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Thinking Family to Guide Nursing Actions Sharon A. Denham

C H A P T E R 3

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

1. Identify various perspectives linked with health and illness. 2. Differentiate among the terms healthy, unhealthy, and societal health. 3. Describe ways in which nurses think family to deliver family-focused care. 4. Discuss ways in which thinking family improves individual, family, and societal health.

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

● Biomedical model ● Health care ● Illness ● Interdisciplinary practice ● Nursing roles

● Public health nursing ● Scope of nursing ● Social Policy Statement ● Societal health ● Theoretical perspectives

Introduction

The world of health care is changing. Health care costs keep rising and many argue about the best approach for health care reform. The Affordable Health Care Act continues to be debated. Health care programs based on need rather than ability to pay, as practiced in Canada and Europe, are continually being reformed as these countries wrestle with the grow- ing costs. Nursing practice the world over is influenced by each nation's health care policies. If nursing is to reach a place where practice can confidently meet societal health care needs, then changes are needed in some of the care approaches nurses use. Nurses have primarily been taught to focus on individual care needs. This perspective too often ignores the at-home family and household experiences and the societal linked health and illness risks. This chapter provides some ways to consider societal health and its meanings for individuals and families. New directions for thinking family in care delivery are described (Fig. 3.1).

Differentiating Among Health and Illness Perspectives

Health is a value or a desirable quality that allows a person to be capable of activities that add worth, quality, and enjoyment to daily life. We all want to avoid illness, 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 2022-05-21 19:03:22.

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threats, and injuries that lead to disease. Being healthy allows us to accomplish many meaningful things. It can be difficult to agree on health norms when a single standard for evaluation is unavailable. We live in a perplexing time with changes coming rapidly from every direction, a time of need for radical innovations that offers great opportunity. An amazing array of health enhancements (e.g., braces, glasses, contact lenses, cataract sur- gery, plastic surgery, gastric bypass) is available, yet many of these advances were unimag- inable less than 50 years ago.

Health care is often considered to entail diagnosis, treatments, tests, and drugs. Impor- tant things that might help avoid being ill, such as sleep, dietary changes, physical activity, and stress management, are often ignored. We might say that health and disease begin at a level difficult to see. Are our bodies really like a 3D print of how we live? What does it mean to live a full, joyful, and authentic life? Some think spirituality and faith are important for the body and the mind. Some say that being physically able is important but then drive around a parking lot several times to get the closest parking place. Many engage in risky behaviors (e.g., tobacco use, overeating, sedentary lifestyle). People often think that disease or illness can be fixed. Nurses mostly see people with medical problems.

Health allows us to be active and do many things. However, the meaning of normal or excellent health is not always clear. Health care consumers often hear confusing media messages. Ideas about norms differ, and it is often difficult to establish a single standard. In 1947, the World Health Organization (WHO) defined health as a state of complete physical, mental, and social well-being and not merely the absence of diseases. Capabilities that have a continuum of function (e.g., vision, sleep, and mobility) are difficult to measure. Some attributes are naturally altered with age. How does one measure a dynamic quality such as health? Even wellness has variability—optimal wellness to lower level wellness. Persons afflicted by the same disease do not suffer in the same ways. People with disabilities are not equally impaired. Healing and rehabilitation occur at various paces. It is not always easy to discuss disease rates, mortality, quality of life years, or environment. Persons in one geographical region may have health advantages not enjoyed by others. Genetic factors differ. Many health alterations are only identified over time. Some cultural and ethnic groups have norms viewed as abnormal in other places. We must take care not to confuse happiness and well-being with longevity and health. Good health does not guarantee a longer or better life. Living longer does not equal good health.

Rethinking the Ways We Define Health

Health and illness have multiple dimensions. Nurses might ask, Who is healthy? Who is sick? How do we decide who is and who is not healthy? Advanced technology (e.g., imaging,

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FIGURE 3 -1 Thinking family.

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genetic screenings) is used to identify medical conditions that we cannot always cure. Di- agnosis confirms that someone is ill, but when did the sickness begin? If a person has a chronic condition (e.g., diabetes, hypertension, heart disease, cancer), does this mean he is unhealthy? What factors cause people to see themselves as sick or well? A medical problem might imply that a special diet is needed, but is this person ill? Someone with a common cold might say she is sick and unable to attend school, go to work, or complete usual tasks. Ways in which individuals and family units interpret symptoms differ. These points of view can be extremely different from those of nurses or other health professionals. Judgments about who is sick or well differ widely.

Perhaps nurses need to discuss health and illness in different terms. What would happen if we spoke less about things related to medical care delivery (e.g., hospitals, physicians, technology, pharmaceuticals) and more about social determinants of health (e.g., environ- ment, water, sanitation, employment, housing, social justice)? Suppose issues were discussed in more measurable terms. For example, would it be better to spend less on repairing people after they are ill and more on keeping people healthy? It is good for nurses to understand some things about the ways money is spent for health care and its implications for families (Box 3.1).

Nursing Actions Related to Societal Health

What does health mean to large groups or broad populations? People often attend to their activities of daily living without giving great thought to health. Yet many actions relate to individual, family, and societal health. Some needs are basic (e.g., food, shelter, sleep, mobility). Others are aligned with quality of life (e.g., stress, hope to fulfill dreams, achievement, self-worth). In the United States, the aging populations have Medicare hospice benefits for end-of-life care. Growing numbers of aged persons over the next decade may need long-term care for chronic disorders that meets care needs at home. Caregivers will be needed more than ever. Older adults have different concerns than younger ones, and more attention will be needed for geriatric care and alternative care arrangements that include family (Scitovsky, 2005). Providing for the costs and needs of family members as they care for dependent family members 24 hours a day, 7 days a week, might be more critical than payment for brief primary care visits. Eight essential care dimensions have been identified that primarily relate to acute care settings (Box 3.2). Five

CHAPTER 3 ● Thinking Family to Guide Nursing Actions 51

BOX 3-1

Evidence Ab out Changing Costs for Medical Care

A decade-old study that examined Medicare outlays in the last year of life in 8,000 deaths found that little change had occurred over the prior 20 years, as 27.4% of medical expenditures were incurred in the last year of life (Hogan, Lunney, Gabel, & Lynn, 2001). Most persons had at least four significant health problems in the year of their death. Medicare expenditures largely included persons with heart disease, cancer, stroke, chronic obstructive pulmonary disease, pneumonia, or dementia. A surprising finding from this study was that minorities living in high poverty areas or factors viewed as social determinants of health were likely to have 28% per capita higher Medicare spending costs than those who did not. In this study, about 50% of those diagnosed with cancer were likely to use hospice care, yet only 10% of all others used it. However, 40% of the Medicare beneficiaries spent some of their last life year in a nursing home, where many deaths occurred. These findings indicate that the high cost of death largely has to do with caring for severe illness, dealing with functional impairment, and covering nursing home expenditures.

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primary drivers of exceptional family-centered inpatient hospital care experiences are identified as follows (Bailey, Conway, Zipper, & Watson, 2011):

• Leadership demonstrates a culture focused on patient- and family-centered care. • Staff and care providers are fully engaged in patient- and family-centered care. • Respectful partnerships among care providers enable them to anticipate and respond

to needs (e.g., information, comfort, emotional, spiritual). • Health care delivery is reliable and competent. • Evidence-based care is practiced.

