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Communication With and About Families Sandra Eggenberger ● Sonja Meiers ● Sharon A. Denham

C H A P T E R 4

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

1. Discuss forms of communication aimed at assessment, care delivery, and health education. 2. Describe use of the individual-nurse-family relationship in communication. 3. Explain nurses’ roles in communication to meet health and illness needs. 4. Identify nursing actions in addressing literacy, health literacy, and information needs during acute

and chronic care situations. 5. Identify various communication models to guide interactions with individuals, families,

communities, and populations. 6. Apply ideas for communication with diverse groups.

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

● Asking questions ● Building trust ● Communication ● Communication barriers ● Communication breakdowns ● Communication theory ● Exchange and resource

theory ● Family systems theory ● Feedback ● Individual-nurse-family

relationship

● Life course theory ● Literacy ● Low health literacy ● Managing conflict ● Motivational interviewing ● Privacy and confidentiality ● Role theory ● Social learning theory ● Symbolic interactionism ● Trust

Introduction

Communication is central to the human experience. Skillful communication is essential for nurses to interact with those receiving health and illness care and make sure appropriate care is provided, health is promoted, and comfort given (Hagerty & Patusky, 2003; Peplau, 1997). Nurses communicate with patients, families, and other health professionals to form relationships, convey information, clarify perceptions, and manage distress. Students often

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Denham, Sharon, et al. Family Focused Nursing Care, F. A. Davis Company, 2015. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/mnsu/detail.action?docID=1963709. Created from mnsu on 2022-06-02 03:08:34.

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have more opportunities to learn about individual communication but less experience com- municating with or about families. Family, as the primary social structure unit, needs to communicate with nurses who are capable and confident in their communication skills. Most individuals accessing health care settings experience a sense of power imbalance. They are unfamiliar with the setting or systems, unclear about health care roles, and may not understand medical terms. Care seekers often assume dependent roles, while health profes- sionals adopt a more powerful position. In this interaction individuals and families may feel uncomfortable and vulnerable. They may not know what is expected or how to respond. Even though family members are often physically present, clear and thorough communica- tion with them is often absent. This chapter describes some basics of effective communica- tion and ways nurses can use them to guide individual and family unit interactions.

Providing Effective Communication

Effective communication needs to be a high priority in nursing practice. Nurses who use ef- fective communication create satisfying care environments. Communication is a transac- tional process. It is how people create, share, and regulate meanings of complex experiences in relationships (Dance, 1967; Segrin & Flora, 2011; Travelbee, 1966). Communication is the transmission of messages from person to person through processes such as writing, speaking, texting, teaching, e-mail, and body language. We are always communicating! Communication requires a transmitter and a recipient. Messages focus on what is intended to be said but often include a relationship message such as how the message is sent, how it influences the relationship and interaction (Watzlawick, Beavin, & Jackson, 1967). Was the intended message conveyed? Effective communication happens when questions are asked, information is given and understood, and comfort is provided. Nurses who think family aim for effective communication with members of the family and the family unit.

Reflect on how you communicate? Like most people, learning some basic skills can improve the way you communicate. Quality communication requires more than just knowing how to speak. It is being cognizant of how your messages are sent and, more importantly, received by the recipient. To analyze your communication skills you need to examine responses of the recipient, reflect on how the message was received and the response, and listen to critiques from others. Effective communication takes practice and conscious effort to improve. Dr. Lorraine Wright has played a key role in promoting awareness of family-focused nursing care and continues her important work worldwide (Box 4.1).

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BOX 4-1

Family Tree

Lorraine M. W right, PhD, RN (Canada)

Lorraine M. Wright, PhD, RN, a native of Canada, is an international lecturer and consultant. She has a strong background in family therapy that she has used in thinking about the ways communication assessment should occur with family members. Her early work about human problems, suffering, and the family dynamics when illness occurs greatly influenced her future work. She collaborated with Dr. Janice Bell in the development of the Illness Beliefs Model. Dr. Wright and Dr. Maureen Leahey developed the Calgary Family Assessment and Intervention Models. She was the director for the Family Nursing Unit at the University of Calgary for 20 years. The sixth edition of the textbook entitled Nurses and Families: A G uide to Family Assessment and Intervention (2013) provides excellent guidance for the best approaches to meeting the needs of multiple family members. In addition to

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Privacy and Confidentiality

Privacy and confidentiality are often addressed separately from communication, but they are essential to building the trust that is needed when providing nursing care. Individuals and families have private information they do not want to share with everyone and they have to know that their information will be protected by nurses. Privacy about health is central to ethical practice and the development of trust relationships (American Nurses Association, 2001). We live in an age in which nothing seems private, and with the increasing use of elec- tronic medical records and communication, individuals and families want to be certain that their privacy is always maintained. What does it mean to keep things private and confidential?

In 2003, the Privacy Rule was added to the 1996 Health Insurance Portability and Accountability Act (HIPAA) to regulate the use and disclosure of protected health infor- mation, which is any information held by the person seeking care that concerns health sta- tus, provision of health care, or payment of health care linked to an individual—essentially, any part of an individual’s medical record or payment history. However, the law allows health professionals to use judgment and experience to decide if uses and disclosures are in a person’s best interests. The idea of best interests is often used with underage children, but it also applies to adults. Best interests are also linked with mental health conditions, physical disabilities, comatose states, and persons unable to understand or speak. It is not easy to make judgments about what is in someone else’s best interest. It is challenging for outsiders to decide who has the right to know and what information can be shared. Today’s families are complicated and past social mores do not fit as well with current family con- figurations. So, determining with whom information can be shared can be difficult. Yet, nurses must be able to consider the family’s needs and concerns when communicating.

Agencies can establish rules for ways in which they verify relationships (Health and Human Services, 2008), but this practice is not mandated. Individuals can always give per- mission for information to be shared or discussed with friends, family, and others. If a person states that he is a family member, friend, or involved in the patient’s care, then HIPAA (1996) does not require proof. Nurses need to be aware of what the HIPAA does and does not regulate. Based on professional judgment, information can be shared by any method when others need to know or are involved in care. HIPAA does not forbid family members staying past visiting hours even when a room is shared. Calling out names is not an infringement of law and neither is posting a name at the patient’s bedside, as these incidental events cannot be directly tied to medical information. Some states interpret regulations differently and this might determine who can be viewed as a family member (e.g., domestic partners). Yet, the nurse must consider the individual and family member’s wishes and needs.

CHAPTER 4 ● Communication With and About Families 75

BOX 4-1

Family Tree—cont’d

this work, she also developed the Trinity Model and, in 2005, published a book entitled S pirituality, S uffering, and Illness: Ideas for Healing. Dr. Wright has widely published many scholarly papers, written many book chapters, and produced educational films and DVDs that demonstrate nursing assessment methods. Her personal Web site < http://www.lorrainewright.com/index.htm> provides much information about her work and some direct contact information. You can visit her blog page, The Wright Perspective, on the Web site, where she shares some personal stories. Dr. Wright has greatly influenced family nursing practice and has paved the way for many students and nurses to grow in their knowledge and communication practices with families. Although now retired, she travels regularly and continues to share her highly respected family work world wide.

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Rights to Information

Individuals and families need information that is clear and understandable so they know what to do, when to do it, and how to do it, and are aware of choices available to them. They need to understand the benefits, risks, and alternatives of care and procedures before they consent to them. They also need to know that they have a right to request other medical opinions, refuse treatments, or choose alternative practitioners or health care facilities. And family members need to know that they have rights as well. (Aspeling & Van Wyk, 2008; Bell, 2011)

Challenges can occur when someone the individual considers family is not legally rec- ognized and health care providers need to discern who has the right to make decisions. Who can decide? Sociocultural influences, end-of-life situations, and decision making can create challenging situations at times. Occasionally a person’s condition may warrant a nurse sharing health information without direct permission from a family member (Zerwekh, 2006). It is useful to have the person receiving care select a spokesperson for sharing family communication and most providers have the individual sign a document defining who they can share information with, if time permits. Nurses who think family know that rules for family communication must be fluid, be respectful, and consider pri- vacy and confidentiality while developing relationships. Breach of confidential and private health information in our technological world is addressed by position statements of the ANA (2006). Health system personnel and regulatory systems need to thoughtfully coop- erate as standards, policies, and laws to protect patient privacy and the confidentiality of health records and personal information change.

Communication and Nursing Practice

The social contract between nurses and society identifies needs for practice that support the attainment of positive health outcomes (ANA Social Policy Statement, 2010). Nurses need to use best practices as information is gathered and shared with families, messages are clearly transmitted, and collaborative relationships established. Nurses are connectors to broad forms of health care information that serve families and nursing practice with families (Box 4.2). Nursing care requires nurses who develop relationships with individuals and families through a focus on communication. Communication with and about families has potential to develop relationships that promote health and ease their suffering (Aspeling & van Wyk, 2008).

Nurses who think family collect information about socially linked persons during as- sessment. They learn about needs, resources, and supports useful in care coordination. If a nurse fails to collect family information during the initial assessment and health history, then essential information that can influence care can be missed. Clear nurse-to-family

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BOX 4-2

Developing the Individual-Nurse-Family Relationship

The individual-nurse-family interaction uses several primary areas of communication to accomplish important goals Meleis, 2012; (Schuster & Nykolyn, 2010):

● Exchange sound information between nurse and family. ● Ensure accuracy in delivering and interpreting of information messages. ● Share patient and family information with diverse health care providers. ● Transfer responsibility to and from the family during the care episode.

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communication conveys authentic care that shows acceptance and support. Nurses who think family use each contact to enhance health outcomes, guard safety, educate, and sup- port. Family-focused communication not only addresses individual needs but also involves the family unit in appropriate ways.

Cultural groups have traditions, customs, values, norms, and behaviors that influence contexts for communication (Box 4.3). Terms, dialects, and health literacy issues influence communication. For example, a nursing student may try to initiate a caring relationship through a teaching project about women’s health with a young Somali woman who is a practicing Muslim. Conversation might be difficult if the Somali woman is uncomfortable with the nursing student. An older Somali woman observing tells the student, “Please cover your breasts more fully if you will be working with my community; it is disrespectful to be showing so much.” The nursing student might think she can dress however she likes, but cultural respect for the values of others is an essential aspect of meaningful communication.

Nurse-Family Communication Perspectives

Health and illness situations and environments present complex challenges that can make therapeutic relationships difficult. Families bring unique life experiences and needs to care situations but nurses see situations through lenses of expert knowledge and professional experiences. These divergent views affect the sender and receiver of all messages (Box 4.4). Differing perspectives create ambiguities, and misinterpretations can hamper effective re- lationships. For example, parents of a young child with depression may believe that the child simply needs to act different and be stronger. They might not recognize the importance

CHAPTER 4 ● Communication With and About Families 77

BOX 4-3

Communication and Culturally Sensitive Actions

Culturally sensitive nursing actions pay attention to the answers to such questions as:

● Who in the family has the greatest influence on member health? ● What are the family expectations? ● Where do ideas about health and illness get attended to in daily life? ● When do family members seek health care services? ● How do decisions get made in this family?

BOX 4-4

Communication Needs of Families

In a health or illness care situation, families need:

● Consistently shared honest information ● Cooperative and collaborative partnership built upon rapport ● Recognition of individual and family perspectives ● Autonomy that honors and recognizes individual and family needs ● Purposeful interactions in an environment where information is not withheld and trust and

inclusion are fostered

Source: Rollnick, S., Miller, W. R., & Butler, C. C. (2008). M otivational interview ing in health care: Helping patients change b ehavior. New York: Guilford Press.

