Week 6 discussion

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Family Assessment Sonja J. Meiers ● Norma K. Krumwiede ● Sharon A. Denham ● Sue Ellen Bell

C H A P T E R 5

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

1. Differentiate between individual, family, and community assessment. 2. Discuss assessment that includes the predictive and protective factors influencing the health and

illness of individuals, families, communities, and populations. 3. Explain ways that genograms, ecograms, and ecomaps can be used to assess family from an

ecological point of view. 4. Describe ways that computer-based geographical information systems can be used to understand

family, community, and population health needs. 5. Recognize ways that genetics and genomics influence health, disease prevention, treatments,

screening, and outcomes.

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

● Assessment ● Clinical nursing judgments ● Ecomap ● Family pedigree ● Family unit assessment ● Genetics ● Genogram

● Geographical information systems

● Individual assessment ● Nursing process ● Social capital ● Spiritual assessment

Introduction

Regardless of the type of care setting, the best nursing care occurs when nurses think family. Although several nursing theorists have discussed the roles of families in health and illness care (Neuman & Fawcett, 2011), many nurses still view the family as the “context of care.” Family members might be included in some discussions when they are present, but this is seldom planned or noted in personal health records. Family-focused nursing recognizes that the accuracy and breadth of assessment data are improved by purposely including family. Thinking family could increase awareness of the breadth of possible causative factors for symptoms (Tanner, 2006). This chapter introduces ways to intentionally think family during assessments, especially about aspects of life pertinent to those living in the family household and within the community. Health and illness outcomes can be improved when predictive

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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 03:08:43.

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factors (those factors that cause risk or benefit to health) and protective factors (those factors that provide a buffer to illness, injury, or disability) are simultaneously considered. This chapter reviews critical aspects of assessments and describes ways to include family units.

Nursing Process

Nurses use the nursing process, a modified version of the scientific method that is holistic and personalized to assess individual needs in planning care (American Nurses Association, 2012). Nursing process includes assessment, diagnosis, care planning, implementation of the planned care, and evaluation. This chapter focuses on assessment. Use of an ecological framework aids understandings about the individuals, families, household, neighborhood, and community links with health and illness (Bronfenbrenner, 1979). A holistic assessment can suggest multiple risk determinants and related nursing actions.

Assessments

Assessments are tools for gathering holistic information to guide nursing actions that support health promotion, disease prevention, illness management, restorative outcomes, and well- being. Assessment is the first step in nursing care and can be used to identify nursing diagnoses (Jensen, 2011; Lunney, 2009) and in planning nursing actions. It is the way nurses come to know the needs of others. Similar assessment processes are used in all forms of care settings.

Individual Assessments

Assessment identifies problems and leads to a medical diagnosis or nursing diagnosis. As- sessments are initially conducted when persons enter a health care encounter and completed during care delivery and before discharge to another setting. In fast-paced health care sys- tems, nursing assessments mainly focus on individuals’ physiological status, health histories, and limited social information. The assessment would include the individual’s presenting problem, history of illness events, symptoms, current medications, and other pertinent clin- ical information. This baseline information can help health care practitioners identify facts about the presenting condition.

In care directed by medical model thinking, nurses can provide dependent and inde- pendent nursing functions (Fig. 5.1). Dependent nursing functions are actions that directly respond to medical orders given by a physician or other professional provider. These actions guide many treatments nurses provide. Independent nursing functions are actions within the scope of nursing practice and do not require a physician’s order. Independent nursing functions can be used in response to individual needs (Snyder & Lindquist, 2009).

Family U nit Assessments

Most assessments consider little about the family unit. A family unit assessment is a sys- tematic process used to collect family household information that is baseline knowledge about resources, strengths, and risks aligned with individual care needs. Family unit assess- ments identify individual, family, household, and community components. The family house- hold provides important information about their usual lives such as the ways members function independently, as a unit, and with social networks. Family structure assessment aids in identifying family health routines that can be threats or supports for the person need- ing care or suggest potential risk factors for illness. Hospice programs have long collected and used this type of information in the care of dying persons and their family units.

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Clinical Nursing J udgments

Clinical nursing judgments involve observation, reasoning, analysis, synthesis, and critical thinking. In a review of about 200 studies on clinical judgment, Tanner (2006) identified that clinical nursing judgments are:

• Influenced by what nurses bring to situations • Linked with knowing individuals and their responses • Influenced by the context of the situation and culture of the nursing unit • Influenced by the nurses’ reasoning skills

Tanner found that reflections about actions taken can improve clinical reasoning. Making appropriate clinical judgments is grounded in what is known. If the nurse has assessed only biophysical data, then few tools for holistic clinical nursing judgments might be available. Nurses who think family want a fully equipped clinical nursing judg- ment toolbox ready to employ.

Moving from an Individual to a Family Assessment

Nurses who think family know that individual assessment, which focuses on the presenting symptoms or complaints, is only the beginning and collecting a family assessment offers a much better insight into health patterns and risks for both the individual and family. Suppose you are admitting a 54-year-old gentleman who complains of upper back pain. What kinds of information do you need to discover during the assessment process (Box 5.1)?

Completing the Physical Assessment

As nurses complete health assessments, they gather objective data that will help formulate a plan of care:

• Screen for general well-being • Develop a baseline for comparison with future assessments

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FIGURE 5 -1 Family assessment includes independent and dependent functions.

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BOX 5-1

Components of an Individual Health History

COMPONENT

Biographical data

Current physical and emotional complaints

Past medical history and health habits

Past and current ability to perform activities of daily living (ADLs)

Available support systems, coping and patterns, perceived stressors

EXAMPLE OF DATA COLLECTED

Mr. M. is a 54-year-old, single, Somalian, practicing Muslim, whose emergency contact is his sister. He does not have a regular physician. He speaks English.

If upper back pain is the symptom, the nurse would ask how long Mr. M. has been experiencing pain; whether the pain is dull or sharp; what activities Mr. M. is not able to do because of the symptoms; and on a scale of 0– 10, with 0 being no pain and 10 being the worst possible pain, what number Mr. M. would assign to the pain.

Mr. M.’s health history includes a past work-related back injury, allergy to aspirin, and a history of hypercholesterolemia and hypertension. He is minimally physically active in his role as a small grocery store owner. He does not smoke tobacco or drink alcohol.

Mr. M. states that he is not able to lift boxes and stock shelves in his grocery store because of his back pain. He also has pain while getting into and out of his automobile.

Mr. M. states that his father, who is 80, is helping him at the grocery store. Mr. M. typically manages back pain by taking acetaminophen and using a heating pad to the area. He is having trouble maintaining his grocery store, which is his source of income, and this is stressful to him. He feels supported by his faith community at the local mosque.

DETAILED ASSESSMENT

Name, contact information, birth date, age, marital/ partnered status, religion, nationality, emergency contact, language, health care providers.

Q uestions are asked to determine the type of symptom, the duration and severity of the symptom, and how the symptom is affecting daily life.

The individual presenting for assessment usually completes a form asking if there have been any health problems in the past; the list of possible health problems is typically organized according to body systems and includes surgeries, injuries, hospitalizations, allergies, immunizations, medications; health habits such as smoking, exercise, diet, and drug use are also included.

The individual may respond to questions about whether the current back pain is limiting his daily activity, either on a paper/electronic form or in response to verbal questions asked by the nurse.

The individual responds to questions about who is present to support him in his daily activities given the pain he is experiencing, how he typically copes with pain and discomfort, and if there are any additional life stressors with which he is dealing.

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CHAPTER 5 ● Family Assessment 111

BOX 5-1

Components of an Individual Health History—cont’d

COMPONENT

Socioeconomic factors

Spiritual and cultural practices, preferences, and concerns

Family patterns of illness

Other assessments (health risk appraisal; dental, nutritional, developmental, vision, and hearing screening; immunizations; tuberculosis screening; and fall risk assessment)

EXAMPLE OF DATA COLLECTED

Mr. M. is a small business owner, with a high school education, who lives with his elderly parents in an apartment. The family has a combined annual income of about $45,000.

Mr. M. practices the daily Islamic prayer rituals and celebrates Muslim holidays. He does not eat pork or pork products in adherence to Islamic dietary laws.

Mr. M. does not have a history of rheumatoid arthritis in his family. His parents both have hypertension, high triglycerides, and high cholesterol.

Mr. M. is screened for tuberculosis based on his history of having spent time in a refugee camp as part of his immigration experience and an immunization history to determine his immunity status.

DETAILED ASSESSMENT

The individual responds to written or verbal questions about income level, education level, occupation status, and housing status.

The individual responds to written or verbal questions about religion and/or spirituality, culture, and related practices, preferences, and concerns.

The individual responds to written or verbal questions about family history of major physical or mental illnesses or illnesses related to the presenting health issue. Alternatively, a family medical pedigree may also be created by the individual.