When physicians discuss end-of-life choices with cancer patients, their health care costs are much lower in the last week of life (Zhang et al., 2009). Yet, many dying persons never get referred to hospice. More than a third of those referred spend only 7 days enrolled, and many would benefit greatly from aspects of care management lasting longer (Jennings, Ryndes, D’Onofrio, & Baily, 2010). Hospice care offers several things that families desire:

• Response to human consequences of profound illness (e.g., comfort, safety, support, choice)

• Continuity of caregiving among settings and providers • Response to evolving community needs (e.g., multiple diseases, children, prisoners,

rural residents, bereaved)

Dying persons and their families want autonomy and dignity. Things like responses to suffering, compassion, and vigilance at the end of life are important.

Concerns about societal health might consider what forms of care delivery are most cost effective in supporting family needs. What does society need when it comes to such prob- lems as cognitive dysfunction, mental illness, long-term disability, genetic disorders, or the homeless? Political leaders’ debates should include pressing family and societal health needs. For example, the obesity crisis is of great concern. About 33.8% of U.S. adults are

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BOX 3-2

Patient-Centered Care

In the late 1980s, the Picker Commonwealth Program for Patient-Centered Care and the Picker Institute identified important care dimensions: care access; respect for values and preferences; care coordination; information, communication, and education; physical comfort; emotional support; involvement of family and friends; appropriate preparation for discharge and care transition. Care needed includes the following things:

● Effective treatments provided by trusted staff ● Patient involvement in decisions and respect for their preferences ● Rapid access to reliable health care advice ● Clear and understandable information that supports self-care ● Physical comfort in a safe and clean environment ● Emotional support and empathy ● Involvement of family and friends ● Continuity of care with carefully managed transitions

Source: Gerteis, M., Edgman-Levitan, S., Daley, J., & Delbanco, T. L. (Eds.). (2002). Through the patient’s eyes: U nderstanding and promoting patient- centered care. San Francisco: Jossey-Bass.

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overweight or obese (Centers for Disease Control and Prevention [CDC], 2011). Obesity is a growing problem for other countries as well. Growing numbers of young children are at risk for becoming obese and even morbidly obese. Obesity is linked with heart disease, stroke, hypertension, type 2 diabetes, and some forms of cancer. Medical costs linked with obesity are in the billions, with obese persons spending $1,429 more annually for health care than those of normal weight (Finkelstein, Trogdon, Cohen, & Dietz, 2009). Others have found that obesity raises medical costs even higher ($2,826 in 2005 dollars), with estimates that annual treatment costs are about 16.5% of the national spending budget on medical care (Cawley & Meyerhoefer, 2010). Another study about relationships between middle-aged individuals, Medicare costs, and mortality found that obese persons at 45 years of age had a smaller chance of surviving to age 65 (Cai, Lubitz, Flegal, & Pamuk, 2010). Obese persons had lifetime Medicare expenditures of $163,000 compared to $117,000 for those at normal weight. Left unchecked, by 2030, it is predicted that obesity-related medical costs could rise to $48 billion to $66 billion a year in the United States (Wang et al., 2011). This is a great deal of money! Increased lifetime costs will sub- stantially increase the overall Medicare expenditures for today’s middle-age population. We are still learning about the full magnitude these costs will have on employment, disability, and health insurance.

In the 1990s, the World Health Organization began warning that the growing burden of obesity was becoming a global epidemic for industrialized nations and developing coun- tries. More still needs to be known about a global food system of processed, inexpensive, and commercially marketed items to children and adults. Nurses and the general public are often unaware of public health measures that might be used to reverse this still-growing epidemic. Some solutions rest outside the health care industry, but clinicians might make important differences. For example, lifestyle choices, the built environment, leadership capacities, prevention, public policy, and government interventions offer alternative approaches to the obesity problem. Coordinated actions are needed to solve a problem of this magnitude. Nurses who think family can help by looking beyond primary care settings and finding ways to address this concern.

While concerns grow about obesity, malnutrition and starvation are also growing problems. Inadequate nutrition affects physical, cognitive, and behavioral development. It can also cause irritability, lead to fatigue, and lessen the ability to concentrate. Not only is hunger a concern for people who are homeless and unemployed, but it is faced daily by families with inadequate incomes. Families often must choose between food and other basic needs (e.g., rent, utilities, and medical care). In 2014, Feed the Children reports that more than 17 million U.S. households face not having enough food for everyone in the family. Nurses who think family consider the health and illness of family units and the larger society, not merely individuals.

Think Family and Improve Societal Health

Health has many points of view. Physical health is usually discussed, but mental and societal health are often ignored. Societal health includes wealth distribution, equal opportunity, human rights, and ways people get along with each other. Health can be discussed as moti- vation, attitude, moral principles, or availability of care providers, systems, or programs. Societal health has been defined by such terms as employability, marital satisfaction, socia- bility, and community involvement (Renne, 1974). Evidence shows relationships between social networks and health status (Haas, Schaefer, & Kornienko, 2010; Song, 2011; Umberson & Montez, 2010). Societal health has effects on individual and family health.

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American veterans from the Iraq and Afghanistan wars number 2.3 million; 20% or more of them suffer from post-traumatic stress syndrome (PTSD) or depression, 19% of them might have traumatic brain injury (TBI), and perhaps 7% or more have both. Alcohol and drug abuse are problems for others (U.S. Department of Veterans Affairs, 2014). These injuries are often accompanied by other physical disabilities. Veteran families from many wars experience trauma, suffering, and challenges that last a lifetime. Homelessness and suicide are other factors faced by many veteran families.

Philosophy can provide other ways to consider social aspects of health. For example, health can imply abilities to adapt to changing environments, social situations, or surroundings (Dubos, 1987). Health is linked with relationships; it is an adaptive process, and is a socially constructed reality (Illich, 1975). Social groups attend to things they prize, things viewed as needed or attainable (e.g., car seat belts, infant seats, drug, alcohol, or tobacco use). Health can be discussed in terms of suffering and recovery. Some find individual suffering valuable, others don’t. Health can be medicalized with prescribed treatments that ignore the potentials of things the human spirit can accomplish.

People live interdependent lives with connections to social institutions. Do we really act on our own volition? Or are we continually influenced by household, neighborhood, and societal factors? So, what health indicators should we measure? What social factors are linked to family and individual health? Individuals and families are bound to the places where they live, learn, work, play, and pray. Social determinants influence thinking about health and are linked with life experiences (e.g., birth, development, live, work, age). Access to nutritious foods, quality housing, health care services, physical activity, workplace environment, and educational opportunity are social determinants of health. They affect everyday lives. An ecological point of view encourages one to see connections between society, individual, and family health.

Financial Costs of Health Care

Health factors can be influenced by one’s culture or nation. For example, even though Canada is part of North America some cultural perspectives differ from those in America (Box 3.3). The United States is one of the wealthiest nations in the world and spends more money on health care than any other country. Yet, the United States has growing health disadvantages with higher mortality rates and inferior health from birth (Woolf & Laudan,

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BOX 3-3

Canadian Perspective of Societal Needs for Medical Care

The Royal College of Physicians and Surgeons of Canada (2011) agrees that when it comes to medicine, societal needs have both quantitative and qualitative perspectives. Q uantitative needs are addressed by having the appropriate type and mix of physicians. These characteristics largely represent the public’s interest and role of educational institutions. Q ualitative needs have to do with the adequacy of the physicians’ knowledge, skills, attitudes, and willingness to assume the roles needed by diverse societies. Similar observations can also be made about nurses and other health care professionals. Professional competencies needed by population groups are often culturally specific responses to societal needs, social determinants of health, and the burden of illness. Although health systems play roles, policy choices that influence distribution of money, power, and resources at local, national, and global levels are extremely influential. Social concerns often result in legislation or laws that greatly influence the health of a society.

