need to plan the ways in which they approach clinical care. One can see family as the context of care or the unit of care. These terms were initially coined by Dr. Suzanne Feetham (1991), an internationally recognized family scholar and researcher (see Box 2.1). Family as the context of care implies that family is connected to individuals seeking care but is in the background. Family members might be viewed as directly relevant, but be seen as visitors, an afterthought, and not essential to immediate care.

On the other hand, when family is viewed as the unit of care, family members are in the forefront. They are viewed as fundamental to individual care. Individuals and family members are viewed as perpetually connected or inseparable. Individuals are inherently tied to others even when they are not physically present. When nurses recognize family as the unit of care, they understand that shared lives, resources, and identities play active roles in one another’s health or illness. Family is an abiding presence and not a transitory aspect of life. Attachments formed in the household are ties that bind even when we wrestle against them. As the unit of care, nurses think about individual care in terms of deep, intricate, entangled, and inseparable household member bonds. The family shares re- sources, provides caring relationships, and gives support for members. Thinking family means meeting holistic care needs of the individual in ways that include family involvement. Table 2.2 compares the ideas of family as the context of care and family as the unit of care.

Patient- and Family-Focused Care

The terms patient-centered and family-centered care are not often used consistently and therefore are poorly understood. Disease-centered care largely uses a biomedical focus with individual attention mainly given to clinical expertise, diagnostic tests, episodic care, and medical management. Patient-centered care requires health care providers who think about patient needs and focus attention on the individual receiving care.

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Patient- C entered C are

The Institute of Medicine (2001) suggests that patient-centered care implies that a respect- ful and responsive partnership among practitioners, care seekers, and their families to ad- dress patient values, wants, needs, and preferences is available. This model assumes that individuals actively seek care and take part in identifying needed services. Many people have limited knowledge about health care systems or the business of medicine. Identifying needed services in timely ways is not always easy. Individual needs are the target, but fam- ily involvement needs to be encouraged. Many are uncertain about how care should look in practice. Care consumers often make quick decisions. Technology and the Internet make access to medical information easy, but wading through Web sites when you have no med- ical background is difficult. Medical terminology and explanations are hard to decipher. The general public is often unsure about what is reliable or accurate. Too often, the first information accessed can be biased, confusing, incomplete, or not supported by scientific evidence.

Primary C are

Primary care is recommended whenever treatment is non-life-threatening and choices exist. Primary care begins when the person meets a health–care professional in a medical practice setting. Most people seek care infrequently over the life course. When the visit ends, the care recipient is expected to follow through on the prescribed treatment. Because care delivered is often limited to 8 to 15 minutes per visit, pertinent questions go unan- swered. In addition, people seldom receive a follow-up call to ask if everything is going well. A national study of 1,837 physicians who practiced at least 3 years past residency found that only 16% communicated via e-mail with patients, only 36% get patient feed- back, less than 50% use patient reminder systems, and only 14% of those in solo practices have adopted half of the patient-centered care practices (Audet, Davis, & Schoenbaum, 2006). Technology is available, but links between primary care providers and care con- sumers is lagging. Box 2.4 provides a list of patient-centered practices that can be used in primary care.

Questions remain about how much power and control are truly shifted to patients or families. The quality of care we currently have in the United States might be far from the quality we could have (Berwick, 2009). Patient-centered care needs to be linked with an experience in which individuals are informed in ways they desire (Berwick). This care should be transparent, individualized, and provided in respectful ways in which the dignity of persons is upheld. Personal choice and family involvement would make this care form superior to current delivery systems (Box 2.5).

CHAPTER 2 ● Moving to Family-Focused Care 39

TABLE 2-2 Families as th e Contex t of Care or th e Unit of Care

FAMILY AS THE CONTEXT OF CARE

Individual is the care focus

Family is in the background

Family is composed of individuals

Individual data reflect family

Care of solitary persons

FAMILY AS THE UNIT OF CARE

Family is the care focus

Family is in the forefront

Family is a unified whole

Family data also reflect individuals

Care of individuals and family

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Integrative C are

Integrative medicine is defined as patient centered, healing oriented, and a care form that embraces both conventional and complementary therapies (Maizes, Rakel, & Niemiec, 2009). It is different from the dominant biomedical model in that it is more focused on holistic needs. It recognizes that high-tech medicine is not always useful in addressing

40 CHAPTER 2 ● Moving to Family-Focused Care

BOX 2-4

Patient-Centered Care Practices

Examples of practices that incorporate actions sensitive to individual needs and evidence-based practices that can be used effectively in the clinical setting:

● Schedule same-day appointments. ● Exchange e-mail with patients. ● Text appropriate disease management reminders. ● Use reminder notices for preventive or follow-up care. ● Keep registries of individuals with chronic conditions. ● Update patient medication lists regularly. ● Store information in electronic medical records. ● Make information from referral physicians available promptly. ● Ensure that medical records or test results are readily available when needed. ● Feed back patient survey data into practice. ● Be aware that patient ratings of care affect compensation. ● Make information on quality of care about the referral physician available.