These assessments are appropriately used based upon the age of the person.

• Validation of the complaints that bring an individual to seek health care • Monitoring for changes in the current health problem

This assessment can be a comprehensive assessment or a focused assessment if it is being done in episodic care to address a specific symptom or problem. It is within the nurse’s purview to expand assessment so that multiple factors that influence individual health or illness are also included.

A complete physical assessment identifies normal and abnormal findings and relates them to the health history for a complete picture. The assessment includes vital signs, general appearance, health habits, past medical and illness-related history, social connect- edness, and education level; combined with results of diagnostic tests, this information

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112 CHAPTER 5 ● Family Assessment

helps identify possible nursing diagnoses (Goolsby & Grubbs, 2011). The way the nurse communicates during this assessment can set the tone for the relationship. Assessment find- ings are analyzed and synthesized to formulate opinions or clinical nursing judgments about the best courses of action to take. Components of a physical examination from individual and family perspectives are included in Box 5.2.

Since the beginning of professional nursing, the goal has been to assess individuals within the environment and pay attention to the healing potential of the family (Nightingale, 1859 and 1946). Nightingale believed nurses should attend to spiritual needs and return indi- viduals to the caring families where they would best be healed. Professional nursing has always included the family as a healing instrument; perhaps this is the true meaning of holistic care. For example, Mr. M. lives with his elderly parents who have similar cardio- vascular risk markers. Mr. M. needs to make some nutritional modifications as a result of his recent myocardial infarction. As the nurse caring for him, you realize the importance of dietary routines. What kinds of assessment data will you need to make effective clinical

BOX 5-2

Components of the Physical Ex amination

PHYSICAL EXAMINATION COMPONENT

Vital signs

General appearance

Health habits

Past medical and health related events

Social connectedness

Education

FAMILY COMPONENT DESCRIPTION

Obtain a genogram; collect information on the type and amount of family resources.

Observe the family’s physical and psychological presence and signs and symptoms of distress to actual or perceived threats.

Ask about the health practices and health maintenance activities of the family.

Complete the family health history and pedigree; collect information on the health-related events the family has faced in the past and ascertain how the family dealt with them.

Obtain a family level ecomap, collect the family social history, and identify interpersonal relationships.

Determine the health literacy of the family and tailor questions and teaching to this level.

INDIVIDUAL COMPONENT DESCRIPTION

Measure the individual’s respirations, pulse, temperature, blood pressure, and assess for pain.

Collect information about the individual’s physical presence, psychological presence, and signs and symptoms of distress.

Elicit information about the individual’s lifestyle that can affect health.

Collect information on the individual’s health status and health-related events from birth.

Collect the social history, determine interpersonal relationships, and create an individual ecomap.

Determine the individual’s ability to read and write and level of health understanding.

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CHAPTER 5 ● Family Assessment 113

nursing judgments and a collaborate with him in a plan for home? Family members who live in a shared household share resources, dietary routines, and habits. When nurses think family, it is important to understand that the family household is the place where health and illness are produced.

Gathering Information From Family Members

Family members often possess valuable information about care needs. For instance, a young man is in the clinic because of intense suffering due to migraine headaches. An individual assessment might just focus on the presentation, duration, intensity, frequency, and exacerbation of symptoms. The young man describes the pain as excruciating and limiting his ability to work. He is primarily seeking medicine or treatment for pain relief. A nurse who thinks family understands the importance of the family household and so initiates a conversation about his family. She discovers that he is married. The nurse knows that his wife might likely have some additional knowledge about the illness trajectory. Even though his wife is not present in the clinic, the nurse wants to include her in their conversation.

The nurse asks, “If your wife were here with you today, what do you think she might say about your symptoms?” He responds, “Well, she would really like me to tell you about the difficulty I have staying awake during the day. Even when doing simple activities I get tired.” He adds, “She has been asking me if missing sleep could cause the migraines.” The nurse then asks more specific questions about the sleep loss. His answers could lead to some additional testing. Without that additional information, the sleep disorder would have been missed and the course of treatment less effective.

Taking a family-focused approach can occur even if family members are absent. Use of circular questioning along with linear questioning during assessments can draw out im- portant information about family members that can assist nurses in making appropriate clinical nursing judgments (Wright & Leahy, 2009). Circular and linear types of questioning were described in Chapter 4. Use of the question, “What do you think your family [family member] would say about . . .” is a valuable open-ended question that naturally takes a family-focused perspective. Using this question during assessments can elicit important information that challenges potential assumptions.

C h allenges in C omp leting Assessments

The importance of information that family members can share during delivery of individ- ual care may not always be valued. But nurses who think family know that health deter- minants in one’s household, neighborhood, and larger community often have relevance to the presenting symptoms. Exploring them can help the nurse identify critical factors about ways the individual and family unit have been managing a presenting condition or even why the condition occurred. Family nurses use sincere and concerned language and nonverbal cues while completing the assessment. It can be a challenge during an assess- ment to listen carefully, ask curious and related questions, and accurately document observations in the health record but the information obtained can have a profound effect on outcomes.

E valuating N ursing O utcomes

Assessment is ongoing and used to later evaluate nursing care outcomes. For instance, the Jones family is greatly stressed because their 14-year-old son Alex with type 1 diabetes con- sistently has high blood sugar levels and is unsuccessful in meeting the target hemoglobin

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A1c of 6.5 to 7.5. At the time of diagnosis, when he was 11 years old, his parents attended classes with him and discussed the need for family change with a diabetes educator and di- etitian. The family has tried to make appropriate modifications to their lifestyle, but has not fully adopted all needed changes. Alex has always been a gamer and spent many solitary hours playing. As he has gotten older, he has taken to closing himself in his room alone for hours every day with the video games. He seems withdrawn and not interested in interacting in real life with friends, but says he has many friends online. His parents encourage him to be more physically active, but he refuses. His sedentary lifestyle and frequent high- carbohydrate snacks of highly processed foods are likely part of the reason for the uncon- trolled blood glucose levels.

Earlier assessments and education had only addressed ways to modify Alex’s diet, ex- plained insulin use, and discussed medical management. The early assessments had treated the diabetes as if it was his problem and not a family matter. Family health rou- tines were ignored and goals to address the family unit’s dietary and lifestyle behaviors were not included in the plans. Target blood sugar readings were not discussed and no one was keeping track of things on a regular basis. Alex was partially responsible for the high readings, but what roles did his family have? How does his family unit factor into his diabetes management? What kinds of things need to be assessed? What is known about his school work, peer group influences, and reasons for socially withdrawing? De- pression is sometimes linked with diabetes. Could this be a concern? A thorough assess- ment of family household factors could provide broader ideas about goals to set and strategies to plan. A plan that only considers Alex and ignores his family household, peer group, and other social factors might be ineffective in making needed changes. An assessment that clarifies relationships among things like his high carbohydrate intake, metabolism, school schedules, grades, peer associations, levels of sadness, and physical activity is important. Nurses who think family realize those connections. An evaluation that only gives a verdict of failure is not likely to encourage meaningful change. Con- tributing factors leading to repeated high blood sugar levels and an inability to reach a target hemoglobin A1c can be altered with family support.

Completing a Family Assessment

Nurses who think family can discover relationships among individuals, family units, and the community that can influence care and outcomes. Using an ecological model such as the Family Health Model (Denham, 2003) can be a good guideline for providing those as- sessments and make it easier to identify family factors. The household is where health is produced and also where illness, disability, and crisis occur. Family unit assessments can include elements about the individual, family, and community (Box 5.3).

Using a single assessment form for everything does help with regulation compliance for accreditations or reimbursement. But use of single standardized forms can miss the mark by not focusing on specific problems. A better approach might be devising instruments that go beyond the general assessment and using targeted approaches along with addressing the supporting roles family members or family health routines play. This type of assessment allows for goal setting, formulating strategic plans for reaching goals, and identifying threats as well as strengths.

It is possible to view the family and the individual simultaneously as the foreground context for any health experience; this approach is important in family-focused care (Denham, 2003). Foreground context implies that individuals and families are essential,

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not optional! The entire family can be the target for care. Family assessment acknowl- edges the uniqueness of each family’s needs and priorities (Wright & Leahy, 2009), even when individuals are respected and treated as the important care seekers. Family assess- ments identify specific concerns that need attention and can use a strengths-based or support-enhancing approach during data collection, one that discovers strengths for health promotion or behavior changes (Haggman-Laitila, Tanninen, & Pietila, 2010). Regardless of whether a needs- or strength-based perspective is used, an intentional systems-focused assessment approach that includes individual, family, and community is part of a family unit plan (Denham, 2003).