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2013). When compared with peer countries, the United States fares worse in nine areas of health (birth outcomes, injuries and homicides, teen pregnancy and sexually transmitted infections, HIV and AIDS, drug-related deaths, obesity and diabetes, heart disease, chronic lung disease, disability) than some other nations. These health problems affect all age groups until after 75 years and are of particular concern for persons up to 50 years. Several reasons for the concerns were found:

• Fragmented health care; weak public health and primary care; and a significant segment of uninsured people

• High-calorie consumption; abuse of prescription and illicit drugs; traffic accidents; more firearms; more sexual activity (earlier, more partners, riskier practices)

• Higher poverty rates; pace of education is falling behind • Stark differences in land use (distance from food sources, residential segregation by

socioeconomic status)

Although U.S. health care spending is almost 2.5 times higher than that of other nations, adoption of health information technology has lagged behind (Organization for Economic Cooperation and Development, 2011). In the United States, the government plays a large role in financing health spending and spends more than any other developed country.

Some might say that the United States is an illness profit industry. Health care and hos- pital cost finances have evolved without clear pricing formulas or attention to wide cost variations across geographical settings (Reinhart, 2006). Few Americans truly understand the complex payment systems. Nurses and other professionals are uncertain about the ways costs are derived and have a difficult time making sense of medical expenses. Some people pay far more for medical care than others. Health care spending involves more than just making everybody’s insurance cheaper; it is also pertains to cutting unnecessary spending and paying for needed things in equitable ways.

Health Care Reform

Health care reform is needed. Dissatisfaction with current processes abound, yet the best ways to restructure things continue to be argued. The Affordable Health Care Act was intended to hold insurance companies more accountable, lower health care costs, offer health care choices, and improve care quality (Box 3.4). The Affordable Health Care Act is intended to improve quality of care and the population’s health, but also to reduce costs of quality care. Yet, this reform does little to alter the ways care services are delivered. Family nurses can lead the change in ways care is provided. Nurses who think family can

CHAPTER 3 ● Thinking Family to Guide Nursing Actions 55

BOX 3-4

Affordab le Health Care Act

The Affordable Health Care Act established a National Strategy for Q uality Improvement in Health Care (U.S. Department of Health and Human Services, 2011) that has set these priorities:

● Make health care safer by reducing harm caused in care delivery. ● Ensure that patients and families are engaged as partners in their care. ● Promote the most effective prevention and treatment practices for leading causes of death

(e.g., cardiovascular disease). ● Enable communities to promote wide use of best practices to enable healthy living. ● Make quality care more affordable for all by developing and using new health care delivery

models.

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identify needs of family units and plan care to truly satisfy unique care needs. A culture of health innovation is essential if acute and home care is to support safe practice, health eq- uity, and comprehensive needs. Nurses who think family can provide leadership in rethink- ing the ways coordinated care is delivered across care settings.

Nurses’ Roles in Societal Health

Nurses who think family can ask: What forms of health care are most needed to promote societal health? A compelling body of evidence suggests that some old ideas need to be reexamined to meet present and future needs. Are biophysical needs the only concern? How can psychological and emotional needs also be considered? What can be done to provide better care for families and society? How can nurses use integrative medicine? What roles can nurses play in partnerships and interprofessional care? How can nurses better evaluate whether quality care has been delivered? Many things are of great concern, but which are within the scope of nursing practice? What would society consider effective nursing practice? In what ways can nurses use critical thinking, clinical judgments, and moral reasoning to set priorities for nursing care delivery?

As one thinks family, nurses must be able to gather, analyze, and synthesize information from a variety of sources. Options and implications need to be weighed. What happens if you act one way instead of another? Thinking family employs intentional actions, evaluates needs, and weighs costs and benefits of actions taken. Societal health is linked with the places people live and what they do in their households. Increasing evidence shows that geography matters and needs are influenced by where people live (Behringer & Friedell, 2006; Cummins, Curtis, Diez-Roux, & Macintyre, 2007). Noting where people live (e.g., rural, suburban, urban) and related concerns (e.g., isolated, dangerous, natural disasters) gives important information.

Reform in moving from a disease management focus to a sustained healing network is needed. Nurses have long had a social contract with the public (Box 3.5). The Social Policy Statement suggests that nurses need to lead in some care processes and be therapeutic collaborators in others (American Nurses Association, 2010). Collaborators can assist individuals, families, and communities in ways that satisfy care needs outside traditional medical delivery sites. Nurses who think family might seek answers to these questions: How can I be prepared to meet individual and family needs? As a nurse, what does society expect from me? What does the social contract imply about nursing roles? Proactive re- sponses to these questions can lead in new directions.

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BOX 3-5

American Nurses Association Social Policy Statement

As early as 1995, the American Nurses Association’s Social Policy Statement described family as a target for nursing care. The Social Policy Statement is a contract that acknowledges the care mechanisms to be incorporated into practice. Ideas included in this contract are public accountability, professional social responsibilities, appropriate stewardship, and a valued scope of practice dedicated to meeting the needs of the society served. The 2010 revision of this contract reaffirms the importance of social roots and nursing’s societal commitments at all levels of practice and educational settings. The scope of nursing practice includes concerns about educational content of nursing programs, clinical practice experiences, varied nursing roles, and population needs.

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Needs of a Nation’s Families

Well-functioning societies need healthy people. So, a big question is how can the family units that make up a society be healthier? What do families need most? In what ways do the needs of individuals and families differ from those of society? What can nurses do bet- ter? How do we set policy that encourages strong families? How do we provide the kinds of care that people really need? Family-focused care can address immediate care needs but it always asks about broader family concerns for now and in the future. Nurses who think family remember that factors that influence illness and health transcend solitary settings and single points in time.

As technologies change and information increases, real needs must be in the forefront of care. Affordability and access to health care services are important, but so are answers to questions about health equity and fair and just service distribution. For example, difficult decisions about who gets what care are important. What are the most efficient, effective, and affordable ways to manage the health of a nation’s families? If families are society’s building blocks, then shouldn’t they be the focus of nurses’ attention?

A wide cast of health care professionals is needed to fulfill society’s needs. Nurses will need to address the challenges that best fit within their scope of practice. Are there tradi- tional practices that need to be questioned? What should stay the same and what must change? What creative ideas can family nurses bring to practice? Attending to family units and global perspectives both require some new practice models. How can nurses use family-focused nursing as an avenue of change? What can nurses do to transform nursing practice so that it better meets society’s needs?

Individual and Family Health Care Needs

Individuals and family units need clear information, adequate supports, and abilities to self-manage health and illness at home. Consumers must be able to navigate through health care systems. Some reorganization of care delivery is needed so individuals and family units can have more active roles in their care (U.S. Department of Health and Human Services, 2011). Health care systems are discussed as if they existed but little about care delivery is systematic. Families are rarely informed about what health care services to access. What is needed? How do people decide when and where to go? How do they choose among the public health department, a nearby clinic, or a medical practice? When should you visit urgent care or an emergency department? Care consumers do not always have good information about what steps to take.

Effective care delivery is not a motto, buzzword, or a mission statement. Effective care provides what people want, the means to solve real problems and answer their questions. Satisfaction levels are likely to be low if needs are ignored. Some people might even think that this is a form of disrespect. We speak of being partners in care. A partner is an asso- ciate, teammate, or collaborator. Partners have voices in decisions and make choices. Fam- ilies need voices in the care they receive and need to be at the table where decisions are made (Box 3.6).