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of scheduled follow-up counselor appointments or the important differences a medication can make. On the other hand, the nurse might view their lack of follow-through as non- adherent behaviors and ineffectual parent care. Ineffective communication could mean missed opportunities for beneficial changes.

Medical language is easily misunderstood. For example, a person may be told that a newly prescribed medication will help with fluid retention. They may assume this means that the medicine will help them hold their fluids better and become concerned when they experience frequent urination. Suppose a nurse fails to clearly inform a person that a further diagnostic procedure needs to be scheduled after a clinic visit. The patient might think that the time is scheduled and assume that the procedure is not needed if she is not called. In- dividuals may be given guidelines for dietary changes to improve obesity, yet family mem- bers may not have the same understandings. Involvement of family members in these situations could prevent mistaken understandings. Nurses can use therapeutic relationships to address the humanity and uniqueness of family units, motivate them in positive ways, and value their strengths in making needed changes (Rollnick, Miller, & Butler, 2008; Wright & Leahey, 2013).

Individual-Nurse-Family Communications

Communication is the way individuals, family members, and nurses come to know and understand each other in the context of the family health experience (Meiers & Tomlinson, 2003). Clear communication can assist persons seeking care and help the family unit achieve wellness and maximize potential health outcomes. Nurses understand that indi- viduals are part of a whole and cannot be separated from their family. Thus, every indi- vidual met in a practice setting should cause the nurse to think family. Even absent family members are still present in the mind and life of the individual seeking care. Individuals have valued relationships beyond the immediate situation and these ties have strong impli- cations for care management and caregiving. Families need not only to be treated in respectful ways but also to be included as part of the care team.

Th inking Family to C ommunicate

Nurses who think family regard family as full partners in decision making about treatment options. Nurses’ roles entail clear communication to achieve the following:

• Deliver family-focused care rather than only individual-focused care. • Act as a health teacher, coach, and counselor to meet individual and family needs. • Use strengths-based perspectives when planning care and nursing actions. • Address the various ecological dimensions pertinent to a health or illness situation. • Assist families to prevent illness, maintain wellness, manage disease, promote health,

and restore health to household members. • Improve care outcomes. • Act as an advocate for the person seeking care and the family unit. • Increase satisfaction with health and illness care situations.

Caring relationships are often time limited but changes in health care delivery models could help nurses to advocate for care that is continuous and coordinated.

Nurses often face complex care situations and may have different opinions from admin- istrators, supervisors, peers, and an array of health care providers. However, those seeking care most often turn to nurses when help is needed and when that occurs. Nurses who think family must effectively advocate for the best care options for the individual and families. That responsibility requires the ability to effectively communicate with all persons involved to ensure the best outcomes (Fig. 4.1).

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U sing th e Individual- N urse- Family R elationsh ip s to C ommunicate

Family-focused care implies that nurses are sensitive to even unspoken individual and family unit needs. Student nurses may be uncertain as they learn ways to provide competent and safe care, but family nurses can learn to use the individual-nurse-family relationship to encourage care seekers to share concerns, describe needs, and ask questions. Nurses don’t always have the answers or solutions but they listen and collaborate to find answers and solve problems.

Meaningful communication is built on trust, respect, and professional concern. There- fore, family nurses must maintain appropriate boundaries, abstain from inappropriately disclosing personal information, and choose to behave ethically. Developing individual- nurse-family relationships can mean shifting away from some traditional practices, for example, viewing the individual and family as experts about their personal lives and moving more care from the acute care setting to the home. Even though nurses will always play crucial roles in providing care, they will increasingly become facilitators for care that extends beyond the present and no longer involves them directly but rather shifts the responsibility for health and illness care to families (Quinnet et al 2012).

Nurses who think family know that families need to be well prepared to give proper and adequate care at home. Nurses who value individual-nurse-family relationships see themselves as “in between”—they are often the potential links between “what is” and “what can be.” Nurses offer support and teach families how to define a critical event and when an emergency room visit is unnecessary, how to stay healthy, and how to manage their disease. To do that, nurses need to be aware of potential health outcomes and financial constraints associated with treatments and actions and be able to provide expert informa- tion, clear instructions, caring support, and proper referrals.

Communication: A Basic Tool for Exchanging Information

Connectedness is a basic need and part of the human condition. A sender, receiver, message, and the nature of the relationship are all involved (Barnlund, 2008). Figure 4.2 suggests

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FIGURE 4 -1 Families benefit when physicians and nurses collaborate.

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aspects in usual person-to-person communication. Nurse communication is rarely a single person-to-person interaction. Communication uses verbal and nonverbal behaviors as mes- sages are sent, received, and interpreted (Arnold & Boggs, 2010). Verbal elements include the spoken, electronic, or written word, while nonverbal communication refers to the voice tone, body motions, facial expressions, eye motions, hand gestures, and body positions (Schuster & Nykolyn, 2010).

Communication occurs constantly. Although some communication is intended, it is not always deliberate or purposeful. Miscommunication occurs when communication is not clear and meanings may not be grasped. In health care, the transfer of accurate information is critical. Failure to listen, interpret appropriately, or understand can lead to medical errors, safety risks, and untoward outcomes. It can also cause unnecessary suffering and increased uncertainty (Spath, 2000). In addition, unintended messages interfere with relationship building and can result in dissatisfaction with the care and less than optimal outcomes.

When communicating, perceptions, assumptions, and interpretations are critical. For example, a nurse enters a hospital room to complete caregiving tasks. Family members use this situation to ask questions. The nurse might view the questions as interruptions to the in- dividual’s care delivery. On the other hand, family members might assume that nurse presence signals availability to answer questions. If the nurse fails to respectfully acknowledge questions, the response might be viewed as rude and cause negative family behavioral responses. People become defensive when they think that they are perceived as unimportant or bothersome. A nurse’s negative relational stance can create future tensions and ineffective communication (Tapp, 2000). Box 4.5 identifies a number of strategies to improve communication.

Families need information about the best ways to care for their members. For example, the admitting nurse in a health care system documents the health history of an elderly gen- tleman with heart failure and notes his usual medications and daily activities. If the family is present, it is optimal to also obtain other information that may influence his care. For example, the family might describe his episodes of shortness of breath when climbing stairs or doing simple activities or discuss that he may not always take his medications as pre- scribed. Their information can be an important factor in evaluating his acute episode. If the individual is unable to effectively communicate, that resource is even more important.

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Message Provider and Receiver With

Assumptions, Perceptions, and Interpretations

Receiver With Assumptions,

Perceptions, and Interpretations

Message

M e s s a g e

FIGURE 4 -2 Traditional person- to-person communication models.

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Communication B reakdow ns

Despite the importance of communication, breakdowns happen when nurses and the health care team face multiple competing demands or fail to fully convey or receive information (Callery & Milnes, 2012; Curtis, Tzannes, & Rudge, 2011; Ellington, Reblin, Clayton, Berry, & Mooney, 2012; Jones, Woodhouse, & Rowe, 2007). Ineffective communication results from faulty assumptions of senders and receivers. For example, a nurse appears hurried as an elderly woman is discharged after surgery. The family senses this and does not ask what an elevated body temperature means even though they are told to monitor it at home. The nurse did not explain the term “elevated temperature,” when to check it or how to keep track of it, when it should be reported, or who gets the report. The nurse

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BOX 4-5

Facilitating Individual-Nurse-Family Communication Strategies

A number of verbal and nonverbal actions can be taken to facilitate the effectiveness of communication. Consider the following:

Introduce self and role to initiate interaction: “ My name is Angela May. I am the registered nurse who will be caring for William today. Can you tell me who you are?”

Eye contact: Be culturally sensitive to what is appropriate use with individuals and families: “ Tell me how your family was caring for your father in the home (make eye contact with each family member).”

Attention to family: Be aware of who is accompanying the individual seeking care, note if no one is present, observe interactions and ways of communicating with one another: “ Would you like to include your wife in your next clinic visit so we can review your medications?”

Create an environment that includes family: “ Would you like to help me walk with your wife down the hallway?”

Acknowledge illness experience: “ This illness must be a difficult time for your family.”

Speak with a tone of authenticity and curiosity about family perception: “ I can see how stressful this illness is for your family. What can I most do for you and your family at this time?”

Make or schedule time to focus on family without tasks: “Would it be acceptable to you if we asked your family to come to the next clinic visit so we can discuss your x-ray results and next steps?”

Use touch when it seems appropriate: Recognize cultural and personal differences in this regard.

Express empathy for family struggle, distress, and suffering: “Coping with these many care needs can be difficult; what needs does your family still have in giving you the support that you need?”

Purposefully involve family members in care: “ Come to the head of the bed and I will explain the purposes of these machines.”

Use nonverbal communication such as hand gestures to suggest the inclusion of family members: “ Please come in the room while I ask your husband some questions. Your name is . . . ? Would that be okay with you (addressing husband)?”

When you speak with other nurses and health care professionals during bedside report, introduce and include family members.

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mistakenly assumes that everyone knows what an elevated temperature is and when to re- port it. Suppose the family mistakenly heard “a temperature is expected” and fails to report an elevated temperature of more than 48 hours. The woman appears in the emergency room because “she is getting worse not better.” She is readmitted and diagnosed with sepsis. Ineffective communication too often results in poor outcomes, costly hospital readmissions, and dissatisfaction.

Even though nurses are busy and often working in stressful situations, they should always strive to avoid failed communication because it can create unnecessary risks such as accidents, errors, unsafe environments, poorer quality care outcomes, and decreased satisfaction (Schuster & Nykolyn, 2010). A landmark report by the Institute of Medicine (2001) estimated that 44,000 to 98,000 people die annually from medical errors and that communication breakdowns are the cause for about 70% of these errors. A report titled Crossing the Quality Chasm emphasized the need to establish effective communication and collaborative relationships to positively influence care delivery that results in therapeutic outcomes (IOM, 2001). Health care teams need to communicate effectively for a variety of reasons (Box 4.6).

B arriers to Family-Focused Communication

Health care systems are complex and not always systematic; weaving one’s way through a web of services and practitioners can be baffling. For example, various levels of nurses and numerous roles of various medical professionals and specialists exist in practice. These dis- tinctions can be confusing to those working in health care but even more so to care seekers.

Several factors in health care such as the system, literacy, stress, and time make effective communication even more difficult. Barriers to communication can exist from the individ- ual, system, nurse, or family perspective (Table 4.1). Barriers signal the need to find alter- native approaches to developing family-focused communication.

System B arriers

The stress of an unknown environment with its many technologies and strangers creates uncertainty, and dealing with unfamiliar physical settings, lack of privacy, need to contin- ually interact with unfamiliar persons, strange smells, and noise contribute to increase anx- iety. Trying to develop interpersonal relationships while managing technical communication within computer-mediated communication systems are concerns for care providers and care recipients (Hrarbe, 2005). While electronic medical devices, medical records, health information technologies (HIT), computerized medical databases, the Internet, telehealth, and social media might be viewed as beneficial, they can also contribute barriers to com- fortable and effective communication for some people.

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BOX 4-6

Health Care Teams’ Use of Communication Sk ills

Growing evidence over the past two decades suggests that collaborative health care teams with excellent communication skills do the following:

● Produce quality outcomes in complex situations that reduce mortality rates in intensive care units (Knaus, Draper, Wagner, & Z immerman, 1986).