Interactions of multiple household members influence one another in ways that can sup- port or sabotage wellness or disease management (Denham, Manoogian, & Schuster, 2007; Manoogian, Harter, & Denham, 2010). When nurses think family, they consider the im- portant family roles and individual responsibilities that can influence outcomes and develop skills for completing assessments useful for family care (Bell, 2003).

Family Assessment Strategies

Family assessment requires perceptual skills or abilities to clearly observe, conceptual skills or the ability to think, and executive skills or the ability to follow through (Bell, 2003). Six things are needed as the nurse completes a comprehensive family assessment:

1. A systematic method for data collection and recording of the data 2. Excellent communication and observation skills 3. Careful analysis of the information collected from the individual and family

members 4. Critical thinking skills to determine which areas of care most need attention

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BOX 5-3

Comparing Individual, Family, and Community Assessments

CARE CONCERN

Child abuse of a 2-year-old boy

Obesity in an elderly woman

Sleep disturbance in a middle-aged man

Eating disorder of an adolescent girl

COMMUNITY ASSESSMENT COMPONENT

Availability of quality, affordable child care

Availability of nutritious food and areas for safe exercise in the community

Ambient noise or ongoing, sudden noises in community

Peer pressure or bullying in the school setting

INDIVIDUAL ASSESSMENT COMPONENT

Physical and psychological symptoms

FAMILY ASSESSMENT COMPONENT

Parental knowledge of growth and development

Understanding of nutritional and activity requirements within the family

Family stress level

Recent losses in family or relocation stress

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5. Sensitivity to what is valued by the individual and family 6. Imagination that allows one to identify ways to use nursing actions creatively to

provide family-focused coordinated care

Nurses who think family also know that four areas give a family perspective to individ- ual situations and provide cues about things to notice and assess:

1. Nonverbal behavior (e.g., affect, silence, eye contact, hesitancy to respond) 2. Verbal behaviors (e.g., who speaks, voice tones, content of dialogue, questions) 3. Interpersonal behaviors (e.g., individual behaviors, types of interactions with others,

visitors) 4. Environment (e.g., household location, work, dependent relationships)

A systematic family assessment requires awareness of the verbal and nonverbal com- munication of those interviewed and observed. This means paying attention to who is and is not speaking. While collecting data, observe the ways family members interact with the individual seeking care and with one another. Does one person talk for another? Does one person never speak? What do these things mean for this family? Respectful attention given to the individual and the family unit needs during these encounters builds trust. A template for a brief family-focused assessment charts how family type, functions, and processes come together (Table 5.1).

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TABLE 5 -1 Brief Family -Focused A ssessment

ELEMENT: NOTES:

Individual demographic data

Family demographic data

Illness or health promotion concern of the individual

Illness or health promotion concern of the family

Family structure and developmental information Complete genogram

Family routines disrupted by illness

Family health promotion activities

Family economic status

Family cultural status

Family connections to the larger community Complete ecomap

Usual ways family manages an illness, injury, or developmental transition

How is this illness or health promotion activity influencing usual management of activities of daily living?

How do you, as a person, typically communicate, solve problems, and make decisions about health and illness? What things help? What things create barriers?

How do you, as a family, typically communicate, solve problems, and make decisions about health and illness? What things help? What things create barriers?

Who or what in your community do you believe could be helpful to you in managing this health/illness challenge?

How can we, as health care professionals, best help your healing, as a person?

How can we, as health care professionals, best help your healing, as a family?

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Case Study: The Cox -Halverson Family

Meet Randy Cox and Sheila Halverson, both 38 years old, the family being discussed throughout the rest of this chapter (Fehl, 2012). Some information is based on a real family that agreed to share some of their story, but some facts and names have been altered to protect their identity. This family provides a way to learn how conceptual ideas apply to family experiences.

Assessment of Family Typ es

Family types are somewhat different from in the past. Individuals in a single household may be extremely different from one another. Multiracial families are more common as a result of increasing globalization, immigration, ethnic diversity in a geographical region, economic shifts, and changing social values. Family forms are increasingly diverse and a growing number of gay, lesbian, bisexual, and transgender (GLBT) people live openly as family units. Nurses in clinical practice are likely to meet transgender and gender- nonconforming people and their families as they seek medical care and some face dis- crimination in doctor’s offices, emergency departments, mental health clinics, and drug treatment programs and by emergency medical transporters (Grant, Mottet, & Tanis, 2011). Health and illness concerns of GLBT families are important. For instance, the In- justice at Every Turn study noted that only 43% of transgendered people maintained most of their family bonds, and 57% experienced significant family rejection (Grant et al., 2011). This study also found that 19% of the participants reported being refused medical care and 50% of transgendered persons had to teach their medical providers about care needs. Transgendered or gender-nonconforming people might have little or no contact with their family of origin and may have experienced an alarming amount of harassment, physical assault, sexual violence, and discrimination in their lifetime. Nurses who think family realize that their practice role calls for them to be tolerant and caring regardless of the family type.

Randy Cox and Sheila Halverson are a blended family. Randy and Sheila started dating about 2 years ago and their relationship became serious rather quickly. Both had previously been in unsuccessful long-term relationships and decided not to marry, but to live together. They each brought children to the relationship, seven of them (Table 5.2). Randy has five children, four biological children from his previous marriage and Brendan who was adopted as an infant when he married his mother. Randy has had contact with his daughter Jess throughout her life, but not custody. She recently moved to the area trying to make a new life. She stayed with her father and Sheila for about 6 months, but has found a job and an apartment. She still has frequent contact with them.

Randy receives a monthly Social Security disability payment based on the debilitating effects of his rheumatoid arthritis and he receives 40 hours a week of assistive services to help with his activities of daily living (ADL). He took Dilaudid and Oxycontin on a daily basis for pain control before therapeutic surgeries and for the first time in years he is not taking prescription pain medications. He has recovered well from his surgeries, but still struggles with knee pain due to years of walking with an impaired gait. The pain is mostly manageable, but flairs often enough to effect his ADL. Randy has been a smoker since the age of 14, but quit after his surgeries with the help of electronic cigarettes. He has struggled to remain smoke free and still uses them and smokes cigars several times each week. At 6 ft tall and 200 lb, he has no other significant health concerns.

Sheila has two children. Amanda, Sheila’s daughter from a teenage relationship, was adopted by Sheila’s parents and had little contact with her until the last 4 years. Initially the relationship was very strained, but it has grown stronger over time. If you use the Family Health Model (Denham, 2003) to understand the family from an ecological perspective,

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you would consider more than the family type and number of children (Box 5.4). The family lives in a three-bedroom, two-bath home in a rural community. They have two cars available for transportation. Currently Randy, Sheila, Alex, Travis, Liam, Amanda, and her two daughters live in the home. Amanda was having difficulties and they encouraged her to move in with them, making their home a bit cramped. At the age of 16, Amanda had Sasha,

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TABLE 5 -2 Cox -H alverson Ch ildren

RANDY’S CHILDREN

Bailey, female, age 11 years, in 6th grade

Liam, male, age 12 years, in 7th grade

Alex, male, age 14 years, in 8th grade

Brendan, male, age 16 years, in 11th grade

J ess, female, age 19 years, has a General Educational Development (GED) diploma

CONCERNS

Born from teen relationship; adopted by Sheila’s parents; currently living with Randy and Sheila along with her two daughters

ADHD and oppositional defiant disorder (ODD); takes medication daily (took Abilify and made remarkable progress but had symptoms of tardive dyskinesia and drug was discontinued); serious social and education difficulties

Q uiet child, does not interact much with others, has temper tantrums and screams when she does not get what she wants

Cries often and Amanda becomes very frustrated; Bailey takes care of her much of the time when she is available

___________

CONCERNS

Mostly healthy, average weight and height, has shown some signs of asthma lately

Attention deficit- hyperactivity disorder (ADHD) and anxiety; takes medication; social difficulties; in special education; conflicts with Alex

ODD without ADHD; no medications; attends school for behavioral disorders; 90th percentile for weight relative to height; conflicts with Liam

Adopted, but does not know this; well adjusted; works part time

Born from a short teen relationship; little contact over the years; lived with them for about 6 months and now has contact

SHEILA’S CHILDREN

Amanda, female, age 19 years

Travis, male, age 14 years, in 8th grade

Sasha, female, age 2 years, biracial (Amanda’s daughter)

Autumn, female, age 5 months, healthy at this time (Amanda’s daughter)

___________

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BOX 5-4

Implications of Family Type

Consider the information provided about the Cox-Halverson family and their blended family living situation. Take some time to consider the various factors associated with the family members described in the family type section. Think about what daily life for this family might be like. What are the implications of these known factors on members’ health and illness?

Answer these questions:

1. List risk factors you see for this family based upon what you know about family type. 2. List the strengths you see in this family based upon family type. 3. Given the risks and strengths identified through the family type assessment data available,

what one or two things would be a priority for Randy’s care needs if you were a nurse talking with him during a physician visit?