Needed Changes in Acute and Inpatient Care

The Institute for Healthcare Improvement has provided leadership to improve inpatient stays and hospital experiences (Box 3.7). Rather than being treated paternalistically, as in the past, families should be considered an essential part of the care team. Nurses who think family do that. Respectful partnerships equip people to participate in their care. They are encouraged

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58 CHAPTER 3 ● Thinking Family to Guide Nursing Actions

BOX 3-6

Changes for Meeting Individual and Family Health Care Needs

ORGANIZ ATION PERSPECTIVE

Choices and decisions need to be made by the persons most affected.

Safety is a concern inside the care setting, but a critical need for those at home.

Family members are not obstacles in the way of efficient care delivery, but important caregivers with responsibilities to the individual receiving care.

Patient and family satisfaction and outcomes are likely to be improved when they are empowered by nurses and other health care professionals.

Family members are not just people to treat politely or view as optional to meeting care needs, but they are necessary and the true caregivers.

PATIENT/FAMILY PERSPECTIVE

Consumers have choices and rights.

Individuals and family members need full disclosure and clear explanation about what is occurring in care settings.

Family members need to be informed about diagnosis, care needs, ways to best support unique individuals, and how to care for themselves.

Individual and family members need information about care to be given, decisions that need to be made, problems that might be encountered, and ways to access needed supports and resources.

Individuals and family members want to be involved, know what is expected, and be prepared to meet the required needs in their households.

BOX 3-7

Criteria for Ex cellent Acute Care Delivery

The Institute of Medicine (2001) recommends redesign of health care systems and aims for improvement in six areas:

● Safety ● Effectiveness ● Patient-centeredness ● Timeliness ● Efficiency ● Equity

Care is respectful and responsive to individual needs, preferences, and values; it includes listening, effective communication, and family presence.

to ask questions so that all aspects of the care delivery are understood. Box 3.8 suggests steps nurses can use to gather information and use that evidence in nursing practice.

Nursing Care That Individuals Want and Need

What do people want when they enter health care settings? Research indicates that consumers do not make rational choices based upon high-quality and low-priced care (Lubalin & Harris- Kohetin, 1999). The weight given to quality-of-care information about health care services chosen does not indicate how quality-of-care information is used (Faber, Bosch, Wollersheim, Leatherman, & Grol, 2009). We lack strong evidence about the kinds of care most wanted.

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Persons seeking care find that good manners, kind treatment, friendliness, genuineness, confidence, and passion of the nurses are important. Some of the best employees are identified as persons who know their strengths and use them to make contributions. Responses to an injection can be perceived differently. Those who receive injections from excellent nurses might report feeling less pain. Differences between the two groups can result from the way nurses set the stage before giving the injections. They might say something like “This might hurt, but I will try to be gentle.” A show of empathy and compassion for the pain of the experience can cause nurses to be higher on a likability scale. Personal skills such as showing self-confidence, using etiquette, giving compliments, or using humor can help them seem approachable and encourage conversation. The best nurses get more compliments than com- plaints. Nurses who enjoy their work and create personal and positive experiences for those in their care might be viewed as more trustworthy. Nurses often have different beliefs and values than care recipients, but care experiences are transformed by use of nursing presence.

D elivering E x cellent N ursing C are

Excellent care is more than hospitality. W. Edwards Deming (2000) is widely known for his work in quality measurement. He said that, if you cannot measure it, you cannot improve it. He also said that even though care delivery is important, most people want an experience that meets their unique needs. They want information they can use. Nurses who listen to individ- uals and family members, provide human touch, and show empathy are valued by most.

Being in a strange bed, sitting alone in the emergency department, waiting to learn of surgery outcomes, hearing unfamiliar medical jargon, and dealing with technical procedures and clinical care systems can be stressful. Nurses who think family offer care that puts people at ease, addresses fears, and answers questions. Dr. Marilyn Friedman was one of the first nurses to pay careful attention to the need for completing family assessments; her textbooks have been used by thousands of nursing students since the 1980s (Box 3.9).

H aving Meaningf ul C onversations

Nursing students and some nurses may fear having certain conversations with individuals. They worry about saying the wrong thing or not knowing all the answers. Sometimes talking with strangers and the uncertainty of what to discuss can be uncomfortable and they avoid situations by busying themselves with tasks. But those diversionary tasks are

CHAPTER 3 ● Thinking Family to Guide Nursing Actions 59

BOX 3-8

Ideas for Moving Forw ard in Evidence-Based Practice

1. Define and clearly articulate the information needed to answer specific questions. 2. Identify and choose appropriate sources of information relevant to the question. 3. Develop and use clear and effective search strategies using predetermined terms. 4. Locate and retrieve all information that appears relevant to your question. 5. Evaluate the usefulness of the information retrieved. 6. Organize and analyze the information pertinent to your specific question. 7. Determine if any important facts relevant to the question asked are still missing

(e.g., economics, legal information, social aspects, policy). 8. Synthesize the findings in ways that best answer the question asked. 9. Determine the strength of the evidence used to answer the question asked.

10. Decide whether evidence identified is strong enough to alter practice or if more information is needed.

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sometimes read as rudeness, disinterest, or not caring. For example, what does it mean if the nurse has a furrowed brow when telling a person he has “bad veins?”

What is a meaningful conversation? It is not measured by length but by the quality of the interaction. Maybe it demonstrates empathy. Perhaps it is about sharing what will happen in a particular experience. What questions do families have as they wait for a surgical outcome? If someone said it was an invasive surgery, what does that mean? Nurses might see some med- ical procedures as mundane, but the family waiting might recall hearing about air bubbles that could kill you, “blowing out” veins, or “bleeding out.” These ideas produce anxiety.

Speaking about death can be an awkward situation and too often these conversations never occur. Yet it is an experience that all humans will face. When is the right time to speak of death? Medical providers might be hesitant or sidestep the topic. Facing the end of life is not a single or simple thing. It is shared with others. It can be a conversation that happens over time. It might not occur until very late in treatment of stage 4 cancer, maybe only weeks or even days before death is inevitable. What opportunities might be lost through this delay?

How do nurses gain expertise in conversing about uncomfortable things? How does one learn the best ways to approach difficult subjects? Nursing students need skills and expe- rience to be at ease. Sometimes it can be easier to talk with strangers than with those who are closest. The best conversations are dialogues, involving give and take. The nurse might say something like "When you think about what is happening, what is of most concern?" When nurses think family, they realize dialogue means listening. Nurses are not required to have “the answer” or give advice. Being an active listener is important. Active listeners ask questions that encourage others to tell their story—it is not your story!

Family Content in Nursing Education

Ideas about nursing education are continually evolving but are based in the biomedical model that guides medical diagnosis and illness treatment in the Western world. This

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BOX 3-9

Family Tree

Marilyn M. Friedman, PhD (United States)

Marilyn M. Friedman is professor emerita from the California State University School of Nursing in Los Angeles, California. She is recognized as the author of the first family nursing textbook. In the late 1970s, while teaching community health nursing to students, she recognized the lack of adequate teaching materials about family care. She envisioned having a book to use in teaching nursing students that would conceptually define family nursing practice. She developed a family assessment framework that has been used by countless thousands of nurses as they have studied family and community health. She used the sociological literature available at the time to create an assessment tool that could be used to measure a family’s structural-functional dimensions. Dr. Friedman has made an important contribution to nursing as she identified that family nursing is distinct and different from ideas of nursing care for individuals. She has helped us realize the importance of family as the unit of care, differentiate potential risks and needs of various types of families, understand the developmental stages of families, and consider behaviors of a well family. Her early work enabled nurses to use theory as they considered the health care needs of families and stressed the importance of completing a comprehensive family assessment. In 1981, the first edition of Family Nursing: Theory and Assessment was published. Over the years the book was revised several times (1986, 1992, 1998), and in 2003, the final version of Family Nursing: Research, Theory, and Practice was published. In 2005, at the Seventh International Family Nursing Conference in Victoria, British Columbia, Canada, Dr. Friedman was awarded the Distinguished Contribution to Family Nursing Award for her important contributions to the field of family nursing.