BOX 2-5

Providing Patient-Centered Care W ith a Family Focus

Care that is patient centered implies that individuals who are patients have more autonomy, share in decision making, and have a voice in what, where, when, and how things are done. For this form of care to truly become family centered, then the following changes need to occur:

● Hospitals would not have visitation restrictions, except those chosen by and under the control of patients.

● Patients determine the food selected to eat and what clothes they wear in hospitals (to the extent health status allows).

● Patients and family members participate in rounds and are included in reports. ● Patients and families participate in the design of health care processes and services. ● Medical records belong to patients. Clinicians, rather than patients, would need to gain access

to them. ● Shared decision-making technologies would be used universally. ● Operating room schedules would minimize waiting time for patients rather than follow the

convenience of the clinicians. ● Patients physically capable of self-care would, in all circumstances, have the option to perform

it and have family assist.

Source: Adapted from Berwick, D. M. (2009). What “ patient-centered” care should mean: Confessions of an extremist. Health Affairs, 2 8 (4), 555–565.

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chronic health problems. Addressing health promotion and disease prevention needs by including other methods such as nutrition and stress management could be more viable options but are out-of-pocket costs. Nurses’ education about integrative medicine is often limited (Box 2.6).

O rigins of Family-Focused Care for Children

Family-centered care was first described by former Surgeon General C. Everett Koop at an American Academy of Pediatrics conference in 1987. He spoke about care access and quality of life for children with special care needs. He called for commitment to establish a national agenda for families and professionals to work together through an initiative to focus on family-centered, community-based, coordinated care for children and their families (Box 2.7).

Many children’s hospitals include parents in care delivery. About 15 years ago, it was suggested that pediatric practice would be improved when nurses and other health profes- sionals approached care in intentional ways in which needs, cultures, resources, and strengths were included (Dunst & Trivette, 1996). Care needed to be delivered with effi- ciency, flexibility, quality, confidentiality, and privacy. Enlisting family members to teach nursing students and hospital staff about family needs has been suggested. Since 1998, family advisory councils have been in place in many children’s hospitals to improve customer service.

Family-centered care assures the health and well-being of children and their families through respectful family-professional partnerships (National Center for Family-Centered Care, 1989). This care focuses on the best interests of the child and family respecting the skills and expertise that each person brings to the care setting. Care hallmarks include trusting relationships, meaningful communication, cooperative decision making, and

CHAPTER 2 ● Moving to Family-Focused Care 41

BOX 2-6

Principles of Integrative Medicine

● Individuals and practitioners are partners in the healing process. ● All factors that influence health, wellness, and disease are considered (e.g., body, mind, spirit,

community). ● Appropriate uses of conventional and alternative methods are used to assist the body’s innate

healing response. ● Natural and less invasive interventions should be used whenever possible. ● All practice should be based upon the best scientific evidence available, open to inquiry or

questions, and allow for new practice forms. ● Individuals must decide on what treatments to have based on their personal values, beliefs,

and available evidence. ● Treatment alone is not enough; broad ideas of health promotion and prevention must also be

included. ● Integrative medicine practitioners should be exemplars of the practices they suggest and be

committed to self-exploration through reflection and continued development.

Source: Adapted from Maizes, V., Rakel, D., & Niemiec, C. (2009). Integrative medicine and patient-centered care. Commissioned for the IOM Summit on Integrative Medicine and the Health of the Public. Retrieved January 29, 2012 from http://www.iom.edu/~ /media/Files/Activity% 20Files/Q uality/IntegrativeMed/ Integrative% 20Medicine% 20and% 20Patient% 20Centered% 20Care.pdf

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willingness to negotiate. Research supports these ideas. For example, highly cohesive fam- ilies with low internal family conflict and a child with type 1 diabetes respond positively to a family-centered care approach (Hanson, DeGuire, Schinkel, & Kolterman, 1995). While family has been included into thinking, planning, and delivery of children’s care, adult care has been ignored.