4. Now think family and identify two or three other things that the nurse might discuss with Randy that could be important for his family’s wellness or illness prevention or management.

5. Using an ecological model to think about this family, what other questions do you have about the family’s context (i.e., interacting factors linked with family, neighborhood, and larger social environments)? List three areas you might want to further assess.

her first daughter, but she has no contact with Sasha’s father. Amanda realized she was preg- nant again soon after she moved to live with Randy and Sheila and her second daughter, Autumn, is now 5 months old.

Sheila Halverson is overweight and has hypothyroidism, polycystic ovaries, and anxiety. At 5 ft 9 in. tall and approximately 260 lb, she has an increased risk for an array of weight- related conditions. She gained much weight while her hypothyroidism was undiagnosed. At the age of 15 she had an induced abortion. She then, at the age of 16, gave birth to a daughter who her father and stepmother adopted as a toddler. Later, at 22 years, she gave birth to a son who she has raised primarily as a single parent. She takes Levothyroxine and oral contraceptives daily. Sheila smokes 5 to 10 cigarettes per day and struggles to find time to make exercise a daily part of her routine.

Neither Randy nor Sheila identifies as religious, but Randy attends church sometimes with the children and extended family. Some of the children occasionally attend youth ac- tivities at the church. Although they do not identify themselves as religious, they define themselves as spiritual. Sheila explains this as feelings of respect for others, contributing to society, and striving to be a good person. Randy and Sheila, both raised on the East Coast, have little knowledge of their family heritage. Although at first Randy and Sheila thought it unlikely that they would ever marry, they decided to blend their family in a more formal way and just recently married.

Learning this background information through an assessment helps one know more about this family. Nurses who think family and use an ecological perspective can deter- mine the factors and traits linked with the family household that have potential implica- tions for the health or illness of the person. Things like culture, religion, ethnicity, and personal values all have implications for health and need to be assessed. One cannot fully understand the struggles multiple household members face by merely noting that this is a blended family. If a genogram and ecomap (described later in this chapter) are completed, even more could be understood about family risks and household needs. Family stories can also help nurses see individuals as whole people and identify nursing actions that can support care needs.

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Assessment of Family Function

Most nursing assessments miss information about things like caregivers, family resources, social networks, and ways family work is accomplished. At minimum, the projected setting where the person will go after discharge is usually recorded and the caregiver for a depend- ent individual will be noted. The word caregiver often refers to a person caring for those seen as dependent but fails to consider caregiving when persons are more able or inde- pendent. In families, members give different forms of care to each other. For example, someone does the grocery shopping and food preparation; these tasks are linked with nu- trition and diet and are relevant to many illnesses. That person would be the caregiver if dietary changes are needed. Although this person contributes to an individual’s care, they are likely overlooked as a caregiver in the traditional sense.

Family functioning has to do with things like member tasks and roles. In well-function- ing families, members’ needs are met and the family unit promotes well-being for individ- uals. Nurses who think family know that all members may not function at optimal levels and some households fail to provide adequate support and resources for members. Al- though families share some needs, these needs are often prioritized and accomplished in distinct ways. Family members assume different roles for the work of caring and nurturing with or without the presence of illness (Meiers, Eggenberger, Krumwiede, Bliesmer, & Earle, 2009). Assessments provide bits of relevant information. For instance, nurses caring for a medically fragile newborn or a disabled veteran living in a rural community need to know about the family’s abilities to provide needed care. Systematic assessment considers five functional roles:

1. Who organizes things in the family and makes certain needed supplies or resources are available for members?

2. How do family members communicate with one another in sharing family work, making decisions, or planning care and how do they maintain connections with primary health care providers?

3. What roles do members take in parenting, disciplining, and nurturing needed by various members?

4. Who are the financial “bread-winners” who assure things like an adequate salary, family income, and health benefits are available to meet members’ needs?

5. Who are the family’s social coordinators, who maintain connections between the family unit, social networks, and larger community to meet various forms of support needs?

When roles are optimally fulfilled, the family’s caring work can be completed with max- imized outcomes met and minimized stress or confusion (Box 5.5).

Functionally the Cox-Halverson family faces significant challenges. Sheila is the chief financial provider for the family. She contributes the major portion of the family income and is the financial manager who pays the bills and handles the money. She was recently promoted to a program coordinator at an adult foster home. This has been a financial ben- efit, but it means a greater time commitment, more responsibility, and additional stress. Randy and Sheila are supporting four children and two grandchildren, a difficult task for even the most financially stable couple. They live in a home that is not ideal, have regular transportation issues due to an unreliable vehicle, and have few prospects for improvement in the future.

Sheila is responsible for much of the family’s health management. She arranges medical appointments for household members and usually accompanies them. She ensures that medications are taken as scheduled and prescription reorders are processed. It was under Sheila’s urging that Randy was able to decide to have the hip surgeries done. Randy’s

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disabilities limit his physical activities, but the surgery outcomes are enabling him to be more active with his family. He loves to cook, but does not embrace healthful cooking methods. This is a concern for Sheila as she battles with weight. Randy enjoys video games and plays with the older boys. Sheila has never had a little girl before and has en- joyed the experience of spending time with Bailey doing “girly” things. Although these parents love their children, they have many problems.

The family supported Randy as he took the necessary, yet somewhat frightening, steps to have the two hip surgeries. The family now has questions about how to move forward. Randy is an experienced mechanic. He doubts that he can physically return to that job and lacks skills to begin a career with less physical demands. He would love to make a substantial financial contribution to his family, but there are concerns about him returning to work before he is ready or to a position that is too physically demanding. Returning to work also means they will lose his Social Security benefits. They also face the dilemma that if he is unable to maintain employment because of physical disability, he might have difficulty regaining these benefits. This loss could put the family at signif- icant financial risk.

Assessment of Family Processes

Family processes are the actions or activities members use as they interact and accomplish family tasks. Family processes include daily household activities, promote member health, parent children, instill rituals and routines, make transitions or accommodate changes, manage conflict, solve problems, make decisions, demonstrate affection, and satisfy indi- vidual needs (Walsh, 2003). A family managing a chronic illness such as Alzheimer’s disease needs to identify goals, plan family work, and manage daily caregiving tasks. As the affected individual’s cognition declines, the individual needs to find new ways of including the

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BOX 5-5

Implications of Family Functions

As you review the five functional roles in families, think about what you know about the Cox-Halverson family from the family type and family function session. Then answer these questions:

1. Who organizes what is needed in this family? 2. How effective is communication among members of this family and their health care

providers? 3. Who plays what roles when it comes to parenting, discipline, and nurturing in this family? 4. Who are the “ bread-winners” in this family and what conflicts do they have? 5. How well are members in this family connected to one another? Are they linked with other

social networks? How effective are their connections to the larger community in obtaining the supports that are needed?

6. Given the risks and strengths identified through the family type and functional assessment data available, what one or two things would be a priority linked with Randy’s care needs if you were a nurse talking with him during a physician visit?

7. Now based upon the family type and functional assessment data available, think family and identify two or three other things that the nurse might discuss with Randy that could be important for his family’s wellness or illness prevention or management.

8. Using an ecological model to think about this family, what other questions do you have about the family’s context (i.e., interacting factors linked with family, neighborhood, and larger social environments)? List three areas you might want to further assess.

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member in valued traditions. The Family Health Model (Denham, 2003) identified seven core processes that can be used to assess family’s health and illness needs systematically and plan interventions: caregiving, cathexis, celebration, change, communication, connectedness, and coordination. These core functions are useful ways to work collaboratively with family units and are fully described in Chapter 14 of this text.

Think about the ways your family managed the last illness of one of your family mem- bers. What family processes came into play? How did your family members communicate needs? Were roles or communications different? Was decision making altered? How did your family negotiate and coordinate various tasks? Who invested the most emotional en- ergy or physical energy in caring for the ill member? How did family members support change as healing occurred? How did your family celebrate the healing? Did the ill member facilitate or hinder usual family work? For instance, did a young child learn to comfort the parent? How was connectedness fostered? What steps were taken to coordinate efforts? The next time you complete an assessment, consider what usual family life is like for the family and the disarray potentially experienced with this member’s condition.

When a member tries to change his or her lifestyle to self-manage a chronic condition or focus on wellness, others can support or sabotage behaviors. Perceived threats to the routine, possibly related to loss of control or power, can be emotional and cause feelings of grief, loss, anger, or frustration. Nurses who think family understand that perceived threats can have a dramatic effect on family members. Members do not always discuss their concerns in ways that create positive change. When members are cooperative, they will respect one another, provide support, and negotiate differences. However, not all peo- ple live in ideal families! Nurses who think family use their communication and assessment skills to learn what families need most.