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focus is on problems, issues that are “not normal.” Nurses learn to do health histories, physical examination techniques, and observation, and use laboratory findings to treat and manage illness. They are taught to view people across the life span and holis- tically, including family and other related factors (e.g., culture, emotions, spirituality, environment).

Yet nurses are not always well prepared to work with family units (e.g., involve them in decision making, support caregiver needs, include them in care) in care settings (Institute of Medicine, 2001) because their education is focused on episodic illness needs. They know they are to address wellness, health promotion, and disease prevention, but do not always know how. Nurses know that coordinated care is needed, but they are not always well pre- pared to ensure that what is needed at home is addressed in the acute care setting. Nurses who think family learn to organize care to anticipate unique needs that might occur in different settings.

Preparation to Address Family Health Needs

To address family and societal health, nurses need to learn more about integrated care. Integrated care is more than cures and treatments. It includes family health history, genetics, current concerns, availability of support, adequacy of resources, personal goals, individual values, community, and environments. It involves consultations with interprofessional care- givers and use of conventional medicine and complementary therapy providers. Integrated care uses an array of cost-effective therapeutic services and processes.

Changing the approach to nursing care requires changes in what is learned and how that knowledge is applied in practice. Perhaps concepts of wellness, the power of the brain, and mind-body relationships need more attention. Letting go of tradition, changing ideas previously learned, and incorporating new knowledge may not be easy. How can nurses be leaders in delivery of new care forms? Will nurses lead or will they follow? Dr. Marilyn McCubbin is an example of a leader; her work has helped nurses around the world under- stand the problem of stress for individuals and families (Box 3.10).

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BOX 3-10

Family Tree

Marilyn McCub b in, PhD (United States)

Dr. Marilyn McCubbin served as the former faculty director at the University of Wisconsin–Madison School of Nursing and as the director of the Nursing Center for Research on Health Disparities at the University of Hawaii at Manoa. Along with her husband, she developed the Resiliency Model of Family Stress, Adjustment and Adaptation. Her research and scholarship advanced knowledge of family responses in health and illness and provided important directions to health professionals who worked to improve family care. Her research underscores the importance of strengthening individual and family resiliency as a mechanism for improving family adaptation. Dr. McCubbin’s work was instrumental in changing the ways in which we understand and conduct research about families with chronic illness. Her important work has moved the focus from family dysfunction and pathology to family resiliency and adaptation. Her work has been translated into German and Icelandic and contributed to our understanding about families from Germany, Korea, Japan, Iceland, Thailand, Taiwan, and the United States. In 1996, Dr. McCubbin was selected as a Fellow in the American Academy of Nursing in recognition of her significant nursing leadership in the United States. She has also received an award from the Family Health Research Section of the Midwest Nursing Research Society and, in 2007, was awarded for her distinguished contribution to family nursing research at the Eighth International Family Nursing Conference in Thailand.

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To think family, nurses need to include family responses to health and illness, have greater communication expertise, and be more familiar with family dynamics, health policy, and ways to do family interventions. Becoming a family nurse requires exposure to the lived experiences and concerns of those receiving care. It also involves the ability to perceive things from a different point of view.

Varied clinical experiences that allow nursing students to see broad life experiences of individuals and their families are needed (Benner, Sutphen, Leonard, & Day, 2009). These exposures can provide greater insights about larger life experiences. That means reaching beyond personal knowing and experience and investigating the other—those different from you. What does health or illness mean personally? Do personal views dif- fer from those of other family members? Is the family prepared to handle needs related to an illness, injury, or disability? Clinical situations suggest questions about ways to think family.

Shifting the Focus to Family

Learning to think family requires some new care orientations and philosophies. How can societal care and efficient, cost-effective, high-quality, and safe individual care be delivered? What is the best way to meet needs? How can nursing practice be transformed so that it meets the unique care needs of particular individuals and families?

Shifting focus from individual to family care will not occur without some battles. Most health care experiences involve only the individual. Some family members may accompany the person to the visit or sit in waiting areas, but they are neither addressed nor included in the care delivery. Unlike in some countries, home care in the United States is mainly for people with disabilities, those unable to travel, and those who are dying with hospice care. Most nurses never learn about household experiences because they never see individuals in their home settings. For example, hospitalized individuals in Malawi are dependent upon family members to bring food from home daily. Their overcrowded hospitals are just not prepared to provide for this basic need. Thus, family remains a constant in each individual’s life and nurses see them and identify their important caring roles.

Learning to think family is a process. Intentionally focusing one’s mind on family as a critical aspect of individual care might seem tedious at first. Family-focused nursing care has expectations whether family is present or not. Think about yourself; although your family is not always physically present, your family is still with you. Human connections occur in minds and hearts. Family-focused care is more than just comfort care, it includes intentional nursing involvement to satisfy unique needs presented.

Approaches to Family Care

Being a family nurse cannot be prescriptive. All will not look or act the same. A definition of a family nurse is one who identifies and attends to family as the unit of care in a breadth of care situations. Classroom, peer, and clinical experiences help one practice and gain un- derstandings about the variety and breadth of family experience. Box 3.11 identifies dif- ferent forms of nursing care, family-friendly care, and family-focused care. Box 3.12 differentiates individual and family care approaches.

Inadequate preparation for thinking family is a roadblock to providing family-focused care. Being a family nurse means investing time and examining personal assumptions and biases, incorporating evidence about complex family lives into practice, and honing skills for working with family units living in diverse community settings.

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BOX 3-11

Diverse Forms of Family Care

Primary focus

Nursing role

Individual’s role

Family role

FAMILY-FOCUSED CARE

Family as care unit: Intentionally included Inclusion Holistic measures Support Empowerment

Collaborator or partner

Care recipient

Care participant

TRADITIONAL NURSING CARE

Individuals: Acute or presenting

needs Cure or “ fixing” the

problem Treatments Procedures

Expert

Care seeker

Not involved in care

FAMILY-FRIENDLY CARE

Aesthetics: Sitting rooms Open visiting hours Private spaces Comfort measures

Consultant

Care recipient

BOX 3-12

Comparison of Individual and Family Care Focus

AREA

Care settings

Assumptions

Solutions to concerns

FAMILY CARE FOCUS

Care needs in traditional and other care settings (e.g., hospice, public health, community)

Family household Aware of importance of family roles in

care

Complex interrelated care needs include family members and household perspectives

Individuals include family, and household members are part of self-management

Individuals are never isolated from others and needs of multiple interdependent persons must be met

Assess needs and capacities of multiple members for needs linked with education and counseling

Interventions target needs of multiple family members and household concerns

INDIVIDUAL CARE FOCUS

Traditional approaches in diverse health care settings (e.g., acute care, ambulatory care, mental health, nursing home, rehabilitation)

Diagnose and treat Individuals make decisions and

family might be involved Individuals act alone and self-

management is tied to individual

Meet needs of solitary persons

Educate and counsel single persons

Interventions target single individuals

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Practical Application of Family Content

Knowledge about families is useful when it can be artfully applied to situations in ways that meets care recipients’ needs. Nurses who think family act responsively and deliber- ately to address diverse needs during clinical care situations. That approach requires prior thought and preplanning to select purposeful actions that satisfy distinct needs. Skillfully applying what has been learned in deliberate ways to satisfy family unit’s needs is the backbone of family nursing. Using deliberate actions implies that the nurse performs as follows:

• Exerts conscious efforts to reflect on assessed and voiced concerns. • Enters into interactions with individuals about family unit concerns that provide

answers to questions and information or support for identified problems. • Collaborates with the family unit to identify solutions. • Assists family units with finding needed resources. • Evaluates care outcomes.