● Reduce lengths of hospital stays and readmissions (Cowan et al., 2006). ● Improve chronic disease management (Bourbonniere & Evans, 2002).

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N urse B arriers

Inaccurate assumptions about people and situations are barriers. Suppose a nurse assumes that adult children do not want to be involved in the care of their father who suffers from Huntington’s disease. They seldom visit in the long-term care facility. This absence causes the nurse to assume that the family doesn’t care and that they are uninterested in their father’s care. The nurse has been heard saying negative things about them to a coworker. This nurse doesn’t know about the family’s complicated personal lives that make visiting hard. She is not aware that two of them are showing early signs of Huntington’s disease and are fearful about their futures. Erroneous beliefs and bias produce communication barriers.

Nurses might assume that the recipients fully understands the information they provided and that the recipients will “do as told.” Research has shown that nurses often use verbal and nonverbal strategies with an overtone of hostility, exclude the fam- ily from care, or maintain distance and a position of power over the family (Abraham & Moretz, 2012; Chesla, 1996; Nelms & Eggenberger, 2010; Soderstrom, Benzein, & Saveman, 2003). Nurses can seem aloof, irritated, angry, or distracted, and fail to respond in ways valued by individuals and family members. This negative communica- tion can increase suffering, vulnerability, and uncertainty, all of which can lead to mis- trust of the nurse (Eggenberger & Nelms, 2007). Nurses often admit they lack sufficient personal experience with some forms of communication, but projecting that attitude can produce ineffective individual-nurse-family communication (Soderstrom et al., 2003). Nurses who think family always strive to be conscious of their responses to others.

Family B arriers

Similar to nurses, with the stress of an illness or complex health care system, family mem- bers may also project emotions, anger, distractions, or irritation at nurses. Nursing students and even experienced nurses can be intimidated by these behaviors but must avoid respond- ing negatively to them by retreating, avoiding the family, or blaming them. For instance, a nurse upset by a family might say to a peer, “The Smith family is so demanding.” Rather

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TABLE 4 -1 Barriers to Family -Focused Communication

Individual

System

Nurse

Family

Poor written, document, and oral literacy Low health literacy Individual emotional, cognitive, or sensory factors

Busy, unfamiliar environment Technology-rich environment Potential for unintentional breach of privacy/confidentiality

Inaccurate assumptions Style of hostility and overtones of power Emotional stance (anger, aloof, distracted, irritated) Cultural biases, prejudices

Negative attitudes Discomfort with family communication skills Negative past experiences with nurses or the health care system Emotional stance (anger, distracted, irritated, fear, uncertainty, anxiety, distrust) Lack of hope, uncertainty, need for information, lack of proximity to the patient

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than resolving the misunderstandings, nurses might blame the person or family and those perceptions may alter the way other team members relate to the families. On the other hand, some family members can use approaches that are frustrating and confrontational. The family nurse strives to understand the family’s perception, experience, and responses in developing ways to partner with and connect with families.

Care seekers and families see communication as important to clinical care (Curtis & White, 2008). Nurse interaction may be the single most important aspect of care from the family perspective (Levine & Zuckerman, 2000). Families use this transactional process to create, share, and regulate meaning for their world (Dance, 1967; Gubrium & Holstein, 1993; Seagrin & Flora, 2011). Emotional state, worry, and other factors affect family ex- periences and perceptions. While some families freely express their concerns, others are silent, so the nurse who cares for the family from a perspective of understanding works to improve communication and nurse-family interaction.

When one family member is ill, other members also have needs. Needs for realistic hope, answers to questions, desire to be included, knowledge that optimum care is received, and current information about changes in condition are family concerns (Benzein, Hagberg, & Saveman, 2008; Eggenberger & Nelms, 2007; Meiers & Tomlinson, 2003). When a loved one is ill, family members often want to be near and included (Vandall-Walker & Clark, 2011). Inability to be near the ill family member increases anxiety and distress in some families as they may sense a family obligation or responsibility to be nearby when a member is ill. Communication that excludes the family or policies that deter their needs to be present and fulfill their family role can result in mistrust and anger. Box 4.7 provides information about Dr. Maureen Leahey, an expert clinician and leader in changing the ways nurses communicate with individuals and families.

Written Communications

Written communication can influence relationships. The way that care or a family response is documented can alter perceptions of the family when read by another health care provider. Objective information, rather than subjective information of opinions, can help prevent assumptions that may influence care.

84 CHAPTER 4 ● Communication With and About Families

BOX 4-7

Family Tree

Maureen Leahey, PhD, RN (Canada)

Dr. Leahey is an expert clinician, an author of many published journal articles and books, educator, and consultant. She is a graduate of Cornell University–New York Hospital School of Nursing and the University of Calgary. She has been an Adjunct Professor in both the Faculty of Nursing and Faculty of Medicine at the University of Calgary. She managed the outpatient mental health programs in Calgary and directed the Family Therapy Training Program. She is a member of the Canadian Nurses Association and a registered psychologist. She is also a clinical member, Approved Supervisor, and a long-standing Fellow with the American Association for Marriage and Family Therapy. Since the 1980s, she has been in the forefront of implementation of mental health programs in the Health Region. Dr. Leahey has collabored with Dr. Lorraine Wright and together they developed the Calgary Family Assessment and Intervention Models. Further, she and Dr. Wright have worked together in the writing of six editions of the family textbook Nurses and Families: A G uide to Family Assessment and Intervention (2013). This textbook is widely used by international audiences. She also worked with Dr. Wright on the series of eight videos in the How To Family Nursing series. She is a member of the International Family Nurses Association.

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Care instructions for individuals and families must be clearly written. Written information is best when it supplements and is not a substitute for a verbal explanation. Clearly written information at the appropriate reading level ensuring the recipient’s ability to read, level of reading, language, and culture are needed. Avoid using technical medical terminology. Poor instructions can have negative outcomes. For example, a child returns home after same-day surgery, but the family may not fully understand the written instructions about what to do if nausea and vomiting occur. Should they call the doctor if the child gags or spits up a small amount of vomitus or did the instructions mean vomiting that persists for 24 hours?

Written information must be effectively shared and communicated among health care team members to support safe and quality clinical decisions (Burns, 2011; Curtis et al., 2011; Dufault et al., 2010). Nurses regularly review medical orders and depend upon ac- curate written communication. It is essential that documentation describing observations, treatments, and other nursing actions is accurate. Nursing documentation is a legal record of the care provided. Be aware when creating written instructions that smart technologies sometimes correct spelling and if the wrong words are inserted, the information could be incorrect. Avoid using street language, slang, or symbols used in texting messages in any professional communication such as in nursing notes.

L iteracy

Accuracy often depends upon the literacy skills of the care recipient. Literacy is the ability to use printed and written information to function in society, achieve one’s goals, and develop one’s knowledge and potential (White & McCloskey, 2003). In the United States, one in three young adults have dropped out of high school. The United States is the only country among 30 Organization for Economic Cooperation and Development (OECD) free-market countries where the current generation is less well educated than the previous one (National Commission on Adult Literacy, 2008). Persons with low literacy might be unable to under- stand some oral language, and to use printed materials successfully the writing must be at an understandable level. Not everyone will admit to not being able to read so it may be difficult to determine if illiteracy exists. Sometimes using pictures or videos rather than describing procedures will be more effective. One can be literate in one language, but illiterate in another. Functionally illiterate persons often develop ways to manage their daily life without reading.

L ow H ealth L iteracy

Health literacy refers to the ability to read, understand, and act on health information. In 2003, the first-ever National Assessment of Adult Health Literacy was conducted. Only 12% of those surveyed were found to be proficient, 53% were at the intermediate level, 21% were at the basic level, and 14% were below basic (National Assessment of Adult Literacy, 2003). Adults in the basic or below basic health literacy category are less likely to access health information from written sources than adults with higher literacy levels. Those with lower literacy get health information from television and radio. Without adequate health literacy, millions have trouble with common tasks (e.g., reading prescription labels, adhering to an immunization schedule). Even high school and college graduates can have low health literacy. Improving health literacy is a goal of Healthy People 2020 (U.S. Department of Health and Human Services [USDHHS], 2010a) and the National Action Plan to Improve Health Literacy (USDHHS, 2010b). Health literacy skills can be learned through Internet courses.

Low health literacy is related to poor health outcomes and poor quality of care (Berkman et al., 2004). Forms of health literacy include document literacy, a measure to understand in- formation in forms, schedules, charts, graphs, and other information. Quantitative literacy refers to the use of numbers found in written materials. People need quantitative literacy to

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follow recipes, calculate tips, and tally costs. These skills are also needed for medication dosage and prescribed medicines. For example, 20% to 30% of medication prescriptions are never filled and about 50% of medications prescribed for chronic diseases are not taken as prescribed (Haynes, Ackloo, Sahota, McDonald, & Yao, 2008). Health literacy skills are needed to follow medication instructions, prepare for diagnostic examinations, understand health insurance plans, identify benefits or risks of medical treatments, calculate nutritional content, understand written test results, and complete a patient history form. Nurses who think family avoid using unnecessary medical jargon and complex general language. The best results for learners occur when information is grounded in experience. Listening to questions and observing behaviors when sharing information are helpful (Roter, 2011). Using dialogue or conversation to convey specific information is needed. Individualizing verbal instructions encourages optimal out- comes. See Box 4.8 to review a case study that provides an opportunity to reflect on the ways nurses can communicate with individuals and their family members.

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BOX 4-8

Family Circle

The Natchez family includes a son, Juan (44 years old), and daughter, Maria (54 years old). They have been caring for their widowed father, Carlos (84 years old), who has chronic obstructive pulmonary disease (COPD). Carlos has been living with Juan and his wife, who have adult children and a grandchild. Maria lives nearby and helps much. She also works full time as a grocery clerk. Carlos is hospitalized with pneumonia and deteriorating COPD. A nurse conducts a brief family interview. The nurse says, “This must be a difficult time for you.” She begins to acknowledge the family’s experience. The nurse says, “Tell me more about the ways you have been helping your father.” She is seeking information and providing the opportunity to find the strengths and challenges in the family. The nurse asks: “What are you the most worried about at this time?” This question allows a chance to uncover areas of concern. The nurse who takes this family-focused approach does not have assumptions about the family that might be barriers to communication. The nurse intentionally creates a context that supports making meaning of events and experiences with nurse-family and family member interactions.

During an individual-nurse-family interaction on the following day, the nurse asks the family to share their story about the illness: “ When did your father’s lung problems begin? Can you tell me about the time of diagnosis and how his treatment and condition have changed with time?” The nurse sits at the bedside with the family and listens attentively to their responses. She asks Juan and Maria about their work, family, and life responsibilities and explores ways they meet caregiving demands. This family communication recognizes the demands, needs for resources, and challenges of illness. The nurse carefully listens to the family story and notes the individual differences that exist in the family members. She begins to identify potential areas of concern for care and follow-up.

Carlos is discharged with plans for visits from the home care nursing services. The nurse prepares written materials and reviews them with the family. The hospital and home care nurse speak about the family. The hospital nurse introduces the home care nurse to the family. They had previously discussed a living will, but decisions have not yet been made. Carlos wanted to talk further with his family before completing the papers. The hospital nurse shares with the home care nurse concerns about whether Carlos and the family fully understand the discharge instructions, the chronic nature of his illness, and living will documentation.