When power is shared, communication is apt to be more direct, honest, and affirming. Families with shared power are more likely to be flexible, adaptable, willing to admit mis- takes, and comfortable trying new things. But not all families are caring or deeply con- cerned for other members. Some are self-interested, inattentive to others’ needs, and controlling. When family power is unbalanced, members might experience anxieties, depression, distrust, distress, or dissatisfaction. These concerns might not be identified if the assessment focuses only on physiological symptoms. Pause and reflect. How would you handle a situation when family members demonstrate power imbalances? What would you say? How might you facilitate the conversation so that the most powerful person begins to relate to the others from an equal or relational position (Knudson-Martin, 2013).

The Cox-Halversons have many challenges with their blended household and multiple members (Box 5.6). Those living in the household have changed over 2 years. Randy pre- viously shared custody of the four children with Mandy, his ex-wife. She moved away after losing her job, giving Randy full custody of the four children. About a year ago, Mandy moved back into the area and now has custody of Brendan and Bailey and they visit the home every other weekend. Randy and Mandy try to be amicable and flexible with the visitation schedule. Sheila has full custody of Travis, her son who has never met his bio- logical father. The father does not provide any financial support. Sheila and Mandy get along, but Mandy sometimes speaks negatively about Sheila to Brendan and Bailey. Despite what might seem like chaos, Randy, Sheila, the children, and the dogs manage their busy household with strengths that mostly complement one another.

Sheila and Randy make most decisions collaboratively, talk openly with one another about concerns, and can usually weigh options and come to decisions together. Children are sometimes included in conversations and are listened to when it is relevant. Several of the children have conflicts with one another. When Randy needed the hip replacement sur- gery, they needed to discuss how the children would be cared for during that time. They

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considered delaying his surgery and making various arrangements for the children. In the end, they decided that it was best to just make the situation work. A similar problem- solving approach was used when Jess and Amanda needed to move into the home within a month of each other. Ten people were living under one roof and Randy was still actively recovering from his surgeries; it was a stressful time. Randy’s extended family provided emotional support and his mother, stepfather, and brother were available to help occasion- ally when needed. Sheila’s mother lives out of state and is neither supportive nor reliable; no other extended family are available. Amanda just became employed by the same com- pany where Sheila works and is at the top of the waiting list for subsidized housing. She recently passed her driving test. Amanda is still in contact with Autumn’s father, Aaron, who is 17 years old and still in high school. She is looking forward to moving in with him and her children and being more self-sufficient. Randy and Sheila have mixed feelings about her moving and are concerned about her parenting abilities and immaturity. They anticipate continuing to help her after she moves.

Nurses can use assessments to identify steps for Randy and Sheila to improve their mem- ber and family health. For example, the family would benefit if Sheila quit smoking. Sec- ond-hand smoke exposure is bad for the children’s health; it increases risks for asthma, upper respiratory infections, and ear infections. In households where parents smoke, risks for children smoking increase. Cigarettes are expensive and the family could also benefit from the financial savings. Several family members have emotional and behavioral con- cerns. Some counseling or behavioral training could assist children and parents, but re- sources to pay for such help and accessibility to services are limited. Randy could benefit from a referral to a vocational rehabilitation program as it is often most effective to keep persons with rheumatoid arthritis active and the family is likely to benefit from his being more fully employed.

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BOX 5-6

Implications of Family Processes

The Cox-Halverson family has a total of nine children for whom they share some responsibility. In turn, they have complications of others who are also involved somewhat with parenting tasks. The children, although connected in some ways to one another, also have connections to other extended family members that differ from one another. Although daily life may not always involve all of these people, at times the family does have to manage these social connections. Sometimes these connections are supportive, but at other times they are stressful.

As a family nurse consider what you know about the Cox-Halverson family’s type, functions, and process. Now think about the Randy’s discharge home and his needs in the next 3 to 4 weeks as he recuperates after his surgery. As a nurse who think s family, how might you answer the following questions?

1. What is the support that Randy will likely need at the time of his discharge? 2. Identify three or four particular accommodations that the family might need to make for

Randy’s homecoming. 3. List two or three problems the family nurse might anticipate in family care based on what

is known from the assessment data that should be considered when doing discharge planning.

4. If you could ask three questions to gain more information you consider essential to satisfy these needs, what they would be?

5. Identify three social networks or community supports that would be useful to this family. Explain what they are and the usefulness of their inclusion.

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Moving From Family to Community Assessment

Nurses who think family acknowledge that the true primary care environment for individuals is the family household and the community where the family lives. Nurses who realize their role is to increase the family’s capacity to support individual members think differently about the consequences and adequacy of community supports. Nurses who think family recognize their central role is to prepare those receiving care to self-manage their conditions to their fullest capacity independently. An ecological perspective incorporates different nursing actions than those derived through the more narrow thinking of the medical model. It means nurses assess the household environments, neighborhoods, and communities where families live in relation to risks, threats, benefits, and supports aligned with health or illness concerns.

Most nurses have had some exposure to community health or public health nursing and may have experience in community assessment using a technique known as a windshield sur- vey, when a nurse may assess risks, supports, and other barriers to well-being or health that might be present in the neighborhood or larger community by driving, walking, or riding pub- lic transportation within the neighborhood. However, nurses who think family can also use a family ecomap to identify community threats or supports; these are described later in this chapter. This tool can be used to anticipate concerns and resources needed in a care transition.

Household Location in Community

Just as individuals and families are unique, so are communities. Understanding the risks and benefits of a particular household or community is similar to thinking about an individual. For instance, it is useful to know whether an elderly woman in an ethnic community is willing to assist a new single parenting mother. A single parent may need the support of a community of people if she is from a culture outside the mainstream. Although it is impossible for nurses to learn everything about multiple persons met during a day’s work, learning to elicit and hear stories about family households and community neighborhoods provides information for care.

Nurses who think family conduct assessments that identify individual connections with family and the community. The Family Health Model suggests family-focused care is aligned with ways individuals are situated within households nested in neighborhoods, communities, and the larger society (Denham, 2003). This perspective encourages questions about what needs to be known about where people live, work, learn, play, and pray. Per- sons are usually seen in a health care setting outside their home environment, so some im- portant environmental influences are overlooked. The following are three scenarios faced by home care nurses conducting the initial posthospital discharge visit; none of this infor- mation was noted on the original referral for care:

1. Trash piled high and cluttering the entire living room from groceries consumed by an obese caregiver living on a couch while the elderly gentleman needing nursing care was confined to a bed in the same room

2. A blind elderly man with type 2 diabetes and open sores requiring treatment and daily dressing changes living alone in a home without running water

3. A semiparalyzed 27-year-old wheelchair-bound woman living alone with her pet in a house littered with dog urine and excrement from when the dog could not get outside

These findings were not expected and in each case they called for immediate problem- solving actions by the home care nurse at the clinical visit. When nurses think family, the assessment includes information linked with household and community.

Coordinated family care relies upon collection of information that provides an accurate picture of the actual living conditions. Dr. Duhamel and many others are working in

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Canada and other nations to advance family-focused nursing care (Box 5.7). Assessing household information including neighborhood safety, access to necessary resources, avail- ability of transportation, and distances to medical care provides a baseline for determining appropriate nursing actions. An ecological model encourages the family nurse to learn if the family household poses risks or offers supports for individuals and family units (Fig. 5.2). Remember, families are greatly influenced by the ways their lives connect with pets, friends, social networks, and many other things in the community where they live.

Family Links With Community

Assessing community factors that predict and protect individual and family health requires innovative thinking about how families are linked within communities and openness to new models of care and technologies. Dr. Janice Bell has global recognition for her work with families and has inspired many to look at nursing differently (Box 5.8). Suppose a family wants to vacation at a mountain retreat where they have gone for years, but they are concerned that the mother’s compromised mobility from multiple sclerosis will make it impossible. The nurse might help the family explore solutions for the transportation problems such as renting a motorized wheelchair from a durable equipment company or facts about a van with a platform lift for raising and lowering a wheelchair because she knows the valued shared time together and memory-making for the family are important. Comprehensive assessment not only examines physiological, psychosocial, and emotional needs, but also identifies whether resources are available or threats need to be addressed.

Interrelationships of larger community factors predict individual and population health (U.S. Department of Health and Human Services, 2010), and family health is often tied to the economic and environmental factors of the family's community. We need a community- based framework to help identify ways to decrease health disparities and promote healthy lifestyles from a family perspective. Two such frameworks are Healthy People 2020 and the one used by the Red Cross Nurse (RCN) in a disaster.