The Institute for Patient- and Family-Centered Care (2010), created in 1992, was orig- inally focused on advancing family-centered care in pediatric, maternity, and newborn care. Their philosophy is grounded in thinking family members should play important roles on the care team. Now, because they realize that family is important in all care processes, too, their mission also includes adult and geriatric care. This vision acknowledges the profound changes needed in health care delivery. Nurses and other health professionals need to build on individual and family strengths, enhance their confidence, and build their competence. Family is indispensable to collaborative partnerships. Empowered relationships matter. Family can serve as advisors.

O rigins of Family-Focused Care for Adults

Family participation in health care is essential to nursing practice (Williams, 2006). Since ideas about family participation have primarily targeted children, there is little evidence of progress in actively including family in the care of all people regardless of age. Family- centered care for adults has been occurring during end-of-life care (hospice). Yet, while decades of results indicate positive outcomes of end-of-life care at home, some still die in institutions where poor communication between family and staff, inadequate support, and rude treatment still occur (Teno et al., 2004).

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BOX 2-7

Elements of Family-Centered Care for Children

More than 20 years ago, Surgeon General Koop identified some critical aspects of family-centered care for children with special health care needs. Ideas suggested then also appear relevant to needs of adult family members seeking health care services. These ideas include the following:

● Recognize that the family is the constant in a child’s life, while the service systems and personnel within those systems continually change and fluctuate.

● Share complete and unbiased information with parents about their child’s condition on an ongoing basis in an appropriate and supportive manner.

● Recognize that families have strengths, individuality, and different methods of coping. ● Encourage and make referrals so parents facing challenging situations with children can gain

support from other parents facing similar concerns. ● Facilitate parent/professional collaboration at all levels of health care (e.g., care of an individual,

program development, implementation, evaluation, policy formation). ● Ensure that health care delivery system design is flexible, accessible, and responsive to

individual needs and families. ● Implement appropriate policies and programs that provide emotional and financial support to

families. ● Understand and incorporate the developmental needs of children and families into health

care delivery systems.

Source: Adapted from Surgeon General Koop (1987).

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Challenges to Family-Focused Care

Clearly, a lack of appreciation for family-centered care by many still exists. Numerous con- straints continue to occur:

• Overly demanding provider-patient staffing ratios • Restricted family visitation • Health care systems focused on a provider-centric model of care • Unequal distributions of power • Lack of time to provide adequate information and support • Communication difficulties • Limits of fiscal resources

Many providers still restrict family visitation. Family care is ineffectively integrated, and information and education are provided without regard for unique needs, literacy level, or culture. Coordinated care still falls short during inpatient stays and is mostly disregarded when it comes to discharge home and the needs of those self-managing home care. Tech- nologies keep evolving and conversations about needs for cost reduction continue. Reduced length of acute care stays and growing numbers of those with chronic illnesses mean care- givers face greater burdens for longer time periods. Caregiver burden, stress, role fatigue, spousal burnout, and inadequate access to needed information are growing concerns. The inability to navigate the breadth of options in an unsystematic health care industry is often neither family driven nor caring. This evidence points to needs for different forms of care.

Nurses face stress from practice roles that make it difficult to separate professional ex- pectations and personal values. Nurses still take directions from the institutions, organiza- tions, and agencies that employ them. They observe the gaps between needed care and what is provided. They often sense they are powerless to make needed changes. Institution-based supports, adequate education for individual care needs, empathetic supervision, nonpunitive workplaces, and safe work environment where nurses can discuss and be included in the resolution of dilemmas are needed. Nurses need knowledge and abilities to be leaders in health care delivery and advocate for sensitive and supportive work environments that at- tend to individual and family unit needs.

Realizing Family-Focused Care

Adding another title to describe nursing care might seem superfluous or unnecessary, but the term family-focused care is used throughout this textbook to claim caring ideas that nurses can call theirs. The terms patient-centered and family-centered care are useful terms, but groups outside nursing largely control them. The term family-focused care is proposed to describe a care form that uniquely belongs to nursing. This practice is characterized by intentional actions and deliberate supports aligned with the wishes and needs of individuals and those they identify as their family unit. Family-focused care uses mindful relationships to meet holistic health and illness care needs; it is a care attitude conveyed through thinking family that intentionally and purposely guides nursing actions. This care values and respects the unique needs of individual and family units. Regardless of the care system or situation, family is always viewed as the unit of care. Coordinated care identifies needs beyond the immediate ones. Nurses who think family look beyond episodic care and identify the preventive actions needed to protect health and encourage wellness for the family unit. Clear communication is a hallmark of every nursing care encounter. Health education relevant to care management is provided in clear language and culturally appropriate ways. While providing family care, nurses ensure that adequate

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resources are available and interventions respect family household and environmental concerns. Family nurses use theories and scientific evidence to guide practice.