In your next clinical rotation, try using the strategic methods applied in this case to improve personal communication. Discuss and compare your experiences with others.

● What are your nursing concerns for this family? ● What things would you communicate about with this family? ● What things would you say? ● How would you interact with different individuals and the family as a whole?

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Theoretical Perspectives of Communication

Communication with one family can be different from that required by other families be- cause families are unique. Given the many barriers to communication, it is important to have skills and experience that facilitate communication in some very varied situations. Theories provide road maps to identify needs from different points of view and suggest useful nursing actions. This section introduces several useful theories that nurses can use to communicate and plan, deliver, and evaluate nursing care.

Family Systems Theory

Nursing students usually learn about family systems theory, of which is derived from biological sciences where a system is defined as a set of interrelated elements (von Berta- lanffy, 1975). This theory views family as an open dynamic system with a past, present, and future. Family members are interdependent and influence one another. Verbal and non- verbal communication occurs within the family and between them and the outside world. Thinking through this theory recognizes that illness in one family member affects the family unit and suggests that feedback loops are used to maintain equilibrium in the family system. For example, to understand the effects of a disease on the family unit, a nurse might say: “Tell me about the ways this cancer diagnosis and need for treatment has been experienced by your family.” Family systems can help explain the varied ways multiple family members interact with health care systems and communicate with those outside the family unit. Nurses can support the well-being of families by considering family communication with various members (Fig. 4.3). When new situations occur, nurses can ask: How has your family communicated to solve problems in the past? Who, in the family, may have the most difficult time making the needed changes? Family systems thinking can help guide communication during troubled times.

Attachment Theory

Attachment occurs in infants through innate tendencies like following the parent visually and clinging to the mother. Infants attach to those who are the source of nourishment and protec- tion (Bowlby, 1958). Attachment is relevant throughout life as persons continue to nurture, protect, and support one another. Death, divorce, lost abilities, geographical relocation, and

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FIGURE 4 -3 Communication with and about families is central to practice.

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even hospital admission are examples of separation that can cause grief and emotional pain. Attachment is an essential human need; when separation occurs, nurses can help by providing the time and space for members to interact, offering to hear emotional stories to help individ- uals know they are cared for, and allowing family members to fulfill their need to protect. Nurses can facilitate connecting conversations during times of uncertainty and vulnerability.

Social Learning Theory

Social learning theory (Bandura, 1977) unites psychology and behavior by focusing on the performance of a learned behavior through reinforcement. Modeling is a central element of social learning theory. For instance, children learn health and illness behaviors from their parents and other family members (Denham, 2003). Individuals learn about consequences and rewards for different forms of communication as they observe others. For example, in one family, frequent cell phone conversations throughout the day may be normal and wel- come; others may see them as invasive or unnecessary. Nurses who think family are sensitive to what is defined as “normal” by a family. Nurses can use communication to model be- haviors that provide mutual rewards to individuals and family members. For example, a mother worried about her 10-year-old daughter’s obesity might describe her television habits after school. Yet, she might not perceive possible connections between the two. Nurses can use social learning perspectives to discuss pertinent ideas: Can you describe your family meals? Do you eat together every day? What kinds of physical activities does your family enjoy together? Open-ended questions can lead to discussion of current behaviors. Questions can help the nurse identify family health routines that need change or ones to strengthen (Denham, 2003). Helping family members identify valued behaviors suggests ways to mod- ify or try new things in a supportive way without placing members on the defensive.

Life Course Theory

The family life course theory is a developmental approach that emphasizes specific expected and unexpected transitions that occur as a family changes over time (Carter & McGoldrick, 1999). For example, it is expected that children generally go to school and eventually leave home. But an unforeseen illness or death is not expected and can create unanticipated stres- sors. Life events affect both individual and family development (Meleis, 2010). Changes in family make-up cause altered member interactions (Duvall, 1977). Nursing actions can support family members when they are stressed by transitions or changes in a member’s health. For instance, an elderly grandmother suffers from some memory loss and the safety of living alone is in question. A nurse might suggest a family meeting to discuss and antic- ipate possible outcomes of decisions.

Role Theory

People play many roles in their personal lives. Role theory explains purposes of different in- teractions. Roles can be prescribed behaviors used to construct a valued life or maintain integrity during troubled times. Roles help members maximize their use of household resources and identify ways members care for one another (Yu-Nu, Yea-Ing Lotus, Min-Chi, & Pei-Shan, 2011). Parent, child, caregiver, wage earner, organizer, disciplinarian, nurturer, encourager, decision maker, and protector are just some of the common roles seen in family units. Some roles tend to be gender or culturally oriented. In the United States and even world- wide, ideas about gender roles are changing. Roles often signify what it means to be part of a particular family and are tied to identity; they might suggest ways family work is done. Some

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family roles evolve, but some stay the same. For example, keeper of the family finances might be viewed as a lifetime role. However, that member’s death or changing responsibilities means someone else will have to do it. Role changes can be temporary, as during an extended acute illness, during which other family members need to do tasks that the hospitalized person nor- mally does. Role theory can be used to help families communicate about expectations associ- ated with any role changes that occur because of a member’s hospitalization.

Discussion about roles might occur formally or informally. Suppose a home care nurse notices a mother’s conflict as she cares for her terminally father. The nurse can say, “It must be hard to make choices about being here for your father and attending your son’s school events.” Indirect questions can lead to conversations and perhaps disclosure about conflicts. The nurse might note, “Others have told me about the difficulties experienced as they try to balance personal needs and the demands of caring for a dying person. How is this for you?” Normalizing a tough emotional battle can steer the conversation to roles and forms of support needed. The nurse might ask: “Would you like me to tell you about some community resources for respite care?” Therapeutic conversation can assist the nurse to identify areas where information, teaching, counseling, or coaching are needed.

Ex change and Resource Theory

Exchange and resource theories focus on ways relationships develop and how resources are distributed or used. Exchange theory describes the flow of information among family members and those outside the family unit (McDonald, 1981; Vangelisti, 2004). Resource theory describes the flow of resources and decisions that affects member relationships inside the family. The ways things are shared influences development and use of social networks. Exchange and resource theory can suggest new ways to access resources and supports during times of illness. Well-connected families often have a great deal of social capital to manage stressful situations (Looman & Lindeke, 2005). Social capital refers to the networks of family, friends, neighbors, and associates that can be called upon.

Nurses aware of exchange and resource theory note the importance of information ex- changes and resources available within a unique family. Identifying resource gaps suggests ways for nurses to act. Nurses can use what they learn to assist families to make decisions, solve problems, and access resources. If a family experiences a traumatic event or a life- threatening surgery, social networks are important. A social media Internet site (e.g., Caring Bridge, Care Pages, Facebook) is a way to remain connected with peers, neighbors, church friends, or others. Online networks are available to receive notes of support when the ill person or family unit is ready for them.

Symbolic Interactionism

Symbolic interactionists assert that people act toward things and other people based on their meanings (Blumer, 1969). People interpret their world based upon prior experiences and use this information to solve problems and create meanings (Buber, 1970; LaRossa & Reitzes, 1993; Mead, 1956/1934). Families maintain or transform their identities as their personal world evolves and new experiences occur. People construct and share stories that become the reality of family experience. For example, parents of a 6-month-old child who has had several cardiac surgeries and never left the intensive care unit are planning for her imminent death because no further treatment is possible. The infant is dressed in infant clothing and her mother is rocking her as she is dying. A nurse comes into the room and says, “Oh, I’m so sorry this is happening.” The mother says, “There is no room for pity here. For the first time in her life, she has no tubes. She has real clothing on. And, I am

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rocking her like a normal child. We are so thankful to have had her, even for this short time.” In contrast, a nurse with a different reality says, “This must be difficult for you, but you are comforting your child.” The mother responds: “It is sad for us to lose her so soon, but this is the first chance that I have had to be her mother.” The nurse’s words trigger dif- ferent responses and conversations. Recognition of the experience and commendation of positive actions can help the mother clarify an experience’s symbolic meanings.

Relationship-Focused Communication

Humans are innately social beings who need relationships to ease pain and suffering, effectively cope with stress, learn from life experiences, and maintain or regain health (Travelbee, 1966). Nursing is an interpersonal process between humans in complex environments filled with other beings (Paterson & Zderad, 1976; Travelbee, 1966). Relationships between nurses and care recipients are part of nursing care’s foundation and the context in which nursing practice occurs (Bell, 2011; Fawcett, 1995; Hagerty & Patusky, 2003; Peplau, 1991). In the past, these ideas have largely centered on communication with single care recipients rather than a family unit.

Relationship-based care places the needs and priorities of individuals and families as central elements in nursing care (Koloroutis, 2004). Family-focused communication occurs through caring relationships with the individual and family unit. Communicating compassion can create healing relationships that improve health outcomes, satisfaction with care, and nurse satisfaction (Chesla, 2010; Koloroutis, 2004; Matire & Schulz, 2007). Approaches such as active listening are used to understand others’ experiences. Intentional caring approaches have potential to produce quality outcomes and increase satisfaction. Relationship-based care that uses clear communication can create effective interactions with the family unit that can posi- tively influence the health of all (Meiers & Tomlinson, 2003; Nelms & Eggenberger, 2010; Weihs, Fisher, & Baird, 2002; Wright & Bell, 2010). Nurses who think family recognize the importance and power of communication among family members, between the nurse and family, and with other health care professionals. Nurses who fail to include family members in decisions about a critically ill family member’s treatment can amplify the family’s suffering (Eggenberger & Nelms, 2007; Meiers & Tomlinson, 2003).

Evidence indicates that the use of psychoeducational and relationship-focused family in- terventions during illness can be more effective than medical care (Chesla, 2010; Hartmann, Bazner, Wild, Eisler, & Herzog, 2010). Medical care often treats symptoms of the problem, but often does not fully address behavioral and family implications. Psychoeducational inter- ventions are used to educate about specifics restraints of an illness and explain ways to manage. This form of communication aims to help families develop needed skills, resolve conflicts, aid decision making, facilitate goal setting, and support problem solving (Chesla, 2010; Eggenberger, Meiers, Krumwiede, Bliesmer, & Earle, 2011; Heru, 2013; Weihs et al., 2002). Nurses who think family intentionally include the family unit in conversations about man- agement of daily routines, medical treatments, and prevention of potential complications.

B uilding Trust

Trust develops through sincere and honest sharing of pertinent personal information in thoughtful ways. Trust has different levels and evolves over time. The foundation of trust is mutual intention, and reciprocity, expectations, and relationships affect abilities to commu- nicate and levels of satisfaction (Lynn-McHale & Deatrick, 2000). Intentional relationships consider what needs to be accomplished and involve cooperation to identify the best ways to reach goals. Some conversations begin with sharing personal experiences or information

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relevant to a current situation. A nurse might say, “I see that your mother has breast cancer. I know how you feel because my mother had breast cancer, too.” Nurses can tell too much of their personal stories and misuse valuable time. Our stories are important, but they should not be the focus in the care of others. Another nurse might say: “It sure has been hot lately, have you been keeping cool?” or “How about those Yankees, do you think they are going to win?” These remarks lead the nurse to spend valuable time talking about irrelevant things. Nurses who think family use all working time to intentionally communicate. In an acute care setting, nurses are often in and out of rooms many times during a single shift. Add up those minutes and ask yourself:

• Who in the family do I need to communicate with? • What topics should I discuss today as I complete tasks? • Where is the best place to have a private conversation? • What is the best time to bring up topics that need to be discussed? • How do I best use my time to develop trusting relationships during this shift? • How do I make sure that the most important needs of each person are met?