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BOX 5-7

Family Tree

Fab ie Duhamel, PhD (Canada)

Dr. Fabie Duhamel, PhD, is a professor at the Faculty of Nursing in the University of Montreal, Q uebec, Canada. She received her doctorate from the University of Calgary, Ontario, Canada. In 2010 Dr. Duhamel and colleagues founded the Center for Excellence in Family Nursing, a partnership between the Faculty of Nursing and several Montreal health institutions. The center’s mission is to promote and sustain advancement of the family systems nursing knowledge through education, research, and clinical practice for graduate nurses. The center provides a unique opportunity for exchanging knowledge among practitioners, researchers, and academicians.

Dr. Duhamel’s scholarship demonstrates a commitment to research focused on family interventions and the implementation of family systems nursing in practice. Her research activities focus on family systems nursing, chronic illness, and knowledge exchange. Dr. Duhamel has numerous family nursing publications in English and French. She has developed a tool, called the Family Genograph, to assist nurses in using genograms and ecomaps in family assessment.

Dr. Duhamel has received funding from the Canadian Institutes of Health Research to bring together family systems nursing colleagues from six countries (Canada, Iceland, Japan, Sweden, Thailand, United States) to create an international collaborative effort focused on knowledge transfer of family nursing to practice settings. She is a member of the International Family Nursing Association and is currently serving on the Board of Directors.

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126 CHAPTER 5 ● Family Assessment

FIGURE 5 -2 Ecological model encourages the nurse to assess the family environment.

BOX 5-8

Family Tree

Janice Bell, PhD (Canada)

Janice M. Bell, PhD, is a nurse educator and registered psychologist who has focused her career on building capacity in nurses and others to care for families with competence, confidence, and compassion. Dr. Bell provides global leadership in family health with a focus on family system nursing. Dr. Bell served as a member of the faculty team of the Family Nursing Unit, University of Calgary (1986–2002), and as the Director of the Family Nursing Unit, University of Calgary (2002–2007). This unique faculty practice unit was built upon an innovative educational model that provided extensive opportunities for faculty and student scholarship.

Dr. Bell and her Canadian colleagues have taught the Calgary Family Assessment and Intervention Model to thousands of practicing health care professionals, graduate students, and academics in Canada, United States, Japan, Thailand, Hong Kong, Singapore, Iceland, Finland, Sweden, Switzerland, Brazil, Portugal, and Poland. Dr. Bell has focused on Family Systems Nursing as a way to guide nursing practice through which nurses form relationships with persons and enter into therapeutic conversations with families. She co-developed the Illness Beliefs Model and focuses her scholarship on illness suffering, family healing, therapeutic conversations, family interventions in health care, and research. Dr. Bell is widely published and greatly respected throughout the world for her work with family nursing.

Dr. Bell is the founding editor of the J ournal of Family Nursing. This journal, first published in 1995, is now a leading reference for work linked with extending understandings of the family experience during health and illness and improving care to families. Dr. Bell was instrumental in the planning and hosting of seven international family nursing conferences (1988–2009). She is a founding member of the International Family Nursing Association and is on the Board of Directors.

Dr. Bell is highly respected and internationally known for her commitment to discovering and translating knowledge that informs practice. She currently offers workshops and consultation about practice knowledge with families to an international community of nurses and other health care professionals.

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Healthy People 2020 identifies 26 Leading Health Indicators (LHIs) organized into 12 topical areas. They include access to health care; clinical preventive services; environ- mental quality; injury and violence; maternal, infant, and child health; mental health; nutrition, physical activity, and obesity; oral health; reproductive and sexual health; social determinants; substance abuse; and tobacco use. The LHIs are guides for national health assessments and interventions; they provide guidelines and benchmarks to measure progress or outcomes. LHIs extend across the life span to address social and physical environments, multisector policies, individual behaviors, health services, and biological or genetic factors that influence the ability of individuals and communities to be healthy. The LHIs apply to health at the individual, family, and community levels and provide focus for assessment when the family enters a disaster shelter.

In disaster nursing, the RCN uses an initial intake and assessment form to collect data about families that include immediate and long-term shelter needs, mental health con- cerns, and planning for the future. Family members who require assessment beyond the immediate concerns about nutrition and shelter are seen by the shelter RCN for a more in-depth assessment. The Red Cross Shelter intake process connects shelter clients with their broader families through local and nationalized disaster disposition databases. When the intake assessment is completed, the result is a conclusion about what the family will continue to need for the duration of the shelter stay and upon reentry into the com- munity of origin. A similar assessment could offer systematic ways to collect a breadth of information for care management relevant to a usual community where families live even when disaster is not at hand.

A Family Health Record

A family health record could go a long way to ensure continuity of care once the individual moves out of the health care setting and back into the home. A multitude of issues can negatively influence outcomes if not addressed. For example, if the person needs to see a medical specialist for a referral, is transportation available after he is at home? Do special arrangements need to be made? Is there someone to transport the person if he can’t do this independently? Does the family believe follow-up care is important and will they see that it occurs? Does the person have a smartphone and is he willing to receive reminders about care management? Is the family willing to spend their money on resources for this visit (e.g., gasoline costs, meals out, co-pays for a medical visit)? In the past, this type of follow-up belonged to social workers. However, nurses who think family can intentionally discuss these relevant family issues to help streamline care from an acute setting or primary care to home and community, possibly preventing hospital readmissions because the families are prepared for self- or family-management. Box 5.9 suggests that family research occurring in Finland needs to expand and faculty in schools of nursing are helping students learn about ways to include families in nursing care.

Thinking family provides ways to view the interdependent care needs of multiple family members simultaneously. For instance, a single family health record could note several things:

• The decline in musculoskeletal function of one of its members • Family responses to falls related to a hypoglycemic incident in that member • Physical therapist notes about member’s declining abilities to navigate uneven

surfaces • Family’s response to these events • Abilities hindered because of barriers and lack of resources in the community

Electronic medical records may or may not be the answer, as they remain largely untested. But some form of an ongoing plan for some chronic conditions that identifies goals, strategies, supports, and outcomes linked with family unit needs and individual

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conditions could be instrumental in improving outcomes. Emerging models must include family unit and household information if coordinated care linked with individual and family health is ever to be fully achieved (Calman, Hauser, Lurio, Wu, & Pichardo, 2012).

Tools to Guide Assessment

Many types of survey tools are available that could be used to guide assessments and collect pertinent data about families units, individuals within families, and families within commu- nities. Some of these tools include genograms (McGoldrick, Gerson, & Shellenberger, 1999) and ecomaps (Hartman, 1995). In addition, geographical information systems (GIS) capture, store, analyze, and display referenced information about specific environmental concerns that are geographically and ecologically pertinent to families (Choi, Afzal, & Sattler, 2006). GIS can be used to identify health risks based upon geographical locations. Tying GIS with social determinants of health, demographic information, and epidemiological data could pro- vide new ways to consider risks for family units. Personal and family health records that take genetics, genomics, and social determinants into account are other tools for assessment.

Using a Family Genogram

A genogram is a visual representation of the family’s membership and health history. A genogram is an effective way to represent visually multiple generations, areas of support, and other information for decision making. Genograms enhance nursing family assessment (McGoldrick & Gerson, 1985). They can be constructed to reveal facts about many dif- ferent elements. For instance, family type(s), roles, relationships between the family mem- bers, demographics, age, developmental level, gender, number of members, employment status, immediate health problems of individual family members, trends of health problems, and genetic illnesses of the family over time can all be depicted. Genograms efficiently organize a breadth of family information to present a useful family picture visually.

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BOX 5-9

Evidence-Based Family Nursing

Family Nursing Interventions in Finland: Benefits for Families

Nursing interventions are actions taken to support and help individuals and families promote personal health, care for self and each other, and die gracefully. The researchers in Finland have determined more research about effective nursing actions is needed in Finland. Family nursing aims to strengthen family resources and resolve problems in all stages of life, and many families are open to these ideas. However, in the Finnish culture, adult persons tend to be viewed as unique individuals living within a family rather than as members of families. When illness occurs, family members show concern and often need support themselves. Interventions that have been shown to be useful for Finnish families include meeting with and obtaining supportive care from nurses. However, family members are not well incorporated into assisting with care for their ill family member. Work in research and practice is only beginning in this nation and much still needs to be studied and better understood. Dr. Paivi Å stedt-Kurki and her colleagues at the University of Tampere, Finland, are leading the way in developing family nursing curricula at the graduate level that assist nurses in incorporating the family in care for the individual ill family member.

Source: Å stedt-Kurki, P., & Kaunonen, M. (2011). Family nursing interventions in Finland: Benefits for families. In E. K. Svavarsdottir & H. Jonsdottir (Eds.), Family nursing in action (pp 115–129). Reykjavik, Iceland: University of Iceland Press.

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Divorce

Separation

Friendship / Close

MarriageMale Female

Living Together

Twins Miscarriage or Abortion

Pregnancy

Genogram Symbols

Identified Patient

Death

Lesbian, Gay, Bisexual,

Transgendered Person

FIGURE 5 -3 Genogram symbols.