Implications of Family-Focused Care

In family-focused care, the individual and family are the unit of care. When single persons are seen in caregiving settings and family members are absent, nurses still identify the family household unit as the focus of nursing care. Because family-focused care is relationship- based, it fosters collaboration or partnerships. Nurses bring initiative, authenticity, and responsiveness to the care situation (Doane & Varcoe, 2005). Nurses who think family listen and hear the voices of those seeking care as well as those they recognize as family.

The nurse is aware that some ambiguity and uncertainty will always be found in caring situations. Family nurses avoid biased opinions, assumptions, prescriptive solutions, easy answers, and quick fixes. These nurses understand that many factors shape experience (e.g., culture, ethnicity, language, policy, systems). Family nurses notice personal strengths and use them in empowering ways. These nurses aim to understand the implications of the family house- hold on individual care needs. Finally, family-focused nursing allows space for personal reflec- tion, examination of biases and prejudices, and promotion of self-care and knowing oneself.

Usefulness of Family-Focused Perspective

People are connected to others through family and their social networks and nurses who think family know that. Even when some family members are not physically present, they have per- sonal meaning and influence. Those who seek medical care services are still attached to the values, fears, and stresses linked with their personal lives. Individuals may never give voice to these concerns unless invited to share them and perceive a caring person willing to listen. In- fluences beyond the immediate interaction may have great relevance to care. When nurses think family, they approach individuals judiciously and respect unspoken needs and concerns. Whenever you are involved in a clinical situation, it is good to take time and reflect about the skills required to effectively interact with individuals and their family members (Box 2.8).

As nurses deliver care, they are aware that other relevant factors beyond the immediate situation might need consideration. For example, a middle-aged gentleman is alone in the hospital room after a surgical procedure and says he is unable to sleep. An immediate response might be that he is awake from discomfort related to the earlier surgery. A nurse who thinks family understands that the sleep difficulties might have their foundation in family or household concerns. He might be worried about missing work and the income it represents. He could be concerned about the extra burden his wife bears for their disabled adult child. He could be anxious about his hospital bill and payment without insurance coverage. Although sleep medicine might resolve the immediate problem, it will not likely solve the more complex family-related hurdles. Family nurses look beyond the immediate and inquire about other possiblities.

Nurses’ Roles in Family-Focused Care

Family-focused care addresses young and old, healthy and sick, and dependent and inde- pendent. Varied needs are treated with sensitivity and the understanding that a larger under- lying story exists. Family members are seen as tangible supports. On the other hand, nurses also realize that sometimes families can be barriers. Some even sabotage the needed care. Family-focused care is used to assess family needs and assets. Outcome evaluation considers what is possible in a given family situation. Nurses build trusting relationships in which they

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can be respectfully curious about things not discussed and experiences not shared. The fused lives of multiple persons can enhance or threaten quality of life and wellness potentials.

Transforming the Nursing Perspective

A biomedical model is a common way students learn about nursing practice. Students are taught using biological, anatomical, and physiological aspects of human function and dis- ease processes. Learning about body systems can be difficult. However, gaining proficiency in responding to the complex interacting biological and social systems can be even more challenging. As the science of care is taught, the art of nursing care (e.g., process, emotions, consciousness, presence) is often relegated to the background. A reductionist perspective, in which individuals are viewed as separate parts or systems, can be shortsighted. It is like not seeing the forest for the trees! Wellness, health, disease, and illness situations have un- derlying stories that are unlikely to be easily or quickly told. Medical diagnosis is important, but it explains only part of the story connected to personal and family lives.

Nurses are usually taught to relate to single individuals. Education and experience com- municating with families or groups can be limited for many students. Often a sick model of care is internalized, with care being sought by an individual only when he senses or ob- serves a malfunction or problem. Most people report physiological problems. Those of an emotional, psychological, or social nature are often ignored or discounted. Immediate acute care needs get the most attention. Chronic disease management, prevention, and lifestyle behaviors to promote health often get overlooked. Family nurses know that coordinated care also includes wellness, health promotion, prevention, community, and population- based care needs. Take some time to review the case presented in Box 2.9 and consider ways the content of this chapter might fashion your thinking about care needs.