Trust relies on the competence and willingness of someone to protect, rather than harm, persons one cares about (Cody, 2013). Trust, respect, and mutuality are essential to rela- tionships (Tarlier, 2004; Cody, 2013). Treating others as worthy equals, accepting, engaging, and attempting to understand is respectful (Cody, 2013). When persons are met, ask: “What is the most important thing that I can do for you today?” Nurses can’t do everything, but they can usually do one important thing for each person given care. Box 4.9 identifies several useful factors to help differentiate between actions that build trust versus mistrust.

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BOX 4-9

Trust Versus Mistrust in a Therapeutic Relationship

TRUST

Use direct communication to solve problems and reinforce strengths

Be generous with saying “ thank you” and give credit to everyone; find ways to commend others

Only make promises you can keep

Be direct in all forms of communication, and if you have uncertainties, then share then openly

Be approachable and willing to engage in open conversation

Be timely in your responses

Admit when you are wrong and own up to your mistakes

Allow others to ask questions, express their concerns, and express their frustrations

Acknowledge uncertainty

MISTRUST

Talk about problem with many others without including the persons directly involved

Take credit yourself or expect others to lavish credit on you

Fail to follow-through on promises made

Do not say exactly what you mean; keep people guessing about what you will do next

Be unavailable, leave without answering questions, and do not give clear answers

Do not answer clearly and blame things on others, authority, or some outside force

Always take the position that you are right and others are wrong

Assume you know all the answers, fail to listen to the needs of others, and talk only about yourself

Fail to disclose the unknowns

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Asking Q uestions

Asking questions is a tool to gather information and understand the main issues confronting persons or family member (Rollnick et al., 2008). Specific information can be learned by questions such as: Where do you hurt? Has your mother been taking her medications?

How long has it been since you, as a family, ate a meal all together? Broader information can be learned by asking more open questions: In what ways can I be most helpful to your family today? What is most worrying your family about this current situation? Open-ended questions allow room for responses. Closed questions often get only single-word answers. The nature of the open question is that it clearly demonstrates that the nurse does not “know it all.” When open-ended questions are coupled with appropriate nonverbal be- haviors (e.g., eye contact, attentive listening, a nonjudgmental context), individuals and families can safely explore their challenges and pose solutions (Rosengren, 2009).

Listening

Learning to listen authentically is a key to healthy communication and ensures that others have been heard and understand you. Think about the “who, what, where, when, and how” that needs to happen during communication. Listening is an opportunity to not just learn information, but also to connect. Listening checks for accuracy and relays information that can be valued, believed, and viewed as important (Rollnick et al., 2008). Sometimes people appear to listen, but they are just waiting for a time to take charge and get their points across. When professionals take time to listen, individuals often think that the time spent with them is longer. Listening is a window to see things through others’ eyes and bet- ter understand their experience. It demonstrates curious attitudes and a way to “live-out” relationship-based care. Good listening habits enable nurses to:

• Use wording that will be understood correctly. • Share personal feelings about comments that were heard. • Ask questions that help clarify experiences. • Use silence when necessary to allow others time to collect thoughts. • Summarize what is heard through reflective statements.

Listening enables nurses to see things differently and hear silences that share meanings. Listening is the milieu for collaborative partnerships and solving real problems.

Informing

Informing is the exchange of information that may be new or different. Information should be offered, not imposed. It involves giving facts, not opinions. It is a give-and-take experi- ence. Informing includes giving feedback to further clarify and direct communication (Box 4.10). For example, after teaching a person with a cardiac condition, the nurse might say, “After all this information, I am not sure what you are thinking. Perhaps it has created more questions or stress. Would you like to share with me anything that is not yet clear?”

Giving Feedback

Nurses need to be culturally sensitive as they respond to things learned. For example, the nurse observes a family member who begins to cry and she’s not sure why. Feedback might involve saying something like “Your feelings are very strong; do you want to talk about what is going on?” Persons who sit silently, avoid eye contact, fail to respond to questions, or leave the room during conversations are likely to be disengaged or be signaling some form of conflict. Nurses

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who think family realize cues and gently confront future trouble spots at the appropriate time. Unanswered questions, lack of attention to detail, and misunderstandings can send unintended messages (Box 4.10). Lack of timely feedback can inhibit positive care outcomes or satisfaction.

Complex Communication in Family-Focused Care

Acute and chronic illness may cause suffering and distress that interrupts the family’s usual communication patterns and overwhelms their coping abilities. Kind and respectful interactions can create a calm healing environment, decrease anxiety and depressive symptoms, and improve satisfaction with care (Curtis, Patrick, Caldwell, Greenlee, & Collier, 1999). Nurses shepherd those unfamiliar with medical management of disease and illness through a chaotic maze.

Nursing Actions

Nurses use many skills to understand the family’s experience. Many issues come to the forefront when families face health and illness challenges. These concerns upset the com- fortable routines of daily life. Nurses are not privy to private family interactions, but must quickly gain insights into key aspects of their lives. Even spending small amounts of time with families or using purposeful conversation while conducting task-oriented care can help identify needs and concerns (Nelms & Eggenberger, 2010). Describing what others can expect from you as a nurse is a good way to start. People need to know what to expect, how long they will wait, what will happen, and how they will be involved. Competence in nursing is greater than the ability to perform tasks (Eggenberger & Reagan, 2010); it is about being able to do expected things while simultaneously engaging in relationship-build- ing practices (Benner, 1983; Brown & Hartrick Doane, 2008). Effective communicators recognize that time during a work shift might go very fast, but for those in distress seconds can seem like days.

Taking Part in Challenging Conversations

The presence of a nurse often invites questions about medical matters such as wounds, indigestion, pain, constipation, impotence, menstrual irregularities, fears of memory loss, or organ donation in situations in which they may not normally come up. Managing these conversations effectively requires an awareness of the sacred trust granted through a caring relationship. Nurses can use this sacred trust to communicate about difficult

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BOX 4-10

Communicating w ith Individuals and Families

● Find out if the information is wanted before you give it. ● Ask permission before sharing information, particularly if you are uncertain whether they want it. ● Describe information within the context of other clients. For example, “ In my work with other

families managing diabetes, I have found. . . .” ● Give people the space to disagree, agree, and ask questions. ● Provide options that might be workable.

Source: Rosengren, D. B. (2009). B uilding motivational interview ing sk ills: A practitioner w ork b ook . New York: Guilford Press.

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topics in ways that are supportive and preserve dignity. While nurses are familiar with having difficult conversations at work, such topics may be unnerving in the community. Nurses are often seen as health professionals in the community not just when they are “on the clock.” Professionalism means nurses always respond respectfully within their scope of practice.

Managing Conflict

Persons usually have some prior personal or shared health agency experiences. If a fam- ily faces an end-of-life situation in which the wishes of the dying member have not been previously discussed, family members might need nurses’ help to communicate with one another in constructive ways (Wiegand, 2006). Nurses can help family members discuss their feelings and differences with one another. Family members can worry, become angry, and get frustrated as they cope with various health care providers. Nurses must not side with persons, but listen, remain objective and help family members communi- cate. Nurses should first reflect upon their own behavior. Sometimes personal behaviors create defensive barriers and create awkward and uncomfortable situations (Box 4.11). Some people have volatile personalities and families may have a history of communica- tion difficulties, which may be heightened by illness. In some cultures, people speak louder and are sharper. An ability to disagree, compromise, and not blame others is a healthy communication approach. Nurses must not side with persons, but remain objective. Whether an acute illness requires hospitalization or a chronic illness demands care transitions for home, communication is critical if quality outcomes are to be realized.

Caregivers

The illness burden, health maintenance, chronic disease management, palliative care needs, and other things linked with family care can create great stress on caregivers. This burden has been linked to depression (Clark & Diamond, 2010), stress (Matire & Schulz, 2007), and other adverse psychological and physical health effects (Clark & Diamond, 2010; Sherwood, Given, Given, & Von Eye, 2005). Complex caregiving roles are com- mon to many families, particularly today when parents are living longer and more people work outside the home. Nurses need to be aware of caregiver burden. Astute family nurses acknowledge multiple struggles families might be facing. Healing conversations about caregiver need might seem uncomfortable at first, but many will appreciate your

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BOX 4-11

Reflections Ab out Personal Actions

Here are some examples of personal behaviors to consider about yourself as you communicate with others:

● Is your tone of voice and body language welcoming? ● Are you sharp or sarcastic in your responses? ● Do you intimidate others by the ways you approach them or things you say? ● Are you sensitive to individual preferences and needs? ● Do you appear impatient or hurried?

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concern. Families might have other family concerns, but the current difficulty can be the one that overwhelms their coping abilities. Families might be dealing with such issues as grandparents raising grandchildren, the imprisonment of an adult child, a recently lost job, care of a son with schizophrenia, lack of health care insurance, or other life difficul- ties. These often unspoken pressures can be part of the caregiver burden faced by families as they manage a new dilemma.

Developing Relationship-Based Care

Relationship-based care built upon effective communication assists individuals and family members to better manage stress and the uncertainties of illness (Koloroutis, 2004). If a family is comfortable communicating with the nurse, members are more likely to eagerly request information to manage care associated with an illness (Benzein et al., 2008). All too often, nurses busily enter hospital rooms thinking about the tasks to be completed without acknowledging the family member. The following script demonstrates the nurse’s role in such an interaction:

Good afternoon. My name is Janet Jones. I am the nurse caring for Mr. Hazelton today. Would you mind sharing with me your name and relationship to Mr. Hazelton? Have

you thought of how you would most like to be involved in your [state family member’s relationship] care today? How could I help you do that?

Failure to ask questions about family’s wishes or ways members are involved in care- giving activities can lead to false assumptions. Family is a critical part of coordinated care.

V ariations in Types of Communication

Care delivery in different clinical and community settings calls for different forms of com- munication. In a stressful critical care situation, the focus might be to assist a family mem- ber in managing caregiving ambiguity, encourage them to be physically present, and assume a protection role (Tomlinson, Swiggum, & Harbaugh, 1999). In contrast, the mother is concerned that her young daughter is gaining too much weight and fears she is at risk for developing type 2 diabetes. In this instance, the nurse’s focus might be on health teaching about preparation of nutritious meals and increased physical activity. Situations require very different care forms and communications. Table 4.2 identifies a variety of communi- cation elements nurses can consider as they think family and provide care. Who is the target of the communication? Will the communication occur with individuals separately or with the family unit? For instance, if the nurse is caring for a comatose person, then family mem- bers are the best informants. If the person is a 45-year-old woman with multiple sclerosis being cared for at home, communication about mobility strategies might be targeted at her and caregiver needs simultaneously.

Consider the context of the message and the timing of its delivery. Is the message to be communicated at a highly stressful time and in an unfamiliar setting? If so, how do these factors influence ways the message might be received? Receipt of the message will be in- fluenced by typical communication patterns. For example, if usual communication is ini- tiated with the family matriarch, but the nurse delivers the message to a child first, the matriarch could resist the message. Perceptions of communication to convey information can affect its acceptance.