Detailed illness information can be added to the genogram to create a family pedigree depicting transmission of such features as genetic conditions, familial conditions, and psy- chosocial patterns, such as chemical dependency and suicide. A family pedigree refers to family groups or line of ancestors; this is useful to identify the passing of genetic traits or conditions. A genogram can be useful for early diagnosis, identification of risk factors for particular conditions, and suggestions for prevention. The genogram is arranged by gener- ation, with three generations considered a minimum data set (Kaakinen, Gedaly-Duff, Coehlo, & Hanson, 2010). Figure 5.3 provides some information about the various symbols that can be used to create a family genogram. It is also possible to show the strength of relationships on a genogram (Fig. 5.4). Think back to the Cox-Halverson family; the com- plicated blended family membership can be clarified with a genogram (Fig. 5.5). Nurses can construct a genogram by eliciting health and demographic information about the individual and family (first, second, and third generations).

Using a Family Ecomap

An ecomap is a different structural form that can be used to visualize the various activities and relationships of the family with the larger ecological environment. To draw the ecomap, the genogram is first placed in the center and then the connections among persons within the family and the entities outside the family are drawn. Entities are drawn as circles surrounding the family genogram. Examples of surrounding environment

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130 CHAPTER 5 ● Family Assessment

Mandy 38

Jess 19

Bailey 11

Sheila 38

Randy 38

Brendan 16

Alex 14

Liam 12

Amanda 19

Autumn 5 mo

Sasha 2

Travis 14

CAT DOG DOG

Cox-Halverson Genogram

FIGURE 5 -5 Cox-Halverson genogram.

Strong

Positive

Hostile

Abuse

Tense

Distant

Cut Off

Fused

Focused On

Strength of Relationship Symbols

FIGURE 5 -4 Strength of relationship symbols.

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entities are extended family, school, work, health care institutions, social services, recre- ation, and friends (Wright & Leahy, 2009). Recall the Cox-Halverson family and con- sider the multiple interactions members might have with their larger community and related systems (Fig. 5.6). Even more complexity can be added to the ecomap by making specific connections between each genogram member and persons or entities in the larger environment.

Geographical Information Systems

Geographical information system (GIS) databases are powerful epidemiological tools that can be used to highlight geospatial patterns of concern that occur in residential living en- vironments (Bloch, 2012). The GIS is a way for health professionals to use electronic means and expand the traditional windshield survey. This type of assessment shows the intercon- nected nature of individuals and community health (Berkman & Glass, 2000). Understand- ing the distribution or lack of physical program resources within communities assists nurses

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FIGURE 5 -6 Cox-Halverson family ecomap.

Cox -Halverson Family

Church

Cox-Halverson Family Ecomap

Jess

Sheila’s Extended

Family

Extracurricular Activities

Aaron

School

Mandy

Mental Health

Services

Randy’s Extended

Family

Sheila’s Work

Strong relationship Weak relationship

Direction of energy flowTense relationship

Bailey 11

Sheila 38

Randy 38

Brendan 16

Alex 14

Liam 12

Amanda 19

Autumn 5 mo

Sasha 2

Travis 14

CAT DOG DOG

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to plan community-located nursing actions with implications for and potential to change health or lifestyle behaviors.

GIS software can be used to identify social determinants of health locally, regionally, and nationally. For instance, geographical locations of spatial attributes can be entered into a map of the area. Each map point has a latitude and longitude identity, similar to Google maps or any type of global positioning system (GPS). Additional data might be added for analysis, such as race, immigration status, and primary care clinics. Nurses can search the map based on different attributes to look for patterns of concern, track improve- ment or decline in health disparities, or illustrate family or community resources available that may help with health promotion, disease prevention, or management of illness. GIS also gives information about physical, program, and potential social capital resources avail- able to persons or families in the geographical area.

Geographical distribution of morbidity and mortality patterns can be geospatially ana- lyzed by policy makers and health care systems to determine service needs of a region, state, or country. GIS databases can be used to examine trends in health behaviors and lifestyle that can identify community assets that support health, such as healthy diet and physical activity (Gebel, Bauman, Sugiyama, & Owens, 2011). Public health nurses have used epidemiological statistics and methods for decades to plan population-level interven- tions and are now using GIS databases to design these interventions (Caley, 2004). Com- munity partnerships have created Web sites that can be used to fine-tune action plans that support healthy communities. An example of an interactive map to support healthy living has been designed by Healthy Living Rochester. Their Web site map can be accessed to identify community resources that can help support a family that wants to become more physically active.

Nurses who use GIS databases as part of routine community assessments can attend to many factors that support or deter healthy behaviors for individuals and families. Many of the GIS databases and map systems contain tutorials or learning modules so that those using the sites can readily access data useful for evidence-based decision making. Nurses can work with community persons and agencies to design GIS databases that support health and contribute to family and community well-being. These can be used to assume active and futuristic advocacy roles that support vulnerable families.

Genetic Assessments

Genetics is the study of the transmission of inherited traits from one generation to another among similar or related organisms. Genes are used to transport traits or characteristics through family descendants, and genetics is concerned with the traits passed from one ancestor to the next generation. Genomics is the study of all genes of a particular organism; the human genome is made up of approximately 35,000 genes (Cutting, 2005). Genomics includes the ways genes interact within persons and with their environment. Nurses need to be concerned about four areas of genomics (Scanlon & Fibison, 1995):

• Basic knowledge of genetic terms • Ability to understand genetic terms such as chromosomal variations • Ability to explain genetic inheritance • Ability to apply knowledge of genetics and genomics in nursing practice

Nurses’ roles in the genomic era include individual and family genetic counseling, clinical care, health education, policy development and analysis, advocacy, and research (Table 5.3).

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Genomic influences and risk factors are important to the health of individuals, families, and communities. In 1996, the National Coalition of Health Professionals Education in Genetics (NCHPEG) was formed to develop core competencies related to genetics for all health care professionals (National Human Genome Research Institute, 2012). An important basic element in genetic competency is the ability to draft a three- generation genetic history for an individual and family (American Medical Association, 2012). Such a genetic history can reveal health risks that deserve attention and tracking

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TABLE 5 -3 Societal Concerns L ink ed W ith G enetics

SOCIETAL CONCERNS

Fairness in the use of genetic information

Privacy and confidentiality

Psychological impact and stigmatization

Reproductive issues

Clinical issues

Uncertainties

Conceptual and philosophical implications

Health and environmental issues

Commercialization of products

* Adapted from U.S. Department of Energy Human Genome Project. Ethical, legal, and social issues. (2011). Retrieved from http://www.ornl.gov/sci/techresources/Human_Genome/elsi/elsi.shtml

Q UESTIONS RAISED

Who should have access to personal genetic information? How will it be used?

Who owns and controls genetic information?

How does personal genetic information affect an individual and society’s perceptions of that individual? How does genomic information affect members of minority communities?

Do health care personnel properly counsel parents about the risks and limitations of genetic technology? How reliable and useful is fetal genetic testing? What are the larger societal issues raised by new reproductive technologies?

How will genetic tests be evaluated and regulated for accuracy, reliability, and utility? How do educators prepare health care professionals for the new genetics? How do nurses prepare the public to make informed choices? How does a society balance current scientific limitations and social risk with long-term benefits?

Should testing be performed when no treatment is available? Should parents have the right to have their minor children tested for adult-onset diseases? Are genetic tests reliable and interpretable by the medical community?

Do people’s genes make them behave in a particular way? Can people always control their behavior? What is considered acceptable diversity? Where is the line between medical treatment and enhancement?

Are genetically modified foods and other products safe for humans and the environment? How will these technologies affect developing nations’ dependence on the West?

Who owns genes and other pieces of DNA? Will patenting DNA sequences limit their accessibility and development into useful products?

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to enhance preventive care. For example, the death of a biological first-degree relative at a young age from a heart attack indicates potential risk for other family members. In this instance, identification of high blood pressure in another family member at a young age would be a concern. Many leading causes of death have genetic aspects including heart disease, cancer, cerebrovascular diseases, chronic lower respiratory diseases, dia- betes, pneumonia, Alzheimer’s disease, and kidney disease. Knowledge about genetic predispositions can be useful in assisting persons to understand family risks and make informed lifestyle choices.

G enetic L inkages

Genetic linkages considered during family-focused assessments can identify many diseases. Family members are often unaware of conditions their ancestors have experienced and are not able to track patterns of disease transmission. Nurses who think family assess for in- cidences of all diseases and disorders known to have been diagnosed in the family, speak to the family about their health history, assist them to reduce risks, obtain health informa- tion, and speak with their doctors about high-risk concerns (Kaphingst et al., 2012).