CHAPTER 2 ● Moving to Family-Focused Care 45

BOX 2-8

Evidence-Based Family Nursing Practice: Trilogy Model of Family Systems Nursing

Use of family systems nursing knowledge in clinical practice has been a challenge in the United States and many other parts of the world. Problems primarily occur in two areas. One is the concerns of nurses about their relationships with those seeking health care and beliefs about their roles. The second area of concern has to do with ways to bring nurse educators, researchers, and practitioners together as partners. These researchers have noted that the prevalent biomedical perspectives may be at odds with family systems nursing (FSN). Their findings suggest that the FSN approach uses a partnership perspective and competencies involve creating space for family members to participate in goal setting and identification of solutions. A study examined different forms and time lengths of education to prepare for practice in a variety of clinical settings. Findings indicated that nurses progressively incorporated FSN in practice as they received positive feedback from colleagues and families. The authors concluded that students and nurses need more time in supervised practicums to develop needed skills (e.g., family interviewing, therapeutic conversations, fears linked with family suffering and emotions, uncertainty). It seems that nurses seek the same level of direction and support for relational skills as they do for technical ones. Findings indicated that educators’ personalities and capacity to comfortably apply FSN skills influenced students use of knowledge. Messages about the potential use of FSN need to be shared among researchers, educators, and practitioners to demonstrate ways these three areas are interlinked.

Source: Duhamel, F., & Dupuis, F. (2011). Towards a trilogy model of family systems nursing knowledge utilization: Fostering circularity between practice, education and research. In E. K. Svavarsdottir & H. Jonsdottir (Eds.), Family nursing in action (pp 53–68). Reykjavik, Iceland: University of Iceland Press.

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Chapter Summary

This chapter introduces many ideas and terms nurses link with family-focused care. The idea of thinking family is used to introduce different ways to provide nursing care. An ecological model—the Family Health Model—is described as a useful way to view the complex lives of individuals and families. More about ways this model can be used in delivering nursing care will be discussed throughout this book. The varied places individuals and family units live influence health and illness. Nurses who think family acknowledge that influences on health and illness can be assessed and this information offers opportunities for nursing interventions. Family units and their households give important clues about resources, supports, strengths, and hurdles to overcome when it comes to getting healthy or well. Nurse who think family know that family is always present to individuals, even when members are not physically visible. This presence has meaning and direct implications for nursing care in all settings. The following chapters explore many implications of family-focused care and thinking family.

REFERENCES

Audet, A., Davis, K., & Schoenbaum, S. C. (2006). Adoption of patient-centered care practices by physicians: Results from a national survey. Archives of Internal Medicine, 166, 754–759.

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46 CHAPTER 2 ● Moving to Family-Focused Care

BOX 2-9

Family Circle

As you begin your early morning clinical experience in the medical unit today, you walk into a room and see Mrs. Cattrell, a frail older woman resting in a rumpled bed. Alongside the bed is a man who appears to be in his mid-30s; he is sleeping, reclining in a chair about halfway covered with a blanket. On closer examination, you notice that two IV lines are on one side of the bed. A large bag of normal saline is dripping steadily into a right arm site and a blood transfusion is dripping slowly into the left arm. The Foley catheter bagging hanging at the end of the bed looks as if it was recently emptied. You were told that her diagnosis is adult acute lymphocytic leukemia. She was diagnosed several months ago, and her condition has steadily declined over the past few weeks. She had experienced severe symptoms for several months before going to her medical doctor and being diagnosed. In morning report, you heard that Mrs. Cattrell has not been eating, slept poorly last night, seems somewhat agitated, and makes frequent demands on the nursing staff. Nothing was said about the man in the chair beside her. You were instructed to obtain her vital signs and assess her condition.

1. Using what you have previously been taught about completing traditional assessments, write a four- to five- sentence summary to describe the approaches you would take and identify the various things you would consider.

2. Now, use what you have learned from reading this chapter and think about ways a family- focused approach might be different from a traditional assessment. Write four to five sentences that describe the different kinds of things to include in a family-focused assessment.

3. Next, compare and contrast your ideas with three to four others in a small-group discussion. Make a list of the pros and cons of each approach to care.

4. Finally, come to group consensus about the best forms of nursing care for Mrs. Cantrell.

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