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96 CHAPTER 4 ● Communication With and About Families

TABLE 4 -2 Important Communication Elements in Family -Focused Care

ELEMENTS OF FAMILY-FOCUSED COMMUNICATION DESCRIPTION ASSESSMENT CONSIDERATIONS

Communicators

Context

Critical thought process

Message

Method

Assign meaning

Effects

Feedback

Communication risk factors

Originators of the message (facts, thoughts, feelings)

Physical, temporal, social, biological, psychological, cultural, spiritual, and professional

Cognitive deliberations to assess best strategy, select communication strategy, create and deliver message, and then evaluate effect and response

Facilitate common meaning

Factors, thoughts, or feelings Content and relational element Verbal behavior Nonverbal behavior

Face to face Technology

Communicators assign meaning to message based on personal experiences

Intentional and unintentional effects of the communication

Response to message

Communication risk factors such as physical, psychological, physiological, and semantic risk factors

Individual-family-nurse communicate to meet needs of individuals and families

Consider context of health care setting for family conversations that may increase stress, fear, and vulnerability

What is family’s perception of the context?

Attend to and evaluate individual and family in the communication strategy

Recognize unique meanings may exist among family members

Identify shared family meanings

Consider “ fit” with family’s typical communication patterns

Recognize differences in family members perception and interpretation

Consider verbal and nonverbal behavior of family members

Consider relational elements of family members

Consider whether to share information with designated person or family as a whole

Family as a unit or family member Family face to face or via technology

Consider “ fit” of message with family goals and family health

Consider individual differences of family members in assigning meanings

What does the message imply for family actions?

What is the effect on individual family members that will impact the family unit?

Is it necessary to receive feedback from all family members to determine if message was heard?

Consider risk factors; family unit conflicts; prior experiences; usual family communication patterns

Consider family culture, faith beliefs, traditions for particular approach to communication

Observe nonverbal cues Think about members’ various

interpretations of the messages Recognize language and literacy

barriers.

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CHAPTER 4 ● Communication With and About Families 97

TABLE 4 -2 Important Communication Elements in Family -Focused Care — cont’ d

ELEMENTS OF FAMILY-FOCUSED COMMUNICATION DESCRIPTION ASSESSMENT CONSIDERATIONS

Purposeful communication strategies used to overcome risk factors when interacting

An outcome of communication process with change as a result of communication

Individual-nurse-family communication to assess, plan, implement family care

Engage family members in reducing safety risks

A family change in the health experience supports health of individual members and family unit

Move toward individual well-being and family health

Person-safety communication strategies

Transformation

Source: Adapted from Schuster, P. M., & Nykolyn, L. (2010). C o mmu n ic at io n fo r n u r s e s : H o w t o p r e v e n t h ar mfu l e v e n t s an d p r o mo t e p at ie n t s afe t y. Philadelphia: F. A. Davis.

Sh aring Messages W ith Families

Messages can be shared with a family decision maker or the family as a whole in a face- to-face method or using some form of technology. Regardless of the method, persons tend to receive messages based on whether things fit with family life goals, beliefs, values, and usual routines. For example, a family is managing the home care of a 7-month-old med- ically fragile child. They want to attend a family reunion and bring their child to “meet the family” for the first time. On the morning of the reunion, the home care nurse notices that the child has spiked a fever of 102°F. This common experience is usually managed with antipyretics. On this day, the message brings tears to the parents’ eyes because it means a significant change in plans. In this case, the child cannot be introduced to the larger fam- ily. The family will need to manage the fever, but also cope with the sadness of loss linked with missing the important family event.

Nurses that think family can be sensitive to situations in which the response received is not the one expected. If a message is about daily decision making, such as in medication administration, perhaps the schedule and information about side effects needs to be given to only those directly involved. However, if the message is about end-of-life decisions, per- haps multiple family members and even a close family friend might need to be involved. Consider a 43-year-old woman who lives alone and is scheduled for knee surgery; the nurse must identify who will assist her at discharge and what supports will be available for the 10 days when her activity will be limited, driving prohibited, and on-going physical therapy needed. Discussion about who caregivers will be might involve extended family, neighbors, and friends. Making sure these temporary caregivers know physical limitations, medication regimens, and other care particulars will be different from a single caregiver responsibility. Message delivery can also be challenging with families in which other conflicts already exist, as in the following situations:

• The son says he is homosexual and the parents do not acknowledge his partner’s rights to make decisions.

• Messages were delivered to the woman seeking care but the family’s culture teaches that the man in the family is the decision maker.

• Instructions for a low-sodium diet need to be given to an 80-year-old Hispanic woman who does not speak English.

• A person’s medical condition quickly deteriorates to life-support decisions. • Parents are faced with the birth of a child with a severe disability. • A colleague administers an incorrect medication to someone allergic to it.

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When such events occur, nurses might need time to debrief and acknowledge personal feelings and experiences. Acknowledgment of personal loss, emotions, and distress can support nurses’ healthy coping. Debriefing includes information sharing and event pro- cessing that reflects on the event actions, outcome, and experience (Dreifuerst, 2009; Hanna & Romana, 2007). Nurses use debriefing to reflect “on action” and “in-action” (Tanner, 2006) and find resolutions that build personal confidence in difficult situations.

Motivational Interview ing

Motivational interviewing (MI) is a communication form that originated from addictions recovery and behaviorism (Rollnick et al., 2008). It has been adapted for use in a variety of situations in which counselors assist persons in changing health behaviors; for example, smoking cessation, weight loss, physical activity, nutrition enhancement, hypertension, car- diovascular disease, diabetes, and psychosis are situations in which MI may be beneficial. Communication aims to strengthen family’s knowledge and support positive behavior changes (Rollnick et al., 2008). Nurses can use MI to motivate or encourage changes by identifying beneficial reasons to make changes. MI focuses on the development of a coop- erative and collaborative partnership (Box 4.12). Individuals identify their resources for change, try new behaviors, and celebrate successes as changes are made.

MI guides rather than directs. Nurses act as a coaches or tutors. Nurses are viewed as resources and suggest what is possible and offer alternative ideas or directions for behavior changes. Three core communication skills particularly helpful in guiding behavior change are asking, informing, and listening. The nurse asks the individual specifically to identify the desired change. Active listening allows individuals to explore concerns, fears, and am- bivalence that might prevent change. With this knowledge, the nurse informs the person about treatment choices, research evidence related to the problem, and some actions others have found effective to manage the problem. At the close of the session, the nurse assists the individual in identifying specific behavioral goals and ways successes can be evaluated. At a follow-up session, the nurse checks to see how the client is doing with those goals and coaches about any needed revisions. When the client is the family, MI can be adapted through the use of modeling as suggested by social learning theory (Bandura, 1977). The family can set goals, identify barriers, plan ways to deal with barriers, identify potential solutions, and evaluate outcomes of the actions taken. Table 4.3 presents the similarities between the techniques of family interviewing and motivational interviewing strategies identifying facilitating and constraining family beliefs (Wright & Bell, 2010).

98 CHAPTER 4 ● Communication With and About Families

BOX 4-12

Principles of Motivational Interview ing

Four distinct principles can be used by nurses in motivational interviewing (Dreifuerst, 2009; Rollnick et al., 2008):

1. Nurses must resist the reflex to “ right” the individual’s behavior by “ telling” them what to think or what they need to change. Instead nurses’ role is to assist individuals to voice personal desires to change.

2. Nurses seek to understand individual interests, concerns, and motivations for making a behavior change; this knowledge helps them to deal with the ambivalence often experienced toward change.

3. Nurses recognize the importance of listening with empathetic interest as motivations are shared. 4. Nurses inform by exploring ways in which a difference in one’s health can be made.

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Creating Therapeutic Conversations

Purposeful conversations invite family members to join, ask questions about areas of con- cern, and offer involvement with potential to be therapeutic, healing, and affirming (Wright & Leahey, 2013). Commending family strengths is a communication strategy that helps family members develop their strengths and reduce distress (Wright & Leahey, 2013). Ask- ing key questions about the family’s concerns, challenges, and expectations provides useful information for the nurse to identify ways to involve the family (Wright & Leahey, 2013). As families share their personal stories, nurses better understand what is needed, and trust- ing relationships are made (Lynn-McHale & Deatrick, 2001; Wright & Leahey, 2013). More information about topics in this section is found in Chapter 8.

Eliciting the Family Story

Families perceive a need to share their stories and be heard whenever uncertainty is faced (Henriksson & Andershed, 2007; Henriksson, Benzein, Ternestedt, & Andershed, 2011). These conversations require clear communication and a partnership with the individual seeking care and family. Hearing the family story acknowledges needs and struggles and it takes time, but knowing that story might save time later and even avoid medical errors or other problems. Box 4.13 identifies the importance of using evidence-based nursing inter- ventions when hearing the family story and helping members alter their routines.

Interventive Q uestioning

Interventive questions are used intentionally to collect information that can help nurses bet- ter understand situations. Linear and circular questioning techniques are skills used to assist the family in making meaningful changes. Linear questions may provide information while

CHAPTER 4 ● Communication With and About Families 99

TABLE 4 -3 Family Interviewing and Motivational Interviewing T ech niq ues

FAMILY INTERVIEW ING TECHNIQ UES MOTIVATIONAL INTERVIEW ING STRATEGIES

Generate hypotheses prior to interview

Comfortable interview setting

As many members as possible present

Family-nurse relationship of reciprocity, nonhierarchical, respect for unique expertise and strengths

Therapeutic conversations

Manners and respectful

Family genogram (and ecomap)

Therapeutic questions

Commendations

Engagement

Assessment

Intervention

Termination

Source: Meiers & J enson (2011) based on Wright & Leahy (2013) and Rollnick, Miller, & Butler (2008).

Draw out ideas and solutions from the client

Comfortable interview setting

Client only

Collaboration/partnership with client

Reflective listening

Focus on behaviors

_____

Open-ended questions

Affirmations

Resist the righting reflex

Understand your client’s motivation

Listen to your client/change talk

Engage your client/summarize needed information

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the circular questions suggest possibilities for new understandings about relationships and meanings (Wright & Leahey, 2013). Linear questions are used to explore family meaning or perceptions about a health experience. A nurse often uses linear questions as new infor- mation about an illness or health concern is collected. For example, a family brings a young child with shortness of breath to the emergency department. The nurse may ask a family member linear questions such as: When did your daughter’s symptoms start? What do you think might have caused them? Is this the first time this has happened? Circular questions are used to determine the family’s understandings, understand the relationships, and examine beliefs and thinking processes (Wright & Leahey, 2013). Circular questions linked to this episodic situation might be: What is your greatest fear about your daughter’s condition? Who in your family has the most difficulty handling stressful situations? How does her older sister respond when this distressful breathing occurs? Has your family made any changes since she was diagnosed with asthma? Both forms of questioning are useful and enable the nurse to gain insights into the family’s response to this illness situation.