Thinking family is not just a cognitive experience, it is an attitude that nurses develop and use. Family nurses know that families have similar needs, but express them in unique ways. For example, the initial loss of vision in a 48-year-old woman with type 1 diabetes may result in uncertainty and fear about the future. However, if the nurse doesn’t under- stand the concerns of family household members, ideas about what is needed are vague. Asking questions will clarify those needs: Does she have a job and will the vision loss affect her economic security? Is she the only driver in the family? What safety risks need to be considered? Is she the caregiver for others? What adaptations need to be made in her lifestyle? In what ways does she need assistance and who will help her? How will she spend her time if she cannot see? Is she responsible for cooking and cleaning? How will she manage daily activities without her vision? As the answers are forthcoming, it is likely that additional questions will arise. What will this vision loss mean to other family members? What are their questions and needs? Thinking family recognizes that every diagnosis not only raises questions for the individual, but also for the family unit. Think- ing family encourages potential vulnerabilities of the individual and family unit to be disclosed (Fig. 3.2).

64 CHAPTER 3 ● Thinking Family to Guide Nursing Actions

FIGURE 3 -2 Nurse uses deliberate actions to collaborate with a family.

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We tend to connect with what we know and have previously experienced. What do you know about yourself?

• Do you acknowledge the way things are or the way you want them to be? • What is it like for you to be vulnerable? • How do you experience others when they are vulnerable?

Learning new things sometimes means earlier ideas have to be unlearned or modified and that is not easy. Are you aware of things that you might need to unlearn as you consider thinking family? For example, does your behavior change in different situations (e.g., in an elevator, waiting in line, sitting in a waiting room, being with friends)? When we are in familiar situations, we know how to speak, where to look, and how to behave. In America, it is customary to walk to the right and let persons pass on the left. Did someone teach this to us? Or did we learn through observation? Notice how awkward it seems when someone tries to pass you on the right side. Yet, persons in other cultures might find our ways unnat- ural. Learning to forfeit what seems natural to learn new approaches takes time and effort.

G aining C onf idence

How is the confidence to interact with individuals and family units gained? Research used a pre- and post-test design to examine the self-efficacy of nursing students in a family nursing clinical practicum as they learned about family practice, home visiting, and collaborative practice (Ford-Gilboe, Laschinger, Laforet-Fliesser, Ward-Griffin, & Foran, 1997). Self- efficacy is the term used to explain perceptions about abilities to be successful in specific situations (Bandura, 1971). Perceptions of success are often remembered observations made over time. Those with high self-efficacy are likely to believe they perform well and often see difficult tasks as things to be mastered not things to avoid. Students took the pre-tests at the beginning of the school year and then again at 4 and 8 months later. It was only after the second post-test that their self-efficacy was noted to demonstrate significant difference. This study found that performing family nursing skills in a clinical setting was an essential source for gaining self-efficacy. Another study completed with nursing students in a com- munity setting yielded similar results (Laschinger, McWilliam, & Weston, 1999). So, learning and practicing skills in clinical settings can enhance self-confidence and perhaps skill use.

Th inking Family

The idea of thinking family is not new to this textbook. In 1997, a paper published by Clarissa Green described that concept as a primary building block for nursing care. She explained that this idea involved “understanding and appreciating the interactive complex- ity of family life from a systems perspective” (p 231). She suggested that a critical focus of nursing practice should be aimed at helping families develop skills and confidence in man- aging illness experiences and adjusting to challenges.

Students had previously completed a course in basic family dynamics. One assignment involved topics in a fictitious case (e.g., divorce, substance abuse, a caregiving crisis, an unexpected serious illness, loss associated with death, financial vulnerability). A second major assignment involved the student development of a fictional family to answer the question: “What is this family’s experience with difficulty?” Students found these topics challenging because they did not have much personal experience with conditions in family lives. The cases caused students to focus on three things: (a) factors contributing to or shap- ing the situation and related pertinent history, (b) family behaviors exhibited, and (c) what happens over time as the family members cope with difficulties. Students worked in small

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groups to consider what would constitute effective discharge planning, ways family health policies influence caregiving capacity, tools family members need to provide adequate care, and ways problems affect family roles, decision making, and health practices. Students were engaged with the ideas, but also evaluated their own thinking. The cases challenged the students and caused emotional responses and some personal discomfort. Students learned about strengths in troubled families and found that even big problems can get resolved without long-term harm to family members. Students were frustrated when they realized that they were ill-equipped to make their families do anything; it was family mem- bers and their unique circumstances that guided outcomes. Activities such as these are frus- trating at times, but learning from them can help one gain the ability to think family.

Putting Family K now ledge into Actions

Critical thinking, decision making, problem solving, and effective communication are essential skills to master to be an effective family nurse. Varied laboratory and clinical experiences pro- vide great opportunities to focus on the reading, writing, listening, talking, and reflecting needed to actively learn these skills. Simulated laboratory experiences can incorporate thinking family into case scenarios and provide time for shared learning experiences during debriefing.

In those experiences, the nurse begins to learn about family care. What does the family want to achieve? What things are needed? Even small changes in the right direction can provide a sense of accomplishment. You might not focus on personal concerns but rather on the immediate family need. For example, how will I answer questions about turning off the ventilator and allowing their father to die? Small things count. Listening, being present, and showing genuine care can make it easier to have difficult conversations once a trusting relationship is formed. Most people know that easy answers to hard questions do not exist.

Spending time doing critical analysis of family nursing and how it fits with nursing prac- tice enhances practice (Hartwick, 1998). Sharing personal stories among peers can affirm that other families with different experiences can have similar responses. Nurses find other useful ways to handle problem situations and collaborate with family members by hearing what their colleagues have done. Nurses who think family are in touch with emotions and notice ways they respond to others.

O bj ective and Subj ective Asp ects of N ursing Practice

Nursing care is objective because it uses scientific evidence, skills, knowledge, formal poli- cies, and standard procedures to guide care implementation. This objective work relates to the science of nursing. However, in the performance of care, the practice of nursing is also subjective and an art. For example, consider two nurses who perform the same pro- cedure with a hospitalized person. Both nurses carefully follow the same steps of the pro- cedure and demonstrate knowledge, skills, and competency. In reviewing the outcomes, one might find that satisfaction does not rest in nurses’ competency skills. Responses to the treatment might relate to the nurse’s attitude or behaviors. A business-like nurse might be seen as less helpful and receive a lower satisfaction score than the outgoing nurse who engages in conversation and appears genuinely interested. Thinking family has both ob- jective and subjective aspects in care delivery. See the case study about a family facing many dilemmas when trying to understand health care (Box 3.13).

Work with families requires emotional balance or what some might call emotional intel- ligence. One needs to show concern, but not demonstrate extremes. Family nurses are not without emotion. They respectfully show empathy and compassion, but remain logical and competent. Nurses are bound to have times when intense emotions are triggered. Also, people show emotions differently. Critically reflecting on laboratory simulation or clinical experiences

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allows nurses to safely discuss responses to care situations. Reflection about things that hap- pened in clinical environments can help one examine alternative ways to approach care.