It is important to include the age at onset of the diseases and disorders. For instance, family clusters of breast, ovarian, colon, and endometrial cancer might indicate possible hereditary cancer syndromes. Medical disorders such as heart disease before age 40 to 50, dementia before age 60, hearing loss before age 50 to 60, venous thromboembolism before age 50, three or more pregnancy losses, several family members with the same condition, or multisystem and bilateral occurrences may indicate genetic disorders (Goolsby & Grubbs, 2011).

A report by the Consensus Panel (2009) has noted that nurses need to be able to incor- porate genetic and genomic information into practice and be aware of personal attitudes, beliefs and values. They need to be aware of many things including those such as:

• The genetic and genomic basis of health or illness linked with care needs. • Ways to obtain a three generation family health history. • Newborns at risk for morbidity or mortality resulting from genetic metabolism errors. • Couples at risk for having a child with a genetic disorder. • Persons with questions about genetics and genomics. • Persons at risk based on assessment data that might benefit from more information

or a referral.

G enetic Patterns

Genetic patterns of inheritance are important not only for individuals and families, but also communities. Some autosomal recessive disorders are more commonly seen among certain racial/ethnic groups. Examples include Tay-Sachs disease in Ashkenazi Jews, cystic fibrosis and hemochromatosis in Caucasians, sickle cell anemia in black Americans, and beta- thalassemia in persons of Mediterranean origin, such as Greeks and Italians (Vallance & Ford, 2003). Amish people also exhibit some rare diseases (e.g., Troyer syndrome, Amish lethal microcephaly) unique to their community due to small founding groups and genera- tions of close marriages. Most Amish people can trace their roots back to a few hundred German-Swiss settlers who came to the United States in the 18th century. It is important for closely related communities to know their genetic histories. It is possible for both parents to be carriers of a genetic disorder without any outward expression of the autosomal reces- sive disease. If one parent is a carrier, there is a 25% chance of the child having the condition. If both parents are carriers, there is a 50% chance of the child having the condition. In such cases, genetic counseling is helpful for expectant parents or those contemplating

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pregnancy to determine the risks of having affected children. Family nurses are attuned to these genetic risks and spend time doing assessments, health counseling, and education relevant to unique risks.

Spiritual and Religious Assessments

Spirituality is not a topic always closely associated with health, illness, or health care in the United States as it is sometimes thought to be unscientific because of the lack of evidence needed to validate it for use in modern health care practices (Chidarikire, 2012; Swinton & Pattison, 2010). However, spirituality and religion are topics that often arise, especially in palliative care, hospice, and at the end of life. Some people use faith and beliefs as a coping resource and these beliefs often originate from and are informed by family culture and traditions. Many who do not ascribe to any formal religious tradition may practice a form of spirituality that deepens meaningful connection with and beyond the self. Consider the Cox-Halverson family. They identified with spirituality more than religious practices and had personal ways to define the experience. Spirituality can be described as a search for purpose and meaning in life, whereas religion is the formal framework used by many to channel the spiritual journey (Power, 2006).

Nurses are sometimes unsure about how to approach assessment of religion, faith, or spirituality (Cook, 2012). Nurses who do assess spiritual care beliefs and listen to illness stories and personal concerns do this with no great predictability (Mamier, 2011). Nurses most likely to engage in spiritual care practices are those who perceive spiritual issues occur frequently in the setting, are spiritual themselves, do not work in pediatrics, and have received education about spiritual care (Mamier, 2011).

Evidence abounds that spiritual beliefs, practices, and experiences are relevant to nursing practice. A systematic review of the literature found spiritual outcome measures and 85 tools that are used in research about spirituality (Selman, Harding, Gysels, Speck, & Higginson, 2011). Spiritual well-being can be assessed with questions that are not specifi- cally related to religion (Table 5.4). Areas to cover in a spiritual assessment include views of a higher power, sources of strength and hope, and religious practices (Carson, 1989). Within a single family, the nurse is likely to find differences of opinion, beliefs, and prac- tices. If appropriate, discussion with the individual seeking care or other family members can provide additional information. Family beliefs and values about spiritual and religious practices can be elicited through a therapeutic family interview (see Chapter 4). Preferences for a clergy visit, orientation to places that can be used for prayer and meditation, or the placement of religious items at the bedside can offer clues about individual practices.

Social Capital Assessment

The completion of a family ecomap can help you gain an understanding about family links to others and with the surrounding community. These links can be both positive or negative influences on the family unit and its members. Social capital is the term given to the posi- tive, health-promoting resources that provide beneficial supports to persons and families; it refers to human networks, social norms, and relationships that create mutual benefits (Carpiano & Hystad, 2011). Social capital viewed from a neighborhood perspective is an accessible network of community resources that potentially facilitate well-being and health. Social capital includes the actual or potential material, informational, and affective resources that persons and families have access to within family and friendship networks. Social capital is typically a benefit to individuals, families, and communities and positively affects health. However, loosely established neighborhood relationships can negatively

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influence attitudes, constrain opportunities, and create actions that are detrimental to in- dividual and family health and safety (Carpiano, 2008).

Social capital includes supports and abilities to access needed resources, receive infor- mation, and maintain social order (Carpiano, 2008). When the terms social capital and social support are compared, common ideas such as social networks, social engagement, sense of belonging, and reciprocity are identified (Kritsotakis & Gamarnikow, 2004). For example, a study of female primary caregivers of children demonstrated that women with social support from their neighbors have less parenting strain and master the parenting role (Carpiano & Kimbro, 2012). Conversely, youth gangs provide social support and so- cial cohesion, but have negative effects because such social capital also promotes a culture of violence. Having people in one’s life willing to do favors increases mental health for urban and rural dwellers (Carpiano & Hystad, 2011). Persons with wide social networks might possess more social capital to manage immediate challenges related to health and illness. Nurses who think family assess social capital to identify availability of supports and gaps to fill.

In 2001, Robert Putnam published a highly acclaimed book titled Bowling Alone. In his book, he described how more people are taking up bowling as a form of recreation, but they are doing it alone as opposed to joining organized leagues. He described the ways contemporary middle-class Americans have focused on work, material consumption, and leisure with less interest in civic engagement or collective activities than in the past. Over the past few decades, there has been less engagement in things like social organizations,

136 CHAPTER 5 ● Family Assessment

TABLE 5 -4 T h ings to Consider in a Spiritual A ssessment

NOT Q UITE A VERY SPIRITUAL IDEAS TO ASSESS AT ALL A LITTLE SOMEW HAT BIT MUCH

I feel peaceful.

I have a reason for living.

My life has been productive.

I have trouble feeling peace of mind.

I feel a sense of purpose in my life.

I am able to reach down deep in myself for comfort.

I feel a sense of harmony within myself.

My life lacks meaning and purpose.

I find comfort in my faith and spiritual beliefs.

I find strength in my faith or spiritual beliefs.

My illness has strengthened my faith or spiritual beliefs.

I know that whatever happens with my illness, things will be okay.

Source: Bradle, J . M., Salsman, J . M., Debb, S. M., Arnold, B. J ., & Cella, D. (2011). Spiritual well-being as a component of health-related quality of life: The Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale (FACIT-Sp). R e lig io n s , 2 , 77–9 4.

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church attendance, family dinners, having friends over, and voting. Decreased social con- nectedness may limit opportunities to build social capital and negatively influence private and public lives. Persons with high neighborhood social participation, more favorable neighborhood perceptions, and high general trust and those who live in lower income households are more likely to have strong core neighborhood ties (Moore et al., 2011). Researchers of a large international study on social capital in 50 countries discovered that higher levels of education were directly related to health and life satisfaction and that these people were less dependent on social capital (Elgar et al., 2011). More educated persons are likely to have spatial ties that reach beyond the local area. Those with higher incomes are inclined to have greater access to resources outside their neighborhood and fewer ties to their neighborhood. However, this can be detrimental if instrumental support is needed for caregiving. Wealthier more educated persons will likely hire help. But those with greater social capital may have family and volunteer resources available.

Chapter Summary

Nurses who think family always consider the family unit strengths and threats as they do an assessment. Although a number of components of a family assessment have been pre- sented, perhaps no single model or framework is all-inclusive or the only correct one. This chapter has reviewed differences among individual, family, and community assessments. Predictive and protective factors such as family type, family function, and family processes that influence health of individuals, families, and communities are described. Genograms, ecomaps, and other tools can be used to describe the structure of families and the connec- tions between members and larger communities. GIS are introduced as resources for com- munity assessment. Ideas about genetics and genomics, spiritual assessment, and social capital are also identified as factors to consider in the assessment process. Some challenges in communicating and documenting family-focused assessments are discussed. More exploration and further development and refinement around the best ways to document family-related assessment data and better ways to tie to the community are still needed.

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