Chapter Summary

Communication is a vital element of family-focused nursing practice. Individuals and family units can face highly stressful times with enormous barriers and great challenges when

100 CHAPTER 4 ● Communication With and About Families

BOX 4-13

Evidence-Based Family Nursing Practice

Strong evidence has shown links between smoking and lung cancer, yet people continue to smoke. Research has demonstrated links between individual behavior changes and the relational processes with their family members. Evidence shows that having a supportive partner increases smoking cessation. Social environments also influence individual behaviors. A qualitative study was conducted with 16 families, in which 13 had lung cancer and 3 had serious lung diseases and the individual with the disease smoked. Study participants were concerned about continuing smoking and wanted the ill person to stop. The family members who continued to smoke were concerned about ill members and altered some smoking behaviors in response. Love and concern for the other were factors in behavioral changes. Many thought the smoking decisions were individual ones. Smoking can be a long-standing relationship dimension between family members, and many members continued to see that preserving the relationship was important and they modified their smoking behaviors. When the relationship with one another is the priority, then adaptive smoking behaviors can serve both parties well. Other individuals in this study thought that it was their responsibility to influence the decisions about smoking cessation for those around them. In this situation, family members were willing to risk the relationship for the short term if they could enable the long-term gain of protecting well family members from lung cancer. This pattern was not successful in positively influencing smoking cessation and created tensions at a vulnerable time. Nurses are in a unique position to help individuals and families with smoking cessation. Many excellent evidence-based programs exist, but these might be more effective if relationships and interactions are considered. Unfortunately, family dynamics (e.g., communication, family processes) are not often regarded when smoking cessation is needed. When family members of the person with lung cancer or other lung diseases smoke, then including them in the plans for actions could be important. Effective interventions with family members might also be useful with other kinds of health or illness concerns.

Source: Robinson, C. A., Bottotoff, J. L., & Torchalla, I. (2011). Exploring family relationships: Directions for smoking cessation. In E. K. Svavarsdottir and H. Jonsdottir (Eds.), Family nursing in action (pp 137–159). Reykjavik, Iceland: University of Iceland Press.

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managing health alterations. Family nurses need skills and experience to share clear mes- sages in trusting environments. A variety of communication strategies can ensure the safety of an ill family member, ease the distress experienced by uncertainties, and increase the comfort of those seeking care. Intentional communication strategies aimed at building and enhancing trusted relationships are important. Relationship-based care includes authentic interactions that recognize the importance of the family unit. Reflection about what has or has not been adequately communicated can help nurses to gain confidence and become more proficient. This chapter has provided information about many skills (e.g., listening, asking, informing, giving feedback, motivational interviewing) to use in building strong individual and family unit relationships.

REFERENCES

Abraham, M., & Moretz, J. G. (2012). Implementing patient- and family-centered care: Part I— understanding the challenges. Pediatric Nursing, 38(1), 44–47.

American Nurses Association. (2001). Code of ethics for nurse with interpretative statements. Washington, DC: Nursebooks.org.

American Nurses Association (2006). Position statement on privacy and confidentiality. Washington, DC: Nursebooks.org.

American Nurses Association (2010). Nursing’s social policy statement: The essence of the profession. Washington, DC: Nursebooks.org.

Anderson, H., & Goolishan, H. (1988). Human systems as linguistic systems: Preliminary and evolv- ing ideals about the implications for clinical theory. Family Process, 27, 371–393.

Arnold, E. C., & Boggs, K. U. (2010). Interpersonal relationships: Professional communication skills for nurses (6th ed.). Philadelphia: W. B. Saunders.

Aspeling, H. E., & van Wyk, N. (2008). Factors associated with adherence to antiretroviral therapy for the treatment of HIV-infected women attending an urban care facility. International Journal of Nursing Practice, 14(1), 3–10.

Bandura, A. (1977). Social learning theory. New York: General Learning Press. Barnlund, D. C. (2008). A transactional model of communication. In. C. D. Mortensen (Ed.),

Communication theory (2nd ed., pp 47–57). New Brunswick, NJ: Transaction. Bell, J. M. (2011). Relationships: The heart of the matter in family nursing. Journal of Family Nurs-

ing, 17(1), 3-10, doi:10.1177/1074840711398464 Bengston, V. L., Acock, A. C., Allen, K. R., Dilworth-Anderson, P., % Klein, D. M. (1993). Source-

book of family theory & research. Thousand Oaks, CA: Sage Publications. Benner, P. (1983). Uncovering the knowledge embedded in clinical practice. Image, 15(2), 36–41. Bennett, C. L., Ferriera, M. R., Davis, T. C., et al. (1998). Relation between literacy, race, and stage

of presentation among low-income patients with prostate cancer. Journal of Clinical Oncology, 16, 3101–3104.

Benzein, E. G., Hagberg, M., & Saveman, B. I. (2008). “Being appropriately unusual”: A challenge for nurses in health-promoting conversations with families. Nursing Inquiry, 15(2), 106–115.

Berkman, N. D., DeWalt, D. A., Pignone, M. P., Sheridan, S. L., Lohr, K. N., Lux L., . . . Bonito, A. J. (2004). Literacy and health outcomes (AHRQ Publication No. 04-E007-2). Washington, DC: Agency for Healthcare Research and Quality.

Blumer, H. (1969). Symbolic interactionism: Perspective and method. Englewood Cliffs, NJ: Prentice Hall. Bourbonnier, M., & Evans, L. K. (2002). Advanced practice nursing in the care of frail older adults.

Journal of the American Geriatric Society, 50, 2062–2076. Bowlby, J. (1958). The child’s tie to his mother. International Journal of Psycho-analysis, 39, 1–23. Brown, H., & Hartrick Doane, G. (2008). From filling a bucket to lighting a fire: Aligning nursing

education and nursing practice. In L. Young & B. Patterson (Eds.), Teaching nursing: Developing a student-centered learning environment (pp 97–118). Philadelphia: Lippincott Williams & Wilkins.

Buber, M. (1970). I and thou. New York: Scribner. Burns, K. (2011). Nurse-physician rounds: A collaborative approach to improving communication,

efficiencies, and perception of care. Medsurg Nursing, 20(4), 194–199.

CHAPTER 4 ● Communication With and About Families 101

2910_Ch04_073-106 06/01/15 11:04 AM Page 101

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 .

Callery, P., & Milnes, L. (2012). Communication between nurses, children and their parents in asthma review consultations. Journal of Clinical Nursing, 21(11/12), 1641–1650.

Carter, B., & McGoldrick, M (1999). The expanded family life cycle: Individual, family and social perspectives (3rd ed.). Boston: Allyn & Bacon.

Chesla, C. (1996). Reconciling technologic and family care in critical care nursing. Image:Journal of Nursing Scholarship, 28(3), 199–203.

Chesla, C. (2010). Do family interventions improve health? Journal of Family Nursing, 16(4), 355–377. doi:10.1177/1074840710383145

Clark, M. C., & Diamond, P. M. (2010). Depression in family caregivers of elders: A theoretical model of caregiver burden, sociotropy, and autonomy. Research in Nursing and Health, 33, 20–34.

Cody, W. K. (Ed.). (2013). Philosophical and theoretical perspectives for advanced nursing practice (5th ed.). Burlington, MA: Jones & Bartlett Learning.

Cowan, M. J., Shapiro, M., Hays, R. D., Afifi, A., Vazirani, S., Ward, C. R., & Ettner, S. L. (2006). The effective of multidisciplinary hospitalist/physician and advanced practice nurse collaboration on hospital costs. Journal of Nursing Administration, 36(2), 79–85.

Curtis, J. R., Patrick, D. L., Caldwell, E., Greenlee, H., & Collier, A. C. (1999). The quality of patient-doctor communication about end-of-life care: A study of patients with advanced AIDS and their primary care clinicians. AIDS, 13, 1123–1131.

Curtis, J. R., & White, D. B. (2008). Practical guidelines for evidence-based ICU family conferences. Chest, 134(4), 835–843.

Curtis, K., Tzannes A., & Rudge T. (2011). How to talk to doctors—a guide for effective communi- cation. International Nursing Review, 58(1), 13–20. Retrieved from http://dx.doi.org/10.1111/ j.1466-7657.2010.00847.x

Dance, F. E. X. ( 1967). Human communication theory. New York: Holt. Denham, S. A. (2003). Family health: A framework for nursing. (2003). Philadelphia: F. A. Davis. Denham, S. A., & Looman, W. (2010). Families with chronic illness. In J. R. Kaakinen, V. Gedaly-Duff,

D. P. Coehlo, & S. M. Harmon Hanson (Eds.), Family health care nursing: Theory, practice and research (4th ed.). Philadelphia: F. A. Davis.

Doane, G. A. H. (2002). Beyond behavioral skills to human-involved processes: Relational nursing practice and interpretive pedagogy. Journal of Nursing Education, 41, 400–404.

Dreifuerst, K. T. (2009). The essentials of debriefing in simulation learning: A concept analysis. Nursing Education Perspectives, 30(2), 109–114.

Dufault, M., Duquette, C. E., Ehmann, K., Hehl, R., Lavin, M., Martin, V., . . . & Willey, C. ( 2010). Translating an evidence-based protocol for nurse-to-nurse shift handoffs. Worldviews on Evidence-Based Nursing, 7(2), 59–75.

Duvall, E. M. (1977). Marriage and family development (5th ed.). Philadelphia: Lippincott. Eggenberger, S. K., & Nelms, T. P. (2007). Being family: The family experience when an adult member

is hospitalized with a critical illness. Journal of Clinical Nursing, 16(9), 1618–1628. Eggenberger, S. K., & Regan, M. (2010). Expanding simulation to teach family nursing. Journal of

Nursing Education, 49(10), 550–558. Eggenberger, S. K., Meiers, S. J., Krumwiede, N. K., Bliesmer, M., & Earle, P. (2011). Reintegration

in families in the context of chronic illness: A family health promotion model. Journal of Nursing and Healthcare of Chronic Illness, 3, 283–292. doi:10.111j1752-9824.2011.01101.x

Ellington, L., Reblin, M., Clayton, M., Berry, P., & Mooney, K. (2012). Hospice nurse communica- tion with patients with cancer and their family caregivers. Journal of Palliative Medicine, 15(3), 262–268.

Fawcett, J. (2005). Contemporary nursing knowledge. Philadelphia: F. A. Davis. Gubrium, J. F., & Holstein, J. A. (1993). Phenomenology, ethnomethodology and family discourse.

In P. G. Boss, W. J. Doherty, W. R. LaRossa, W. R. Schumm, & S. K. Steinmetz (Eds.), Sourcebook of family theories and methods: A contextual approach (pp 651–672). New York: Plenum Press.

Hagerty, B. M., & Patusky, K. L. (2003). Reconceptualizing the nurse-patient relationship. Journal of Nursing Scholarship, 35(2), 145–150.

Hanna, D. R., & Romana, M. (August 2007). Debriefing after a crisis: What’s the best way to resolve moral distress? Don’t suffer in silence. Nursing Management, 39–47.

102 CHAPTER 4 ● Communication With and About Families

2910_Ch04_073-106 06/01/15 11:04 AM Page 102

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 .

Hartmann, M., Bazner, E., Wild, B., Eisler, I., & Herzog, W. (2010). Effects of interventions involving the family in the treatment of adult patients with chronic physical disease: A meta-analysis. Psychotherapy and Psychosomatics, 79(3), 136–148.

Haynes, R. B., Ackloo, E., Sahota, N., McDonald, H. P., & Yao, X. (2008). Interventions for enhancing medication adherence. Cochrane Database System Review, CD000011.

Health and Human Services. (2008). Health information privacy. Retrieved July 31, 2012 from http://www.hhs.gov/ocr/privacy/hipaa/faq/disclosures_to_friends_and_family/534.html

Henriksson, A., & Andershed, B. (2007). A support group programme for relatives during the late palliative phase. International Journal of Palliative Nursing, 13(4), 175–183.

Henriksson, A., Benzein, E., Ternestedt, B., & Andershed, B. (2011). Meeting needs of family members with life-threatening illness: A support group program during ongoing palliative care. Palliative and Supportive Care, 9, 263–271.