Interacting w ith Families

Family members can be intimidating. The following situation illustrates this point. A co- worker came to the nurses’ station and asked if she could be reassigned to a different patient as she was quite disturbed by the way the patient's wife acted. It seems she had a notebook and every time the nurse entered the room, she wrote something down. The nurse complained, “She makes me nervous, I think she is trying to build a case against me for a lawsuit.” The nurse manager went to speak with the wife and inquired: “I see that you are writing things down in a book. . . .” The wife readily answered: “I am trying to keep a record of things, so I will remember them later. People come and go all day and each one tells me things. My memory is not as good as it used to be. Things happen one after another all day and it gets confusing. I am afraid I will forget, so I just write it down. Besides, it gives me something to do.”

Boredom and confusion that come from sitting all day in a hospital room seemed good reasons to keep a written record. She was not trying to catch anyone doing something wrong, but merely passing time and ensuring that she could recall things later. A brief con- versation easily clarified things. The other nurse was informed about reasons for writing. Later that day, the first nurse reported that she had spoken with the woman and discovered that they shared a common interest in quilting. Finding ways to relieve anxieties and get better acquainted with family members is a good way to correct false perceptions.

CHAPTER 3 ● Thinking Family to Guide Nursing Actions 67

BOX 3-13

Family Circle

Larry Hopsen had an excellent job until the recession hit. After a year of fear and frustration as he looked for work, he found a job. On his first day, he attended an orientation program and received information about health insurance options. He was told to return the paperwork by the end of the week. He took the papers home and gave them to his wife. She asked, “What do you want me to do with this?” He replied, “We have to choose a plan.” The Hopsens are in their early 30s and have two children. David, their 2-year-old, was born with a form of spina bifida called meningocele. Sandra has just turned 4 and appears healthy. Larry had asthma as a child, but it was well controlled until they moved into this new apartment, which seems to have mold. The Hopsens think that they might want another child. Mrs. Hopsen experienced gestational diabetes with Sandra. Many Americans do not understand their health insurance plans. They do not know how to choose a plan. If you were to counsel the Hopsen family, what would you suggest they consider? Consumers need two skills to understand health plans. One is the ability to read and understand the choices. The second need is numeracy, or the ability to reason with numbers and use mathematical concepts. Here are some questions to consider:

Traditional approach:

1. What can you afford? What are the monthly, quarterly, or annual payments? 2. How much is the co-pay? Are there any deductibles? 3. Are you or is anyone in your family being treated for any illnesses?

Family-focused approach:

1. What is the best value for your family? Tell me about potential problems in your family that might lead to health concerns.

2. Do you have any questions about the meanings of terms like co-insurance, annual benefit limit, out-of-pocket limit, drug tier, or allowed amount?

3. Is anyone in your family taking any specialty drugs? Do you know how much they cost?

It is a good idea to focus on wellness and health. Let us review the health care plans together and see what each family member needs.

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W orking w ith D if f icult Situations

Some situations can be difficult. For example, one might seem to be an intruder when en- tering a space that a family seems to claim as theirs. Maintaining privacy is not easy in an acute care setting. As nurses and others attend to clinical care needs, they often disrupt conversations. Nurses who think family learn ways to enter a family’s private space. For example, concerns about genetics and related diseases can be troubling for families. Dr. Marcia VanRiper has long engaged in research with families with Down syndrome and has demonstrated many ways nurses can work with these families (Box 3.14). They manage some common problems, such as setting boundaries, forming relationships, and finding things to talk about and learn to effectively ask tough questions.

Wondering what you will talk about with a family can be troubling, but recognizing the family’s strengths and competence can help (Wright & Leahey, 2013). For instance, the nurse might say: “Today, when the doctor explained the surgical procedure to your wife, I noticed that you listened carefully and asked several good questions.” This positive remark might be followed with something like: “I was just wondering if all of your ques- tions were answered or if there is something else you would like to know.” Entering a conversation in this manner can seem welcoming and easy conversation can follow. Some- times it is useful to be silent and just listen, then commend actions or behavior and ask for further details. Routine use of immediate and delayed affirmative responses can engage family members in useful conversations.

U sing N arrative Ap p roach es

A narrative approach can encourage family members to tell stories linked with everyday concerns and suffering; it is a valuable way for nurses to learn ways to take actions (Chesla, 2005). Conversation and stories can put family members at ease. It is good to have a few general questions that you can use in speaking with any family member, such as, what is most troubling to you about this situation? What can I do today to put you most at ease?

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BOX 3-14

Evidence-Based Family Nursing Practice

Marcia Van Riper, RN, PhD (United States)

Dr. Van Riper is currently a Professor at University of North Carolina at Chapel Hill, with a joint appointment in the School of Nursing and the Carolina Center for Genome Sciences. Dr. Van Riper teaches genetics courses. The main focus of Dr. Van Riper’s research has been the family experience of being tested for or living with a genetic condition. She has conducted numerous studies with national and international colleagues concerning families of children with Down syndrome. Dr. Van Riper completed a Mentored Research Scientist Career Development Award where she examined how families define and manage the ethical issues that emerge during four types of genetic testing: maternal serum screening for Down syndrome, carrier testing for cystic fibrosis (CF), B RCA1 and B RCA2 testing for families at high risk for breast cancer, and mutation analysis for Huntington disease. As part of this work, she engaged in a 3-year intensive, supervised career development/training plan that included (a) formal coursework in genetics, bioethics, and qualitative methods, and (b) interdisciplinary experiences, such as clinic and laboratory rotations, case rounds, journal clubs, and workshops. She recently completed a study about feeding issues in children with Down syndrome. Other work includes pilot studies on how minority families make sense of and use the results of genetic testing. Dr. Van Riper has been active in ISONG and served as the first president of the International Association for Family Nursing.

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What do you think is the biggest problem your family needs to solve? Who is having the greatest difficulty? Family members will tell their stories if invited. Family insights offer the best guidance for nursing intervention. Meaningful conversations with family members create a therapeutic context for healing changes. Stories can help nurses gather information, organize it, make sense of it, and use it to plan nursing actions or interventions.

Chapter Summary

Nurses need to understand the ways health and illness are defined and regarded by the larger society. Not everyone sees these conditions in the same ways. Families are the building blocks of a society. Some health care services may not be what the family needs most Nurses have a social contract. this encourages them to think about what society needs and apply this understanding to the nation’s families. The family household has great sway in determining individuals’ needs and resources. Much about health and illness is learned first from family and then influenced by larger societal forces. Individ- uals stay healthy or get sick in the presence of family members. Nurses who think family can take the reins in modifying clinical practice so that it better addresses family and societal needs. These nurses are keenly aware of the complex factors that influence health and illness.

Providing family care does not always come naturally. Practicing skills in class, in clinical situations, and with peers can be useful for determining the best ways to provide family- focused nursing care. This chapter introduces many topics that will be explored more deeply later in this book.

REFERENCES

American Association of Colleges of Nursing. (2011). The essentials of master’s education for advanced nursing practice. Washington, DC: Author.

American Nurses Association. (2010). Nursing’s Social Policy Statement. Silver Spring, MD: Author. Bailey, B., Conway, J., Zipper, L., & Watson, J. (2011). Achieving an exceptional patient and family

experience of inpatient hospital care. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement. Retrieved March 3, 2012 from www.IHI.org

Bandura, A. (1971). Social learning theory. New York: General Learning Press. Behringer, B., & Friedell, G. H. (2006). Appalachia: Where place matters in health. Preventing

Chronic Disease, 3(4), A113. Benner, P., Sutphen, M., Leonard, V., & Day, D. (2009). Educating nurses: A call for radical trans-

formation. San Francisco: Jossey-Bass. Cai, L., Lubitz, J., Flegal, K. M., & Pamuk, E. R. (2010). The predicted effects of chronic obesity in

middle age on Medicare costs and mortality. Medical Care, 48(6), 510–517. Cawley, J., & Meyerhoefer, C. (2010). The medical costs of obesity: An instrumental variables ap-

proach. National Bureau of Economic Research, Working Paper No. 16467. Retrieved February 2, 2012 from http://www.nber.org/papers/w16467

Centers for Disease Control and Prevention. (2011). Adult obesity. Overweight and obesity. Retrieved February 1, 2012 from http://www.cdc.gov/obesity/data/adult.html

Chesla, C. A. (2005). Highlights from the 7th International Family Nursing Conference. Plenary Ad- dress: Nursing science and chronic illness: Articulating suffering and possibility in family life. Journal of Family Nursing, 11(4), 371–387.

Cummins, S., Curtis, S., Diez-Roux, A. V., & Macintyre, S. (2007). Understanding and representing "place" in health research: A relational approach. Social Science & Medicine, 65(9), 1825–1838.

Deming, W. E. (2000). Out of the crisis. Cambridge: MIT Press. Dubos, R. (1987). Mirage of health. New Brunswick, NJ: Rutgers University Press.

CHAPTER 3 ● Thinking Family to Guide Nursing Actions 69

2910_Ch03_049-072 05/01/15 12:15 PM Page 69

C o p yr

ig h t ©

2 0 1 5 . F

. A

. D

a vi

s C

o m

p a n y.

A ll

ri g h ts

r e se

rv e d .

Faber, M., Bosch, M., Wollersheim, H., Leatherman, S., & Grol, R. (2009). Public reporting in health care: How do consumers use quality-of-care information? Systematic review. Medical Care, 47(1), 1–8.

Finkelstein, E. A., Trogdon, J. G., Cohen, J. W., & Dietz, W. (2009). Annual medical spending attributable to obesity: Payer- and service-specific estimates. Health Affairs, 28, w822–831.

Ford-Gilboe, M., Laschinger, H. S., Laforet-Fliesser, Y., Ward-Griffin, C., & Foran, S. (1997). The effect of a clinical practicum on undergraduate nursing students’ self-efficacy for community- based family nursing practice. Journal of Nursing Education, 36(5), 212–219.

Gerteis, M., Edgman-Levitan, S., Daley, J., & Delbanco, T. L. (Eds.). (2002). Through the patient’s eyes: Understanding and promoting patient-centered care. San Francisco: Jossey-Bass.

Green, C. P. (1997). Teaching students how to “think family.” Journal of Family Nursing, 3, 230–246. Haas, S. A., Schaefer, D. R., & Kornienko, O. (2010). Health and structure of adolescent social net-

works. Journal of Health and Social Behavior, 51(4), 424–439. Hartwick, G. (1998). A critical pedagogy for family nursing. Journal of Nursing Education, 37(2),

80–84. Hogan, C., Lunney, J., Gabel, J., & Lynn, J. (2001). Medicare beneficiaries’ costs of care in the last

year of life. Health Affairs, 20(4), 188–195. Illich, I. (1975). Medical nemesis: The expropriation of health. London: Marian Boyars. Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century.

Washington, DC: National Academy Press. Jennings, B., Ryndes, T., D’Onofrio, C., & Baily, M. A. (2010). Access to hospice care: Expanding

boundaries, overcoming barriers. In D. E. Meier, S. L. Isaacs, & R. G. Hughes (Eds.), Palliative care: Transforming the care of serious illness. San Francisco: Jossey-Bass.

Laschinger, H. S., McWilliam, C. L., & Weston, W. (1999).The effects of family nursing and family medicine clinical rotations on nursing and medical students’ self-efficacy for health promotion counseling. Journal of Nursing Education, 38(8), 347–356.

Lubalin, J. S., & Harris-Kojetin, L. (1999). What do consumers want and need to know in making health care choices? Medical Care Research & Review, 56(suppl. 1), 67–102.

National Organization of Nurse Practitioner Faculties National Panel for NP Practice Doctorate Com- petencies (2006). Practice doctorate nurse practitioner entry-level competencies. Retrieved from http://www.nonpf.com/associations/10789/files/DNP%20NP%20competenciesApril2006.pdf

Organization for Economic Cooperation and Development (OECD). (2011). OECD health at 2011. Retrieved on January 12, 2012 from http://www.oecd.org/document/30/0,3746,en_2649_37407_ 12968734_1_1_1_37407,00.html

Reinhart, W. E. (2006). The pricing of U.S. hospital services: Chaos behind a veil of secrecy. Health Affairs, 25(1), 57–69.

Renne, K. S. (1974). Measurement of social health in a general population survey. Social Science Research, 3(1), 25–44.

Royal College of Physicians and Surgeons of Canada (2011). Addressing societal health needs. Retrieved January 12, 2012 from http://www.royalcollege.ca/shared/documents/fmec/societal_health_needs.pdf

Scitovsky, A. A. (2005). “The high cost of dying”: What do the data show? Millbank Quarterly, 83(4), 825–841.

Song, L. (2011). Social capital and psychological stress. Journal of Health and Social Behavior, 52(4), 478–492.

Umberson, D., & Montez, J. K. (2010). Social relationships and health: A flashpoint for health policy. Journal of Health and Social Behavior, 51(1), S54–S66.

U.S. Department of Veterans Affairs. (2014). National center for PTSD. Retrieved August 20, 2014 from http://www.ptsd.va.gov

U.S. Department of Health and Human Services. (2011). National strategy for quality improvement in health care. Washington, DC: DHHS. Retrieved March 3, 2012 from http://www.healthcare .gov/law/resources/reports/quality03212011a.html

Wang, C. Y., McPherson, K., Marsh, T., Gortmaker, S., & Brown, M. (2011). Health and economic burdens of the projected obesity trends in the USA and the UK. Lancet, 378, 815–831.

Woolf, S. H., & Laudan, A. (Eds.). (2013). U.S. health in international perspective: Shorter lives, poorer health. Washington, DC: The National Academies Press.

70 CHAPTER 3 ● Thinking Family to Guide Nursing Actions

2910_Ch03_049-072 05/01/15 12:15 PM Page 70

C o p yr

ig h t ©

2 0 1 5 . F

. A

. D

a vi

s C

o m

p a n y.

A ll

ri g h ts

r e se

rv e d .

World Health Organization (1947). The constitution of the World Health Organization. WHO Chronicle 1, 6–24.

World Health Organization. (2012). Social determinants of health. Retrieved January 12, 2012 from http://www.who.int/social_determinants/en/

Wright, L., & Leahey, M. (2013). Nurses and families: A guide to family assessment and intervention (6th ed.). Philadelphia: F. A. Davis.

Zhang, B., Wright, A. A., Huskamp, H. A., Nilsson, M. E., Maciejewski, M. L., Earle, C. C., . . . Prigerson, H. G. (2009). Health care costs in the last week of life. Archives of Internal Medicine, 169(5), 480–488.

CHAPTER 3 ● Thinking Family to Guide Nursing Actions 71

2910_Ch03_049-072 05/01/15 12:15 PM Page 71

C o p yr

ig h t ©

2 0 1 5 . F

. A

. D

a vi

s C

o m

p a n y.

A ll

ri g h ts

r e se

rv e d .

2910_Ch03_049-072 05/01/15 12:15 PM Page 72

C o p yr

ig h t ©

2 0 1 5 . F

. A

. D

a vi

s C

o m

p a n y.

A ll

ri g h ts

r e se

rv e d .