Heru, A. M. (2013). Working with families in medical settings: A multidisciplinary guide for psychi- atrists and other health professionals. New York: Routledge.

Hrabe, D. P. (2005). Peplau in cyberspace: An analysis of Peplau’s interpersonal relations theory and computer-mediated communication. Issues in Mental Health Nursing, 26(4), 397–414.

Institute of Medicine. (1999). To err is human: Building a safer health system. A report of the Committee on Quality of Health Care in American. National Academy Press.

Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: Committee on the Quality Health Care in America, National Academy of Science, National Academy Press.

Jones, L., Woodhouse, D., & Rowe, J. (2007). Effective nurse parent communication: A study of parents’ perceptions in the NICU environment. Patient Education & Counseling, 69(1–3), 206–212.

Kendall-Tacket, K. A. (1993). Postpartum depression: A comprehensive approach for nurses. Newbury Park: Sage.

Knaus, W. A., Draper, E. A., Wagner, D. P., & Zimmerman, J. E. (1986). An evaluation of outcome from intensive care in major medical centers. Annals of Internal Medicine, 104, 410–418.

Koloroutis, M. (Ed.). (2004). Relationship-based care: A model for transforming practice. Minneapolis: Creative Health Management.

LaRossa, R., & Reitzes, D. C. (1993). Symbolic interactionism and family studies. In P. G. Boss, W. J. Doherty, W. R. LaRossa, W. R. Schumm, & S. K. Steinmetz (Eds.), Sourcebook of family theories and methods: A contextual approach (pp 135–166). New York: Plenum Press.

Levine, C., & Zuckerman, C. (2000). Hands on/hands off: Why health care professionals depend on families but keep them at arm’s length. Journal of Law, Medicine & Ethics, 28, 5–18.

Looman, W. S., & Lindeke, L. I. (2005). Health and social context: Social capital’s utility as a con- struct for nursing and health promotion. Journal of Pediatric Health Care 19(2), 90–94.

Lynn-McHale, D. J., & Deatrick, J. A. (2000). Trust between family and health care provider. Journal of Family Nursing, 6(3), 210–230.

Machnowski, G. P. (1997, Fall). Correlation seen between communication skills and malpractice risk. Details in Professional Liability, 11(3), 1.

Mason, P., & Butler, C. C. (2010). Health behavior change. Toronto: Elsevier. Matire, L. M., & Schulz, R. (2007). Involving family in psychosocial interventions for chronic illness.

Current Directions in Psychological Science, 16(2), 90–94. Mayberry, L. S., Kripalani, S., Roghman, R. L., & Osborn, C. Y. (2011). Bridging the digital divide

in diabetes; Family support and implications for health literacy. Diabetes Technology Therapeutics, 13(10), 1005–1012.

McDonald, G. W. (1981). Structural exchange and marital interaction. Journal of Marriage and Family, 43(4), 825–839.

Mead, G. H. (1956). On social psychology: Selected papers (Anselm Straus, Ed.). Chicago: University of Chicago Press (originally published in 1934).

Meiers, S. J. (2002). Family-nurse co-construction of meaning: Caring in the family health experience (Doctoral dissertation). Dissertation Abstracts. Minneapolis: University of Minnesota. Retrieved from UMI Order AAI3041946.

CHAPTER 4 ● Communication With and About Families 103

2910_Ch04_073-106 06/01/15 11:04 AM Page 103

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 .

Meiers, S. J., & Jenson, C. (2011). Family interviewing and motivational interviewing: Comparisons and contrasts. Unpublished manuscript. Rochester, MN: Winona State University, Department of Nursing.

Meiers, S., & Tomlinson, P. (2003). Family-nurse co-construction of meaning: A central phenomenon of family caring. Scandinavian Journal of Caring Sciences, 17(2), 193–201.

Meleis, A. I. (2012). Theoretical nursing: Development and progress (5th ed.). Philadelphia: Wolters Kluwer Health.

Meleis, A. I. (Ed.). (2010). Transitions theory: Middle range and situation specific theories in nursing research and practice. New York: Springer.

National Assessment of Adult Literacy (2003). Institute of Education Sciences, National Center for Education Statistics, U.S. Department of Education. Retrieved from http://nces.ed.gov/NAAL/ kf_demographics.asp

National Commission on Adult Literacy. (2008). Reach higher, America: Overcoming crisis in the U.S. workforce. New York: Council for Advancement of Adult Literacy.

Nelms, T. P., & Eggenberger, S. K. (2010). Essence of the family critical illness experience and family meetings. Journal of Family Nursing, 16(4), 462–486.

Paterson, J. G., & Zderad, L. T. (1976). Humanistic nursing. New York: John Wiley. Peplau, H. E. (1991). Interpersonal relations in nursing: A conceptual frame of references for

psychodynamic nursing. New York: Springer. (Original work published in 1952.) Peplau, H. E. (1997). Peplau’s theory of interpersonal relations. Nursing Science Quarterly, 10(4),

162–167. Quinn, J. R., Schmitt, M. H., Baggs, J. G., Norton, S. A., Dombeck, M. T., & Seller, C. R. (2012).

Family members’ informal roles in end-of-life decision making in adult intensive care units. American Journal of Critical Care, 21(1), 43–51.

Robinson, C. A., Bottotoff, J. L., & Torchalla, I. (2011). Exploring family relationships: Directions for smoking cessation. In E. K. Svavarsdottir and H. Jonsdottir (Eds.), Family nursing in action (pp 137–159). Reykjavik, Iceland: University of Iceland Press.

Rollnick, S., Miller, W. R., & Butler, C. C. (2008). Motivational interviewing in health care: Helping patients change behavior. New York: Guilford Press.

Rosengren, D. B. (2009). Building motivational interviewing skills: A practitioner workbook. New York: Guilford Press.

Roter, D. L. (2011). Oral literacy demand of health care communication: Challenges and solutions. Nursing Outlook, 69, 79–84.

Rubin, R. (1984). Maternal identity and the maternal experience. New York: Springer. Sarkar, U., Karter, A. J, Lieu, J. Y., Adler, N. E., Nguyen, R., Lopez, A., . . . Nykolyn, L. (2010).

Communication for nurses: How to prevent harmful events and promote patient safety. Philadel- phia: F. A. Davis.

Schuster, P. M., & Nykolyn, L. (2010). Communication for nurses: How to prevent harmful events and promote patient safety. Philadelphia: F. A. Davis.

Segrin, C., & Flora, J. (2011). Family communication (2nd ed.). New York: Taylor & Francis. Sherwood, P. R., Given, C. W., Given, B. A., & Von Eye, A. (2005). Caregiver burden and depressive

symptoms: Analysis of common outcomes in caregivers of elderly patients. Journal of Aging and Health, 17, 125–147.

Soderstrom, I., Benzein, E., & Saveman, B. (2003). Nurses’ experiences of interactions with family members in intensive care unit. Scandinavian Journal of Caring Sciences 17, 185–192.

Sorenson, D. L. S. (1990). Uncertainty in pregnancy. Clinical Issues in Perinatal Women’s Health Nursing, 3(1), 289–296.

Spath, P. (2000). Reducing errors through work system improvements. In P. Spath (Ed.), Error reduction in health care (pp 199–234). San Francisco: Jossey-Bass.

Spinda, B. (1997, Fall). What prompts a patient to sue? Details in Professional Liability, 11(3), 2. Tanner, C. A. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing.

Journal of Nursing Education, 45(6), 204–211. Tapp, D. M. (2000). The ethics of relational stance in family nursing: Resisting the view of

‘Nurse as Expert.’ Journal of Family Nursing, 6(1), 69.

104 CHAPTER 4 ● Communication With and About Families

2910_Ch04_073-106 06/01/15 11:04 AM Page 104

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 .

Tarlier, D. (2004). Beyond caring: The moral and ethical bases of responsive nurse-patient relation- ships. Nursing Philosophy, 5, 230–241.

Tomlinson, P. S., Swiggum, P., & Harbaugh, B. (1999). Identification of nurse-family intervention sites to decrease health-related boundary ambiguity in PICU. Issues in Comprehensive Pediatric Nursing, 22(1), 27–47.

Travelbee, J. (1966). Interpersonal aspects of nursing. Philadelphia: F. A. Davis. U.S. Department of Health and Human Services (USDHHS) (2010a). Healthy people 2020.

Retrieved from http://www.healthypeopole.gov/2020/ U.S. Department of Health and Human Services (USDHHS) (2010b). National action plan to improve

health literacy. Retrieved from http://www.health.gov/communcation/HLActionPlan/ Vandall-Walker, V., & Clark, A. M. (2011). It starts with access! A grounded theory of family mem-

bers working to get through critical illness. Journal of Family Nursing, 17(2), 148–181. Vangelisti, A. L. (Ed.). (2004). Handbook of family communication. Mahwah, NJ: Lawrence

Erlbaum Assoc. von Bertalanffy, L. (1975). Perspectives on General Systems Theory. In E. Taschdjian (Ed.),

Scientific-philosophical studies. New York: George Braziller. Walsh, F. (Ed.). Normal family processes (3rd ed.) (pp 424–459). New York: Guilford Press. Watzlawick, P., Beavin, J. H., & Jackson, D. D. (1967). Pragmatics of human communication. New

York: Norton. Weihs, K., Fisher, L., & Baird, M. (2002). Families, health and behavior: A section of the Commis-

sioned Report by the Committee on Health and Behavior: Research, Practice and Policy. Families, Systems and Health, 20(1), 7–46.

Weiss, B. D., Mays, M. Z., Martz, W., Castro, K. M., DeWalt, D. A., Pignone, M. P., . . . Hale, F. A. (2005). Quick assessment of literacy in primary care: The newest vital sign. Annals of Family Medicine, 3(6), 514–522. doi:10.1370/afmm.405

White, S., and McCloskey, M. (2003). Framework for the 2003 National Assessment of Adult Literacy (NCES 2005-531). Washington, DC: U.S. Department of Education, National Center for Education Statistics. Retrieved from http://nces.ed.gov/naal/fr_definition.asp - top

Wiegand, D. L. M (2006). Withdrawal of life-sustaining therapy after sudden, unexpected life-threat- ening illness or injury: Interactions between patients’ families, health care providers, and the healthcare system. American Journal of Critical Care, 15(2), 178–187.

Williams, M. V., Baker, D. W., Parker, R. M., & Nurss, J. R. (1998). Relationships of functional health literacy to patients’ knowledge of their chronic disease. A study of patients with hyperten- sion and diabetes. Archives of Internal Medicine, 158, 166–172.

Wright, L. M., & Bell, J. M. (2010). Beliefs and illness: A model of healing. Calgary, Alberta, Canada: 4th Floor Press.

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

Yu-Nu, W., Yea-Ing Lotus, S., Min-Chi, C., & Pei-Shan, Y. (2011). Reconciling work and family caregiving among adult-child family caregivers of older people with dementia: Effects on role strain and depressive symptoms. Journal of Advanced Nursing, 67(4), 829–840. doi:10.1111/ j.1365-2648.2010.05505.x

Zerwekh, J. V. (2006). Nursing care at the end of life: Palliative care for patients and families. Philadelphia: F. A. Davis.

CHAPTER 4 ● Communication With and About Families 105

2910_Ch04_073-106 06/01/15 11:04 AM Page 105

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 .

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. A

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